Tuesday, July 28, 2015

Back to the Future Garden of Eden

The very first thing Adam and Eve did after acquiring the wisdom to distinguish between good and evil was to cover themselves up and hide from view. Privacy was the first concern of a newly enlightened humanity. The punishment for acquiring this peculiarly human self-awareness was harsh, swift and unforgiving. Yes, it is legend, but you should never underestimate the genius of an author whose collection of stories has been the number one global bestseller for almost six millennia and counting. Today, a new legend is forming. If we agree to take off our loincloth and step out from the shadows of our privacy, the eternal punishment of blood, toil, sweat and tears will be rescinded by a new generation of supreme beings.

Is it possible for us to unbite the proverbial apple? Is it possible for us to revert to naked grazing among the magnificent bounty offered by the new gods, completely oblivious to benevolent surveillance and unobtrusive discipline? Our government thinks so. The billionaire class thinks so. And many of us agree and think it’s for the best. After all, honest people have nothing to hide, nothing to be ashamed of, and privacy has no tangible benefits anyway. Better yet, a little less privacy, and a little more supervision, for criminal elements and people we don’t like, is probably a good thing. Insisting on an archaic “right to be let alone” in a globally interconnected world, other than being laughable, is hindering the democratization, simplification, cheapification and commoditization of all life’s endeavors, including prevention of disease and curing cancer. Privacy is the last barrier to an eternal life of leisure and joy.

There is currently a well-coordinated, well-funded and extremely successful campaign to help us shed the ball and chains of privacy. Whereas three quarters of a century ago we realized that work made us free, today we recognize that sharing our private information will bring us personal liberty. Freedom and liberty, contrary to what you may have learned in kindergarten, are earned by hard work and individual publicness. Since the innocent days of prancing naked on the banks of the Euphrates, we learned the hard way that free markets are the engine, the heart and soul, of humanity, and free markets are hampered by the original sin of privacy, which introduces an information asymmetry that makes the markets anything but free. To liberate ourselves, we must liberate our markets first.  

America, as usual, is leading the way in liberating international markets. Our unique form of government with its three famous branches of corporate, lobbyist and executive is best suited for freeing humanity, because our government has evolved from representing a small group of citizens to representing global markets. For those too old to see the glory, rest assured that there are large checks flowing freely between the three government branches and balances are meticulously calculated by our leaders. The Singularity, you see, is not a nebulous prophecy about cyborgs. The Singularity is here and now, as this is the precise moment in human history where governance, technology, apathy and savvy leadership are perfectly aligned to take us back to the future Garden of Eden.

On Friday, July 10, 2015 the 21st Century Cures Act was passed by the House of Representatives of the U.S. Congress with overwhelming bipartisan support. Relatively speaking, the bill is rather short and concise at 362 pages, so one can be certain that our wise representatives have read every syllable and understood all the technical intricacies of this groundbreaking legislation before casting a vote. Having been a skeptic in the past, I must admit that I am particularly awed by the mathematical prowess of our legislators who empowered the Secretary of Health and Human Services to require that scientists use Bayesian statistics in their pharmaceutical research.

The Act that will cure us in the present century is the culmination of a gigantic effort by the corporate and lobbyist branches of our government to bring potentially lifesaving medicines to the market faster, in larger numbers and at lower costs to the manufacturers. To accomplish this the Act is cutting through the useless regulatory red tape of the Food and Drug Administration (FDA) and bypassing the obsessive scientific insistence on rigorous clinical trials, which can take decades to produce an approved medication, while people continue to needlessly die. Instead, an iterative and more agile process is being put in place by the Act. Do a little research, a little testing, a little checking and regulating, fail soon, fail often, and pivot quickly based on post-market laboratory surveillance.

Sure, people will continue to die (not necessarily the same ones and perhaps a few more), but now they will die for a good cause. The road to heaven, you know, is paved with necessary atrocities. Privacy of course is not congruent with the needs of a learning laboratory system, and the Act has taken the first steps to remove some of the anachronistic obstacles erected by the privacy sections of HIPAA. Once the Cures Act becomes the law of the land, personal health information will become shareable for research purposes, and the cumbersome need to obtain informed consent from human research subjects will be waived if illustrious researchers estimate that the experiment poses “minimal risk” to those experimented upon. Illustrious researchers have always been humanitarians first, and scientists second (savage sadists was a distant third), so we should be fine.

