Social Thermodynamics

My undergraduate work was as a physics major,  which has colored my approach to problem solving.   Physicists prefer not to waste their own energy on useless computation, so when they are facing a question of "How would X happen?" they usually fall back and ask first "Is it even possible for X to happen?"   If it's not possible, then there's no point in straining your brain to figure out HOW it will unfold.

So, for example, suppose a set of balls with given locations and speeds are at the bottom of a valley,   often colliding with other balls, and you're asked to solve for which ball will be the first to get knocked out of the valley.   The mathematics of many balls bouncing off each other is quite complex.  However,  it may be very simple to look at the total energy kicking around down in the valley, which is just the sum of the energy of each ball,  and add those up, and see if the total energy is larger than the energy needed to lift a ball out of the valley.  If it's not, you can stop -- there is no combination of bounces that will get any ball out of the valley.

Physics has these laws of "thermodynamics" which state, in layman's terms, that

• (1) you can't win, 
• (2) you can't even break even, and 
• (3) you can't get out of the game.

Paraphrased,  things in a closed system, (with no energy coming in from outside) always go, net, downhill.  If you want a particular thing, say a plant or an animal or a person  to grow MORE complex and LARGER,  you MUST bring in energy from outside (food, sunlight, etc.).    There is no point in looking for a free-lunch strategy where the system will improve "on its own".  

Systems, like sailboats or sailplanes,  always go and only go, DOWNHILL.

Now, of course, it turns out that sailboats can sail UPwind, and sailplanes (gliders) can often "ride a thermal" and climb up into the sky -- but they do these things by tapping into the external energy (wind) supply.    A sailboat on a calm day will go nowhere.  A sailplane / glider sitting on the runway will not suddenly take off on it's own and start climbing into the sky.

Now, holding that thought in mind,   consider the question of a system of people and machines which is a "health care system" that patients come to and are treated within.    Suppose we would like this system to become "more organized" or "more harmonious" or have "less duplication" or operate "more efficiently".    We are thereby asking a system, controlled by natural laws,  to move from a state of low energy and low organization to high energy and high organization.    In other words, we want the system,  now sitting in an energy and organizational valley,  to move, after some intervention, to a higher state up on some peak of energy and organization.    We are asking it to move uphill.

So, before we strain our brain and budget trying to figure out HOW this can occur,  we first need to save ourselves a great deal of time and money and ask WHETHER this COULD conceivably occur.

I'll affirm that, to a physicists eyes,  the answer is obvious and not in question.  The system will go "uphill" if, and only if,  energy is supplied to it from outside.    There is nothing the system can do, within its own borders, that will move it uphill. We don't need to known who will push on whom to do what.   We don't need to know what shape or color or flavor or vendor or kind of "computer system" might occur in the middle of the activity.    What we need to know is,  where is the social energy coming from that could EVER lift the system to a higher state of being?

If someone says "We will give you this free software, and then things will be better" you can be sure the answer is,  "No, that won't change anything.  In fact, by itself, that will only make things somewhat worse."   ("you can't even break even.")  

For the system to "get better", for life to "get better",  LIFE ENERGY has to be poured into the system FROM OUTSIDE it.

One way to accomplish that is for human beings to come into the system,  pour in time and effort and caring,  soak up into their own body the costs of disorder and pain,  and then the humans could "go home" and pour the pain out on their family and neighbors and other activities.   The people go home, "recharge", gather will-power and energy to "face a new day",  then "go to work" , pour in their love and attention and caring energy,  which leaves them empty of it -- or have their life energy sucked out of them into the maw of "the system",  and the system could grow and sustain itself that way.

Usually,  this amount of additional pain, suffering, patience and energy-sucking behavior is not well advertised, since it is not a great way to SELL people on the "new computer system" which, it is said, will "make things better" or,  if things improve due to all the efforts of the staff, will "claim credit" for the improvement.

It's critical to realize that the computer system by itself is inert, lifeless, and cannot possibly be a source of either energy or order.  By itself, the computer system is only a drain on energy and effort. BUT,   it may provide an occasion for the hard caring diligent work of someone to be "captured" and "preserved" and "transmitted" to another person elsewhere in space and time,  who is then "saved" the effort of digging out all that information themselves.  For example, an army of clerical staff and nurses could put great effort getting accurate and timely data  INTO the system,  which could then result in a smaller (net) savings of energy and time on the part of, say, a doctor,  who used that information to treat a patient.     The "computer system" per se does not save the organization (net) work -- it only captures work of many people at one point in space and time, often hidden out of sight in back offices, and conveys the resulting value to be utilized at a later point in space and time, whereupon the "computer system" typically CLAIMS CREDIT for saving the time of the doctor using the system.

In reality, however,  just as word-processors removed most "secretaries" from the workforce and thought it would "save money" to have executives do their own typing,    so electronic health records typically ultimately end up asking the DOCTORS to do their own typing,  and data encoding, instead of leaving these things to staff specialized in and trained to do those things more efficiently.

In other words, this is exactly the opposite of the whole concept of saving money and time by having specialists, with special equipment and training,   doing steps (eg, typing) very cost-effectively, and instead CLAIMS to "save time and effort" by asking doctors, instead of caring for patients,  to do the data entry, typing, and data-coding.       It is argued that this can be done at the same time as the doctor is "seeing the patient", but, barring transparent screens,  it turns out to be rather difficult to SEE a patient and fill in little fields on the screen at the exact same second.  Since the total time to "SEE" the patient is fixed at, say,  8 minutes or 10 minutes or 12 minutes --- the NET time the doctor has left to actually take their eyes off the screen, refocus,  regain local context, LOOK at, and actually SEE the patient is diminished by the length of time they are attending to data entry, under the banner of "saving time and effort" for .. um... er... so that doctors have more time to see patients?

Well, perhaps it is the hospital which is "saving money", because now they no longer need the army of transcriptionists and data-coders because the nurses and doctors are doing this added work, at no additional pay,  stealing the time, focus, and energy away from actual patient care.   Actually, again, there is no free lunch,  and doctors and nurses are already fully tapped out and accounted for,  so for them to put effort and energy into data-entry means it is coming OUT of and being removed from "patient care".

Only by the clever trick of broadly including data-entry into the category "health care" can it be said that health care has not been diminished by this additional data-entry burden.

For doctors or nurses to benefit from what is "in the record" (thanks to prior efforts by other people, not the computer)  they have to be able to acquire, understand, and believe the record in a short enough period of time to be usable in such a short-burst visit setting.

It is not at all clear that this benefit is produced by Electronic Health Records.  I've personally been to multiple "encounters" where I first met with a nurse or intern or several interns who asked me a set of questions which I dutifully answered,    followed shortly thereafter by meeting with the doctor, who asked me essentially the same questions as if I had never talked to the prior people .

I don't think my experience is unique in this event.  In fact,  I have trouble finding anyone who has had a different experience.    OK, so hit the pause button and let's stop and look at this.

The NURSE asks all these questions, because they have been assigned to enter this data "into the system".    The DOCTOR asks these SAME questions because at least one, and often all, of the following:

1)   the nurse hasn't had time to enter it into the computer yet

2)   it takes the doctor LONGER to read the nurse's typed notes than it does to simply ask the questions over again,

3)  the answers that the doctor gets are DIFFERENT from the answers that the nurse gets to the very same questions.

4)  The information the doctor gets is not from the CONTENT (data) of the answer, but from the meta-contextual epigenetic components of the patient's reply.     The doctor can distinguish an enthusiastic "yes" from a reluctant "yes" from an instantaneous "YES!" from a delayed and unsure "... um... yes, I guess so .. whatever that means I mean.... I guess."

5)   The doctor is not engaged in gaining INFORMATION or DATA from the patient, but is engaged in establishing a conversational context and relationship with the patient,  which nobody else can do for them.

Now, someone might ask, such as I am now,  if the doctor is going to ask these questions anyway, why isn't the nurse there at the same time writing down the replies so that the total length of time the patient is seen is decreased?  Or, if the nurse being there would somehow disrupt the intimacy of the doctor patient relationship ( and the computer doesn't? !! )   why can't the nurse be behind one-way-glass or at the other end of the TV monitor eavesdropping and capturing and recording the encounter and videotaping it for instant replay if some item is unclear.   Why must the patient always have to put up with answering the same questions twice?   (I await enlightenment in the comment section.)

Or,  wouldn't it be even more powerful emotionally for the patient, in perceiving a CARING environment (recall the advertising phrase "health CARE") if BOTH parent surrogates, a male and a female in white coats,  were there TOGETHER equally concerned with the patient, equally asking questions,  learning from each other's questions as well as from their own?

At the same time, a third party, a coding specialist, could be on the other end of the TV link, eavesdropping, and prompting for more information as they attempt to determine the correct unique primary and seconding billing codes for this patient's symptoms, condition(s), diagnoses,  and treatment? For billing purposes, the patient cannot be "maybe x, maybe y".   A false sense of certainty must be affirmed "the patient is / has X" -- which psychology teaches us is fraught with downsides of labeling, categorizing, and stereotyping the patient so that further data flow is FiLTERED based largely on that which CONFIRMS this initial diagnosis.    A toss-up call between equally likely diagnoses becomes increasingly supported by data which support it,  as data which don't support it are discarded out of hand, increasing certainty in the "correctness" of the initial diagnosis.   In psychological  terms,  there is "cognitive dissonance" occurring, which protects the physician from the stress of fretting about possibly being mistaken on somethings so crucial.

