Mercifully, the Singularity seems to be receeding.
On the other hand, the days when I was smarter than Google Maps are now only a fond memory.
It's now clearly better than I am at finding routes through the Twin Cities. I've taken to checking Google Maps' recommendations on routes I routinely travel just to see where I shave a few minutes.
Barring a true global dacopalypse Google Maps is only going to get smarter, and barring a scary miracle I'm only going to get dumber. Our ships have crossed in the night.
I'm getting that old John Henry feelin'.
Sunday, January 11, 2009
Saturday, January 10, 2009
Health care reform. Be humble. Be afraid of the accounting rules.
We're going to change American health care again.
It would be good to learn from past mistakes. In particular it would be good to remember that accounting is terribly dull and terribly powerful, which means it's terribly dangerous.
Consider the way we account for ambulatory care today.
In the 1980s, when I was doing my family medicine training, the Feds wanted to encourage primary care physicians. They looked for a "fair" way to divert money from procedural specialties to primary care and came up with the "RBRVS" (emphases mine) ...
Who developed that accounting system?
The AMA.
Who funds and controls the AMA?
Surgeons and procedural specialists.
So the RBRVS, aimed at improving reimbursement for non-procedural work, was transformed into accounting rules by an organization dominated by proceduralists.
It worked about as well as one might expect. From the mid 1990s through 1999 the "E&M" rules went through 3 revisions amidst a bitter struggle between physician specialties. The controversy was so great that the 1999 rules were never implemented, and today variations of the 1995 and 1997 rules are both accepted.
The rules are, and I say this carefully, insane. I've designed expert system solutions that worked with the rules, and no human should ever have to think about them. The saving grace is that despite all the complexity and branches and calculations and summations and variations, there are only 3 likely code choices for the care of a particular patient. Physicians pick what feels right, knowing that they must be breaking the rules some of the time and so, on average, tending to bill a bit on the low side.
The worst effect, however, is how the accounting rules perverted primary care. The penalties for error are theoretically severe -- for a while the FBI devoted a special team to looking for cheaters. Physicians are required to document all that's done, and thus care was radically changed to focus on documentation of material of virtually no clinical value. The modern medical note is almost unreadable.
Lastly, since the accounting rules involve points for bits of the body examined, physicians are incented to spend too much time on rote and pointless examination and documentation, at the cost of thinking about a patient's needs and problems.
Primary care is in bad shape today. I wonder if William Hsiao has any idea what came of his original work. It's a beautiful example of the unintended consequences arising from accounting rules.
Let's try to remember the lessons of the RBRVS and the E&M coding story.
Accounting is dull, Accounting is terrible.
Be afraid of accounting.
It would be good to learn from past mistakes. In particular it would be good to remember that accounting is terribly dull and terribly powerful, which means it's terribly dangerous.
Consider the way we account for ambulatory care today.
In the 1980s, when I was doing my family medicine training, the Feds wanted to encourage primary care physicians. They looked for a "fair" way to divert money from procedural specialties to primary care and came up with the "RBRVS" (emphases mine) ...
Resource-Based Relative Value Scale - Wikipedia, the free encyclopediaTo implement the RBRVS rules an accounting system had to be developed. That accounting system is expressed as the rules for "Evaluation and Management" codes.
... RBRVS was created at Harvard University in their national RBRVS study from December 1985 and published on September 29, 1988. William Hsiao was the principal investigator who organized a multi-disciplinary team of researchers, which included statisticians, physicians, economists and measurement specialists, to develop the RBRVS.
In 1988 the results were submitted to the Health Care Financing Administration (today CMS) to be used in the American Medicare system. In December of the following year, President George H. W. Bush signed into law the Omnibus Budget Reconciliation Act of 1989, switching Medicare to an RBRVS payment schedule. This took effect in January 1, 1992. Starting in 1991, the AMA has updated RBRVS continually. As of May 2003, over 3500 corrections have been submitted to CMS.
Physicians bill their services using procedure codes developed by a seventeen member committee known as the CPT Editorial Panel...
Who developed that accounting system?
The AMA.
Who funds and controls the AMA?
Surgeons and procedural specialists.
So the RBRVS, aimed at improving reimbursement for non-procedural work, was transformed into accounting rules by an organization dominated by proceduralists.
It worked about as well as one might expect. From the mid 1990s through 1999 the "E&M" rules went through 3 revisions amidst a bitter struggle between physician specialties. The controversy was so great that the 1999 rules were never implemented, and today variations of the 1995 and 1997 rules are both accepted.
