Mark Dimor

Notes & Links: November 13, 2013

The Complex Relationship of Realspace Events and Messages in Cyberspace: Case Study of Influenza and Pertussis Using Tweets
Nagel, Tsou, Spitzberg, et. al publishing an original paper in JMIR examine the internet and real time surveillance. The authors focused on Twitter. They wanted to explore the interaction between cyberspace message activity specific to Tweets and real world occurrence of influenza and pertussis.

In general, correlation coefficients were stronger in the flu analysis compared to the pertussis analysis. Within each analysis, flu tweets were more strongly correlated with ILI rates than influenza tweets, and whooping cough tweets correlated more strongly with pertussis incidence than pertussis tweets. Nonretweets correlated more with disease occurrence than retweets, and tweets without a URL Web address correlated better with actual incidence than those with a URL Web address primarily for the flu tweets.

The authors concluded that keyword choice is critical in how well tweets correlate with disease occurrence. Makes sense.

Dead Man Walking
NEJM has perspective from Stillman and Tailor that speaks to the real reasons we need healthcare in the country and why the screaming voices wanting to shutdown the ACA or pointing out the problems with the web sites are missing the reality, we as a nation needs to care for and serve Americans, all Americans not just the ones who are lucky enough to have health insurance.

Public Reporting, Consumerism, and Patient Empowerment
Huckman and Kelley writing in the NEJM offer insight and hope for what we are seeing in the press and online. Perhaps, just perhaps we are at a tipping point in our American healthcare mess. Patients are becoming healthcare consumers and are beaming more and more empowered based on reporting by healthcare providers.

Consider this, healthcare providers are reporting cost and quality metrics. What the authors contend may be needed is data needs to help patients determine is the treatment/procedure the option for my need, budget, and personal and family situation?

The rub here is that who is going to explain this to the patients/consumers? HCP are not getting paid for cognitive services. And there is a cost associated with developing and sharing this information. And will they hire old marketing communications pro’s like me to do this so they can deliver care?

6 Lies We Tell Ourselves
No, two of them are not those. Digital Tonto makes us stop and take a hard look at our business strategy acumen. Here are the six. Hope over to see the details.

1. I’m Rational And Make Decisions Based On Facts
In reality, we rarely have the time or inclination to think things through, so we take shortcuts called cognitive biases.

2. I’m Above Average
Research in a variety of has consistently shown that when people are asked to rate themselves on just about anything—their professional skill, driving ability, honesty— a majority believes that they are better than most.

3. My Competition Will be Static As I Transform
“The same fundamental error is also common in business life. Strategy sessions are big on charts and graphs, but you rarely see any scenario planning.”

4. My Employees Love (And I Inspire Them)
“The truth is that power relationships are inherently mistrustful because one side can more easily opt out. People who work for us have a strong incentive to make us believe they like us a whole lot more than they actually do, but research has shown that employees opinions are rarely aligned with their superiors.”

5. I Have The Right Information
“We’re wired to jump to conclusions if our evidence is consistent, even if is incomplete.”

6. It’s Not My Fault And I Deserve All the Credit
“When things go well we feel a justifiable sense of pride. We worked hard, we worked smart and we prevailed. We believe that we should be rewarded and are angry if we are not. On the other hand, when things don’t go our way, there are always mitigating circumstances and we don’t think we should be penalized.”

Greg does his usual excellent job at making us all stop and see the reality not the unicorn rainbows.

Quote: Uwe (Need I say More?)
Austin Frakt has a quoted from Uwe Reinhardt in JAMA. I will take the liberty of copying it here since it is some important that I would hate to see you not jump to it.

[T]he often advanced idea that American patients should have “more skin in the game” through higher cost sharing, inducing them to shop around for cost-effective health care, so far has been about as sensible as blindfolding shoppers entering a department store in the hope that inside they can and will then shop smartly for the merchandise they seek. So far the application of this idea in practice has been as silly as it has been cruel. […]

In their almost united opposition to government, US physicians and health care organizations have always paid lip service to the virtue of market, possibly without fully understanding what market actually means outside a safe fortress that keeps prices and quality of services opaque from potential buyers. Reference pricing for health care coupled with full transparency of those prices is one manifestation of raw market forces at work.

Why Local Marketers Need to Start Thinking About Their Instagram Strategy
Okay I confess I have been a long time fun maker of Instagram calling it Twitter for people who can’t read. ( I am hearing the G and T of GTFH reminding me that good marketing and communications that captures attention uses graphics with copy). Street Fight makes a great argument on why we, no I, need to consider it.

More than anything, Instagram presents an unparalleled opportunity to build and share a brand — to show a different side by leveraging this highly visual medium. Plus, the rate of customer engagement is off the charts compared to other social channels

Great read but I would guess most of you are already heavy users of Instagram. If not see why and what a local business, healthcare provider, physician practice, etc. should consider it part of a social media strategy.

Video Break for the Day
GoPro: Combing Valparaiso’s Hills

Just watch it. Makes you want to be a 20 something again this time sans the 60s drama.

Caregiving, Loss, Grief, and Recovery: A Journey

“The sun comes up even when the curtains are closed.”

Brandy Clark

Donna, my wife of 28 years, died two plus years ago. I have written about caregiving, HPM, loss, grief, a film project and more. What I haven’t written about is adaption, recovery, and growth. How and why is it possible to traverse caregiving, loss, and grief to find meaning? Can we find a new better and improved self? Is there something more post trauma? What does the science say?

Within us and prior to a trauma are schemas that dictate self-discovery. It supports our being who we are and our growth. Those schemas were severed when Donna was diagnosed with Stage IV NSCLC.

This is no self-help DIY answer to horrific loss and sadness. There are reams of literature on the topic of grief and loss most of which will guide you better. This is simply a look back though a different set of eyes to identify the elements and process of loss, grief, and recovery. And those out there that have been my discovery partners you know what you’ve done and what it means to me. Thank you!

A Narrative of Sorts

On August 7, 2011 Donna died in hospice. Her life during her illness has been documented here. On that day I began phone calls to friends and family sharing Donna’s passing. A dear and respected friend and his wife were called. Ron said the following that set my grieving in motion and characterized my caregiving. “Do not run from the emotions and feelings. Face them full on so they can be understood and managed. If not you will never heal.”

This struck me because it felt true and spoke to me personally. I also knew that during the time I was caring for Donna I cared for her full throttle, perhaps at times a bit too aggressively.

