Healthcare innovation and the digital madhouse gulag effect

I spent the day hanging out with healthcare innovators, entrepreneurs and investors at the Innov8forhealth Business Expo at the Northern KY University METS Center, a beautiful conference center across the river from Cincinnati. I really enjoy these events. It’s an occasion for me to improve my own work, and an opportunity to compete with other startup ventures for the attention of investors and healthcare system buyers.

As I have written before, healthcare is now a galaxy.  At the center is a black hole where everything that happens is mandatory and payment is by and large measured in bulk on a population-served basis. A little farther out is a ring of fee-for-service places, the Primary Care Zone. Out beyond that is the realm of health educators and “healthy support” people. Think of the nurse that calls from your health insurance company, or the educator that shows up at the senior center. Or folks like me, with books and programs.

The space between these layers is becoming filled in with health data transaction machines, satellites really, that people in the population hook their phones, gadgets and computers up to, so the information infrastructure of the galaxy can check in and measure what the population is doing.  Or they phone back to tell you how you are doing.

Some examples: Phone apps now connect older adults to caregivers. People can know when their elderly relative has forgotten to take her pills, because the app sends an alert to the caregiver’s phone when it’s time to call and complain. (Sorry, I mean “remind the person to do better.”)  Exercise bikes can email out gift cards when a person racks up enough miles. Smartphone sensors can work like always-on stress detectors, heart rate monitors, blood gas measuring devices. Phones can even wake people at just the right time to optimize their dreams.

Within these apps, the experience is being turned into a game. Healthcare is becoming “gamified.”  If I lose a couple pounds, my scale will report in and I will get a coupon for vegetables I probably won’t eat. The coupon will let my grocer know to report in if I bought them.

As all these trends come together, people in a position to access data profiles for employment, justice system, credit, insurance, political and other economic purposes will be able to view each of us as avatars, or data constructs. (We will all check the box on some form that says this is okay.) A job applicant’s “permanent record” might include what he buys at the grocery, the books he has downloaded, the restaurants and clubs where his face has been seen, the people he travels with, how well he sleeps and more.

Over the next few years, the gamified data incursions on personal privacy will be absolutely horrifying to people concerned about personal autonomy and freedom from intrusive monitoring.

I think this has significant implications for mental health. What algorithms will we develop to track personal growth? Will people be permitted a “fresh start” in a data-dominated ultra-competitive economy?  And what will the data profiles of people experiencing trouble of one kind or another look like?

The future madhouse will, I think, be a data-driven invisible economic gulag. People with mental health concerns will be identified easily because their data profiles will reflect their relative poverty and isolation from the main stream. Mechanized online psychological pre-employment testing has already become super-inexpensive. In the past month I learned of two people applying for jobs who were required to take psychological tests. One person was applying for a first job at Pizza Hut. He spent ten or twenty minutes answering a few dozen multiple choice questions. The other was applying for an executive level position at a healthcare system. This executive spent half a day working through a barrage of questions (many of them forbidden to standard personnel departments because they are plainly discriminatory). In the future, the very near future, job seekers will check a box and employers will just look this data up.

One consolation for me on this otherwise data-driven day was the opportunity to have a chat with my own cardiologist about his life in a very busy practice involving several patient offices across the city, as well as hospital work. We talked about the disconnect between the major layers in the healthcare system, about the difficulty doctors face getting to know the people they see every day in their office caseload, plus the logistical challenges of seeing patients when they have a hospital stay.

At some point, healthcare must confront and balance out the human element in the equation. Patient encounters make more sense to people at both ends of the stethoscope when they meet each other face-to-face. We have this primitive capacity and a need to know that what needs to be said has been heard, by a real person,  not just by some robot attached to the other guy’s phone.


Learn more about healthcare innovation in Cincinnati at http://www.innov8forhealth.com.

Building a life despite tough symptoms

Barbara Altman’s memoir of a life affected by mental illness, set in the latter half of the twentieth century in the American Midwest, tells about what many people experience. Trauma is connected with substance abuse and is embedded in family life. Accomplishments also play out in intimate settings: homes, schools, churches and workplaces. Ms. Altman’s book tells the story of a someone who faced challenging mental health issues but still discovered meaning and success, and a life of grace, service and dignity.

Ms. Altman writes about her life from childhood to the middle of her sixth decade. She tells of a difficult home life centered around an alcoholic father. She experienced her father’s harsh temper, and possibly worse. At age 15, Ms. Altman became aware of vague nonspecific memories of sexual trauma when her father admitted to having sexual thoughts about young children.

As Ms. Altman worked through anxiety, psychosis, eating disorders and depression, she discovered her talent for music, and built a career in music education and music therapy. She writes about finding meaning and a place in the world through the support of other people and the consolation of her Christian faith. Overcoming anxiety was a matter of exposure in small increments. She writes about facing challenges deliberately, building up courage bit by bit, at a pace she could tolerate. It took a year for her to learn to swim a complete lap in an indoor pool, but she did it.