Sadly,  this does NOT protect the patient against the downside of being mis-diagnosed in such a way that the incorrect diagnosis is now STICKY and almost impossible to shake, regardless how much contrary or dissonant data now comes into the picture.  MD's are far less likely to override another MD now that "a diagnosis" has been made.

In other words,  here are some downsides of electronic health records.   The patient has to be categorized into pre-defined slots, which officially the MD can ignore, but there is strong administrative pressure for them to adhere to.   The slots, by their nature, constrain diagnoses to a certain mental model of medicine.    Some slots are far more attractive than others, in terms of how much money the hospital or clinic or doctor will make by picking that choice,   and this information is often known to the doctor, resulting in a strong bias pressure on their answers.

Some studies have shown that physicians will tend to pick the FIRST item in a list of alternatives they are presented.   This can easily be measured by presenting possible medications for a given diagnosis in different orders to different people or on different days.     It is somewhat scary that the drugs MD's select are effectively determined even somewhat by the order in which the possible drugs are listed.

UNCERTAINTY is not captured gracefully, and "boolean" (yes, no) fields tend also to force an uncertain reply into a falsely recorded certain answer.   The uncertainty is not removed by differential diagnosis, but by time pressure and social pressure, perhaps invisible, to stick with what's already there as the lowest risk, lowest conflict, fastest choice for an MD. After, say, 4 other physicans have similarly "concurred" with the first physician,  HE or SHE now is under strong pressure to stick with their initial diagnosis and not consider bringing it back up into question.  After all, others have agreed with it.

Summarizing -- the data in the EHR is forced to appear certain where there is actually doubt,  forced to remove all of the "epigenetic" and body language that the patients (or consulting physicians) used to soften or strengthen the words used,  forced to fit into a predefined set of categories determined by billing codes more than medical categories,    pressured (perhaps invisibly) to fit into the HIGHER VALUE diagnoses that result in more revenue or less chance of lawsuit later on,  and entered sufficiently late in the process that it has to be repeated or asked again when it is not clear that a DIFFERENT answer by the patient, a changed answer from what they told the nurse,  makes it into the EHR versus the patient's first answer to the nurse.    The doctor and patient may walk away confident that X has been cleared up to be TRUE,  while the nurse has already entered into the EHR that X is FALSE and may be off already taking action based on X being FALSE. 

( More on patient opportunities to REVIEW and CLARIFY or QUESTION the chart in a later post.)

None of this even gets into the problems when the patient, after getting back home and talking to say his wife,  reviews what he said and his wife goes "No,  you keep getting that wrong, X is FALSE, it's EX that's TRUE,  and the patient calls back and tells some clerk who answers the phone that the answer to X should be changed to FALSE, please, thank you,  hang up.   The whole question of how new information, coming into the SIDE of the EHR like that, is handled is a story in itself.   Who needs to be told that X has changed?   Who has already taken action on it and left the building? Has this incorrect information already gone out on the wire to 2000 other sites?  Can each of those be informed that the prior value is wrong, please fix it? HOW fast does that occur? What can happen during the period in which the WRONG data is thought to be true? Etc.

This gets to another terribly inconvenient fact of life.  In the USA,  when paper records are used, and a value is changed, there are VERY strict rules about the change.  It must be indicted by striking through the wrong data, leaving the old data legible.  The new data must be entered, with initials or the name of the person who made the change, and the date and time.        If computer systems are used instead of paper, they must do the equivalent.

DING.

No, the law SAYS that computer systems must do the equivalent, but none that I've ever seen HAS done the equivalent, because it's HARD TO IMPLEMENT.    The regulatory bodies all conveniently ignore this blatant disregard for the regulations.  It may be POSSIBLE to figure out which field was changed when, but if someone knows of a vendor system that makes it OBVIOUS that a field's value used to be something else (click here to see what), please let me know. 

The downstream result of this flaw or shortcoming in the EHR (versus paper) is that there is some pressure on people not only to GET the data right the first time, but, well, frankly, NOT to spend a lot of time looking for errors to fix.  Errors are expensive to fix.   Old data is stale, focusing on new data may be more important clinically.  Etc. Etc.  Regardless,  seldom is there a cry of joy and happiness when an error is detected in some field of data.   There is some social pressure and legal pressure NOT to tell everyone in the world that this field was wrong, but we caught it (now) and fixed it. It's kind of, you know,  wink, nod, OK with the legal department and "risk-management" (risk to the hospital of being sued). if it's not so obvious that mistakes were made.

Another implication of this climate of "confidentiality" also acting as a surrogate for "cover-up" is that it is POSSIBLE, theoretically, to rate the reliability and accuracy of each source of data and each type of field,  based on the total number of corrections that have ever been made to it,  but that sort of meta-information about datasets isn't generally funded to be collected or made public.

Among the people who have to pull data OUT of 20 legacy databases in order to complete new mandatory government reports,  there will always be some knowledge, rules of thumb, however, about which data source is more reliable and should be used when data FOR THE SAME FIELD (such as, oh, "date of visit") has different values in different legacy sub-systems.

Few hospitals have "data architects" who design overall data architectures that work to prevent such errors occurring, and fewer have quality-control processes in place that routinely and deeply compare data daily or more frequently, on a 100% basis, between various subsystems to detect discrepancies and take appropriate action to fix them.   To a large extent, historically,  if no one complained, "it ain't broke and don't need to be fixed."

The result whether intended or accidental, is that stewards of legacy systems often seriously over-estimate how correct their own data might be.  Often they have vendor systems with no built-in way to validate data,   and WISH they could, but don't have time to do it manually and don't have access to the data or convenient programming tools to write their own validation and correction scripts.

I've seen systems that recorded actions taken on patients which are shown to occur weeks or years AFTER or BEFORE the patient was actually in the hospital / clinic.  The values cannot POSSIBLY be true, and the simplest Quality Control program one can imagine could pick up and flag these errors, but I've been assured that they don't have the staff to write such programs, or don't have the authority to write such programs, or don't have the time to figure out what the right values should be, especially for data fields they themselves don't use for any clinical purpose, but are collected for someone ELSE to use LATER in the process of care or billing.

Again, systems, like many managers or bosses, are often GREAT at exporting data, or telling the world what is true, but are reluctant or totally refuse or have no mechanism to LISTEN or to CORRECT mistaken impressions they hold.    As a result, I've gone to people saying "here's a list of what's wrong" and been told "we don't have the staff to fix it."  I've gone to people saying "I can write HL7 transactions to fix all these errors" and been told "Our system has HL7 INputs disabled or  we never paid for it" etc. 

The result is that bad data are collected at the data-entry screens in one place and time by one person, who doesn't really care whether the values are correct or not,  and the costs don't show up, perhaps till billing time, or until the system has to try to MERGE data between this system and other systems, and the large number of conflicting values now suddenly come to light.

It is a general truth that quality control does not "just happen."   Data quality degenerates as attention is pulled elsewhere until and unless someone takes ACTION to detect and fix it.   This is a sensible method of operation in the real world - don't spend time and energy on things no one considers important.  The problem is that some of these things ARE important -- but important to OTHER people far away in space and TIME from the data-source process.

AS "times get tight" and "budgets get tight",  people and departments that used to take extra time to get data correct and "clean" can consciously decide this is "not their job", it's "not a priority anymore" and decide to abandon such quality control loops.    There may be no indication downstream that the upstream quality control process just terminated, because the fields are still populated with numbers, -- it's just that now the numbers are garbage and totally unreliable.

It can take some time for larger scale, system wide processed to detect that this data source just changed from "highly reliable" to "unreliable",  so the larger system may elect, based on data coming from a "trusted source"  to discard conflicting (but correct) data from other sources, for some period of time,  perhaps a year or so, before it is figured out that the previously reliable source is now no longer reliable.

Again, the central EHR design is seldom built in with a "meta-layer" to data, indicating the source of the data value in each field, let alone flagging the fact by color or typeface or font or something that multiple sources of data DISAGREED as to the value of this field and were over-ridden in arriving at the displayed value.   Probably national intelligence agencies keep such meta-data, so they can update databases when a previously-thought reliable source turns out to be a traitor, but private hospitals seldom track such things.   

Human beings are well known for their need for "UNDO" -- often with the realization that something is wrong coming barely a second after the "ENTER" key has been hit.    It is worth looking at an EHR system and screen to determine if such expectable realizations on the part of humans are dealt with gracefully, or awkwardly, or not provided for at all.

So, Paper systems allow for yellow sticky notes to be affixed (or lost) with ancillary meta-information on them that real human systems use FREQUENTLY to manage data and processes.  ("Sally - When you go upstairs to relieve Nancy,  tell Mary her records are available."  )   Like the human genome, a great deal of functional operating data "doesn't fit" into the coding scheme, and has to be encoded "epigenetically" or, in the case of EHR's, by some sort of workaround process.  ("DON;T PRINT THIS FORM! The printer in 37G is out of order. Phone this in instead this week!")