The rules are, and I say this carefully, insane. I've designed expert system solutions that worked with the rules, and no human should ever have to think about them. The saving grace is that despite all the complexity and branches and calculations and summations and variations, there are only 3 likely code choices for the care of a particular patient. Physicians pick what feels right, knowing that they must be breaking the rules some of the time and so, on average, tending to bill a bit on the low side.
The worst effect, however, is how the accounting rules perverted primary care. The penalties for error are theoretically severe -- for a while the FBI devoted a special team to looking for cheaters. Physicians are required to document all that's done, and thus care was radically changed to focus on documentation of material of virtually no clinical value. The modern medical note is almost unreadable.
Lastly, since the accounting rules involve points for bits of the body examined, physicians are incented to spend too much time on rote and pointless examination and documentation, at the cost of thinking about a patient's needs and problems.
Primary care is in bad shape today. I wonder if William Hsiao has any idea what came of his original work. It's a beautiful example of the unintended consequences arising from accounting rules.
Let's try to remember the lessons of the RBRVS and the E&M coding story.
Accounting is dull, Accounting is terrible.
Be afraid of accounting.
Friday, January 09, 2009
Election turnout numbers: Highest in MN, GOP voters stayed home
My home state of Minnesota is just so darned fabulous ...
Incidentally, I'm fine with a 60% turnout. As best I can tell about 40% of Americans have no idea what's going on, and far too many of them vote for people like Cheney/Bush. I'd rather they stayed home ...
Update 1/11/09: As noted in comments, MN has a special advantage -- we're not on the west coast. After PA was called west coast voting really fell off. So my comparison is a bit unfair ...
FactCheck.org: Is it true that 36 percent to 37 percent of eligible voters failed to vote in the recent presidential election?The GOP voters stayed home, the Democrats came out, and we had a historic win with a small increase in overall turnout which was, still, high by historic standards.
... Minnesota ... had the highest voter turnout, at 77.8 percent. Hawaii and West Virginia are tied for the lowest turnout, with 50.6 percent each...
... Before Americans went to the polls on November 4, much was made in media reports about record levels of voter registration and high enthusiasm levels among the electorate. And while the 61.6 percent turnout number doesn't seem that impressive – in 2004, after all, 60.1 percent of eligible voters cast a ballot for the highest office – it is the highest turnout in the U.S. in decades. As the CSAE report says, "If the rate of voting exceeds 61.0 percent of eligibles, turnout will have been the highest since 1964."
But why was it not even higher? Republican turnout, according to CSAE, dropped, while Democrats voted in higher numbers. The percentage of those voting for the Republican presidential ticket dropped by 1.3 percentage points and those voting for the Democratic ticket went up by 2.6 percentage points from 2004. Curtis Gans, the center's director, said he, too, thought even more Americans would vote in 2008. "... we failed to realize that the registration increase was driven by Democratic and independent registration and that the long lines at the polls were mostly populated by Democrats...
Incidentally, I'm fine with a 60% turnout. As best I can tell about 40% of Americans have no idea what's going on, and far too many of them vote for people like Cheney/Bush. I'd rather they stayed home ...
Update 1/11/09: As noted in comments, MN has a special advantage -- we're not on the west coast. After PA was called west coast voting really fell off. So my comparison is a bit unfair ...
Ultrasound and the developing brain – lessons from manipulation of mouse neurons
There’s a bit of wing-nuttery on the net about a possible relationship between the widespread use of obstetric ultrasound and an increase in the percentage of children diagnoses with autism (though there’s also been a simultaneous decrease in the percent of children diagnosed with mental retardation).
Sometimes the discussions have even had humorous consequences.
Still, there’s some reason for interest.
Which brings us the use of intermediate intensity ultrasound for altering the brain …
Sound and no fury | The Economist
… William Tyler and his colleagues at Arizona State University..
… knew from experiments done by other groups of researchers that ultrasound can have a physical effect on tissue. Unfortunately, that effect is generally a harmful one. When nerve cells were exposed to it at close range, for example, they heated up and died. Dr Tyler, however, realised that all of the studies he had examined used high-intensity ultrasound. He guessed that lowering the intensity might allow nerve cells to be manipulated without damage.
To test this idea, he and his colleagues placed slices of living mouse brain into an artificial version of cerebrospinal fluid, the liquid that cushions the brain. They then beamed different frequencies of low-intensity ultrasound at the slices and monitored the results using dye molecules that give off light in response to the activity of proteins called ion channels. (An ion channel is a molecule that allows the passage of electrically charged atoms of sodium, potassium, calcium and so on through the outer membrane of a cell.)