In the middle of year two Donna and I were arguing at a restaurant over her getting whole brain radiation (WBR). For her WBR was intractable alopecia and the radiation oncologist lied. That broke her heart and spirit. For me I drank the evidence kool-aid WBR means survival. We were getting more and more heated. I behaved as the spouse who wants survival at all costs. Donna behaved as one who values QoL. I started to use my words, the four letter ones. A woman and her 10 year-old son were sitting at the next table and she told me to watch my mouth. I told her she is in NYC and her kid goes to school here so he knows these words. I felt guilty for all of 30 seconds.

After her passing I did not shy from the same aggressive driven behavior, only this time it was for me without care or giving just grief and pain.

At the time of Donna’s diagnosis and for nearly a year and a half and again following her death I was seeing an amazing counselor at CancerCare (A wonderful and brilliant organization to help patients, caregivers, family etc.) She was an angel and allowed me to be me. In fact she identified that my grieving began at Donna’s diagnosis because there would be no happy ending. CancerCare and this person gave me the platform and place to test drive and feel my emotions. I began to structure my sense of loss well before Donna’s death.

My friends and family allowed me to be me as well. Each one of them stepped up embraced and comforted me. I discovered a rich, robust, and embracing set of friends on line though Twitter, G+, and a blog. Groups like #hpm #dwdchat, #eol, #hcsm, etc. gave me a reference point for sharing.

During this immediate post loss period I failed to discover what I lost. Obviously it was Donna. But today I see there were other parts of her that I lost which were directly connected to me and in some regard pre-dated our marriage. I kept plugging on. I kept the traditions of cooking a large Sunday meal, trying my hardest to make sure the linens on the bed matched the shams and duvet, and not to forget to groom the dog. There were missing parts. None of this was working well.

It wasn’t until a friend opened my eyes saying she cooks as a hobby to get through the weekend etc. I realized that I was cooking for Donna and not for me. A small but significant insight, you grieve for someone yet live for yourself. And don’t forget to grieve for yourself. Within the trauma of loss resides our loss. I like to think of it as learning vs. discovery. You can learn something (I suffer incontrovertible grief) but never discover its meaning (truly understand what was lost). Loss and grief can be an opportunity for discovery. Discovery about what was lost and not one directional but a full 360 understanding. That occurs only when our receptors are open. Trauma can drive cognitive processing if we allow it or are allowed do so in a safe place because it will yield affective engagement.

I was making progress and adapting to the loss. Yet there remained a sense of emptiness. I was hitting the grief hard, doing what was needed. It was a year post Donna’s passing that I had a bike accident and developed a subdural hematoma. Those are slow bleeders that took a month and friends and neighbors to be discovered, almost too late. Emergency surgery, a month in rehab, family and friends caring for Nina and me. My grief for losing Donna was replaced by a grief for my being limited to a wheelchair and having to do PT and speech therapy. But again it was all about working my butt off not wanting any more institutional food, getting the hell out and on my own. After a month I went to my sisters. For the first few days I was afraid to cross the street. But one foot in front of the other I was going to get back to normal. Hell with traffic. The neurologist and neurosurgeon said I have fully recovered.

Once back home and recovered I went to a local rehab facility to do some PT and since the area of speech was affected I wanted to be tested for that. Speech was fine and PT was fine. I set up my bike as stationary and got back to burning calories. An old and wise friend told me that neuropsychology might offer some insight. Now this friend was one of the smartest, kindest, and most amazing (think Mensch) people I know. If he did it I can.

So the long and short of it, off I went to be evaluated. Results were unremarkable. There were some areas that were low normal, I heard mediocre and to tell the truth I was furious, do I hate mediocre. But going back to Ron’s comment about not hiding or avoiding the hard emotional work of grieving. Knowing that right now I was grieving for me as well as Donna there was only one path to take. I was going to learn what this neuropsych had to teach me. This was going to be Vulcan mind meld. I would not be daunted from discovering/learning all I could. An old friend said the only thing that changes our consciousness is learning. Little did I know how true that was because what I achieved at Cancer Care and subsequently WITH the neuropsych changed my consciousness.

Nine months later after working with someone who has the patience and understanding of a saint and the brains of Stephen Hawkins I understood the person I became after my loss and TBI was not me. I learned that grief and trauma alter our self-perception in ways both subtle and dramatic. It changes who we are. We can either become that which the loss, grief, and trauma created or we can pad in our bare feet down the darkened hall and find who we were and integrate what we’ve learned post trauma to discover something new. This is not a story of how I ran a marathon or climbed K2. It’s simply not wanting to vomit thinking about my loss, and trying to learn from life, friendships, and discovery.

That is the narrative. For about 30 seconds I harbored the magical unicorn rainbow sense that all this self-discovery sprang like an artisan well de novo. Then I was introduced to PTG and embraced the idea my de novo self-discovery can be anchored in science and evidence. Finally, in the harsh light of day it seems PTG was integrated into my life by the social and neuro science professionals like an inexpensive folding chair thrown into the trunk of a car and driven to the beach. No matter which of these are valid the elements and process works, we just have to look and listen to our hearts beating and our synapses firing.

Post-Traumatic Growth

A Pubmed search for “Post-Traumatic Growth” found 113 articles. The same search in Google Scholar found 4,060 links and a regular old Google Search “Post-Traumatic Growth” found 45,200 links. PTG exists but may be limited to scholars, researchers, and scientist.

Many have characterized PTG by “what doesn’t kill us makes us stronger“. How true. The science sees it this way: PTG is a positive psychological change, which occurs following a traumatic life experience, and those negative experiences drive people to reexamine their world and life. (30 -70 % of survivors say they’ve experienced positive changes Linley & Joseph 2004) Put another way, we fall into poop and come up smelling like a rose.

In 1984 I was working on Adriamycin an antineoplastic agent. At an advisory panel with global key opinion leaders one of the oncologist said that many of his patients when given the diagnosis of cancer make significant changes in their lives. The majority of others present agreed. PTG is not new. What’s new is, it now has a name and an important place in psychology.

Though the idea of growth emanating from the cauldron of hell is old, like Plato old. It is now becoming an important concept within psychological research and the positive psychology movement, which works to improve/build mental functioning as opposed to working toward repairing mental health pathology.

Following a traumatic event people have self-identified the following:

Relationships are enhanced and improved
Their self-assessment and views change
They have changed their life philosophy

Tedeschi & Calhoun, 1996 “The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma” introduced post-traumatic growth along with a tool to measure PTG called Post Traumatic Growth Inventory it is considered the start of PTG. PTGI identifies five factors:

Relating to others
New possibilities
Personal strength
Spiritual change
Appreciation for life

Clinical psychology works to moderate or eliminate negative emotional states. Positive psychology is focused on activating positive emotional states. Do we feel better about what we are doing and thinking? PTG is about gaining more autonomy, environmental mastery, positive relations with others, openness to personal growth, purpose in life, and self-acceptance. And the research at this point is examining the association between actual and perceived growth. Post-traumatic growth does occur and what I will share below are reviews of the literature that examine PTG and its elements.

