Saturday, November 21, 2009

Twilight of the mail

It's been a couple of months, so I went through my home paper mail. As usual there were about 3 items of interest, 3 periodicals for the bathroom, and a 2 journals for the office.

We know the periodicals and journals are going to move to some form of "ePad" in the next year or two. At that time I will get valued paper mail less than six times a year -- mostly from family over 80.

I get nothing at work.

Of course there's a trick. Emily gets all the bills and the Netflix DVDs, but fairly soon vendors will stop mailing paper. We're fed up with broken Netflix DVDs, so that will end within a few months time. (Suck it Netflix.)

Paper mail is going the way of paper news.
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Friday, November 20, 2009

Health IT Standards - what I would do

I almost never blog about anything that's work related. For example, if you visit my blog page you'll see a "label cloud" with 360 posts on Economics, but I'm no economist.

This post, written as a private citizen, is different. I'm going to write about something that I really do know quite well. It's a sufficiently obscure topic that there are probably only a handful of people who know it as well as I, and I doubt any of them have been invited to participate in the Health and Human Services IT standards process.

I wasn't invited, but I feel a moral obligation to contribute anyway. I can't see a good way to do that, so I'll post my contribution here. Sometimes these posts travel in odd ways.

My unusual expertise is in combining the realms of healthcare "accounting" (ICD-9-CM, HCPCS, CPT) and the realms of industrial ontology (gritty knowledge representation) such as SNOMED. I've been personally grinding these pieces together for over twelve years in various software systems. I know them rather better than I'd like.

The accounting systems matter. Their idiosyncrasies distort health care statistics, change people's insurance, impede and break computerized decision support, dictate care and determine how most clinicians define disorders. They are fashioned in obscure dark rooms, and they alter health care as surely as technical accounting dictates corporate software development.

They matter so much that they are deeply embedded and almost impossible to displace. ICD-9 was obsolete 30 years ago, but it staggers on. ICD-10-CM is a merely improvement that will cost many fortunes to implement.

On the other hand, SNOMED, a language for healthcare, is a very rich tool. Buggy, yes. Imperfect, yes. Even so, it's a powerful tool for anyone who wants to provide cost-effective decision support that will make all health care providers smarter and faster.

So why don't we implement things like SNOMED now? Are there technical issues? Well, there are some technical challenges, but they're not too big. The real problem is the deadweight of ICD-9, CPT and all that layers upon them, such as vast "medical necessity" (LRMP, medical coverage) databases. Since payment is closely bound to ICD and CPT coding, the easiest route to legal maximization of reimbursement is to stay close to ICD and CPT.

I don't think we have the energy to move America quickly to better health care standards like SNOMED CT. Maybe we do, but this kind of change is very hard. Even so, I think we can do it gradually. The trick is to keep the current system in place, while incrementally building up an alternative approach.

For example, consider the "coverage determination" database. This is a reasonably complex set of tables that define relationships between ICD-9-CM (aka "ICD" in the US) codes and CPT codes (AMA owns CPT btw). The tables express rules such as "we will pay for procedure X (CPT) if a patient has condition Y" (ICD).

I think those tables would be simper, and more internally consistent, if the rules were expressed using SNOMED CT. Medicare (CMS) could then publish rules in both SNOMED and, through things called "mappings", ICD-9-CM and CPT too. The transaction systems would still use the ICD and CPT codes of old, but developers could represent the rules internally using SNOMED, thereby facilitating SNOMED use in their clinical systems. This alone would remove a very large hurdle.

State governments could encourage clinicians to include SNOMED CONCEPTIDs (codes) in a new class of public health and/or payor transactions. This would be entirely optional, but transactions could have come with small payments and regulatory rewards.

We could express new ARRA reporting requirements in SNOMED as well as in the traditional ICD and CPT code sets. Again, accept either data set.

Lastly, we could accelerate implementation of SNOMED-founded ICD-11, perhaps even foregoing ICD-10-CM plans and doing an early partial implementation of the full ICD-11 vision.

It's very hard to move things as deeply embedded as ICD-9-CM and CPT. This deadweight is heavy weight. We can't do it all at once, but we could take doable steps that would provide us with better decision support and more portable electronic health records.

