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April 1, 2008
The Media Re:Public group at Berkmanhas announced a breakthrough technology that promises to take the “conference” out of “un-conference.”
March 26, 2008
TechCrunch has a good explanation of Footnote’s digitizing of the Vietnam Memorial, which is handy because the Footnote site is getting hammered with traffic right now, so the app is running slowly. The site lets you browse the Wall by multiple categories, and links together bunches of information. Sounds very cool.
The Vietnam Memorial wall is an argument for stone over information. But information is good, too.
March 25, 2008
Ashish Jha at the Harvard School of Public Health is giving a Berkman lunch talk on “U.S. Healthcare: Can Information Drive Better Care?” [Note: I am typing quickly, getting things wrong, missing stuff…]
He says the first few minutes should leave us depressed about the state of health care in this country. A major problem underlying all this, he says, is a lack of transparency.
We spend $2.1 trillion dollars on health care in the U.S. in 2006. That’s about a sixth of the economy, about $7,000 per person (minimum wage is $11K/yr). It’ll be a fifth in the next decade. We spent a much bigger percentage of our GDP than other countries.
What do we get for this, Ashish asks. He cites a Rand study that came up with 439 “indicators of healthcare quality.” These are core, non-controversial treatments and practices. Rand found they get done about 54% of the time, suggesting “the care we get is pretty inadequate.” Even for privileged groups — e.g., white, wealthy, educated men — it doesn’t go much above 58%. “There’s a disconnect between what doctors think they do and what they actually do.” One of the listeners says that recent studies show that this is because there are typically 7 health care people involved with any one medicare patient, and they don’t get this done because they don’t know what others in the group are doing. “It’s completely about the system,” says Ashish.
He continues depressing us: About 10% of people admitted to hospitals suffer an injury there. One in four doctor visits lead to medication injury. (Ashish says he’s not confident in that study.) 44k-98k deaths come from medical errors.
His conclusion: The quality of care is unacceptable.
Why? 1. Because we pay for the quantity, not quality, of health care. 2. Care has gotten complex, but the health care systems haven’t kept up. 3. Little transparency. E.g., usually we don’t usually know how much our medical care actually costs (as opposed to what our co-pay is). We know how much health care for our pets costs, but not for our children. 4. No adequate feedback loop: Medical malpractice has been a failure and regulation sets the bar too low.
Ashish talks about one part of the response: The Ny State Cardiac Surgery reporting program. In the early 1990s, NY found huge disparities in cardiac surgery mortality across 31 hospitals: 1 in 200 dying vs. 1 in 14. So the state started publishing mortality info about every hospital and surgeon. As of about 2000, it’s all on the Internet. Over the course of 12 years, the rates dropped dramatically. Why? The market share of the hospitals didn’t change; the bad hospitals didn’t lose business. But the hospitals now had data that reinforced good practices. There’s anecdotal data that physicians began to learn from one another. Most dramatically, the rate of surgeons leaving their practices among the bottom fourth was way higher. Ashish’s project tracked them: Some quit, some moved. Even after adjusting for age, etc., people in the bottom quarter were 3x likely to quit.
People don’t check the ratings. Ashish thinks this is a place where the Internet could help.
90% of hospitals are still paper-based. Even those that are electronic can’t share info. The law says patients always have a right to get their records, but the doctor or the hospital owns the record. Patients can view it but it’s not in exportable, shareable form. (There’s a discussion about the state of electronic health records and why it’s a more complex problem than it seems.)
Ashish says that the HQA initiative has hospitals reporting on 23 quality indicators, and performance has improved steadily. HCAHPS makes patient experience data available.
Gene Koo: Health care decisions aren’t made by purely rational agents. All sorts of quirks come into it. So, how does the transparency of info help us?
A: Maybe consumer involvement in health care won’t work out. I’m looking for empirical data.