The single best paper on this topic is from 2006 Zoellner and Maercker “Posttraumatic growth in clinical psychology- A critical review and introduction of a two component model”. It is exceptionally well-written and accessible to most of lay people and for the scientists reading this, an excellent critical review. I would advise reading this paper for a complete understanding of the topic. I want to highlight what the authors found when they examined the empirical investigations on cognitive factors and processes that may help predict PTG.

Openness to new experience: These are people identified as imaginative, emotionally responsive, and intellectually curious. They “draw strength from adversity”. It correlates with new possibilities and personal strength.

Hardiness and sense of coherence: These individuals have three sets of cognitions: commitment, challenge, and control. Commitment is our curiosity about making sense of the meaningfulness of the world. Challenge is our expectation that change is what life is all about. Control is our belief that we can influence course of events. Think how I identified myself as driven to provide caregiving and learn and my control of that. Zoellner and Maercker noted that the data for hardiness was associated more closely among POWs or those with higher levels of PTSD.

Dispositional optimism: Seems pretty clear Pollyanna works. The authors note that those self-identified as optimistic are more problem focused. They reframe and accept those uncontrollable situations. They also note that the evidence points out optimism and personal growth seem related and second, optimism and PTG may not have as strong a relationship.

Internal locus of control: This is where individuals employ personal resources to drive successful coping. Said another way if you perceive personal growth and the perception of controllability of the event then it is real. Perception is reality. But they go on to note the data here points to ‘an illusory side in PTG’.

Positive re-appraisal: Following a trauma how do we review and assess the event as in work our butts off (love the word Zollner & Macrcker use here effortful) processing beneficial information. This is a coping strategy and as such leads to PTG.

Acceptance coping: This is one of the more important factors that can lead to personal growth. “PTG was highest for those who used adaptive coping strategies including positive reinterpretation, the use of humor, and acceptance coping.” It was noted that this was associated with a highly stressful event.

Sense making and the quest for meaning: Trying to find meaning is central to psychological adaptation and associated with the perception of PTG. The authors note “The quest for meaning seems to be involved in PTG, but PTG is not necessarily linked to having found meaning.”

Rumination: Taking a long hard look at what happened and what you feel. It is important that rumination can be adaptive or maladaptive. Someone who lost their husband at about the same time I lost Donna tells me she cannot get him out of her thoughts and how lost her life is to the point of crying for hours on end. The evidence here supports cognitive processing as helpful.

“The data presented here suggest, from a theoretical point of view, that interventions aimed at increasing optimism, social support, and specific coping strategies may promote positive changes in the aftermath of trauma.” Zoellner & Maercker

In 2009 Prati & Pietrantoni published “Optimism, Social Support, and Coping Strategies As Factors Contributing Posttraumatic Growth: Meta-Analysis. They examined 103 studies and identified coping strategies that were contributors to post-traumatic growth. I recommend this study as well for its easy access and clear analysis. I will highlight what the authors found in the 103 studies they examined.

The following are the strategies that the authors identified:

Optimism
Social Support
Spirituality,
Acceptance coping
Reappraisal coping
Religious coping
Seeking support coping

In summary “positive reappraisal and religious coping are more related to postrumatic growth than optimism and social support”. Social support did not have as great an effect though it helps in framing the trauma and allows the individual find perspectives that can be used during reappraisal.

Optimism was moderately related to PTG and supports what (Zoellner & Maercker, 2006) contend that they are overlapping concepts. They further noted that optimism promotes PTG because it effects threat appraisal and adaptive coping strategies. Tedeschi & Calhoun 2004 note that optimists’ ability to focus on what is needed and avoid that which is unnecessary and unachievable based on the reality of the trauma (Donna is not coming back) is crucial for cognitive processing in PTG,

Seeking social support (friends, family, support groups, online, etc.) had a moderate effect on PTG. It may be as (Tedeschi & Calhoun 2004) noted that individuals may not be all that cool with disclosing their emotions and perspective on the trauma and the reactions other may have. Though a longitudinal study found that a great predictor of of PTG was emotional expression. Talk about it, write about it, share it, Reasons are that the negative feelings are turned down with a sense of closeness in relationships, and a sense of personal strength.

Spirituality was moderately predictive with positive changes following trauma. It is surmised that spirituality might drive PTG because of the community or community support in addition to the meaning-making and transformational coping. Other authors identified the benefit of spirituality including health, variables, psychological variables, and social variables.

Religious coping was a strong predictor of PTG. Though it shares similar explanations as spirituality, which maybe attributed to the use of religious resources. It has a strong framework to gain a feeling of control over the trauma, comfort, intimacy with others in the religious community and helping people make changes during this difficult time. The analysis of the literature noted that religious coping strategies are not equally adaptive.

Positive reappraisal coping was strongly related to growth. Though there are other studies that small or no significant relation between the two. This may just be as described, self-fulfilling prophecy and bingo positive changes.

Acceptance coping was small but significant predictor of PTG. If we can accept what cannot change specific to the trauma it is a good predictor of growth. But the authors note that the n was small.

In 2012 Joseph, Murphy, and Regel published “An Affective-Cognitive Processing model of Post-Traumatic Growth“. This paper examined a general overview of the field, reviewed the evidence, addressed a curvilinear relationship between PTSD and PTG, shared a new affective-cognitive processing model of PTG, and identified ways therapists can facilitate PTG. This is another excellent paper worth the read. I am going look at the intersections of intervention for the professional. There is an extended section on a post-traumatic affective-cognitive processing model. That discussion is well beyond this post or my current knowledge to allow me to simply share its key points.

Joseph, Murphy, Regel identify the fact post traumatic stress may indicate a working through the issue and is the engine of PTG. There is a lengthy discussion of this relationship between PTSD and PTG. They present it as a curvilinear relationship. Greater post-traumatic stress was associated with greater PTG but only to a point and then it declines.

The section on clinical practice is important. Key for the therapist is to support “the continuous cycle of processing”. Read that to say work the pain and emotions.

Joseph, Murphy, and Regel list the following:

Help the client identify and obtain other forms of support outside the therapy sessions
Promote reappraisal of the trauma including activities that provide for confrontation of the trauma related information in a safe environment.
Facilitating reappraisal
Promote helpful coping strategies, hopefulness, and finding socials support
Reduce negative emotional states and promote positive emotional states

I found a Masters Thesis completed in 2013 by Michal Keidar Conceptualization of Post Traumatic Growth in the Work of Expert Trauma Therapists. This is another good review of PTG well worth the read. He notes the following, which is important in relation to the recommendations for clinical practice that Joseph, Murphy and Regel make.