The purpose of all this was to coax the cells to release neurotransmitters. These are molecules that carry information from one nerve cell to another. When they arrive, they cause ion channels to open and thus trigger the electrical impulses that pass messages along nerve fibres. When those pulses arrive at the other end of a fibre they, in turn, trigger the release of more neurotransmitters.
Disruption of this system of communication is characteristic of several medical conditions, including Alzheimer’s disease, Parkinson’s disease, depression and epilepsy. Ways of boosting the release of neurotransmitters may thus have therapeutic value. And the ultrasound did indeed boost their release.
How that came about is not absolutely certain, but Dr Tyler thinks the shaking that his ultrasound gave to the cells in question opened up some of their ion channels. The cells were thus fooled into acting as though an impulse had arrived, and released neurotransmitters as a consequence…
So the obvious question is how does the intensity and duration of the ultrasound used in these experiments compare with the intensity of ultrasound used in obstetric scans? After all, “disruption of this system of communication” is also a characteristic of autism.
It feels like it would be wise to do further animal model studies, and to discourage obstetric ultrasound done largely for entertainment purposes rather than to truly guide and manage pregnancy.
Thursday, January 08, 2009
Palm Pre - unimpressed
I don't care if the Palm Pre is the world's greatest mobile web wonder.
I have that problem solved.
The problem I have is work/home calendar/task/contact integration in a world where corporations hold tight to their Exchange data.
If Palm were addressing that problem, I'd be interested. The original US Robotics PalmPilot made a stab in that direction, and in the 90s we could connect a serial cable and suck data from Outlook at work while synchronizing at home.
It wasn't pretty and it didn't work that well, but the Palm Pre appears to be in a totally different zone.
A zone owned by the iPhone.
I have that problem solved.
The problem I have is work/home calendar/task/contact integration in a world where corporations hold tight to their Exchange data.
If Palm were addressing that problem, I'd be interested. The original US Robotics PalmPilot made a stab in that direction, and in the 90s we could connect a serial cable and suck data from Outlook at work while synchronizing at home.
It wasn't pretty and it didn't work that well, but the Palm Pre appears to be in a totally different zone.
A zone owned by the iPhone.
Apple's product cycles - handy for purchase planning
Phil Schiller described Apple's product cycles for David Pogue ...
Gmail - Circuits: A Strange Macworld ExpoSo we have by month
.. the holiday season (Novemberish), the educational buying season (late summer), the iPod product cycle (October), the iLife development cycle (usually March), the iPhone cycle (June)..
- March: iLife
- June: iPhone (? and MobileMe?)
- August: Educational (iWork? Hardware tweaks?)
- October: iPod
- November: holiday things - hard to know what this means
Wednesday, January 07, 2009
NYT in the ICU - why?
Readers of Henry Blodget's (yes, that Blodget) articles for Silicon Valley Insider know that the NYT is on its deathbed.
What we don't get is an explanation of why the New York Times, and most other large papers, are so ill.
We know that many media owners carry a lot of debt unrelated to newspapers, but in that case healthy newspapers would face sale -- not extinction.
We know that the internet killed the classified business, but no-one's suggesting that was huge for the Times.
We know subscribers have left paid print for free online reading, but online circulation has vastly lowered the average cost of delivering product while also increasing the pool of readers. In theory subscription losses should be outweighed by advertising revenues.
Ahh, but there's the rub. If I'm reading this VentureBeat article correctly, the problem is that the advertising model isn't working, either because online ads in newspapers don't seem to work and thus aren't worth much, or because there are a huge number of equally useful (or useless) routes to reader eyeballs. No one route can reach readers ...
I'm optimistic an escape route will appear. It is a rough spot though ...
What we don't get is an explanation of why the New York Times, and most other large papers, are so ill.
We know that many media owners carry a lot of debt unrelated to newspapers, but in that case healthy newspapers would face sale -- not extinction.
We know that the internet killed the classified business, but no-one's suggesting that was huge for the Times.
We know subscribers have left paid print for free online reading, but online circulation has vastly lowered the average cost of delivering product while also increasing the pool of readers. In theory subscription losses should be outweighed by advertising revenues.
Ahh, but there's the rub. If I'm reading this VentureBeat article correctly, the problem is that the advertising model isn't working, either because online ads in newspapers don't seem to work and thus aren't worth much, or because there are a huge number of equally useful (or useless) routes to reader eyeballs. No one route can reach readers ...