We now return you to the regular amateur hour ...
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How much is the gBook in the Window?

So yesterday Google does a presser on their coming Chrome OS ("chromestellation") netbook. Buried away, and rarely reported, Google's Sundar Pichai says ...
Q: Do you know what this Chrome OS netbooks will cost?
SP: You will hear that from our partners. They will be in the price range that people are used to for netbooks today. But it’s hard to predict a year from now. Also remember, they will be bigger.
Huh?

The price range people are used to netbooks today?!

Err, that wasn't what I was expecting. What am I, wrong?!

Who cares about "bigger", we want cheap, cheap, cheap! We want that sucker under $150 (battery extra).

Not everyone heard Mr. Pichai ...
What ChromeOS Means For Netbooks And Why Microsoft Needs To Be Scared
... ChromeOS may not be powerful, it may not play Far Cry and it may not run Microsoft Office but it’s a game changer. The underpowered laptops that limped along under Vista, XP, or 7 will fly under a new ChromeOS regime and thin-and-light laptops will fall below the vaunted $199 mark as the so-called “Microsoft Tax” – basically the small cost manufacturers pay for OEM licenses – disappears."..
The XP tax, by the way, is less than $25.

If Google intends to sell a Netbook at $400 then Microsoft can relax.

I hate being wrong.

Thursday, November 19, 2009

A smart mind is a dangerous thing to waste

When I did my undergrad the USSR was a going concern. The military-industrial complex sucked in a lot of smart grads. Their work would be classified, and would add little to the greater good.

Then came the fall of the wall. For a magical decade smart minds had good work to do.

Somewhere along the way, though, smart minds started working on novel financial instruments, malign pricing innovations, games with insurance plans, and other emergent frauds. Instead of building better bridges and inventing new conservation strategies and clean energy sources, too many of our brightest minds have been investing in complexity attacks.

We need a cultural reform movement that values people not by what the money they take, but by the worth they make. Anyone see signs of this anywhere?
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Paul Graham on the price of the App Store

Apple needs to fix the App Store ...
Apple's Mistake

... I suppose Apple has a third misconception: that all the complaints about App Store approvals are not a serious problem. They must hear developers complaining. But partners and suppliers are always complaining. It would be a bad sign if they weren't; it would mean you were being too easy on them. Meanwhile the iPhone is selling better than ever. So why do they need to fix anything?

They get away with maltreating developers, in the short term, because they make such great hardware. I just bought a new 27" iMac a couple days ago. It's fabulous. The screen's too shiny, and the disk is surprisingly loud, but it's so beautiful that you can't make yourself care.

So I bought it, but I bought it, for the first time, with misgivings. I felt the way I'd feel buying something made in a country with a bad human rights record. That was new. In the past when I bought things from Apple it was an unalloyed pleasure. Oh boy! They make such great stuff. This time it felt like a Faustian bargain. They make such great stuff, but they're such assholes. Do I really want to support this company?
Start with allowing Google's products.

Health insurance: we're defeated by a complexity attack

It's time again to play spin the insurance wheel.

This year my employer is offering only a "HRA" (Consumer directed) plan. What we used to call a "medical savings account plan". My employer self-insures, so presumably this saves them money.

So we tried to figure out what plan makes sense. My wife and I are both physicians. I'm a wee bit of a computer geek. We have, between us, at least 35 years of post-secondary education.

The enemy has hundreds of analysts and extensive simulations. They can throw up pages of unreadable and meaningless computer generated descriptions.

It's really no contest. The best we can do is run the provided simulations through optimal, average, and disastrous scenarios and assume that the strange seeming results are accurate. The simulations, of course, don't ask about tax brackets, and they mix pre-tax dollars (our premiums) with post-tax dollars (out-of-pocket expenses).

We can offset the post-tax dollars by gambling on Flex dollars -- but then we run the risk of sending the Flex money back to yet another gambling corporation (and probably, eventually, to my employer).

In the end we'll probably pick the middle option and go light on the Flex.

This, like mobile phone services, is a complexity attack. I'm guessing if I worked this one through I'd put it in the large class of emergent frauds - an echo of the crash of '08.