Eight trauma expert therapists active in the Seattle area were recruited and interviewed. The interviews, using sensitization by an interview guide, were coded using grounded theory and finding summarized in nine themes. Interviewees were not familiar with PTG as a term, but recognized it as an important concept in their work, a phenomenon that enables survivors to thrive in spite of their trauma.

This circles back to the beginning. The outcomes from trauma and loss are seen and known but the science of PTG and its ability to be added to care for survivors is coming into its own though it is not fully understood or applied. Perhaps the PTG movement and new data being published will help standardize its application to the care for those who have suffered trauma and aid the professionals treating those same individuals. Additionally patients family members of those who have suffered trauma should learn about consider PTG. It is my opinion that those who have suffered loss/trauma may benefit from at least a recognition that PTG exists and consider how they may engage in the process with their HCP.

My Narrative and the Evidence

Let me see if I can match my journey to the evidence. This is my perception and observational. As such it is of less interest to the social and neuroscientists. Yet it is part of PTG and my reappraisal? Rumination? An exercise? So on some level it is a testimony to PTG.

My narrative came well before reading the literature. And since the professionals imbued me with PTG like throwing fertilizer on a mushroom in a dark cellar I ate it up. This is not an amazing unicorn, pixie dust, Pollyanna view of my growth/recovery. More to the point, I have adapted to my life’s shit storm in a positive way. I guess that’s an outcome of sorts.

Openness to new experiences: Yes I was and am driven to learn and understand
Hardiness and a sense of coherence: Yes to a point though I am not sure I see it. Perhaps I am not attuned to what I can’t do. I do plunge ahead. Check with expert on this one.
Dispositional optimism: Not me
Internal locus of control: Beyond my pay grade to say yes or no
Positive re-appraisal: I would say no, but if you are reading this it must be yes
Sense making and the quest for meaning: After editing this over and over I would say yes
Rumination: Yes
Spirituality/religious coping: No
Acceptance coping: Yes

In Closing

PTG is not a one size fits all panacea. Zoller & Maercker closed their review with the following

Clinicians ought, however, to remember that the absence of growth should not be regarded as a failure. Therapists should be particularly careful not to suggest that patients must grow from their experience. Such suggestions may be offensive and minimize the patient’s experience. Furthermore, we would like to remind that there is no evidence up to date that PTG is necessary for successful recovery from trauma.

And I would caution the authors I have cited and linked to spend considerable time examining the controversies and questions surrounding PTG and what future studies should do or not do. Basically they all want to see longitudinal cross sectional studies that do not reside solely on patients self-perception.

PTG may not be necessary for recovery but in my view, albeit 20/20 hindsight, it presents an interesting and important model that warrants consideration and further study which all these authors and others are doing. For those of us in the middle of loss and trauma and have a certain life view PTG is something to consider. Think about the kid locked in a room with 10” horse poop on the floor. He is digging holes for hours in the poop. When asked why he’s doing that he responds, “All this horse poop means there is a pony in here, I’m looking for it.” Perhaps whether it’s PTG or just plain old stubbornness and desire to climb out of the pain, looking for a pony may yield results. And consider this in light of the aging baby boomers, CS Lewis said in his essay on grief that one member of every couple will suffer grief. A lot of people going forward will need help.

Additional Reading

Here are some links that take this topic further.

Factors Contributing to Posttraumatic Growth

Coping processes relevant to posttraumatic growth: an evidence-based review.

Bibliometric analyses on the emergence and present growth of positive psychology

Yet in comparison to other psychological sub-disciplines and areas, literature output remains rather low. However, results on publication types and media point at a broad‐range impact of positive psychology on various applied and basic psychological sub-disciplines. Together with the solid empirical foundation of positive psychology’s literature, this leads to a positive prognosis for the further development of positive psychology

Positive psychology: Introduction to the special issue

Human strengths and well-being: Finding the best within us at the intersection of eudaimonic philosophy, humanistic psychology, and positive psychology.

Great expectations: A meta-analytic examination of optimism and hope.

Trauma and Transformation: Growing in the Aftermath of Suffering

Notes & Links: November 4, 2013

What’s a Hospitalist? Thanks for Asking
The Healthcare Marketer has a post helping consumers know what a hospitalist is. I’ve wondered that as well so I was interested to see where this was going. Print ads for this campaign are included in the post but it is not the only effort, it includes digital, transit, blog, video, etc. A rather concerted effort lead from the pediatric hospitalist. But kids and dogs work well at getting the readers, viewers, etc. attention.

The print ad does a good job of differentiating a physician from a hosptialist. But I wonder, will that drive consumers to think about how Boston Floating Hospital for Children in a new light? It strikes me that this is positioning the hospitalist as separate from a physician and why should a patient want to see just a physician. Why see a physician, or NP? I wonder what the department of medicine thought about this campaign?

Making Hospital Prices Matter
Peter Ubel in The Health Care Blog shares some insight and analysis of OpsCost. It is a web site to help people figure out how much various hospitals charge for a range of treatments and procedures. It’s database is from Medicare.

Ubel enters “Hip & Femur Procedures Except Major Joint Without Complications And Comorbities/Major Complications And Comorbities”. He breaks down what is presented at three local hospitals and addresses what it may mean for the Medicare patient, the uninsured, and those with private insurance. All fair and accurate analysis. Ubel ends with

Will this improve consumer decision-making? That remains to be seen. With an increasing number of consumers signing up for high deductible health insurance plans, it’s easy to imagine a large number of people going to websites like this before deciding where to receive their care. And it may not take much of a shift in consumer behavior to force high cost hospitals to lower their prices, or to make sure to explain to consumers why their higher prices are justified.

For better or worse, mainly for better in my opinion, we are entering into a new world, where American hospitals can no longer expect to hide their prices behind a veil of secrecy.

I agree and further I think with all the attention healthcare is getting and the changes underway we will be seeing more in the way of improved outcomes and hopefully lower cost.

Healthcare Triage: What is health insurance, and why do you need it?
Aaron Carroll of The Incidental Economist (TIE) has just launched a new YouTube Channel called Healthcare Triage. He has two videos up.

Obamacare and October 1st: Healthcare Triage #1
What is Health Insurance, and Why Do You Need It?: Healthcare Triage #1

Two observations, TIE is well written and clearly evidence based in its work. Second, this is sorely needed in healthcare

I just viewed #2 and it was informative, high energy, and great quality. A great place to send friends, family, patients, etc.

Notes & Links: November 1, 2013

IMS: Half of Android health apps have fewer than 500 downloads
The report by IMS ends with the following:

The report also identifies a number of barriers that need to be addressed to increase app adoption and improve the quality of apps, including a curation platform of some kind, app integration with other parts of care, better safety and security, and more robust efficacy measures to prove the value of apps to all stakeholders in the ecosystem.