One thing paper charts could handle gracefully was multimedia such as a Photograph, say, for dermatology, or a sketch,  by a surgeon, of work done or a work plan.    Some EHR's have no provision for graphics ("in version 2.0, we don't support that yet.").   This is a major decrease in value of an EHR compared to paper for surgeons or anyone who is used to putting photographs in paper charts.  Also, a photo is a photo is a possibly faded photo, but a computer jpeg may vary depending on what screen is used to view it with. A whole new set of processes are required to deal with images


========== back to thermodynamics ===

I've listed a whole series of ways that an Electronic Health Record may constitute steps BACKWARDS,   away from the quality of care that existed prior to their introduction.


All of these "flaws" may be dealt with, but as I said yesterday, the path from one mountain of optimized care (the old system) to a higher mountaintop of optimized better care (the new system, once burned in)  is the valley of despair  (the new system partially instantiated but not yet fleshed out with work-arounds,  needed changes,  modified expectations about who now has to do what, etc.)

And I've asserted that only the DOWNHILL part of that journey will occur on its own, due to laws of thermodynamics that apply to all systems, including human care-giving systems.

The UPHILL part, the transition of care and transformation of disorganized fragmented action into coherent, organized action,  requires SOCIAL INPUTS of a large amount of time and energy.  The "computer system" is not going to provide those inputs.   Only PEOPLE can provide those inputs.


So, for the "computer system" to produce the benefits that the VENDOR will almost certainly claim credit for (and desire to be paid for),   HUMAN BEINGS have to do the actual work which is different work than the work they have been doing up to this point, and may in fact be work ON TOP OF, In ADDITION TO their prior work    In fact, it  may be on top of not only their prior work, but NEW work correcting the mistakes that partial reliance on a partially installed new system has generated.

This new work will almost certainly be somewhat uncoordinated at first, and often not even the correct thing to do, because of confusion in the ranks about who is supposed to be covering what base how.

If there is not provision for sufficient extra new space, time, hands, and staff, and managers for this NEW ADDITIONAL WORK during crossing the valley,    there will be rumbling, then anger, then outrage, then work actions,   then total tissue-rejection of the impossible task of doing 3 people's work on 1 person's energy.    Things will only go from bad to worse, as "the computer" cannot make the system go "uphill".   The project will crash and burn at this point if this isn't prepared for and funded by NEW EXTERNAL resources.    SOME kind of EXTERNAL energy source will always be required to 'cross the valley" and even get to the point of breaking even, doing as well with the new system (and the HUMAN epigenetic additions to it) as had been done with the old system (and the human epigenetic additions to it.)

 Then, to do BETTER with the new system than the old one, will require yet MORE human energy and caring and effort and pain be put into the system.

The Electronic health Record does not DO the work involved in getting socially reorganized on a higher plane of existence.  The PROCESS of IMPLEMENTING the EHR is a structured OPPORTUNITY for and OCCASION for people to do this additional effort,  but doesn't actually DO the work for them.     People need to do far more than "buy into" the idea of a new system.  They need to change all their work habits and patterns to accommodate the new tissue, the new kid on the block.
They need to actually DO the work that the computer geeks and vendor will be claiming credit for and getting paid to do.

The only sustainable way for humans to be doing more work is for them to be receiving more social support than they were before for doing that work.  They need to be appreciated and respected more, and know they are appreciated at last, and feel it to be sincere.   This is possible.  This however cannot be purchased and 'installed" by the vendor.   This is a "side effect" of the pathway used by the IMPLEMENTATION TEAM in  selecting,  installing, implementing, cutting over to the new system.

If people are going to put out more, and sustain that,  they need to drink in more social approval and appreciation than they did with the old system.  They need to see that their concerns were actually heard, understood, attended to, and addressed by management and the implementation team.

There is nothing the vendor or the computer can do to get around this fact.  The success or failure of the implementation of a new EHR is in the hands of the users.  For the new system to die and fail a terrible death, the users simply have to just continue working at the level they were working at before the implementation began.


Users can be EXHORTED and URGED and PERSUADED to "put out an extra effort" for a relatively short period of time before they get additional social energy in return, or they will burn out.

The pathways by which people feel heard, respected, valued, and appreciated are not in the skill-set of the geek squad or the IT department.    Generally, they are not in the skill-set of the vendor of the Electronic Health Record.   These human factors cannot be purchased at the store, or bought-off for cash.    Often on huge EHR projects,  the problem is NOT a shortage of cash, it can be raining cash.  The problem is that cash doesn't purchase love.  Cash won't purchase honest respect.

Maybe this post has added some insight into T.S. Eliot's observations;

They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect that no one will need to be good.
But the man that is shall shadow
The man that pretends to be.

Electronic Health Record systems will not cover-up all prior errors and make-up for failures of human systems to surface and cope with problems in an honest fashion.

The social transformation and changes during implementation of an EHR are not "side effects" -- they are and should be direct explicit intended and monitored and managed and desired EFFECTS of the project,   put in place by the steering committee.


These social factors cannot be managed by IT-management or even by clinicians. Clinicians are not generally social psychologists and anthropologists.    Culture needs to be changed.  This is the type of work professional anthropologists and behavior modification specialists understand. Those people need to be at the table and not as an afterthought.

You need to plan "what else needs to go right" not be shaking your head asking '"where did we go wrong?" If human beings are involved all along the way, and if they have honest input and are heard and their social needs met, then the project will be "a success" whether the computer system itself "works" or turns out not to work. 

The success factors are not "inside the box" or "inside the shrinkwrap."

Complexity, Policy, and Big IT -- reflections on Tricia Greenhalgh's work

Note - the following hasn't had peer review or a day or so to reflect on it, but it's my initial impressions from Tricia's talk and the thoughts it induced in my travel-weary mind.  Still, they might generate a discussion and I wanted to get them down, however raw, before they evaporated.   Then I can distill them, cross-reference better to other work,  and see if we can work this into an actual paper and get the best of the ideas out for serious peer-review and discussion on a professional level.

I felt like I'd discovered New Zealand's beauty again upon hearing Tricia Greenhalgh describe her work in evaluation of Big IT projects yesterday at the HINZ conference in Wellington.   It's wonderful to find someone with her eyes wide open who can illuminate the difficulties of policy analysis when applied to interventions, such as shared Electronic Health Record systems  in complex adaptive social environments.

I haven't done my homework and read the key papers she refers to, to integrate my experience into those, so that's on my new to-do list, but I think I have evolved a few concepts that help me in sense making that I wanted to get down and share first.   They may spark some better ideas among other readers.   I'll presume that there might be value in totally fresh eyes brought upon this subject by someone like me crossing fields (and oceans), and beg apologies for seeming to take credit for ideas that others have already presented.

Let me state that in 1976-7 I had the joy of working with a group of people who "ported" the patient record system from Massachusetts General Hospital,   probably the best system in the world of electronic health records,  to the New York State College of Veterinary Medicine at Cornell Univerity in Ithaca, New York, USA.    We had a fully functioning EHR, with 200 terminals, subsecond response time,   automated decision support, etc. -- 34 years ago.     The technology was able to do this then, on machines with far less capacity than a single 1 Gigahertz $400 laptop computer today.

I met with the head of BAZIS,  a group responsible for computing for hospitals in the Netherlands, in 1989 at a SCAMC conference (precursor to AMIA) in San Francisco.   They were running 2,500 bed hospitals, with sub-second response time,   on a single microVax computer -- again, with less processing power that a single $400 laptop has today.

On the basis of those experiences, and everything I've seen in the last 34 years,  I feel confident in asserting that the issues around Electronic Health Records have nothing to do with technology.

There are no show-stopping technical problems.  The key problems are organizational, political, psychological, and social.   


THEREFORE -- it doesn't MATTER what kind of technology or computer hardware or database system or data architecture a vendor can supply, aside from the fact that if these are BAD choices, this can KILL a project.    These things, however, cannot MAKE a PROJECT succeed.   This is a crucial
distinction.

That little thing called "implementation" of a change, in a clunky-but-functioning large social system, turns out to be huge. It also turns out to be something that I.T. People,  in their little technical silo's, seldom care about and know almost nothing about, and have no methodology for dealing with.

Here's a test of an steering committee -- count the number of psychologists, group psychologists, behavioral change specialists, and anthropologists on the steering committee.    My assertion would be,  if this count is ZERO,   you should pack your bags and walk away.   Again, presence of these perspectives will not guarantee success --- but absence of them will guarantee failure.

I've spent the last 40 years working in IT and one thing is clear to me, captured in this basic rule of thumb:  There is no computer system so perfect that hostile users cannot make it fail. 

In fact,  getting much further away from the purely technical paradigm of "health records", I'd suggest a long review of what the poet T.S. Eliot meant, in Choruses From the Rock, when he said: 

They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect that no one will need to be good.
But the man that is shall shadow
The man that pretends to be.

So, lest this be to long, here's my own observations on this area of evaluation of evaluation of social-scale IT projects, making an effort to use language that is accessible at the risk of being less precise.   In other words, the question is whether our method of evaluation itself needs more evaluation.  I'll use "principle" and "implications" bullets.


1)  Social reality has dynamic, interconnected, multidimensional, feedback processes that are  continuous and unbounded in space and time.