Less than a fortnight after the Cures Act swished through Congress, the lobbyist branch came up with a whitepaper to guide the next steps in our road to redemption.  Calling it as Oracle, IBM, Intel and PhRMA, all esteemed members of the corporate branch, see it, the lobbyist prescription is to dismiss any shreds of privacy and self-determination laws left standing, including the Common Rule which protects the rights of human subjects of medical research. The Common Rule is the American implementation of the Declaration of Helsinki, which was developed by the World Medical Association, following the peculiar events that led to the creation of the Nuremberg Code. The Common Rule is thus a relic, an overreaction to a bunch of idiots who thought they could somehow engineer a perfect race of humans, and among other things engaged in ample exploratory research. Stuff like that cannot happen anymore, because now we have Internet, so it’s time to get over it, put it all behind us and move forward.

Privacy rules, you see, have “opportunity costs” for the corporate branch of government, and as such are strongly affecting the movement of checks between the branches, and the size of balances everywhere. The lobbyist whitepaper is making an exceedingly compelling argument for permitting unchecked collection and trade in all sorts of personal information, not just medical or genomic. The banks have been doing it forever and it's all working just fine, other than a little innocuous leakage into marketing databases. Why should other corporate clients be treated differently than the banks? It’s simply not fair, and “lives are being lost” because of our failure to equally protect all corporate members from undue regulatory burdens. A stark example of unfairness is the preferential treatment afforded to the Centers for Medicare and Medicaid Services (CMS). 

On November 13, 2014, the CMS published a final rule regarding its physician fee schedule for 2015. Tucked neatly inside it, there is a little section promising to “provide clear legal authority for Health Insurance Portability and Accountability Act (HIPAA) Covered Entities to disclose any required protected health information” to the CMS. The “required” disclosure is for information ranging from clinical to “health behaviors” to a catchall “other data”, such as “participant employment status, participant educational degrees pursued/achieved, and income”, all “with identifiers that allow linkages across time and datasets”. The subjects of said disclosure are all entities “participating in the testing of past, present, and future models” funded by the CMS, including people not covered by the CMS, which is pretty much all people in this country.

The CMS needs the information to evaluate results of research projects, which by its own admission could have adverse effects on participants, with no mention of informed consent being needed from test subjects. How is this fair? If the CMS is asserting such latitude, why shouldn’t the corporate branch enjoy equal opportunities? What has the CMS done for you lately? If you are going to trust someone, why not trust a good solid brand-name, like say, the Coca-Cola polar bear, or the Marlborough man? If somehow doctors came to your mind in this context, the lobbyist whitepaper is quick to point out that, by winning Jeopardy, IBM’s Watson proved once and for all that “doctors are no longer the experts they once were”. And no whitepaper can be complete without reminding us that if we don’t get our act together quickly, China is going to eat us for lunch.

So that as they say is that. We must comply. Yes, for some of us it will be a little awkward in the beginning, but many have already made the transition, and frankly they seem to be just fine. This is after all an inevitable stage in human development. After losing our innocence, we began eking out a meager and perilous living by scratching food from the dirt beneath our feet. We looked underneath the dirt and discovered carbonized dead vegetation and digging deeper we found other fossilized lifeforms. We sustained ourselves comfortably on the dead bodies of those who came before us. For a brief moment, we looked up and considered the infinite bounty of the universe, but that seemed too hard.  The disruptive innovation of our times is to fast forward to a distant past and turn on each other to extract untold fortunes from mass digital cannibalism.

Tuesday, July 14, 2015

Health Care Viewed from Alpha Centauri

If someone was sitting on a veranda somewhere in the Alpha Centauri system, reading about health care in America of planet Earth, one would most likely conclude that the family of viruses known as the common cold are destroying a health system already crippled by a glut of poorly educated physicians practicing their miserable craft on a slow-moving and slow-thinking bovine population. One would also be likely to feel optimistic, because, America is bravely tackling its health care problems head on, and a resolution is all but imminent. Relieved, the sympathetic observer would take another sip from his refreshingly molten krillonade, and fast forward to the intergalactic sports section.

As our Alpha Centauri Aamericanophile surely gleaned from far away media reports, retail medicine is the fastest growing and most talked about innovation in American health care. Retail medicine comes in two closely related, yet very different flavors: cramped little rooms in the back of brick and mortar convenience stores, and cramped little apps from forever scrolling websites on mobile Internet devices. There are also hybrid solutions that combine the store backroom with the Internet in one glorious health care kiosk. Nurse practitioners or physician assistants are always provided, but for now, physicians are offered for sale exclusively through the Internet.