Pair that with the following from the same report and what we have is, let’s throw some poop against the wall and see what sticks. I am not sure that any consideration of strategies, objectives, etc. are made when launching these apps. And it is not as if there is not seasoned smart healthcare executives available to help. Oh wait we are old and can’t code. Gee look how well you’re doing.

Analysis of the widely available consumer healthcare apps on the iTunes app store shows that at present there are 159 apps which link to sensors,” IMS writes in the report. “However these are dominated by fitness and weight apps which monitor pulse rates when exercising and measure weight and body mass index (BMI). Fewer than 50 of these 159 apps relate to actual condition management or provide tools and calculators for users to measure their vitals. There is therefore considerable room for growth in this sector.

Sociotechnical Challenges and Progress in Using Social Media for Health
Munson, Cavusoglu, Frish, et. al out of the University of Washington shared their view on social media in healthcare and how these tools that hold so much promise are not meeting their established goals. This is a long well referenced piece that has many nuggets of knowledge. I must say it is hard to read. Damn near turgid. Of course it may be my modest IQ but I shared the work with colleagues and they felt the same.

At a recent Peter Wall Institute for Advanced Studies workshop, our group was tasked with reflecting on contemporary and coming technical challenges for using social media to promote healthy behaviors, communicate health information, and to gather information on current health behaviors or events. We hope to see a continuation and extension of recent technical developments in sensing, connectivity, and large-scale data aggregation and analysis. There are clear areas for improvement—for example, activity inference can be unreliable and drains battery life, and Google Flu is still poor at detecting atypical flu trends, as the most severe often are. We believe, however, that these challenges are being fairly well addressed by current research and market forces, and thus we do not dwell on them here.

Grab a coffee, print this out, and explore all it has to offer. The next step will be assigning sets of goals and strategies to what is presented here in clear simple language.

An Epidemic Out of Control: Poor Children and Psychiatric Drugs
Howard Brody, MD, PhD writing on Hooked: Ethics, Medicine, and Pharma reports from the American Society for Bioethics and Humanities a presentation by Dr. Melody J. Slashinski of the Center for Medical Ethics and Health Policy at Baylor College of Medicine.

Slashinski’s presentation was based on discussion with mothers and their ‘folk-knowledge network’ linking them and information about drugs commonly prescribed for children today.

That might sound easy to do, but the data went on to show that it’s extremely difficult in this population especially. The mothers also feared, quite realistically, that any evidence of “medical noncompliance” on their part would end up with a report to Protective Services and eventually losing custody of their children. So the stories Dr. Slashinski told generally depicted a delicate balancing act—moms on the one hand certain that they would not give these medicines to their children, and on the other hand going through as many hoops as they could to appearcompliant and submissive to the medical system so as not to set off alarms.

There is a long passage where Dr. Slashinski speaks to a pediatrician’s office check-up for a 9 year-old son and 8-year old daughter she witnessed. You must read the entire description but here is part of it.

The doctor then examined the daughter and said something at one point about her “boobies.” The daughter apparently became offended by this comment and stopped cooperating with the exam. The doctor immediately asked the mother how often the daughter had these “tantrums” and started talking about the possibility of bipolar disorder.

Brody’s post and his comments speaks to the massive level of drugs that are being prescribed to poor children and to the reality that parents of these children find the only way parents can protect them is by not taking them to the physician.

Can Everybody Please Just Calm Down?
Ann Mond Johnson writing on the Healthcare Blog gives another perspective on Obamacare and the whirling Dervishes surrounding its failed launch. Johnson asks that the private sector to step up to the plate and “counteract what much of the media refers to as a complete debacle”.

First, just calm down and focus on helping clear up the confusion
Help people shop remind people of their options under this healthcare plan
Provide perspective Americans must have healthcare by law and now that is easier

There are voices out there who are rational, not shrill, that speak to the need for the ACA to be successful for the health of America. We all should try and find these voices and listen if for no other reason but to calm the !*#@ down.

What Would Darwin Think Of Obama’s Health Insurance Exchanges?
Ian Shepherdson a contributor at Forbes gives us another step away from that epic disaster of a launch called Obamacare and its Insurance Exchanges breach birth.

Amid the chaos, it is easy to overlook the key point, which is that the insurance exchanges are here to stay. Despite their difficult birth, they will evolve over time as lessons are learned, bad technology is fixed, and operational difficulties are overcome. They will persist, even if a future Republican administration succeeds in unravelling some elements of Obamacare.

Shepherdson goes on to point to the fact the idea which was originally a Republican concept in the 80’s. But the primary message is this is not easy task making a sea change to a nations healthcare and a change that hopefully will manage costs and improve outcomes. Those are huge targets sitting on the back of anyone trying to make Obamacare work.

Good ideas spread, unless something really powerful gets in their way. Next time you swat away a mosquito, remember how it got to be buzzing around your ear in the first place. Insects were the first flying creatures on earth, but they didn’t always have wings. They didn’t really fly, either. Instead, a random mutation in the genetic code of a non-flying insect affected the shape of its body, helping it hop or jump a bit further than its siblings, or ensuring it was blown a bit further by the wind.

Another rational voice. Perhaps I am looking for hope for America’s healthcare crisis.

Notes & Links: October 29, 2013

Making Health Addictive
Joseph Kvedar writing on HealthWorks Collective is presents the premiss that people’s addictive relationship with their smartphone can be leveraged to improve health. Kvedar admits right up front “…is there any way health can really be addictive? Probably not.” What he wants to present is the “juxtaposition of motivational health messaging with some other additive behavior, specifically checking your smartphone.”

Next comes the science of checking our phones 100 times a day (I’ll raise my hand) and how that is addictive and it releases dopamine associated with ingestion of addictive substances. Yup we get off on our phones looking for emails, stock news, weather reports, news, cat videos, etc. So far still good.

Why are smartphones so additive? All the apps, video, social networks, and just plain curiosity. Kvedar makes the following statement.

Many have talked about the transformational possibilities of mobile health including: the opportunity to use an always on, always connected device to message you in-the-moment about health; to capture health-related information about you via the camera and through connected sensors; and, of course, the ability to display relevant information in context. All of these are exciting, but if we can exploit the addictive quality of smartphones, it will be the most important characteristic of mobile health as we move forward.

Here are his strategies for doing the above:

1. Make it about life: Learn what the person wants from life his/her aspiration and tie health related messages to those aspirations.

2. Make it personal: Put it in the context of the phone user in relevant ways. Personalized medicine

3. Reinforce Social Connections. We all want connections to others and especially around health problems or questions we are seeking to solve. They are very powerful tools and as Kvedar notes not just for friends and family but for accountability and adherence to care and wellness plans.