Our attempts to "evaluate" an "intervention" typically impose upon this reality a digital, discrete "event" model with sharp boundaries in both space and time of "what" it is we are evaluating.   These boundaries can dramatically alter the results and need to be justified, or at least made explicit.   At a minimum we need to ask if different boundaries in space and time would have given different answers to our questions.

Example -- WHEN do you evaluate "the impact" of something on society?  How long do you have to wait before you are relatively sure that all of the longer-term impacts of an intervention have had a chance to percolate through the system and show themselves?

This is a classic problem in evaluating teacher competence -- how do you compare a teacher who students just love, but is quickly forgotten,  to one they intensely dislike, but, a decade or two later, they realize was the most important beneficial influence on their lives of all their teachers?

To paraphrase John Sterman in Business Dynamics,   "There are no side-effects, only effects."

Which of those effects we are willing to acknowledge and measure, and which we deny responsibility for and refuse to measure totally alters the picture.     We know from social wisdom that it is possible to "win the battle but lose the war".  We have heard the quip " The operation was a success -- but the patient died."

I'd affirm my own belief that the impact of an intervention's decision and implementation process upon society is at least as important as "the intervention" itself.      At the end of the day,  have we put in some sort of technical fix, but done it in such a way that we've alienated everyone and created new polarizing rifts or driven away good people in a way that will take years to heal?   It's a key principle in Baha'i consultation for example that the social impact is far more important than "the decision" in guiding discussion.   Better to make a "wrong decision" and preserve working relationships, than to make a "right" decision which destroys working relationships -- because a healthy living social structure can recover from a wrong decision, and will,   but a destroyed social structure cannot benefit from a "right" decision down the road as it has become non-adaptive and will soon crash the bus.

(2)  The measure of an intervention (good versus bad)  is generally a function of SCALE, and we should expect that it is not a monotonic value but can easily be one that changes with scale.

This type of concept was very hard for my MBA students to grasp, when comparing investments by "net present value", a metric that meant that which investment was "better" depended upon what rate of inflation or time-value-of-money you used.   At 0%,   investment  A might be better.  At 5%, investment B might be better.  At 10 %,   investment A might be better again.    This sort of non-monotonic comparison is rampant in life, but unrecognized in our decision making processes, and often so startling to people that they become incapacitated upon beholding it.

Similarly, we can find interventions that measured immediately are "good" by some metric,  but that measured over a two year period are "bad" by the same metric,  and that measured over a ten year period are "good" again, by exactly the same metric.       We cannot assume that "goodness" is independent of the size ruler we use to measure it.

(3)  When we are comparing two or more alternatives with multiple dimensions,  there is no reason that the term "better" is even meaningful . 

 Martin Gardner in Scientific American Mathematical Games did a wonderful job of popularizing the concept of a set of 4 "non-transitive dice" where die A "beats" die B 2/3 of the time.  Similarly B beats C 2/3 of the time.  And C beats D 2/3 of the time. And D beat's A 2/3 of the time, closing a "strange loop".   There is in fact no "best" die.  Again, this concept is infuriating to many people who cannot accept it.  (see youTube video)

Despite this incredibly inconvenient fact,  our society is just rife with occasions on which people struggle to identify the "best"  wife / employee / location / house / cell-phone / etc.  when the term is simply non-applicable.

(4)  When faced with the inconvenient truth that a popular process is non-applicable,  people will almost always nod in agreement, then proceed to apply the process as if it were applicable. 

We see this all the time when people attempt to apply the General Linear Model of statistical reasoning, which assumes there are no closed-feedback paths between "cause" and "effect", to social systems which clearly have feedback paths between the two.

I'd allege that ALL social systems and large-scale interventions have such feedback paths, and therefore ALL attempts to apply flat GLM-based statistical techniques to them are invalid, inapplicable, and wrong, wrong, wrong.    That said, people will go ahead and do them anyway.

(5)   When the non-applicability of popular techniques is blatant and brazen,   researchers will simply alter the data until the "problem" with their mental toolbox "goes away."

Example. My wife and I attended a conference on "Self Regulation of Health Behaviors" at the University of Michigan in the US a few years ago.   All the top researchers around the world in health behavior were there and presenting.  As the conference I kept noticing that people were giving examples of successful interventions,  such as paying a woman's CHILDREN ten dollars for every pound she lost, instead of her,   in which the actors were not the "self" of the conference, but other people in a contextual support group.

At the panel at the end of the conference, I called the question, and asked, was I correct in noticing that, to a person, every single researcher had noted that the most successful interventions in "self-regulation" were, in fact,  interventions that involved other people.  After conferring briefly, the panel agreed.

In my typical annoying way, I then asked WHY it was that NONE of these examples were in the papers these people had published.   Again they conferred, and agreed that these interventions were difficult to measure, and impossible to compute a "p-value" or confidence value for,  so they left out those data points.

In other words,  for the single most expensive component of health costs in the USA (behaviorally mediated),  the single most effective strategy (social support) was simply erased from the data set because it "didn't' fit" the way the researchers felt they had to evaluate the data.  They agreed to this, nodded, and then went on as if this was no big deal.

Hmm.


(6)  There are many laws of physics and mathematics, as it were, that apply to feedback-controlled systems. These are generic laws of "control theory" and as valid as Newton's law of F=ma.   These apply to ANY system with feedback, whether it is animal, vegetable, mineral, social, mechanical, etc.   (See for example this post) 

These laws are not contested in the field of control systems theory and practice.  They are well burned in , and have tool-kits in, say, MATLAB, which can be used to apply them. They are used to design our cars, elevators, electric motors,  airplanes,  bridges, etc.   Textbooks on them are in their 5th edition.
This is not magic, nor is it wild speculation.. This is solid boring engineering.

The problem is, this work is in a silo and essentially unknown in the medical and policy and IT worlds.  Therefore, the basic principles are violated or partially rediscovered on a daily ad hoc basis.

Control theory deals among other things with issues such as "stability" of a system after application of an "intervention".  It deals with "rise time" - or how long it takes a system to respond to an intervention.    We can stop here and realize that these concepts would be extremely valuable already if they even were on the radar of discussions of policy interventions in society, but they are not on the table.   For example, in any active system, if you change something,  will it (a)  tend to change back to where it was, (b)  tend to amplify your change and change even further (eg, fall over entirely once tipped.),   (c)  generate a huge firestorm of protest and cause you to remove your bloody stump from the sacred stones you just touched?  (Stir up a hornets nest you cannot put back in the hive.)

Here's a truly inconvenient fact then:


(7) You cannot push a social system to change faster than a certain intrinsic speed.  If you attempt to push faster than that,  instead of changing the system,  you will rip, tear, shred, or destroy the system.     There is no reason that this maximum rate of change is conveniently within the term of office of a particular political party that would like to "see the results" of their intervention before the next election.

Again, we expect people to sagely not agreement,  then get right back to what their plans are for Big IT that they will "implement" within the "next 5 years".     This time frame is typically not chosen on the basis of evidence that the social fabric can support a change of this magnitude at that speed, but because we have 5 fingers on each hand and 5-years is before the next election.


(8)   If you are trying to change the state of a system from one mountain top (locally optimized in some metric) to a higher mountain top (even more optimized in that metric),  you almost certainly will have to go down into the valley in-between on your journey.


Anytime you replace one functioning system with another, there will be a "settling-time" period in-between where the pain of the new system and lack of system-wide coherence  is evident and even dominant.

 In short, things have to get worse on the pathway to getting better.

This is a topic that is not popular for discussion.  How much worse is acceptable? How high are the stakes and the costs of new issues that you had previously "under control" the old way, and have to be made "out of control" for a while before they become "under better control" the new way?

(8) In a medical environment,  during this instability and disrupted time,  there will be more mistakes, more errors, higher mortality and morbidity for a period of time, until the parts of the system reaquire "phase lock" and start working smoothly again as a unit with larger-scale coherence.

In aviation, for example,  at Johns Hopkins in the course in Patient Safety, we got the figure that 74% of all commercial airline  "accidents" occur on the first day that the flight crew is assembled and has to "work as a team."    The people are all trained professionals, highly competent, "error free", but the STRUCTURE OF THE TEAM, THE METASTRUCTURE, the SYSTEM has not yet "found itself" and established "phase lock."  (my choice of words).

This is a very general phenomenon.

This is going to occur any time you change a complex system. There is nothing you can do to get around this problem.  It will not go away if you pretend it is not there.

The coordination signals, the feedback loops have to "ramp up", fill the buffers, take up the slack,  and run a few entire cycles before each part of the system becomes "aware" of the changes to the overall environment due to the ACTIVE involvement of each other agent in the overall system.

All systems have this property.  The identity of each agent is a function of each other agent, and until they have detected, by action,  the torques generated by the new presence of new agents elsewhere in the system,  they will mis-compute, mis-construe what action they need to take in order to accomplish a certain outcome.     They will push a lever, as it were,  and turn around to find that someone else has now ALSO pushed the same lever, applying an impulse twice, or giving a drug twice.  Or someone else, thinking it is their job will UNpull the lever.  Etc.

It is not a "FAILING" of the system that this period of nascent-presence occurs, but it can well be a FAILING of the implementation team if they have not provided massive external temporary auxiliary support sensors and actors to detect and mitigate these cross-signal pathways during this "burning in" period.   It will be typified my massive amounts of "But, I thought YOU were going to handle that!" or "Then what DID you mean when you said you "had it"?"