All three models address the most immediate and most prevalent health issues at a fraction of the costs and the hassles of traditional medicine. As the public gets educated on the endless possibilities afforded by these innovations, health care should become integral to everyday life to provide much needed safety and peace of mind. For example, say you are at your desk at 3pm and get one of those annoying eye twitches for no apparent reason. One push of a button will get you in front of a smiling doctor to allay your worst fears. A few hours later, while changing the baby, you notice a faint rash. Will it get worse? Is it infected? One click of a button and strategic placement of your mobile device will allow a board certified dermatologist to answer all your questions. Next morning, your eight year old refuses to get dressed because his tummy hurts and he is not feeling well. Why gamble? Another easy click and a pediatrician will look at little Jimmy right then and there in his bedroom, and see that he gets to school on time.  

You would certainly not click that button if the baby was burning up and wheezing, or if Jimmy slipped in the bathtub and cut his forehead, but you know, for the little things, the doctor button is a life saver. It makes you feel safe, like you’re never alone, and that’s worth every penny for a busy working mom.  And not just working moms. There are hundreds of millions of little health things happening every day in America, and if everybody used the doctor button on their phone for each one, America would save billions of dollars, because traditional doctor visits and emergency room visits are two to ten times more expensive than doctor apps. Of course, it will take time to build virtual capacity, but seeing how entrepreneurs are knocking each other out in a mad rush to help the country, it won’t be much longer before every American is safe from worry.

When our technology is as good as that of Alpha Centauri, virtual medicine will be all we need, but in the interim there are other little things that sadly require physical proximity to certain apertures and chemical compounds. For that we have brick and mortar retail clinics, conveniently located at the corner of every street, or so it seems. Retail clinics can do more than virtual doctors in the way of blood tests and physicals, but the most important benefit is the immediate access to pharmacies, and other stuff people often purchase. Retail clinics will eventually go the way of the old doctor’s office, but until then they will pitch in and help us save billions of dollars more by covering all remaining little health things that are not yet virtualized.

You may wonder about the big things in health care, those that are consuming all our resources right now, but from the Alpha Centauri vista, the big things don’t look so big. First, big things are rather rare as it is, and are affecting mostly non-productive members of society. Productivity, as Earthlings are about to discover soon, is what makes the Cosmos tick. Second, as America begins to invest its resources in waves of little things, a resonant frequency will be achieved. The incremental effects of successively applied inconsequential actions are cumulative, and will eventually give birth to infinite natural health amplitudes. The process is called prevention, and it is a fundamental law of interstellar biophysics, which causes big things to gradually evaporate. 

Now that we know how wonderful things will turn out to be for us in the future, the only remaining question is what we should do with the doctors. They served a noble cause and they were instrumental in bringing us to the cusp of an unprecedented quantum leap in human health. But just like freedom fighters everywhere, and our own olden days militias, once the goals are achieved, there comes a time when rugged individual heroism must be replaced by well oiled machines to protect those achievements.  We will always look back fondly on Paul Revere, Ralph Steinman, John Paul Jones, Eugene Braunwald, Joseph Warren and all other heroes of past struggles, but we won, and now we must build armies of uniformed and rigorously disciplined soldiers.

Preventive health will need its generals to be sure, but our future health workforce will consist mostly of “virtualists”, to borrow an Alpha Centauri term. A virtualist is what you see and hear when you push the doctor button on your mobile device.  A virtualist is a doctor trained in the intricacies of health’s little things. He or she is supported by precise protocols and a vast array of technologies interconnected by the Internet of Things (IoT). This will save America billions of dollars in education and training, while adding a decade of productivity to each doctor. We will keep the doctor title because its original meaning of teacher is even more accurate in the new order, than it was during revolutionary times. It will be a health doctor, or HD, instead of MD, because medicine is only needed when health fails, and once we reach the resonant frequencies of prevention, health will never fail us again. 

So what’s to become of our doctors? They will adapt. They are adapting. Some are already virtualists. Many are hooked to the doctor button part of the time. The majority will follow suit. But, as is the case for any reorganization that demands strict discipline and obedience, some old warriors will be unable to make a successful transition. A few will die tilting at the windmills of progress, while others will become doctors of fortune, selling their very particular set of skills to discerning customers. Two, three, four, perhaps five generations, a mere blink of an eye for our Alpha Centauri observer, and it will all be over.