Here are the tactics that are offered:

1. Subliminal Messaging. “Imagine if every time you checked your phone, an unobtrusive brief message appeared on YOUR health issue and how to improve it.”

2. Use Unpredictable Rewards. ” B.F. Skinner proved that operant conditioning is more effective when the stimulus and reward are tied only some of the time.”

3. Use Sentinel Effect. “This effect of having an authority figure look in on your life is a really powerful tool that can be used to effectively promote good health through mobility.”

Kvedar ends with reference to this in the Boston Globe

What’s going on here? We’re witnessing the death throes of advertising’s “Mad Men” era, and the birth of the Mr. Spock era. Mad Men were all about coming up with clever ideas for ads, treating clients to steak-and-martini dinners, and putting TV spots on the most popular shows. You didn’t know exactly who saw your ad when it ran on “Bonanza,” or what impact it had on sales, but you knew it reached a lot of people.

Mr. Spock is all about making logic-driven decisions based on data collected about consumers and the context surrounding the ad. Who is clicking, and is that click leading to a transaction? Is this ad worth what we’re paying?

I agree with his premiss we should leverage the smartphone we are all addicted to in order to maximize the technology that will drive outcomes and improved patient care. I agree that for this to work we need to determine what the patient wants or needs. Where I split hairs is around how we do that? Using surrogate markers of sites visited or other behaviors on the phone or even the computer is not accurate and may not directly address the problem the patient wants to solve. What needs to be done are for patients to say I need to understand this about myself and my health. I want to opt in and I want to opt in with a trusted partner or partners.

The problem here is that will we ever reach a critical mass of patients who will drive community outcomes? Will we be able to go beyond those who are active healthcare participants and move to the next demographic those who have a minor interest? This is similar to getting the young invincible’s to sign up for ACA. How can we apply all these ideas to successful marketing?

Overcoming Fragmentation in Health Care
John Noseworthy writing on the Harvard Business Review Blog Network addresses the reality that the quality of healthcare in America is fragmented which drives ‘unsustainable health care spending.’

Noseworthy points to the fact healthcare is in the throws of consolidation through mergers and acquisitions and that is at the root of fragmentation because the larger and more complex a system becomes the greater its fragmentation and cost.

It is different at the Mayo Clinic

At the foundation of our approach is a knowledge-management system — an electronic archive of Mayo Clinic-vetted knowledge containing evidence-based protocols, order sets, alerts and care process models. This system, which can be made available to physicians in any location, brings safer care, better outcomes, fewer redundancies, and ultimately cost savings for our patients. Ask Mayo Expert, one of the many tools in our system, helps physicians deliver safe, integrated, high-quality care. Through this system, physicians can find answers to clinical questions, connect with Mayo experts, search national guidelines and resources, and find relevant educational materials for patients. This knowledge is updated in real time and made widely available.

Knowledge and access to knowledge is the single most important driver of better patient care. HCP are life long learners and being able to quickly and easily access experts etc. will slow fragmentation and hopefully slow cost expansion. And that is achieved through the following activities

Through this commitment, Mayo Clinic physicians and scientists have contributed more than 400 peer-reviewed papers on quality improvement in the last five years.

Noseworthy ends with this

To transform health care in America into high-quality, patient-centered care that the nation can afford, we must address fragmentation, we must address variable quality, and we need to create a sustainable health-care financial model. Collaboration is key. Mayo Clinic has a long history of innovation focused on improving the value of health care, but we can accomplish much more by working together — integrating and sharing knowledge with one another.

This is mom and apple pie and spot on regarding learning and how it drives change. What was missing for me was the patient component. Clearly Mayo Clinic is patient centric in its care. That is known and proven but I was surprised to see it not referenced or tied to this article. Fragmentation is the the goal of the institution but the patient is at its center and can benefit if not address fragmentation. Just to make sure I didn’t miss a patient reference I searched the article and the only reference to patients was in the comments.

Great blog! First off, please let me commend you on the amazing work that you, your organization and your employees do everyday. The software you reference to address fragmentation on the hospital side sounds fantastic! May I ask how you are addressing fragmentation in the eyes of the patient? We launched a pilot program in Cleveland, OH that used Lay Patient Navigators to decrease fragmentation. By developing key relationships with patients, the lay navigators were able to massively decrease fragmentation and positively impact patient outcomes. It was a very successful program! Not only did it decrease fragmentation and increase both outcomes and patient satisfaction – it also positively contributed to the hospital’s bottom line! Just another way to think about decreasing fragmentation in the eyes of the patient because as we all know – this health care system is incredibly fragmented and confusing! Do you use lay patient navigators?

We should not forget that the patient is at the center of care and they drive our brave new world of patient engagement.

The legal justification for mandate penalty/open enrollment realignment
Nicholas Bagley a University of Michigan Assistant Professor of Law submitted a quest post to The Incidental Economist. Let me see I can explain this, the Obama administration offered guidance to ease concerns surrounding the imposition of the individual mandate using “hardship exemption”.

Here’s what the administration is worried about. Under the ACA, an individual doesn’t get slapped with the mandate penalty until she’s gone without health insurance for a full three months. That means she’s got to be covered before April 1 rolls around—which is to say, by midnight on March 31. By regulation, a plan that is purchased in the first half of a month takes effect on the first day of the following month (e.g., a plan bought on February 10 takes effect on March 1). For coverage purchased in the second half of the month, the coverage period starts on the first day of the month after that (e.g., a plan bought on February 20 takes effect on April 1). As a result, to get coverage that kicks in before April 1, an individual has to purchase a health plan by mid-February.

Yet the open-enrollment period lasts all the way through to the end of March 31.

Still, the administration is right that the awkward conjunction of the ACA and the coverage-effective dates has created a trap. Pretty much everyone who purchases insurance in the open-enrollment period will assume—reasonably if wrongly—that they’ve done what the mandate requires of them. That shared assumption provides an eminently plausible basis for invoking the hardship exemption: the assumption, by encouraging delayed enrollment, means that loads of people will face a financial penalty they hadn’t anticipated. That penalty, even if it’s assessed after the fact, will reduce their “capability” to afford the health plan that they purchased. Invoking the hardship exemption to deal with that reduction in capability makes sense, especially because the whole point of the exemption is to alleviate affordability concerns.

I have a headache trying to figure this out and understand it. Bagley has some terrific links and information which helps. But more importantly I believe the ACA is organic and will move forward in fits and starts to what I hope becomes a valid and working healthcare model. What frightens me is the fact that this looks like how sausage is made at its worse. I wonder how much faith we can hold on to while we wait for some positive metrics?