(9)   Shutting off sensors does not cause the problem they were sensing to "go away" in a lasting sense, regardless how good it appears or feels in the short run.

It appears extremely common that change managers implement a policy of "I don't want to hear about problems!  Make this work!".   Often,  people on the front lines with eyes will continue to raise the fact of problems,  and management's resolution of this is to remove them from "the table", not allow them to voice their "negative opinions", or even to fire them entirely to get their "negative" voice and "opposition" out of the system.   This typically only makes the underlying problem that had been sensed WORSE, because everyone else who was not fired now knows that they are not allowed to even mention this problem, so it has to become enormous as the "elephant in the room" before management will be faced with it, often via multiple or class-action lawsuits.

In other words,  you cannot FIX a piece of software by refusing to print the "error log".

(10)  A GOOD system implementation will be characterized by discovering,  surfacing, and dealing with a huge number of coordination problems and local issues in a fractal world that were invisible and unsuspected when someone higher up or to far away to see or appreciate the devil in the details said "Just do it."

If someone tells you "things are going smoothly" and "there were no issues",   your sensors are broken. There is no way you can change a complex set of processes and meta-processes without there being "issues".


(11)  To a good first approximation, all social systems have the "wicked-II" property.


"Wicked" problems, have been defined as "

"Wicked problem" is a phrase originally used in social planning to describe a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems.
C. West Churchman introduced the concept of wicked problems in a "Guest Editorial" of Management Science (Vol. 14, No. 4, December 1967)

I have defined an even  worse category,  "wicked-2" or "wicked-II",   which is problems that are visibly wicked at a local level,  but APPEAR from far off, or from management's over-simplified view of what it is their employees do all day,    to be SIMPLE.

They are almost always described from above using the term "Just",  with some exasperation, as in "Why don't you just merge those two data sets and be done with it!" followed by NOT remaining around to HEAR the answer or refusing to believe that anything so "obviously simple" can possibly "take so long" to do.  "Surely" the employees are malingering, or heel-dragging,  or trying to sabotage the project by refusing to cooperate.

(12) Rephrased for importance -- All complexity APPEARS to "go away" if you stand back far enough from it, or get high enough in an organization that the successive series of oversimplifications in management reports or powerPoint slides have taken their tool. 

This, however, does not mean that the complexity has gone away. It only APPEARS to have gone away, or not to be there in the first place.  Thus, at a distance level, it seems "EASY" to "JUST" combine patient records from these 8 different practices into a single combined Clinical Data Repository, and, voila, we're done!  What can possibly be so hard about just doing that! (Followed by laughter at the the simplicity and obstruction of the lower-level fools who balk when asked to just do this.)

What is less clear from above is that one of the data sets is only 20% accurate, and that when the 8 are merged with to trail as to where data came from,   the final data set will only be 92% accurate,  which is not good enough to be reliable and will result in massive incorrect issues followed explosions of anger and blame, followed by refusal to use the data "until these problems in data quality are fixed."

(13)  Large scale IT is not just large -- it spans multiple levels and contexts in a social systems. This means that not only does it APPEAR to be different things to different people, it actually IS different things to different people.      The phrase "it', implying that "it" is a "single" thing,  is therefore misleading.

In fact,  it would be far more instructive to leave the "it" OUT of the equation when talking about how people respond to "it" -- and focus instead entirely on the processes that are affected and impacted OUTSIDE the box.

This is, of course, exactly the OPPOSITE of what classical I.T. management and thinking will do,  if they are providing leadership to "the project."    I.T.  managers would have many people concerned with what is INSIDE The box -- at least in the view of clinicians.

Now, as one who has labored in the vinyards INSIDE the box for the last few decades,  I can state confidently that IT Managers often do not look INSIDE the box either.    The concerns from computer science perspectives about little things like "architecture" are often taken as "minor" voices from an "interest group" of "stakeholders",  not as definitive statements about a different type of physical laws and principles that totally determine how the data flows within the system will behave.

For one example,   a coherent "data architecture" will have the property that some "fact" that is true in one part of the system will also be true everywhere in the system -- at least, it will be true once the truthiness (thank you Jon Stewart and Daily Show for that term) of it has propagated from the "source of truth" and the "trusted gold-standard source" outward, across hill and dale, across silo boundaries and messaging links, to all the different component legacy systems that "make up" the larger simulated "coherent system", and within each legacy system, to the far internal corners and all the places where this "fact" is stored, or represented, or has affected what else is stored there.

For those outside the box,  this process may seem "instantaneous" and occurs when a user "inputs the data."    For those who labor in this vinyard,   the process is anything but atomic or instantaneous, and is fraught with pitfalls and dark spaces and places where this new fact, this new state of the world,  is at first glace rejected and denied.   "I'm sorry" the system may say (right), 'but you are not authorized to change this piece of information."     Now we have a hopefully-transient state where half of the sub-systems think the patient is, say, "male" and the other half think the patient is "female."  

It is a "demand" of the architecture group and the database group that this kind of state should not be allowed to exist long enough to be visible to the users.   Management may consider this a negotiable demand,  failing to grasp the implications of such data inconsistencies on decisions based on "the system."

(14) Here is the "deal" however -- for a single truth to be maintained (after this invisible-to-user transition period) it is ABSOLUTELY REQUIRED that "the system", the greater system, MUST be able to OVERRIDE any particular sub-system and INSIST that a data field be changed from what the legacy sub-system thinks it is to some new value.

Well,  this is no small matter. In fact, this is a HUGE matter.  You have no idea of the implications and ramifications of this on people, processes, responsibility, and behavior.

Example -- after 5 years of incredible effort, a particular subsystem has FINALLY managed the data quality effort and has the data 99.99% correct.   This is almost certainly becomes some person, call her Edith,  personally cares about and owns the data and you should beware of your life should you attempt to reach in to "her" system and arbitrarily enter unclean, unvalidated, or inconsistent data!

Edith will not be a happy camper when told that,  now,  her almost perfect system and household is going to be MERGED with the much larger and much more conspicuously sloppy neighbor's household, with "shared responsibility" for data quality. Suddenly, everywhere Edith turns in her once perfect home,   there are dirty socks on the floor,   old T-shirts on the chairs,  and half-empty boxes of food on the tables.    Not only that, but if this mess is cleaned up,  tomorrow she will arrive and found it has been messed up yet again.

So,  what will Edith do? Think about this.   How is a somewhat detail-obsessive compulsive person going to deal with this situation.  First, she will oppose the merge violently, vehemently.   This will be over-turned for political reasons, and she will be told it HAS to happen, there is no choice.   At this point either (a)  Edith will leave the organization because she refuses to put up with this clutter, or (b) Edith will stay, but she will psychologically leave the organization and STOP CARING if the house is clean any more.

So, what we have here is a sort of Gresham's law (cheap money drives out good money) applied to data quality.     Everyone who cares deeply about data quality (always a minority!) will be consistently over-ridden,  in the short-run, by the "demands of the greater good to merge these data sources."

Here we see the system moving into the valley of the shadow of death, as it were, between the older optimization mountain of high-quality maintained by Edith, and the new mountain,  still perhaps a year or so away,  when the NEW management finally comprehends WHY the older staff was so anal-compulsive about data quality, and comes up with new processes and mandates about data quality. In between times,  even the databases that used to be highly reliable will become LESS reliable.

This will result in some extreme cases where users of the data, placing reliance on the database that turns out to be unjustified in hindsight, will produce very bad patient outcomes (e.g., death),  which will produce very large social firestorms,   which will result in many users now refusing to use the new system "until these problems are fixed."   Well.  When will that be, now that Edith is gone?


By the way, the accuracy required is very high.  How many times would you need to look up a blood type and get a definitive but incorrect value before you would stop using that source?  Not very many high-profile instances,  shared at mortality conferences,   are required to cause clinicians to refuse to use this system and boycott it.

15) Similarly,  the overall reliability of the system depends strongly on this thing called "architecture", and in bad architectures,    the overall reliability is determined by the WORST SINGLE COMPONENT in the entire system. 

What is desired, in computer terms, is an actual "distributed operating system" and a "distributed data architecture" that maintains truth regardless where data elements are stored or accessed.

What is often used instead, in fact, what is almost ALWAYS used instead,  because managers and policy makers don't understand the crucial distinction,   is a collection of legacy systems connected to each other with some kind of "messaging" links,  typically HL7.


Here is a fact of life -- a collection of systems connected by messaging links is NOT automatically the distributed single-truth system which is implicitly required.   Some very strong statements can be made about such systems, based on computer science.


The odds that a collection of systems will "form" or "emerge" a coherent super-system,  of its own accord, is identical to the odds that a group of people from different cultures and stakeholder groups, put into a room,   will form a "working team" with coherent vision, goals, processes,  terminologies, and methodologies.  In other words -- ZERO. 


Even with a highly-paid "coach" person, and extensive "practice" sessions, and strategy sessions, and reviews of prior actions,   a collection of sportsmen, even individually very professional,   will not form a "team" capable of spectacular, or even non-laughable teamwork.  This doesn't "just happen".

Management telling the players "We MUST work together!" does not produce this outcome. -- were that it were so easy.

