health – Looking Forward

December 2, 2020

You To Me, You To Them - More About Network Effects

Not that we have to be reminded, but COVID has certainly reminded us of the fact that we are all connected, in varying degrees, and have an impact on each other. This reminder from a pandemic shouldn’t be a surprise since some of the earliest and best work on real network effects between people has been done by public health experts.

The now classic 2009 book, Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives, by Nicholas Christakis and James Fowler showed the ways that our networks with other people affect, among other things, our emotions, political views, wealth, and health (even body weight). Given that one of the most important origins of the study of human networks was in public health, it won’t be surprising that Christakis, who specialized in public health, was particularly interested in the long-running Framingham study of health.

For the rest of us, who are not in public health, it would seem that viral pictures and memes on the net form our understanding of network effects. But there is much more to these connections than simply passing images and memes to one another – even much more than passing diseases to each other.

There have been, at least, three relatively recent books that help describe in more useful and original detail the impact of each of us on each other. The ideas in these books apply not just to health, but to the economy, business and career success as well.

Robert H. Frank is one of the most creative and insightful economists around. His book this year, “Under the Influence: Putting Peer Pressure to Work”, is a review of behavioral economics, with an emphasis on network effects. That includes how it is not only the absolute value of goods and wealth that motivate economic behavior, but our ownership of goods relative to others. Rather than maximizing wealth, per se, many people want to maximize their relative position. Thus, he points out that having another billion dollars is not so important to the richest man, as long as he is richer than other men. (This has important implications for tax policy and other public policies, which he discusses the book.)

Matthew O. Jackson’s 2019 book “The Human Network: How Your Social Position Determines Your Power, Beliefs, and Behaviors” extends the work of Christakis with explanations of network measures and phenomena in the economy. Those economic phenomena include two very relevant to our times – economic inequality and economic crises (or, to put it more simply, economic bubbles that burst). He shows how the well-known tendency of people to connect with others who are similar to themselves can generate inequality.

In an elaboration of the old adage – “it’s not what you know, but who you know” – Jackson also describes the various ways that our position in our networks influence our behavior and outcomes for us in those networks.

Of course, you may know some people very well, like family, and others not so well. As Duncan Watts showed in his 2004 book, “Six Degrees: The Science of a Connected Age”, the people you don’t know so well – those with whom you have weak ties – can connect you to almost anyone else on the globe in just a few steps.

One popular application of that idea is that it is weak ties that are the key to success in finding out about job openings or getting major initiatives accomplished in a large organization. We’ve all heard about the importance of “networking” in career success. But, like all such popular ideas, the importance of weak ties has been applied to too many situations, some of which are inappropriate.

That is the point of Damon Centola’s 2018 book, “How Behavior Spreads: The Science of Complex Contagions”. He provides a more nuanced view of the best time to use weak or strong ties. If the goal is to quickly pass information – such as about a job opening or a cute meme – then weak ties will indeed do the best job. However, if the goal is to change the behavior of people, something not as casual as passing along a joke, then having someone lead the change in a networks of strong ties are more effective.

This post can only provide a summary of three of the most interesting authors. It is worth reading each of these books as well as other books and articles that have contributed to our understanding of this important, but complex, subject of human interactions.

Expect more new knowledge in the future. After all, there is now a lot of and a growing amount of big data about human interactions that can provide a gold mine to be explored with network analytics, but more generally machine learning and AI.

A final thought … You would expect that the importance of these phenomena of social influence would be built into many models of individual human behavior and then aggregated, network style, into larger models to understand macro phenomena and trends. Curiously, such network-informed models are few and far between – but that’s a topic for a future blog post.

July 6, 2016

Updates Of Earlier Reports

Some of my blog posts seem to be ahead of news reported elsewhere,
which is ok with me, but also means that it might be helpful to list
some interesting articles that continue past stories. Here are some
recent examples:

My two-part series in March on the Coding Craze
questioned the long term value of the plan by many public officials to
teach computer coding. While the general news media continue to talk and
write about coding as an elixir for your career, WIRED Magazine
recently ran a cover story titled “The End of Code”. See their web
piece at http://www.wired.com/2016/05/the-end-of-code/

I’ve
written several posts on one of my special interests – the related
subjects of mixed reality, virtual reality, blended physical and digital
spaces. I noted sports as a natural for this, including highlighting the Trilite project last year. So it was great to read
the announcement in the last few days that NBC and Samsung are
collaborating to offer some of the Rio Olympics on Samsung VR gear.

We’re
all inundated with talk about how “things are changing faster than ever
before” in our 21st century world. Taking an unconventional view, in
2011, I asked “Telegraph vs. Internet: Which Had Greater Impact?”
My argument was that the first half of the 19th century had much more
dramatic changes, especially in speeding up communications. In what I
think is the first attempt to question the fastest-ever-changes meme,
the New York Times Magazine also recently elaborated on this theme in an
Upshot article titled “What Was the Greatest Era for Innovation? A Brief Guided Tour”.