Q: What’s the role of the consumer in this? Are there data now that consumers are taking on more of the responsibility for their health care?,br>
A: People on the right say that consumers aren’t behaving like consumers because they don’t have any skin in the game. You don’t know how much things cost. So, we need transparency (they say), linked to having skin in the game (i.e., you pay for visits out of your pocket). But, few have high deductible health plans. My personal feeling (says Ashish) is that this isn’t going to be big. People are generally in them not because they want to be involved but because the plans are cheap.
Rob Faris: There’s a huge role for intermediaries. Intermediation is not working well right now. We need intermediaries who looks at outcomes and figures out what works and what doesn’t. And I’d like to see how quality considerations can be inserted into this.
A: We’re at the beginning of a very interesting journey. If someone like you can’t navigate the health care system…
Q: What do you think of the candidates’ positions?
A: They all talk about the uninsured, which is just one part of a complicated set of issues. We have 47M uninsured because health care is expensive. Most of the health experts I talk with think Clinton’s health plan is a little more realistic. But all of this falls apart if we can’t get a grip on healthcare costs. They’re rising at twice the rate of inflation, and neither Obama nor Clinton have gotten serious about healthcare costs.
Q: (me) How do you contain costs?
A: Electronic records would help. Payers should pay more for outcomes not for particular tests, etc. And there;s a whole “comparative effectiveness” movement. E.g., what do you do for someone with low back pain? You get different treatments based on locality. Payers should start taking more of an active role. But payers have not wanted to take up that responsibility.
A (person in the audience): Part of the answer is that the amt of money spent in the last 6 months of life is shockingly high. We should spend more earlier on preventative measures.
Ashish: You don’t always know when the 6 months are. And there’s a huge issue around managing expectations at the end of life. Plus, when someone else is paying…From a policy point of view, it’s very hard to fix this stuff. Even though health reform comes up every five years, it doesn’t get done because the status quo is everyone’s second choice.
March 24, 2008
Solana Larsen has a fabulous idea. For those of us vegetarians who love faux meat, why doesn’t a restaurant serve up something besides the usual mock chicken, beef, pork, etc.? Why not faux endangered species? Solana suggests a menu…
March 22, 2008
I am so disappointed that I had to miss Lisa Stone’s Berkman talk. She’s blogged a transcript here, and pretty soon the video will be up here. Sounds like a great talk…
March 19, 2008
Jeff Jacoby, a conservative columnist for the Boston Globe, is angry at Obama and at those who cheered his speech. We (I not only cheered, I wept) are guilty of accepting a double standard because, says Jacoby, if our clergyman had said the hateful things that Wright did, we would not have sat quietly in our pews for twenty years. Yet, we are willing to give Obama a pass. Obama not only should have objected to Wright’s words all along the way, he should have left the church or worked to get Wright fired, just as Jacoby would have done if his rabbi had said equally awful things.
I know Jacoby’s synagogue. It’s in my neighborhood. I’ve been there. It’s lovely. Airy. Light. It’s in Brookline, a terrific part of greater Boston. Jacoby’s synagogue’s got comfortable seats, pretty ornamental touches, and a well-dressed, affluent, overwhelmingly white congregation.
The notion of a double standard assumes, in an odd way, a single standard. The criticism only makes sense within contexts uniform enough that our moral judgments should be the same. If I condemn a Democratic governor for paying for sex but excuse a Republican congressman for the same offense, then I’m guilty of applying a double standard.
But Jacoby apparently didn’t hear what Obama said in his fearless, epochal speech. Who is this “we” who applied a double standard? Our glorious union is nevertheless imperfect because it is riven by divisions deeper than we are comfortable acknowledging. The racial division is so deep that politicians never talk about it except in platitudes so empty that they function as lies. Now Obama has.