This is a problem I discuss extensively in this blog, the problem of "unity with diversity".   The specialty sub-systems have to maintain individual identity and their own "Ediths" for quality control, or their contribution to the overall mix will go to zero.  At the same time,  each system has to be capable of being OVERRIDDEN when the greater system is CERTAIN that some data element, regardless of Edith's diligent efforts, is incorrect.

This is no longer a "technical" problem -- this has now become  a social problem.

16)   The odds of success are inversely proportional to the number of users of the system whose perspectives and needs are considered "marginal" or "slack elements",  who are expected to simply "adapt" their work to the new system's demands,  on top of their already overburdened lives.

In particular,  I'm trying to recall any system put in that did not have the phrase in the summary "We didn't really consult with nurses before doing X, and it turns out we should have."

Hmm.   It's fascinating that this very same lesson is encountered over and over and over with zero social learning.    I would suggest that there is a very strong paradigm / myth / belief in place,  held by GP's and Managers and often government administrators,  that "nurses don't matter" and, "whatever it is they do,  we don't need to plan around it."

I'd suggest someone do an actual count of the number of times the post-hoc evaluation report says that "nurses should have been consulted more, earlier,  in greater depth than they were."    This TRUE FACT needs some kind of extraordinary PUSH from LEADERSHIP to make it into control of action, when push comes to shove,  apparently. It seems to be a VERY forgettable fact,  the true baby in the bath-water, one that is almost ALWAYS discarded very early in implementation plans,  and then almost always SERIOUSLY regretted only later -- again, apparently, because it flies in the face of the internal belief system of the de-facto power brokers, who are not themselves nurses.

So, let me put that as a separate point:


17) NURSES MATTER AS MUCH AS DOCTORS for success of an EHR implementation.  If nurses don't have an equal voice at the table, in both numbers and volume and power,  you might as well plan on system failure and walk away and cut your losses.  Study after study reveals this, and time after time the next guys on the block reject and ignore this advice.

In the USA the Institute of Medicine has finally realized this in a report this year on the future of health care in the USA, with a call for nurses, not doctors, to lead the IT direction.   Not too surprisingly, this has outraged many doctors who feel they either speak for nurses, or feel they understand all the key issues that nurses require.   From what I've seen, nurses would disagree with this, and believe they have important issues that are simply invisible to doctors, issues that will not be addressed by even wise and well-intentioned doctors.

Again, simply by reading the after-action reports on prior installations, or failed implementations of EHR's,   there are clearly some key success factors for EHR's that are NOT visible before-the-fact to the standard methods for managing such projects, but that seem to be visible AFTER the fact to those managers, who, sadly,  are unable to communicate this lesson to the NEXT group of people attempting exactly the same kind of effort, and about to make exactly the same mistakes.



  

Domestic violence rises in Christchurch after earthquake

The level of domestic abuse and violence is reported to have risen substantially (50%) in Christchurch after the earthquake in September.

According to the New Zealand Herald,

Burglaries in quake-ravaged Christchurch are actually down but family violence offences have soared more than 50 per cent, say police.

Provisional data showed that burglaries have decreased by 11 per cent in comparison with the same time last year. ..

However, it was also a time of significant stress on families for a number of reasons, he said.
Provisional statistics show there has been an increase of 53 per cent in family violence offences since Saturday morning in those areas affected by the earthquake.
"We know from experience that times of stress do correlate with an increase in family violence incidents and this has occurred.
"It is a time to show tolerance and patience and realise when you are under stress and may need to take affirmative action to prevent the stress escalating into violence to those closest to you."
Police urged people suffering from stress to talk to family or friends or seek advice and assistance from agencies that can help such as Women's Refuge.

Women under Perpetual Guardianship of Males in Saudi Arabia

The government of Saudi Arabia gives women very few rights that are taken for granted in the West.

This treatment is not a feature of Islam itself, but is a feature of the particular way Islam has been interpreted by the ruling elite.  It is important not to paint Islam with a broad brush, when so much of the practices are local interpretations that vary widely with country and region.

According to Wikipedia, on Women in Islam "
William Montgomery Watt states that Muhammad, in the historical context of his time, can be seen as a figure who promoted women’s rights and improved things considerably. Watt explains: "At the time Islam began, the conditions of women were terrible - they had no right to own property, were supposed to be the property of the man, and if the man died everything went to his sons." Muhammad, however, by "instituting rights of property ownership, inheritance, education and divorce, gave women certain basic safeguards."^[13]"

The Wikipedia article also quotes an opinion that  Islam is neither more nor less patriarchal than other world religions especially Hinduism, Christianity and Judaism.^[7][8]
It is interesting how so many aspects unrelated to Islam are ascribed to it in an effort to tar and feather it.
The headscarf is a source of massive dispute in various countries, including the US and France. Yet, every picture in a Christian bible shows Mary, mother of Jesus, with a headscarf. Interesting.

The United Nations Convention on the Elimination of Discrimination Against Women ("CEDAW") committee on Saudi Arabia "noted with concern that the concept of male guardianship over women seemed to be widely accepted and severely limits their rights under the Convention", according to The Circular from the National Council of Women of New Zealand (The Circular, No 537, October 2010, p8).

The news item continues "The consequences of the system of male guardianship include:"

• A girl of any age can be forced into marriage by her male guardian.
• A woman can be forcibly divorced from her husband by her male guardian.
• A girl cannot be educated without the consent of her male guardian.
• A woman cannot get a passport without the permission of her husband or male guardian.
• A woman cannot travel or take her children anywhere without the permission of her husband or male guardian.
• A woman cannot be admitted to or discharged from, a government hospital without the permission of her husband or male guardian.
• A woman cannot make decisions regarding medical care, including family planning, without permission of her husband or male guardian.
• She cannot be employed without the approval of her husband or male guardian.
• She cannot run a business unless it is in the name of her husband or male guardian and she has his permission to manage it.
• A woman cannot enter a police station to file a complaint unless she is accompanied by her husband or male guardian.
• A woman cannot file a court case or appear before a judge without the presence of her husband or male guardian.

The CEDAW committee urged the government of Saudi Arabia to take immediate steps to end the practice of male guardianship over women.

(quoted Source: Equality Now Women's Action 31.2 Update May 2010).

Love and survival - or, no, technology is not what will save us!

The Wall Street Journal has an article this morning titled "Latino Aging Stumps Experts".

Why Hispanics such as Mr. de Leon—often poor, uneducated and without health insurance—live long and strong has long confounded health professionals, scholars and other experts. This week, the first official life-expectancy data released for U.S. Hispanics shows they outlive whites by 2.5 years and blacks by almost eight years.

The life expectancy for Hispanics is nearly 81 years, compared with 78 years for whites and almost 73 for blacks. As a whole, people in the U.S. can expect to live 77.7 years, according to the report from the Centers for Disease Control.

"The findings can imply the Hispanic population is healthier overall" than whites and blacks despite its low socio-economic status, said Elizabeth Arias, lead author of the report...

While there is no conclusive explanation for Latino longevity, possible factors are related to migration, culture and lifestyle....

Another theory holds that U.S. Hispanics live longer than whites and blacks because they are more likely to eat a healthy diet, get exercise and belong to a supportive social network.

 I'm not sure what "experts" are stumped by this kind of result, although it does fly in the face of two popular myths

1. that the USA has some kind of superior health care, compared to other countries,and 
2. that technology and high-tech medicine and surgery are more important than social factors

An implication of the second item is that the debate about "healthcare" should become a debate about exactly what sort of third-party payer insurance we need in order to pay the huge costs of such high-tech interventions.  This is, of course, precisely what the last several years have seen in the US.

These myths, narratives, and mental models have a profound impact on our social policies and generally, in my mind,  cause us to misallocate a huge portion of our national wealth down pathways that yield no actual benefits, while simultaneously depriving us of the needed solutions.   This is, in other words, almost the classic definition of "quack medicine", and a bad, bad, bad thing to let continue unchallenged.

I highlighted the section of "social support network" because it is the factor that allows people to eat and exercise correctly.    It is highly unlikely that things go the other way, i.e., that eating and exercise cause us to join social support networks.     It is very likely that having a community ethic and support network provides that key thing, the thing we don't even have a word for in common English,  which allows people to endure pain, overcome adversity, and hold the course (hold the faith?) when the going gets rough.

Hispanics are not the only group that shows such an advantage. Another dramatic example is the Church of Latter Day Saints ("Mormons").      Here's their data to consider when picking your next health-care insurance plan.   There are more authoritative sources than this weblink, but it was fast and they show the same data:

 

 

Life expectancy among LDS and Non-LDS in Utah

Ray M. Merrill

VOLUME 10 - ARTICLE 3 PAGES 61 - 82 Date Received: 26 Jul 2003 Date Published: 12 Mar 2004

http://www.demographic-research.org/volumes/vol10/3/

Abstract: (excepts)

This paper compares life expectancy between members of the Church of Jesus Christ of Latter-day Saints (LDS or Mormons) and non-LDS in Utah.

Complete life table estimates were derived using conventional methods and cross-sectional data for white males and females fr1994-1998. 