If the New York Times dies, does the news die? VentureBeat
The death of an institution isn’t far off, writes the Atlantic in an article titled End Times, and with it an entire industry may be preparing to slip underwater. Low on cash, high in debt, the legendary New York Times is reeling from the recession. There’s no guarantee that it, or many others of our best newspapers, will survive the next year.
The immediate effect of the Times ending its storied run (or degrading to a lesser entity) will no doubt be the journalistic equivalent of a nuclear explosion...
... The New York Times has done an excellent job of growing its web property. ComScore says the company’s pageviews are approaching 200 million a month; that’s a lot for any website...
... Getting a New York Times-caliber feature article requires paying a Times-caliber writer for a week or more of research and writing. That will set you back between $1,000 and $10,000, depending on who is doing the work. That figure doesn’t include the editing and expenses, by the way.
For most sites, that means they need 100,000 to a million pageviews to break even, for a single article...If the NYT does die, I think it will take decades to replace it. I keep returning to the death of BYTE in the 1990s -- we still don't have anything like it on the web.
I'm optimistic an escape route will appear. It is a rough spot though ...
Tuesday, January 06, 2009
Kurzweil - not so good at prediction after all
Kurzweil, to his credit, has kept his 1999 predictions for 2009 online.
He doesn't do very well, though I give him credit for trying. Most of the things he mentions seem credible, but the hardware items are more 2018 and the software items 2028 or later.
Last September Scott Aaronson critiqued Kurzweil's prediction of a 2045 Singularity. Aaronson voted for 2300. I worried then about 2100.
After seeing how far we are from Kurzweil's 1999 predictions 2045 looks extremely unlikely and I'm feeling better about 2100 (meaning it will be later than 2100).
So not in my lifetime, or, and this is rather a problem for him, not in Kurzweil's lifetime either.
He doesn't do very well, though I give him credit for trying. Most of the things he mentions seem credible, but the hardware items are more 2018 and the software items 2028 or later.
Last September Scott Aaronson critiqued Kurzweil's prediction of a 2045 Singularity. Aaronson voted for 2300. I worried then about 2100.
After seeing how far we are from Kurzweil's 1999 predictions 2045 looks extremely unlikely and I'm feeling better about 2100 (meaning it will be later than 2100).
So not in my lifetime, or, and this is rather a problem for him, not in Kurzweil's lifetime either.
GD II: How large is the unused economic capacity?
I must be up to at least 30 Crackpot points in my recent economics threads, but I just can't help myself.
I swear, I'm going to stop soon, just not quite yet.
In past recessions, and even recently, I've read of estimates of the unused capacity of the US economy, and how much must be done to move us closer to using all of our capacity.
So today's question is whether the US economy is the right denominator.
What if we're now so entangled economically with China that the right denominator is not the US workforce, but rather the US and Chinese (and perhaps Indian) workforce? That's a rather bigger number; it could absorb a lot of stimulus ...
Crank roll:
I swear, I'm going to stop soon, just not quite yet.
In past recessions, and even recently, I've read of estimates of the unused capacity of the US economy, and how much must be done to move us closer to using all of our capacity.
So today's question is whether the US economy is the right denominator.
What if we're now so entangled economically with China that the right denominator is not the US workforce, but rather the US and Chinese (and perhaps Indian) workforce? That's a rather bigger number; it could absorb a lot of stimulus ...
Crank roll:
Dyer - the last articles of 2008
It's been a while, but Dyer has 5 new 2008 articles:
- November 27 Terrorism is Marginal
- December 2 Four Harsh Truths about Climate Change: it's too late. We're in big trouble, climate engineering better work.
- December 6 Small Earthquake in Canada, Not Many Hurt: the political crisis is small stuff, Canada is in good shape
- December 9 Global Zero: eliminating nuclear weapons
- December 14 The Old Thailand Returns
(this has a bad link, should be fixed soon. Go to the site to find it.)
Apple preps for a year of living dangerously?
Does this mean Apple figures nobody will have any money to spend on anything?
Apple is supposed to be brilliant at forecasting consumer spend.
They may be settling in for a very tough year ...
Live from Apple’s last Macworld - Apple 2.0and ... no iPhone 3.0 hints, no MobileMe fixes ... in other words, pretty much nothing.
... There was no Steve Jobs cameo, no Mac mini, no new iMac, no Snow Leopard ship date, no memory upgrades for iPhone or iPod touch, no new iPod shuffle, no revamped Apple TV or Time Capsule. There was a new unibody 17-inch MacBook Pro with an impressive (if non user-removable) battery...
Apple is supposed to be brilliant at forecasting consumer spend.
They may be settling in for a very tough year ...