In “Art and the Imitation Game”,
March 2015, I wrote about how artificial intelligence is stepping into
creative activities, like writing and painting. While there have been
many articles on this subject since, one of the most intriguing was from
the newspaper in the city with more attorneys per capita than anywhere
else, as the Washington Post invited us to “Meet ‘Ross,’ the newly hired legal robot”.

I wrote about the White House Rural Telehealth meeting in April this year. The New York Times later had a report on the rollout of telehealth to the tens of millions of customers of Anthem, under the American Well label.

Going
back several years and in both that post and one on “The
Decentralization Of Health Care” about a year and a half ago, I’ve
touched on the difficulties posed by the fee for service health care
system in the US and instead wondered if we would be better off by
paying health systems a yearly fee to keep us healthy – thus aligning
our personal interests with those of the system. So it has been
interesting to see in April that there was movement on this by the
Center for Medicare and Medicaid Services (CMMS), which is the Federal
government’s health insurance agency. Here are just some examples:

That’s it for now. I’ll try to update other posts when there’s news.

[http://njacknis.tumblr.com/post/146994917695/updates-of-earlier-reports]

June 7, 2016

White House Rural Telehealth — Continued

Two months ago, in “The Last Big Barrier To A Rural Renaissance: Healthcare”,
I reported on a White House meeting on rural telehealth that I
participated in. On June 1, we had a follow-up conference call.

This is sort of a report on that call, intertwined with my
observations from this call about why it’s hard to get things done in
the Federal government.

First, there was some encouraging news, including these items:

The
White House is starting to fund research on how telehealth improves
medical outcomes, which will be important for future changes.
Because
of changes in Federal law and market conditions, there has been such a
rapid growth of integrated health care systems that, on their own, some
are now reaching out to serve rural areas.
In various ways,
there was agreement that telehealth is now expanding into remote patient
monitoring. This is especially good news for rural residents who may
have to travel miles even to get to a local clinic which is in turn
connected to a major medical center.

This last item also reminded me of Longfellow’s Little Girl:

“There
was a little girl, and she had a little curl right in the middle of her
forehead. When she was good, she was very, very good, and when she
was bad she was horrid”

At the same time the Veterans Health
Administration has had its problems with waiting lists at some
facilities, it is has taken the lead in innovations, like tele-health, to bring health care to veterans at work or at home in small towns, rural areas and other places where it is difficult for the veterans to get to major facilities.

I’d
note that I’ve spent much more time with local and state government,
where with good leadership, things can get done fairly quickly, even
when major innovations are involved. Many of these governments are at
least as efficient, if not more efficient, than most large
corporations. As we’ve heard and seen many times in this election year,
the Federal government is another story.

Here then are some relevant, if not new, observations based on the rural tele-health work:

It’s very hard to get things done even if you’re sitting in the White House.
To
some extent, this is built into the constitution, the system of
government, which divides power and ensures that Federal agencies almost
suffer from a kind of matrix management with multiple parties having a
say about what happens.

And when the Federal government gets
around to doing something it needs to be very careful and thoughtful
about the rules because its impact is so outsized – part of its slowness
is to ensure it doesn’t behave like a bull in a china shop.
There
are millions of Federal employees to contend with, each of whom has
his/her own sense of what their public responsibility calls for. This
can lead to a silo effect where people in different departments don’t
work with each other or even know each other are working on the same
issue. As an example, psychiatrists who are encouraged by one part of
the Federal government to provide face-to-face services through
videoconferencing worry about running afoul of the concerns of the Drug Enforcement Administration about electronic prescriptions of controlled substances.

Having said all this, the White House staff should still be applauded
for continuing to push these innovative tele-healthcare services,
despite the built-in obstacles and the short time they have left.

[http://njacknis.tumblr.com/post/145558168934/white-house-rural-telehealth-continued]

April 5, 2016

The Last Big Barrier To A Rural Renaissance: Healthcare

I’ve written before about the ways that small towns and rural areas
can take advantage of broadband Internet connections to gain access to
global economic opportunities, educational and cultural resources, even
the virtual equivalents of coffee shops that used to be only available
in big cities.

Perhaps the biggest remaining barrier to a 21st century rural renaissance is access to world class health care.

With
that in mind, President Obama’s Rural Council brought together about
three dozen experts to the White House complex last week to identify
innovative ways of bringing health care to the countryside and to
establish a “community of practice” that will help the Obama
administration and hopefully its successor to address the problem.

The
group included:

Federal officials from various agencies, including Secretary of Agriculture Vilsack
Leading broadband providers and the Rural Broadband Association’s CEO, Shirley Bloomfield, and Joshua Seidemann, Vice President of Policy (who helped organize this meeting)
Exemplary providers of tele-health, and
A
couple of other experts, including myself (in my role as Senior Fellow
of the Intelligent Community Forum and director of its New Connected
Countryside initiative)

This “convening” was led by Doug O’Brien, Senior White House Advisor for Rural Affairs.

It
was noted, although not news to those around the table, that the nearly
60 million Americans who live in rural areas were hit especially hard
by the Great Recession. Their local economies have taken longer to
recover, still not back to pre-recession employment levels.