Life expectancy was 77.3 for LDS males, 70.0 for non-LDS males, 82.2 for LDS females, and 76.4 for non-LDS females....

although differential tobacco use explains some of the higher life expectancy in LDS, it only accounts for about 1.5 years of the 7.3 year difference for males and 1.2 years of the 5.8 year difference for females. Higher life expectancy experienced among LDS not explained by tobacco-related deaths may be due to factors associated with religious activity in general, such as better physical health, better social support, and healthier lifestyle behaviors. Religious activity may also have an independent protective effect against mortality.

In short, and this is supported by other studes,  LDS males live on average 7.3 YEARS longer than the rest of us. 

Surpisingly, (to those stuck in the insurance myth), this is not due to health insurance or high tech medicine.    General statistics on the population are given here.

Again, part of the result is "explained" by substantially better health habits, such as rejecting smoking and drinking -- and, again,  the deeper explanation of how people are able to resist the marketing pressures encouraging drinking and smoking gets back to the factors of social support and a shared ethic or religion that provides such strength to stick to those behaviors in a larger culture that has enormous pressure to behave more poorly.

A good book to read that presents much more in the way of solid academic support for these types of findings is the book by Dean Ornish, M.D.,  titled  Love and Survival - 8 Pathways to Intimacy and Health.     That link has a substantial portion of the book readable on-line for free.

This book also is available on Amazon for under $12 new and for as little as one cent ! used, plus shipping.    It's well worth the price.



From the preface of the book:

Smoking, diet, and exercise affect a wide variety of illnesses, but no one has shown that quitting smoking, exercising, or changing diet can double the length of survival in women with metastatic breast cancer, whereas the enhanced love and intimacy provided by weekly group support sessions has been shown to do just that...

Love and intimacy are at a root of what makes us sick and what makes us well, what causes sadness and what brings happiness, what makes us suffer and what leads to healing. If a new drug had the same impact, virtually every doctor in the country would be recommending it to their patients. If would be malpractice not to prescribe it -- yet, with few exceptions, we doctors do not learn much about the healing power of love, intimacy, and transformation in our medical training.  Rather, these ideas are often ignored or even denigrated.

That legacy thinking of the medical establishment is one reason that the Institute of Medicine's latest report on health care in the US is recommending that nurses, not doctors,  lead the way into the new health care era -- because, in my somewhat sharp words,  they understand long-term chronic care, home care, and the "rest of people's lives" when they are not in those brief moments a "patient" in a "hospital" or "health care setting" where "providers" will provide "health care" to them in a 12 minute burst, for as little as $200 a pop, provided they have the right insurance company.

I leave this discussion of the myths around health care, and what really matters, with a few longer-term perspectives on the issue.

Regarding the enormous power of mental models and the grip the high-tech med-surg-pharmacy industry has on our thinking:


"If we believe absurdities, we shall commit atrocities."   (Voltaire)

"If they can get you to ask the wrong questions, then they don't have to worry about the answers" (Thomas Pynchon, Gravity's Rainbow).

And a view of health "science" is coming back to at last, from several thousand years ago:

"A joyful heart is good medicine, 
   but a broken spirit dries up the bones."   (Bible,  Book of Proverbs,  17:22)

"The spirit of a man can endure his sickness,
   But a broken spirit, who can bear?"       (Bible, Book of Proverbs, 18:14).

"Every man's way is right in his own eyes,
   But the Lord weighs the hearts."        (Bible, Proverbs, 21:2)


"He how shuts his ear to the cry of the poor
    Will also cry himself and not be answered"  (Proverbs,  21:13)

It seems amazing, doesn't it, if technology is so powerful, that we, surrounded by technology and 20 years of higher education, are just now coming to understand what was written several thousand years ago!

I'll close with  a quote from T.S. Eliot in Little Gidding

We shall not cease from exploration
And the end of all our expWe shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time. 

Brainflowing - interesting looking seminar for ITSE in Second Life today

(image is from artist Alex Gray,  at http://www.alexgrey.com/  who has some truly AMAZING images along the ideas of cosmic consciousness and shared human existence. )

Thursday, October 14, 2010
Brainstorming with Brainflowing at ISTE (strengths of Second Life and current alternatives to this Virtual Environment)

Copied From here

Thursday, October 14, 2010, 6-7 PM SLT (that's 9PM EST)
ISTE (International Society for Technology in Education) Educators Social Events at Second Life

Facilitator: gloriadiago Galicia & Draceina Pinion
Location: ISTE Island Campfires http://slurl.com/secondlife/ISTE%20Island/182/91/23

Gloria Gómez-Diago (gloriagdiagoGalicia SL) and Akemi Mochizuki (Draceina Pinion SL) will introduce Brainflowing, a device for brainstorming in Second Life, and for transferring the outcomes generated to other contexts. After explaining how the tool works, two brainstorming will be held with all the participants. First we will be focused on identifying tasks which can be undertaken in this Virtual World for achieving objectives involved in a teaching/ learning process. Then, taking in mind the removal of the educational/non-profit discount in Second Life_ issue considered worthy of attention_ we will brainstorm about the current alternatives to this Virtual Environment. Therefore, by sharing experiences about the use of other platforms, we will to seek their salient advantages and failures.
Brainflowing has a symbolic price of 1000 linden Dollars, which are equivalent to $3.64, £2.34 or €2.76, and it is available in Dracy´s Virtual Shop.
Posted by gloriagdiago at Thursday, October 14, 2010
Labels: brainflowing, brainstorming, events

Migration from Second Life to OpenSim

(The above image was in google images with no creator given. I guess if CEO's can "abandon ship" taking their goodies with them, so can customers or service users!)

 Prompted by the recent announcement by Linden Labs that they are increasing rents (doubling them) for educational and non-profit organizations,   I'm joining the exiting throngs (rats?) cutting down my footprint in Second Life, and expanding it in other virtual worlds such as OpenSim.

I'm now a proud resident of 3rd Rock Grid as well as Jokaydia, and have an account but no land yet in Reaction Grid.  We'll just see how those work out, what physics engines are like, and get started rebuilding health care training and virtual hospitals, clinics, and outreach centers in the OpenSim environment.

Maybe, someday, Linden Labs will get me back.  Like any emotional relationship, I sort of doubt it, now that they've prompted me to have to come to grips with moving,  because cognitive dissonance will set in, and my mind will magnetically attract reasons why this was a good move to make, and repel reasons why this was a bad move to make.

So be it.

In any case substantial sums of money in grants and contracts are now flowing to OpenSim communities, and I'm definitely not alone in this transition.

Here's a few relevant posts from other blogs on the subject.

Vendors offer help migrating out of Second Life (but only if you own everything yourself,  which also means, no "megaprims" can be transferred.) If you do own everything, they'll move it all for you, for 2 weeks work and prices in the order of $100 USD to $500 USD per island -- using grunt labor in the Philippines to copy each script!

A manifesto for educators seeking life after second life
(by Iggy O on www.hypergridbusiness.com)

There is still no universal currency in the Hypergrid (grid of OpenSim etc. grids that share a Hypergate access, so you can jump from one to another with a single login and single inventory you carry with you.)

There is also no generic store of things you can buy.  Linden Labs has both a great store and a functioning currency, but they have shown no sign that they intend to provide such facilities for "the rest of the virtual world."   T'is a pity -- they are missing such a bet,  apparently under the impression that Second Life will always be the only game in town.     Doesn't look that way to me.

Wade

Will technology be our salvation?

Today's Wall Street Journal has an inteview with entrepreneur / investor Peter Thiel, subtitled "Technology = Salvation".   

I've written about this topic before, including the immediate prior post, linking to a dark humor YouTube video on "Technology in the Classroom",   comments on social media,    and on productivity gains from "Sharpening the Axe"

The area of need for technology is clear in my posts on  "Seriously, Why didn't we see it coming?" and "Hypnotized in high places."

The technology I'm talking about is not the type that T.S. Eliot warns us about, "systems so perfect that no one needs to be good" -- it is "socio-technology" -- the technology of making people work more productively together than they would working separately, or in the "parallel play" world of most office settings.

The first example that comes to mind is the Neanderthal activity called "a meeting", often mocked as "the acceptable alternative to work."      Another example is "the committee", a structuring of human activity with the curious property that adding more and more helping hands to the mix makes the outcome less and less helpful.


In terms of basic math or common sense,  since our problems grow at least as fast as the number of people in our world,  is a method of addressing those problems that utilizes people as resources, not liabilities, and also grows at least as fast as the number of people in the world.

Instead, we have a method of addressing problems that has flattened out only slightly above the capacity of a very bright single person,  albeit one with very strong , technology-enhanced muscles.   Sadly,  our technology has, by simple observation, done nothing to enhance vision, insight, and understanding of the world.  We have the paradoxical situation that GM executives are actually surprised that a rising price of gasoline might cause people to prefer cars that get better gas mileage.   It's not just GM -- the larger the organization, based on "Meetings" and "reporting",   the blinder it appears to be to actual reality on the ground. 

Even General Colin Powell has noted that he would tend to trust the opinion of a private on the ground at the site over the central War Room,  on whether a bridge existed or had just been blown up.

The technology we need then,  to dramatically get back on the productivity increase curve, is technology that creates a work structure where adding people to the decision-making group improves the decisions that come out of it.  In math or basic computer science algorithm terms, we need a process whereby N+1 people make better decisions than N people, for any N.