Notes & Links: October 28, 2013

What the ad biz needs is to exorcize direct marketing

Doc Searls Weblog begins with a Michael Wolff’s article in USA Today “What ad biz needs are writers“. Searls primary message in this piece is that advertising and direct marketing were kept apart with top notch writers, art directors, creative directors, etc. wanting to go into direct marketing. And as Searls points out.

In the online world, advertising messages are not much about increasing brand awareness, or other old-fashioned advertising purposes. (Though today’s ad folk love to throw the word “brand” around.) Instead the main purpose is getting direct responses: clicks and sales, aimed by personal data, gathered and analyzed every possible way. The idea is to make the advertising as personal as possible, as far as possible, regardless of how creepy it gets. It’s all fully rationalized. (Hey, you canopt out if you don’t like it.)

Terry Heaton in Street Fighting Magazine is quoted

Operating within the soul of every marketer is the ridiculous assumption that people want or need to be bombarded by advertising, and that any invasion of their time or experience to “pass along” an attempt to influence is justified. If this were true, there would be no looming fight over DVRs, which allow viewers to skip ads. You have no inherent right to my eyeballs, and it is precisely this axiom that makes today’s instruments and gadgets so powerfully disruptive to the culture

What we have here is the fact technology is changing marketing. It is timely that the next post from Greg at Digital Tonto takes us into the future of marketing.

The Future of Marketing

Greg writing on Digital Tonoto points us toward the future of marketing. And in todays techno world Greg sums it up nicely when he says “…brans will have to learn to be more like publishers and develop content skills. It also means that marketers will have to create a genuine value exchange rather than just coming up with catch ad slogans and price promotions”

Greg points out the following:

From Rational Benefits to Passion Economy
From Strategic Planning to Adaptive Strategy
From Hunches to Simulations
From Brands to Platforms

This is a great read full of ideas and links you won’t find elsewhere. And with Twitter Chats like #hcsm what Greg offers us are tools, ideas, a directions for those of us interested in healthcare to focus and build. We are marketing outcomes, care, management, cost, etc. It’s time we had the tools to think of it that way.

Sugar Linked To $1 Trillion In U.S. Healthcare Spending

How sweet it is. Dan Munro Contributor at Forbes takes a deep dive into the Credit Suisse report on sugar and finds this pearl:

So 30% – 40% of healthcare expenditures in the USA go to help address issues that are closely tied to the excess consumption of sugar.” Credit Suisse Report

This is a financial report about the sugar industry, which the US subsidizes in a big way. Americans pay three times the world price of sugar to the tune of about $3 billion a year in estimated taxes. See the full article here. In essence we pay to get sugar and we pay to fix what sugar broke.

What is of interest is how detailed this report gets into the health aspect of sugar. And below is a chart “Annual Global Soda Consumption Versus GDP per Capita” Check out where the USA sits. No where near the trend line so far above it think heaven. And you really need to see the chart titled “Average Daily Caloric Intake of Sweeteners By Country”.

Notes & Links: October 25, 2013

Raising the Medicare eligibility age is now a REALLY bad idea
Aaron Carroll and Austin Frakt at The Incidental Economist give us all the smart economic reasons why raising the eligibility age for Medicare is dumb.

Put these two things together, and the new estimate for federal savings is much lower than it was before. But all the non-federal costs (not in the CBO report but covered by us before — see links above) remain, as does the concern about the viability of the exchanges and the fact that Medicaid hasn’t expanded in all states. So if raising the Medicare eligibility age before was a bad idea (and it was), it’s an even worse idea now.

This is a great smart clearly written read.

FDA to Regulate Gluten-Free Labeling
Jennie Bragg at Healthworks Collective shares the new FDA rule on what a product has to do to be labeled Gluten-Free.

…a food or beverage must contain fewer than 20 parts per million (20ppm) of gluten. This translates to approximately two-hundredths of a gram of gluten per kilogram (2.2 pounds) of food.

I can’t help but wonder if some of the foods currently saying Gluten-Free who have sales that show many people buying them and feeling better will end up not making the cut because they are not strickly Gluten-Free. Can you say placebo effect?

GOP’s Oddest Obamacare Objection
Michael Millenson a Contributor to Forbes shares his shock and awe at the the following:

The reason that Republicans shut down the federal government, it turns out, was to “restore patient-centered healthcare in America.”

Really? Worried about patients and patient centered care? The GOP? One quote to capture the complete and utter lucency of this.

Obamacare opponents assert that the ACA undermines the traditional doctor-patient relationship – although I suspect that being able to pay your doctor because you have health insurance actually improves it quite a bit. Yet in calling for “patient-centered healthcare” instead of the more common “patient-centered care” or even patient-centeredmedicine, conservatives unwittingly abandoned doctor-patient language in favor of business-speak.

Go read this piece and smile.

Polio eradication: where are we now?
The Lancet editorial reminds us that it would be wrong to forget this disease still exists, still can cause suffering, and still needs world attention.

With regard to the technical dimension of ending polio, global eradication efforts led by WHO, UNICEF, and the Rotary Foundation have made remarkable progress. Poliomyelitis cases have been reduced by more than 99% and there are only three remaining polio-endemic countries—Afghanistan, Nigeria, and Pakistan. In 2013, the number of polio cases from the three endemic countries—99 in total—is 40% lower than in 2012.

Technically we cannot do better at eradicating this disease it is now a battle of political will.

Shine again
Jonathan Barnes writing in The Lancet reviews Stephen King’s new novel a sequel to The Shinning titled Doctor Sleep. When I saw The Lancet had a book review I was drawn to like link bait. The book follows Danny the son from The Shinning into the 21 Century where he is a physician working in a hospice in New Hampshire.

The review is good and the fact it is in The Lancet and ties the loose ends of addiction to King and his previous work is interesting.

Notes & Links: October 23, 2013

Austin Frakt writing in The Incidental Economist shares a chart from NY Magazine article by Stepen Hall on the cost of cancer drugs. Here is the chart showing the rising price of oncology drugs since 1966 at the time of FDA Approval. Austin implored readers to read the article to the end. I am such a compliant (PC incorrect term) reader (patient too) I read the article. Here is the link to the charts are MSKCC and PowerPoint slides.