I like this book. It describes experiences common to many, recounts personal growth and service to others, and talks about what helps.

Recovering from Depression, Anxiety and Depression: My Journey through Mental Illness, by Barbara Altman is available through Amazon. Learn more about Barbara Altman at .


Sorry, Brian Williams, “disgusting horrific criminal” didn’t make the DSM-5

If every grieving widow has a place in the DSM-5, why not Ariel Castro?

I saw some of Castro’s remarks at his sentencing. He seemed completely disconnected from the standard world. His behavior was out of bounds, abnormal, inexcusable and, to use a word favored by some within mental health advocacy community, he appears to have anosognosia of the criminal type. If madness has a spectrum, Castro has a place within it.

I’m glad to see some awkwardness around labeling Castro. It gives us an opportunity to consider the negative effects of labeling anyone as anything.


The picture below is by Malaika Puffer, from her blog "Sort of just a person"

Even well-intentioned diagnostic labeling can hurt.

Is your mental health expert smarter than a second year college student?

If we took what we know about how mental illness plays out in the world and let some second-year college students work on fixing it, would we end up with something better than what people experience today?

Today’s experience of mental illness, such as it is, developed through accretion. It is a mishmash of good and bad intentions, a clump of attitudes and practices, a basket of  traditions, economic and political factors, plus choices made since time immemorial. We have “cures” that include home remedies, scripts for talking with people, and manufactured pills and potions. We have “lifestyles” that include disempowerment, isolation, poverty, broken families, unemployment, poor health, even death.

What if we told our students to start from scratch, rejigger the whole thing. Redesign it,  using standard design techniques, a reasonable budget and some consensus-based mental health practices. What might this design team come up with?

Here are some of the principles the design team would use.

Unification.  The team would pull elements of the proposed solution from everywhere, not just from one discipline, but many. Whatever the origin, the product would work cohesively, as a unit.

Diversity. Designers are known to be self-referential. Men design for men, women for women, everyone for their own home culture. A diverse team delivers results appropriate for more people.

Accessibility. Users would know how the product functioned. The technology would be evident to the user.

Safety. The designer would understand the human factors involved, making sure the technology is safe for the user.

Simplification. Reducing the number of paths, parts and processes.

Problem solving. Addressing the user’s concerns, delivering something that makes a person’s life better.

Waste reduction. Reduce the burden of the product on the environment and on society at large.

Responsiveness. Deliver what the user demands. Create what the consumer wants, respecting the consumer’s motivations, even when the designer does not agree.

Appropriateness. Don't confuse commercial products with consumer products. Commercial products are money and process-driven, whereas consumer products must address the human needs of product users.

Deep research. Designers must immerse themselves in the user’s world to ensure they are reflecting the user’s desires, not their own.

* * *
Yesterday I watched as these principles played out at the school where I teach, Cincinnati State Technical and Community College. Six industrial design technology students presented their capstone design projects, products ranging from bike racks to assistive devices to squeeze bottles to trash can bags. A group of experienced designers from Procter and Gamble, GE Aircraft and other local companies coached and mentored the students. Over the course of the four-hour event, the advisors highlighted additional opportunities to learn from users. What does the client want? How do you know what the client wants? Was the client satisfied with what you delivered? When something wasn’t safe, how might you fix it?  Would the fix be satisfactory to the client?

Needless to say, this was eye-opening for me. Mental health services are consumer products, after all. Why does no one listen to service users, people the system calls consumers?

This classroom of second-year undergraduate-level design technology students were figuring out how to solve any problem by listening to people, applying some basic prototyping and fabrication, and checking to see if the user’s needs were met.

How many of today's mental health experts can honestly say they do that?

Extraordinary Popular Delusions and Madness in America

One of my favorite books is Extraordinary Popular Delusions and the Madness of Crowds, written in 1841 by Charles Mackay. It’s about the herd behavior of humans: fads and crazes and financial market follies. It covers witch trials, alchemy, superstitions. The book also covers the 17th Century “tulip bubble,” when flowers were currency, more valuable than gold. The lesson in the book is that once the populace gets convinced of something that turns out to be plain wrong or completely irrational, bad things happen. People die at the stake. Awakening to the realization that your tulip bulb investment is as worthless as a sack of onions is no picnic either.

There are signs that the world of mental health is in the midst of this sort of wake-up. The ruthlessness and greed implicit in the pharmaceutical industry’s marketing strategies is undermining the credibility of medication efficacy claims. The authority of the mental health’s secondary prevention model (early detection and treatment) and tertiary prevention model (treatment forever) is being confronted by research that shows better long-term outcomes on a whole-population basis when people do not use as much medication. The DSM is even becoming untethered from neuroscience.

I think the most significant development is that we now realize that people with mood problems, delusions and hallucinations deserve to be heard when they assert that what they experience has meaning. It means that writing people off is abusive and unethical. Someone with a mental health problem is not an irrational sub-human, but a valued person, no matter what he may be experiencing. We are also learning that social support is powerful on its own. It helps people with difficult symptoms stay on course.