Theory Y management and mindfulness get us much of the way there, but, harking back to TS Eliot's wisdom, we expect to run into the equivalent of the sound barrier -- a wall at which humans who arrive with the intent of fighting each other cannot pass without setting aside their "differences" in the consultation process.

Can technology help us with that transition?  This is not about "Powerpoint", or other ways to shout at each other more loudly -- it is about socio-technology that helps us calm our anxieties,  touch our better selves, and honestly seek out win-win solutions together.

For this, we need to leap to the next level of computing -- from processing "contents" to processing "contexts". 

 In other words,  we need assistance not in dealing with the complexity of details within a particular frame of reference or viewpoint,  but in dealing with how those contents and available solutions appear to change, based on the framework or viewpoint that form the context for those detail.s.

The reason is that there is a huge amount of important stuff buried in the tacit relationship between the details we are seeing, and the reference frame that gives specific meaning to those details.



Meetings at which people simply continue to assert loudly their details and which dots form an "obvious straight line when connected" with others doing the same, but from different viewpoints, will only generate anger and confusion.    It is not the details that are the problem -- it is that we have failed to adjust in a rational way for the differing perspectives  and frames that are invisibly but critically attached to those details.

This is where the next breakthrough in productivity will arise - in solving this problem.
And this is where I see the power of virtual worlds, such as Linden Labs "Second Life" coming into play, becuase, there, it is possible to shift the entire visible context of a meeting in a keystroke.

That means that we have a way to get our contexts out of our heads into a space where we can compare and contrast them, and understand how much our differences are due to different frames, not different data.

More on this in a later post.

Wade





























 

Technology in the classroom -- how NOT to do it!

This is painfully recognizable in some cases!
Warning - dark humor, akin to The Office.
Worth watching at least weekly and asking .."Is this me?! "

http://www.youtube.com/watch?v=6svk_R_rVhA

Wade

On evaluating teachers by how they teach to the test

(picture by "Editor B" on Flickr)

From today's New York Times:
http://www.nytimes.com/2010/09/01/education/01teacher.html

Formula to Grade Teachers’ Skill Gains in Use, and Critics

"

A growing number of school districts have adopted a system called value-added modeling to answer that question, provoking battles from Washington to Los Angeles — with some saying it is an effective method for increasing teacher accountability, and others arguing that it can give an inaccurate picture of teachers’ work.
The system calculates the value teachers add to their students’ achievement, based on changes in test scores from year to year and how the students perform compared with others in their grade.
People who analyze the data, making a few statistical assumptions, can produce a list ranking teachers from best to worst.
Use of value-added modeling is exploding nationwide. "

(etc)


My comment to it was as follows:

Your Submitted Comment

Display Name

Wade Schuette

Location

Ann Arbor

Comment

OK, I had 6 years of post-calculus math and did very well, but I cannot for the life of me grasp why the average person needs to be able to factor polynomials to be a better human or worker or friend or parent or citizen.

If the students' reaction to what we are feeding them is to vomit and flee, maybe that should tell us something about the food, not the students.

From what I can see students do NOT need way more math and science in order to thrive in later life and contribute to the world. They need to learn to work together, resolve conflict, surface issues, and dare to care and take action on the issues they see.

Seriously. If every person in the US Government at all levels had twin PhD's in science and math, would things be better for us? How? Hey, in fact, didn't those "Quants" who demolished our banks and retirement funds HAVE PhD's in math?

Teachers need the ability and power to look UPWARD and say, "You know, I don't see how any of this stuff you ask me to do is helping." Students need the ability to look UPWARD and say, "Tell me again, after 8 more years of this, I become unemployed and then ... then ... what?"

Judging by the state of the USA today, our educational system has failed to produce people who are individually or collectively healthy, wealthy, or wise.

I'll speak for the students. "OK, grown up people. Please show me how another 8 years of THIS kind of schooling will guarantee me a good job in a great community, for me and for my children and their children. Because, doh, we look at the Social Value Added (SVA) to the community, state, country, and planet by the school system as a whole over the last few decades, and have to rate it as a total failure. Why should we even LISTEN to you? We don't believe this \"school\" is much besides a thinly disguised warehouse or prison system that even YOU can't see the point of anymore, except that it's what we've always done so SURELY, all evidence aside, it MUST be the right thing to do."

Surely. Oh, and fire all the teachers who question that narrative.

Tackling bad nursing management effectively from below

Here's a post from Those Emergency Blues,
and two comments, on it, one of them mine.

Your comments would be welcome as well! This is an important issue!

Unbearably Unhappy

Any experienced nurse can walk in to any particular unit and tell almost immediately if it’s a happy place to work. There’s something about the body language, maybe, or the lack of laughter, or how the nurses present themselves. Like pornography or good art, you can’t exactly put you finger on defining it, but nevertheless, you know it when you see it. I like to think (for all of my moaning and biting) my own little corner of nursedom is a fairly happy place to work, or at least, it’s far, far better than most of the places I’ve worked.
My father has a chronic condition which requires fairly regular if infrequent visits to a particular Toronto-area hospital for consultation. So today I spent the day with him and his wife at this hospital while he was getting treatment. While my father was in the procedure room, I remarked to his wife (who incidentally is a retired nurse, and a pretty sharp observer, to boot) that the nurses working in the short stay unit seemed particularly unhappy.
“Oh yes,” she replied. “I’ve talked to a few of them and they’ve all said it isn’t a pleasant place to work.” She lowered he voice. “In fact, I’ve seen the manager come on the floor and ream out a few of them here in front of patients and families. Totally, totally inappropriate.”
At that moment the manager came out. She was short and pale, and looked like she ate nursing licences for breakfast. Hell, she scared even me. There was an immediate stiffening amongst the nurses, and a couple of them, I noticed, surreptitiously left the unit through a back exit. Definitely an authoritarian, then. I felt sorry for this gem’s staff.
If I were a manager, and my staff were avoiding me like the Ebola virus, I might think I may have a problem. She probably thinks she’s doing a good job, and has mastered the voo-doo arts of human resources management.
I emphatically would not work that particular unit, nor would I work in a hospital that supports that management style. It’s bad nursing and bad for nursing.
I wondered though: in choosing between a happy work place and an unhappy one, wouldn’t you choose the former and eschew the latter as being unfavourable for morale and a quality nursing work-life environment, and therefore poor inducement for retention and recruitment, and more importantly, an indicator for poor patient outcomes?

This entry was posted on 23/08/2010 at 1921 and is filed under Battered Nurse Syndrome, Health Care Policy That Matters to Nursing with tags Nurses, Nursing, nursing management, Nursing stupidity. You can follow any responses to this entry through the RSS 2.0 feed You can leave a response, or trackback from your own site.

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   Diana Says:
   23/08/2010 at 2057

   That unit sounds a lot like mine. I’ve only been there 2 1/2 years, and morale seems to be at an all time low. Weekends are the least stressful as our manager isn’t present to micromanage the trivial while ignoring the relevant. Something’s got to give. I’ve definitely been thinking of what I’ll do when my initial contract is up. For now I’m simply encouraging our unit nurses to utilize existing councils to exercise autonomy in the day-to-day running of our unit. We’re up for magnet re-certification next year. Now’s the time to force administration to take the councils seriously.

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   Wade Says:
   24/08/2010 at 0657

   I’d say it’s more than an “indicator of poor patient outcomes” … it’s a direct cause.
   It’s fascinating, in a morbid way, that a unit with a leak in the ceiling and wet floor would be cited by JCAHO as a patient risk, but a unit with a manager who clearly damages the psychological-safety and open feedback teamwork required to catch errors and deliver safe care is allowed to continue without comment.
   So stick a red flag and GPS-location-transmitter on that problem and let’s group think about how to do something more powerful than notice it, complain, and dismiss it. This is a clear and present danger to patient’s lives, and should be a clear duty to address, but in some more effective way than whistleblow-and-be-fired-for-life.
   Pondering. As W. Edwards Deming noted, management is generally not interested in hearing about the fact that management IS the problem. Retaliation for even THINKING such a think seems common. So, the direct approach of presenting credible peer-reviewed studies and evidence is off the table.
   Similarly, going over management’s head outside the chain of command has a pretty dismal track-record of success.
   So, for this effort, to fix a hazard to patient care, is going to need to come from higher, such as JCAHO or better CMS – now that Don Berwick is in charge, bringing IHI’s focus on quality. HE certainly understands the direct cause-effect relationships here.
   So, assembing the fragments of thought here, it would seem that (1) nurses (or anyone) could substantially improve patient care if they could take effective action that would remove rattlesnakes, wet floors, and dangerous managers from the system.
   (2) For anyone to try this alone, unaided, by pushing UPWARDS is a proven no-win approach.
   (3) Don Berwick is the right guy to lead an effort to put teeth in a move to deal with such managers, and CMS certainly has the clout to threaten to cut off all medicare funding for a hospital that refuses to listen. So that part is in place, finally.
   (4) So how can individual nurses contribute to this nascent action coming to fruition. Probably, that’s what professional organizations are about and for.
   Conclusion — it’s within nurse’s professional duty to lean on and assist their collective professional organizations to put pressure on Berwick to “do the right thing”, and to rally other nurses to join them in this move to improve patient care AND, as a side effect, to improve working conditions, retention, cost-effective care, hospital survival, etc.
   Is that logic solid?