We must, as a nation, figure out a way to beat this stuff back.

Update: EL has been working with pencil, and it now looks like
  • The graphical portion of the simulation is probably wrong.
  • Disregarding the graphical part, and parsing out rollover of the "HRA" part, and factoring in various combination of pre-tax and post-tax contributions and Flex guesses the plans are more similar than the appear -- but the numbers may be wrong
  • The numbers in one resource are quite different from the simulation/web site numbers. They don't add up. On the other hand, one of the simulation numbers is probably wrong.
See also:
Update 5/28/10: Our sense of doom was well justified. Midway through the year we found that mental health payments were not handled in the MSA-like plan. They're handled through a separate, traditional, indemnity plan. Since these payments constitute our major healthcare expense, our entire analysis was rendered moot. Needless to say, in all of our review neither my wife nor I saw this in the materials we were given.

AT&T “A List” – the gift that’s not

AT&T markets a new “A List” feature…

Enjoy unlimited calls to and from the phone numbers in your A-List. Your A-List can include valid domestic phone numbers for any domestic service provider - wireless or landline.

I’ve added my corporate conference call number to my AT&T “A List”. The list already includes my home landline and, especially, the Google Voice number that connects me to Canada for free.

Once this is effective my corporate conference calls shouldn’t use any of my minutes (even toll-free calls use minutes).

Since Google Voice and Google Talk combined with the A List mean my whole family uses less than 300 minutes a month, we no longer need our family plan of 1,400. I’ve be fine with only 550 minutes.

Wow! I could drop my bill from $80 to $40. What a great feature …

Ahh. But you know there’s a hook, don’t you?

The A list feature is only available for plans with 1,400 minutes and up.

AT&T isn’t stupid. Crooked, sure. Stupid, no.

Wednesday, November 18, 2009

The cat brain simulator. Game over?

I used to say that the day we had a computer roughly as smart as a hamster would be a good day to take the family on the holiday you've always dreamed of.

Today, two articles, both, oddly, from The Register (emphases mine) ...

... IBM said it has already simulated a cat-sized cerebral cortex — the area of the brain that's key to memory, attention, and consciousness — using a massive Blue Gene supercomputer at Lawrence Livermore National Laboratory in California.

This feline-scale cortical simulation, which was made with the help of researchers at Lawrence Berkeley National Lab, included 1 billion neurons and 10 trillion individual learning synapses. The simulation ran 100 to 1,000 times slower than real-time, said Dharmendra Modha, manager of IBM's Cognitive Computing unit at its Almaden Research Center, in a blog post.

and from a completely different direction ...


... According to Dean’s presentation, Google is intent on scaling Spanner to between one million and 10 million servers, encompassing 10 trillion (1013) directories and a quintillion (1018) bytes of storage....
The simulation, presumably, is not actually doing any cat like things. It merely represents a substrate upon which cat like intellect might operate.

So maybe the next step to the hamster-equivalent AI will be long, my prediction of singularity 2100 will hold, Kurzweil will be indeed wrong about 2045, and we really should worry about carbon emissions.

Or maybe not. In which case I hope Kashmir becomes peaceful quickly as I'd like to visit the Lakes before it's too late.

Oh, what does this have to do with Google Spanner? I'll leave that as an exercise.

See also:

Tuesday, November 17, 2009

The paradox of 21st century prosperity

I've had a post brewing for weeks that I'm still playing with. It's not quite right, and may never be, but this Reich comment is pertinent ...
Robert Reich's Blog: Obama, China, and Wishful Thinking About American Jobs

... The dirty little secret on both sides of the Pacific is that both America and China are capable of producing far more than their own consumers are capable of buying. In the U.S., the root of the problem is a growing share of total income going to the richest Americans, leaving the middle class with relatively less purchasing power unless they go deep into debt. Inequality is also widening in China, but the problem there is a declining share of the fruits of economic growth going to average Chinese and an increasing share going to capital investment...
I'd love to see either DeLong or Krugman dig into this claim.

See also

Monday, November 16, 2009

The world is going to get bigger

I don’t fly that much these days – maybe 10 flights a year. Yesterday I took one of my longer flights – from Minneapolis to San Francisco. On that flight I again thought about how the world is getting a bit bigger, and that it may get a lot bigger fairly soon.