I fully agree with Frakt read the excellent and telling article to the end. There is so much there to cull, learn, and act on. For my reading I came to this having worked on Adriamycin and other cancer drugs going back to 1985. With that particular history I can’t help but look at this this article and wonder if Zaltrap is being used as part of initial therapy with some off label messaging? The firewall for that is clearly the oncologist but we know that:

And because the economics of cancer drugs have always been colored by emotion, where patients facing a grim prognosis are desperate to try anything (as are their doctors)

This is a very powerful and telling quote

Kantarjian has brought a rhetoric to the price debate that is unusual for such a prominent figure in oncology. He accuses the pharmaceutical industry of “greed” in its pricing of CML drugs, argues that “there is zero correlation—zero—between how effective a drug is and the cost of the drug,” and becomes especially indignant when pharmaceutical-industry spokespeople suggest that any effort to contain drug prices will curtail innovation, calling it a form of “blackmailing” against the national interest. He’s pretty exasperated with his fellow oncologists, too. “In the last decade, we have become glorified employees of the drug companies,” he says.

Again read this and consider what we need to do not just to bend the cost curve but to deliver better patient care. In light of this article and the indictment of oncology drug pricing we need to consider what palliative care delivers and not solely on a cost analysis but a quality of life basis. Studies need to be done. I would like to see a trial to compare palliative care to cure and measure outcomes of both survival and Q0L.

Pediatric Caregiver Attitudes Toward Email Communication: Survey in an Urban Primary Care Setting
Dudas and Crocetti published and original paper in JMIR. There have been much discussion regarding the usage of email communications between patients and HCP and how it will drive major change. The authors performed a survey to measure pediatric caregiver access to and attitudes toward the use of electronic communications.

We hypothesize that parents bringing their children to a pediatric primary care clinic have access to the Internet and email and would be interested in communicating with their health care providers by these modalities. The aim of this study is to document pediatric caregiver attitudes toward and access to these technologies in an urban pediatric primary care clinic.

The authors concluded:

Caregivers of children in an urban pediatric primary care practice have access to email and would be interested in communicating with health care providers by this method. African-American caregivers and those in lower socioeconomic groups hold less favorable views toward email communication; thus, the use of email may exacerbate existing disparities in health care delivery. Future studies should examine the reasons for these attitudinal differences.

Why is the right question and do we have time to wait?

Awesome Video from the Children’s Hospital at Dartmouth-Hitchcock (CHAD)
The Healthcare Marketer shares this emotionally powerful video from Children’s Hospital at Dartmouth-Hitchcock. Tear alert… you will tear up. Powerful. Let’s get the number of views up.

This has to be the idea from the agency because it works so well. Not your usual in house effort. And I am right the agency is Sublime Eye.

Notes & Links: October 22, 2013

Six Frightening Facts You Need to Know About Healthcare

I saw this on my news reader and thought I would write about link bait. So reading Robert J. Szczerba contribution to Forbes made me stop and think shit healthcare in America is worse than the Health Exchanges web sites. I knew most of these facts from various sources But to see them in one place at one time is a WTF moment.Here is the list

Up to 400,000 people are killed each year due to preventable medical errors.
765,000,000,000, or 30% of all U.S. healthcare costs, each year is wasted.
33% of hospital patients suffer some form of preventable harm during their hospital stay.
58% of clinicians felt unsafe about speaking up about a problem they observed or were unable to get others to listen.
Critical care patients each experience nearly 2 medical errors per day
92% of U.S. physicians admitted to making some medical decisions based on avoiding lawsuits, as opposed to the best interest of their patients

Generally I would say this is a good read. Not so much, I am typing this from under the covers wrapped in bubble wrap so I don’t end up in the hospital.

Radiant

Graphic novel well more tot he point Slate has 12 Panel Pitch which is an idea for a feature film boiled down to 12 panel. This is one is titled Radiant and is about the women who suffered at Radium poisoning during WWI.

Simply great

Chart: Euthanasia in Europe and the US

Austin Frakt got the chart those of interested in end of life care, hospice and palliative care, death with dignity etc. are dying to see.

Notes & Links: October 21, 2013

Yesterdays news today. Sorry but life got in the way of life.

Just How Bad Is That Federal ACA Health Care Exchange Problem Anyway

Tim Worstall, Contributor at Forbes hits us with the good stuff. This was written prior to the speech by Obama on ACA which for now I will allow others with an ax to grind to parse its meaning. Clearly the execution of this technology has failed. And it appears from this article and from Obama’s comments a lot of code will need to be rewritten. Worstall makes a great point and one that is at the core of this issue

It’s not just Java for the script kiddies, for sure, but the complexity is actually in the design, not the programming. That design should have been nailed down two years ago, the code written and then tested for a good 6 months. Rather than what actually happened, which was that the design itself was still changeable into September of this year. That those insiders are still misdiagnosing the problem shows quite how far out of a technical understanding they are. There is this:

This is a good article in light of Obama’s speech. But it is even more important when you consider this Poll: Majority believe healthcare website problems indicate broader issue with law.

Fifty-six percent of Americans say the website problems are part of a broader problem with the law’s implementation while just 40 percent see the website problems as an isolated incident.

The bungled rollout has not soured support for the health law overall, however. Forty six percent now support it while 49 percent oppose it. That compares favorably to a 42 to 52 percent negative split last month.

Somewhere in this long painful road to healthcare in America is a Harvard Business School. I hope this ends with something more, better patient care, bending of the cost curve, improving outcomes, and just giving Americans a chance to live better

New Obamacare Numbers – Success Or Failure?
Dan Munro contributor at Forbes looks at the numbers from the state exchanges and talks about his experience applying. Today the administration said about 476,000 health insurance applications have been filed through federal and state exchanges. It remains a mystery on how many people have actually enrolled in the insurance markets. But to note a bit over half of those are from 36 states where the Federal Government is running the markets. The remaining half is from state run exchanges.

Munro ends with this and keep in mind the ACA is the single biggest target on the presidents back and when those of a certain ilk are looking to be haters ACA/Obamacare is what to aim for.

All of which suggests that rendering a success or failure verdict at this early stage (based almost entirely on the initial and poor performance of the public exchanges) seems premature. Either way, success or failure, one thing remains certain. We’re likely to see a lot more political math between now and the end of the year.

Study adds to growing recognition hat improving graduation rates can improve public health
The Pump Handle on Science Blogs has post by Kim Krisberg looking at new data showing that dropping out of high school increases the risk of illness and disability in young adulthood. Here is the open access to BMC Public Health here

Interesting to note that high school graduation was never singled out as a major public health objective. And the data clearly shows the link between morbidity and mortality.

Among the results, study authors found that the risk difference for long-term sickness or disability between those who complete high school and those who drop out was 21 percent. And even after adjusting for the accompanying risk factors listed above the risk difference was still 15 percent.

Krisberg shares some data regarding the US drop rate and the fact it has declined from 12% in 1990 to 7% percent in 2011 with rates declining among whites, black, and Hispanics. Now I guess the question becomes do we use a health strategy to drive getting a high school diploma or do we drive the message that a high school diploma will help you live longer?