Monday, January 05, 2009
The less we use cash, the easier counterfeiting is
Modern counterfeiters don't bother with the fancy stuff (like Iran's alleged scheme ). They often desperate sorts who use cheap ink jet printers. Nobody cares enough to prosecute. The interesting bit is that they can do quite well ...
Today my vending machine rejected my $5 bill -- because it's a modern design. I barely recognized it myself. Paper money is going the way of the telegram .
Schneier on Security: Trends in Counterfeit Currency
... Part of the problem, Green said, is that the government has changed the money so much to foil counterfeiting. With all the new bills out there, citizens and even many police officers don't know what they're supposed to look like.
Moreover, many people see paper money less because they use credit or debit cards.
The result: Ink-jet counterfeiting accounted for 60 percent of $103 million in fake money removed from circulation from October 2007 to August 2008, the Secret Service reports. In 1995, the figure was less than 1 percent...
The Onion loves the Mac
The Onion's “MacBook Wheel” cannot be missed.
Firstly, it's flat out brilliant -- full of fine touches that only a geek could catch. Secondly, it must have taken an immense amount of work to put it all together. Thirdly, at least for a Mac geek, it's teary-eyed funny.
It's a labor of love.
Steve Jobs is an intensely private person
Until I read the letter Jobs released on his health, I didn't fully understand what a contradiction he is ...
A fascinating example of the contradictions that can live in one person, albeit a most unusual person.
Update: Incidentally, his statement makes no medical sense. Another Jobs contradiction is that he's simultaneously a technologist and a fan of alternative medicine. He famously attempted to treat his cancer with diet. So his description of his condition isn't to be relied on.
Letter from Apple CEO Steve JobsJobs is an unparalleled showman and salesman, the ultimate control freak, a world class celebrity, a notorious trickster who's often cruel to others, and yet he's also an intensely private person who is appears to have been personally hurt by doubts of his probity and dedication.
... I have given more than my all to Apple for the past 11 years now. I will be the first one to step up and tell our Board of Directors if I can no longer continue to fulfill my duties as Apple’s CEO. I hope the Apple community will support me in my recovery and know that I will always put what is best for Apple first.
So now I’ve said more than I wanted to say, and all that I am going to say, about this...
A fascinating example of the contradictions that can live in one person, albeit a most unusual person.
Update: Incidentally, his statement makes no medical sense. Another Jobs contradiction is that he's simultaneously a technologist and a fan of alternative medicine. He famously attempted to treat his cancer with diet. So his description of his condition isn't to be relied on.
Sunday, January 04, 2009
WSJ Editorial pages fuming about Franken
Heh, heh, heh: Funny Business in Minnesota - WSJ.com.
I love the smell of the WSJ editorial pages fuming.
Now if the WSJ news pages were concerned I'd pay attention. But the editorial pages?
That's just delightful in a wickedly funny sort of way.
Senator Franken. Ahhhh.
I voted for him of course, but when the Minneapolis Star Tribune double-crossed the state and endorsed Coleman (a notorious weasel) I figured he was toast. Despite working very hard and despite the state going strongly to Obama he didn't seem to be getting a lot of traction -- so I wasn't optimistic.
Happily I was wrong. This is a very good day, though the lawsuits may go on. (Some insiders seem to think Coleman will give up rather than incur large legal bills in pursuit of a lost cause, but my native pessimism assumes a long hard battle.)
Update 1/5/09: 538 dismantles the WSJ OpEd. Wow. I knew the WSJ editors were slimeballs, but they really outdid themselves this time. Murdoch is famous for calibrating to power. How longer before some of those scum join the breadlines?
I love the smell of the WSJ editorial pages fuming.
Now if the WSJ news pages were concerned I'd pay attention. But the editorial pages?
That's just delightful in a wickedly funny sort of way.
Senator Franken. Ahhhh.
I voted for him of course, but when the Minneapolis Star Tribune double-crossed the state and endorsed Coleman (a notorious weasel) I figured he was toast. Despite working very hard and despite the state going strongly to Obama he didn't seem to be getting a lot of traction -- so I wasn't optimistic.
Happily I was wrong. This is a very good day, though the lawsuits may go on. (Some insiders seem to think Coleman will give up rather than incur large legal bills in pursuit of a lost cause, but my native pessimism assumes a long hard battle.)
Update 1/5/09: 538 dismantles the WSJ OpEd. Wow. I knew the WSJ editors were slimeballs, but they really outdid themselves this time. Murdoch is famous for calibrating to power. How longer before some of those scum join the breadlines?
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