That’s new. For most of my life the world got smaller. Air fare, especially as a percentage of average income, kept falling. Families spread out. My generation moved to take new jobs.

Air fares aren’t falling any more, and most people’s incomes aren’t rising much. When I consider increased costs of health insurance, my disposable income will be down this year – and I’ve been relatively fortunate.

On the other hand, air fare to Montreal (for example0 has more than doubled in the past nine months. The carriers reduced capacity, bought the competition, and now fly fewer but fuller planes at 2-3 times past fares.

Industry consolidation will continue to boost prices, but so will cap-and-trade carbon tax equivalents. There’s something much bigger coming though…

Energy security body calls for 'urgent' review of impact of oil shortages - Business – guardian

… Swedish academics unveiled their latest assessments of the numbers and came to even more gloomy assumptions. The study from Uppsala University entitled The Peak of the Oil Age estimated that by 2030 the world would be able to rely on only 75m barrels of oil a day, compared with the 105m forecast by the IEA.

Until relatively recently the agency was assuming the output figure would be as high as 120m and it still believes a peak of production could be reached in 2020, while Uppsala believes it might have already been reached…

I made my own “demand/supply peak light sweet” call in 2008 – in which I made wild ass claim that it would be apparent by 2015 that the demand/supply ratio for light sweet crude would cause prices to rise and crash and rise and crash their way to the $200/barrel mark (rise and crash because of secondary recessions, $200 because at that point serious conservation starts to align supply and demand).

Between some kind of carbon-tax-equivalent and “peak oil” of any form, air travel will at least double in cost over the next five years – even as profits continue to be squeezed.

That means a much bigger world to cross for the dispersed families of my generation. Maybe the next generation should stay closer to home base.

High speed rail, by the way, is looking pretty interesting.

Update 11/16/09: A follow-up article by The Guardian’s Monbiot: The one thing depleting faster than oil is the credibility of those measuring it - George Monbiot

Update 11/17/09: It occurs to me that a good measure of how real this stuff is would be to watch how very wealthy and smart people invest. I recall thatWarren Buffett recently bought some railways, and of course I'm not the only eccentric sort to make this connection ...

Saturday, November 14, 2009

There are only two fixes for the Apple iPhone App Store

Good essay with links to other good essays ...
Manton Reece: The only 2 fixes for the iPhone platform
... There are a lot of well-intentioned suggestions for improving the App Store, but the result will always be the same until we acknowledge the root problem. The only fix is for Apple to remove itself as gatekeeper, or let us route around them...
Apple is channeling the wrong side of 1984. Apple has become the enemy.
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Thursday, November 12, 2009

Mobile phone fraud - The accidental data charge and other scams

I experienced this with Sprint and AT&T alike. I now pay $5 or so a month for a the honor of tracking my son's phone use -- that includes disabling his data access.

Here's Pogue's expose
Verizon: How Much Do You Charge Now? - Pogue’s Posts Blog - NYTimes.com:

...Starting next week, Verizon will double the early-termination fee for smartphones...

...The phone is designed in such a way that you can almost never avoid getting $1.99 charge on the bill. Around the OK button on a typical flip phone are the up, down, left, right arrows. If you open the flip and accidentally press the up arrow key, you see that the phone starts to connect to the web. So you hit END right away. Well, too late. You will be charged $1.99 for that 0.02 kilobytes of data...

...Every month, the 87 million customers will accidentally hit that key a few times a month! That’s over $300 million per month in data revenue off a simple mistake!..

...Now, you can ask to have this feature blocked. But even then, if you one of those buttons by accident, your phone transmits data; you get a message that you cannot use the service because it’s blocked–BUT you just used 0.06 kilobytes of data to get that message, so you are now charged $1.99 again!...