But the comparisons of rural versus urban health care were most striking. Here are just some highlights:

Rural areas have higher rates of disease and higher mortality rates than urban areas. In 1980, the rural mortality rate was 2% worse than the urban rate and now it’s 13% worse.
While
approximately one in six Americans live in rural areas, only one in ten
physicians practice there. There are even fewer medical specialists per
capita.
Suicide rates are higher and getting worse in rural
areas. Along with a growing drug abuse problem, this is a reflection of a
growing need for mental health services.

None of these
medical problems are helped by the fact that rural residents are poorer
and less likely to have health insurance. Of course, given the lack of
sufficient nearby medical resources, rural residents need to travel
further – often hours further – than their urban counterparts.

In
the Internet age, that last problem should be able to be mostly overcome
with health care delivered remotely. So most of the meeting was
devoted learning about the use and deployment of tele-health care. In
this post, I won’t be able to describe all of them or any one of them in
detail, but here are some that stood out to me:

Using cost-effective solutions, like iPads, Vanderbilt University Medical Center
has established a network of rural tele-health services. This even
includes virtual group sessions for people with drug addictions.

The
US Department of Veterans Affairs has pioneered the use of virtual ICUs
in its rural clinics and facilities. With a fully developed set of
tele-health tools, to the patients and local staff, it’s like having the
expert ICU doctor at the bedside. As a byproduct of these virtual
ICUs, the medical staff at these facilities are also getting an
education in newer and better medical techniques.

Through East Carolina University School of Medicine, there is now a tele-psychiatry network in North Carolina. The relatively low cost of making tele-psychiatry available is helpful, given the increasing need for mental health services.

Obviously,
many rural areas do not yet have the broadband which is necessary to
deliver these services. But there are clearly broadband providers,
especially telecommunications coops, which are up to the task. We heard
about just two of those who had completed gigabit deployments to every
household in their rural areas in Kentucky and North Carolina. One of
those, Peoples Rural Telephone Coop was reported on in a Daily Yonder article last month, “One of the Nation’s Fastest Networks Serves Two of Its Poorest Counties”.

Even
before the recent recession, there were long term trends in rural
America that called out for a different and new economic strategy. In
his closing remarks, Secretary Vilsack noted that, since 1950,
agricultural productivity has increased a hundred fold on 27% less land
and with 22 million fewer farmers. So the challenge today is what
opportunities and quality of life can the remaining families have.

The
people around that table last week and ICF believe that a revived rural
community can be built upon the intelligent and creative use of
technology – and improving access to quality healthcare is just one very
important example.

[http://njacknis.tumblr.com/post/142294161516/the-last-big-barrier-to-a-rural-renaissance]

February 11, 2015

The Decentralization Of Health Care

Eric Topol is a physician and editor-in-chief at Medscape. He was interviewed on the Colbert Report last year. His new book, published last month, has been reviewed in the major newspapers. Yet this book, “The Patient Will See You Now: The Future of Medicine is in Your Hands”, hasn’t received the attention it deserves.

The book is about the future of health care – what’s already happening and what could be coming that’s even better.

Topol’s theme is that new technology and practices make it possible to democratize medical care – to move away from the traditional, paternalistic, hierarchical relationship between doctor and patient.

Hence the title which inverts the traditional words of a medical receptionist that the “doctor will see you now.”

Here’s a sample of some of his key arguments:

“… the world is changing. Patients are generating their own data on their own devices. Already any individual can take unlimited blood pressures or blood glucose measurements.”

“We are embarking on a time when each individual will have all their own medical data and the computer power to process it in the context of their own world. There will be comprehensive medical information about a person that is eminently accessible, analyzable and transferable.”

“Today patients can rapidly diagnose their skin lesion or child’s ear infection without a doctor. That’s just the beginning. … your smartphone will become central to labs, physical exams, and even medical imaging; … you can have ICU-like monitoring in the safety, reduced expense, and convenience of your home.”

“The doctor will see you now via your smartphone screen … they will incorporate sharing your data – the full gamut from sensors, images, labs, and genomic sequence, well beyond an electronic medical record.”

The book is very well researched and comprehensively covers all kinds of ways that technology is interacting with and affecting health care. Dr. Topol provides dozens of examples from all over the field – a laboratory on a chip, smart phones with all kinds of attachments that enable easy measurement of health conditions anywhere, etc.

As a physician, he rightly is concerned about the doctor-patient relationship. As a sometime patient myself, this is of course of personal interest to me as well.

But more than that obvious reason, why else is the picture he presents so important?

With my perspective on how technology will affect where andhow we will live and work, his story is as much about the decentralization of
medical care as it is about the democratization.

With this decentralization, Dr. Topol envisions the
patient’s home becoming an instant medical lab or even a temporary hospital
wing. This means that you can dramatically
improve the quality of your health care even if your home is in the
countryside, miles from a major medical center in the center of a metropolis.

And it’s this distance from medical care that frequently
worries those who live in the countryside.
So when the transformation of medical care becomes more common, one more
traditional disadvantage of rural living that will disappear.

[http://njacknis.tumblr.com/post/110724183408/the-decentralization-of-health-care]