As I see it, here is what we are waking up to.

Authority over madness is shifting to people with symptoms and away from experts and keepers. Despite symptoms a person may have, his life remains meaningful and valid. People can tolerate some level of chronic recurring symptoms and live safely, even flourish. People deserve opportunities to figure out what works and what is tolerable, and to choose an option that is presented accurately and supports their wishes. Nearly everyone wants normalcy anyway. Expertise is important, but should be advisory, not directive.  Mental illness, practically speaking, is not that complicated. Ordinary people, friends and relatives and neighbors, are perfectly capable of supporting the people they care for. They are already doing it, in every nation and every culture on earth.

There are certainly some tough cases and more difficult situations, but even these require individualized approaches. We say we do that now, but if we have been applying bad theory, it’s time to face up to that, and reckon with society’s folly.

Our Grand Inquisitor says you can’t have treatment

Are states using targeted auditing to disrupt mental health services?

New Mexico used a recent audit to completely de-fund 15 mental health providers serving the bulk of the state’s publicly funded mental health care. Some 30,000 individuals have had their care interrupted. A number of for-profit and nonprofit providers are closing because they cannot maintain operations while fighting the proposed findings.

Although the state’s actions are authorized by law, they were not mandatory.

There’s no public access to the allegations within the audits. The audit findings are secret.

Similar events are playing out in North Carolina. According to newspaper reports, a 2012 Public Consulting Group audit that cost North Carolina $3.2 million found that North Carolina had overpaid behavioral health providers by $38.5 million, but the state found that less than 10% of the amount in question could be recovered.

Some coverage of this trend:
Administration at odds with state auditor over mental health fraud claims http://www.kob.com/article/stories/s3106244.shtml

Fraud probe update: CMS defends New Mexico's defunding amid questions about audit findings http://www.behavioral.net/article/fraud-probe-update-cms-defends-new-mexicos-defunding-amid-questions-about-audit-findings

NC Medicaid: Are New Mexico and NC Medicaid Providers Fraternal Twins? At Least, When It Comes to PCG! http://medicaidlawnc.wordpress.com/2013/07/18/nc-medicaid-are-new-mexico-and-nc-medicaid-providers-fraternal-twins-at-least-when-it-comes-to-pcg/

Company owner Has to have a Enterprise Worth

Enterprise Worth Businesses certainly are a essential part of every single enterprise business deal. They need to end up being conducted by the reliable Enterprise Worth Organization for a lot of essential causes that is to be reviewed more. The business enterprise Worth Organization utilised also needs to be considered a alternative party to guarantee objectivity in the worth. Furthermore reviewed will probably be common main reasons why a business person need to get a enterprise worth and also things that make a difference benefit.

There are numerous main reasons why a business person has to have a enterprise worth. Virtually any enterprise business deal will be needing any worth advance to be able to rationalize the particular price tag and then for any customer for taking the owner critically. With no one particular, there exists almost no possibility any customer may post a deal around the enterprise. A small business worth furthermore exhibits business people where they stand available in the market and also market. They could check out research worthwhile individuals, talents, disadvantages as well as other elements to further improve the worthiness and also salability of these enterprise. Masters also often make use of enterprise worth businesses to get a worth regarding reduced stress, lover breaks, breakup, real estate organizing and others beneficial causes.

Several business people feel they will really know what their particular enterprise will be worth. They use a straightforward calculations to generate a price. This is always a amazing blunder. There is not any one particular calculations that will correctly decide the true market value. You can find economical, industry and also surroundings elements, levels of competition, chance of progress, range regarding customer base, plenty of benefit individuals, related revenue and lots of data that will influence benefit. Any customer evaluations each of the things that influence benefit to discover their particular comfortableness self-assurance it to be a solid enterprise worthy of a deal.

A couple of tips which can be vital while receiving a enterprise worth are usually secrecy constantly comes first, a 3rd party enterprise worth should be used in fact it is essential to possess knowledgeable manifestation by the reliable Enterprise Dealer similar to a Neumann and also Colleagues. Many business people simply knowledge one particular enterprise business deal inside their term, the absence regarding business deal knowledge can cause amazingly huge blunders. Working together with a small business dealer you can trust for instance a Neumann and also Colleagues will assure secrecy.

Any Neumann and also Colleagues is included in 1000s of enterprise worth thus genuine the true market value will probably be dependant on a professional alternative party enterprise worth businesses. Their particular background as being a reliable organization several satisfied clientele will be supported by enterprise revenue usually marketed faster compared to the regular and then for genuine the true market value together with very good phrases. Business people may be cozy they're not going to depart funds up for grabs as well as the business deal might be a win for everybody.

Any Neumann and also Colleagues provides above twenty-five years regarding Mergers and also Transactions knowledge and also 435.00 office buildings across the country. Their particular determination to be able to secrecy and also superiority has turned these in to a major enterprise dealer organization.

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