“They have started training us reps that too many data blocks are being put on accounts now; they’re actually making us take classes called Alternatives to Data Blocks. They do not want all the blocks, because 40% of Verizon’s revenue now comes from data use. I just know there are millions of people out there that don’t even notice this $1.99 on the bill.”"
For the record, here's a list of the mobile phone scams I know of ...
  1. Early termination fees that exceed plausible costs
  2. The time eating pointless answering machine messages
  3. The "accidental" high priced data fees
  4. The surprise fees and taxes with just about any transaction
  5. The covert contract renewal with service changes
  6. Recipient pays SMS transaction fees
  7. The unusable cash card rebate fraud (AT&T settled with NY state on this one)
  8. Uninterpretable cell phone bills.
  9. Passive revenue from OAN Services and other cramming scams.
  10. Unblockable SMS marketing.
  11. Long distance interconnect fees.
Add them up and were talking billions of dollars in fraud. These scams didn't have to be planned out, all you need is fertile soil for emergent fraud.

See also:
Update 11/17/09: More on how complexity attacks are used by mobile phone companies (and, incidentally, by health care insurance plans).
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I add the despised comment captcha

I dislike Captcha (usually a text recognition test) as much as anyone -- but lately my email has been clogged with notices of blog comments to review. They're almost all spam.

So I had to turn on the Captcha test. If the spambots get bored I'll try turning it off again.

Tuesday, November 10, 2009

About that health care bill …

Joseph Paduda despairs ….

… I'm really disappointed with the Republicans. They are supposed to be the budget hawks, but instead they've spent their time railing against abortion funding, illegal immigrants, and death panels, along with scientific research and taxes on device manufacturers. Instead of attempting to govern responsibly, they've abandoned all morality in their quest to re-energize the lunatic fringe of their once-dominant party…

… While there's plenty of blame to pile at the door of the Republicans, it is the Democrats who are to blame for coming up with a huge entitlement program set up to do nothing but grow…

Well, yes.

The GOP decided that their one and only mission was to make Barack Obama look bad. That meant this bill would attract no more than 1-2 GOP rebels. That in turn meant no constituency could be offended, which meant no serious efforts to control costs.

If we had a less dysrational electorate, then we’d have a better GOP. But we’re stuck with the GOP we’ve got.

So any bill that can pass will give everyone everything they want.

It’s not even lying. Anyone capable of perceiving reality knows there will be a reckoning. This is about building the arena for the real battle to come.

Not pretty, but that’s modern America. It’s the best we can do, and it’s much better than nothing. In stage II, assuming we get this sausage made, we’ll be talking price.

Reason – it’s more than IQ

Temperament is what you’re born with. Character is what life does with temperament.

Things aren’t so clear with intelligence. It’s very likely that one’s maximal “IQ performance” is largely determined by genes and intrauterine environment, but even so we know that IQ measurements increase with test training. More than that, there are lots of smart people who seem unable to reason rationally.

Reason is more than IQ …

Rational and Irrational Thought- The Thinking That IQ Tests Miss- Scientific American

  • Traditional IQ tests miss some of the most important aspects of real-world intelligence. It is possible to test high in IQ yet to suffer from the logical-thought defect known as dysrationalia.
  • One cause of dysrationalia is that people tend to be cognitive misers, meaning that they take the easy way out when trying to solve problems, often leading to solutions that are illogical and wrong.
  • Another cause of dysrationalia is the mindware gap, which occurs when people lack the specific knowledge, rules and strategies needed to think rationally.
  • Tests do exist that can measure dysrationalia, and they should be given more often to pick up the deficiencies that IQ tests miss.

I’m excited by this analysis. I’d have more to say but the full article isn’t available online yet and I can’t find much extended commentary.

I can note that analyses of errors in reasoning are very old – at least as old as Greek analyses of rhetoric. In the 1970s and 1980s several excellent books on medical reasoning and diagnosis characterized common errors of cognition, and in the early 1990s my CogSci grad coursework plumbed the depths. We’ve developed an extensive language for talking about errors in reasoning.

Even so, this recent article’s explicit study of the persistently dysrational (a better term than “arational” or “dysreasonal”) feels like a useful way to reframe the discussion. From Bush to Rumsfeld to Climate change deniers we’ve seen some fairly smart to brilliant people stuck in dysrational modes. If we can understand what produces dysrationalia, and how to intervene in early life, we may take a big step towards enlightenment 2.0 and rational discourse though not universal agreement.

See also: Be the Best You can Be- IQ and reasoning - not quite the same thing