If we apply a single standard, we are denying the fact that synagogues in Brookline are very different from African-American churches in Illinois. We can, and should, express our strong disagreement with the particularities of Wright’s sermons, but if we stop there — and every political advisor in the land would have urged Obama exactly to stop right there — we will continue in our fantasy that there is a single culture, a single set of values, a single set of assumptions, a single view of history, a single vision of the future, a single set of constraints, a single set of opportunities for all in our imperfect union.
Obama is asking us to do what is perhaps hardest. What it takes adults to do. Obama’is speech asks us to embrace difference and simultaneously to transcend it. That’s why Obama presented contexts that not only helped us white Jews in Brookline understand why a Black pastor might say such things, but also acknowledged how African-Americans can seem to white folks who don’t see why they should be disadvantaged for crimes they did not commit.
Unless we accept double, triple, multiple standards, we are invisible to one another, and thus to ourselves. The thoughtless insistence on a single standard is unseemly and unhelpful, especially when it comes from those who live in privilege for whatever reason.
Jeff, you and I live in what is pretty much a white part of Boston. As far as I can tell, Brookline has made little progress in integrating itself in the twenty years I’ve lived there. We’re stalled. Stuck. Now, who did I hear talking about this just yesterday?
What a tragedy it would be to throw away the hope Sen. Obama presented us yesterday. It, at long last, gives us a way forward.
March 18, 2008
I just watched Obama’s speech on race. Before the commentariat bashes the speech into a shape they can sell for the next few cycles (Wolf Blitzer: “It was a preemptive strike” – feh!), I want to say that I thought this was a fearless speech that shows the way forward on the issue we Americans fear more than death, taxes, and terrorism.
I listened thinking about what Obama chose not to say. He could have condemned racism and tried to put the whole race issue behind him, as Mitt tried to remove religion as an issue. Instead he seized the moment and put a push-pin into the timeline: Here’s where we started to confront in public the racial divides the majority culture has refused to acknowledge.
He could have given simple platitudes. Instead he trusted us with the complex truth. Think how any other major politician would have handled this.
And we saw a bit of how the audacity of hope can not only move us, but move us forward.
March 15, 2008
I can’t say much makes me happier than this photo of the One Laptop Per Child laptop I donated in the hands of its owner. (I had done the “buy two, get one” program, and then donated the laptop they’d sent me. That’s the one you see here.)
Thank you, Waveplace, for doing this, and for letting me see what you do.
(I am on the road and have not yet seen either of the two videos available (1 2)). [Tags: xo olpc waveplace haiti]
March 11, 2008
Here’s the society for all you Puerto Rican Danes and Danish Puerto Ricans. Heck, it’s even got its own refrigerator magnets. [Tags: puerto_rico denmark everything_is_miscellaneous]
February 28, 2008
Clay Shirky is giving his book talk. Here Comes Everybody was released today. It’s immediately necome #1 at two Amazon lists. [Note: I’m typing quickly, getting things wrong, paraphrasing, etc. For an accurate report of what Clay’s book is about, please read Clay’s book.]
The Internet isn’t a decoration on society. It is a challenge. It is important on the order of print and broadcast. Previous media either were two way or they didn’t create groups. Now we have a network that is natively good at group forming. And this medium contains the contents of the others. In a single bullet point his book says: “Group action just got easier.”
Humans are great at forming groups. But they get complicated faster as they get large. A workgroup of 10 has four times more connections than a group of five. There are native disabilities once a group passes a certain size. The typical answer has been to install a hierarchy. Now we’re seeing a set of tools that make it easier to create large groups: Ridiculously easy group forming. E.g., email unexpectedly became the dominant service used on the original Internet. That was because of the “reply all” button, a social feature.
But there’s been an enormous social lag. This tech has not transformed society as rapidly as it might. That’s because groups are innately conservative. No one wants a protocol that shuts out group members. It needed to become ubiquitous and boring. That’s when the social effects become interesting. Clay tells the story of his parents’ first date, a story that is not about internal combustion engines but that depends on the presence of them. We needed the Net to be always present and invisible for it to have its social effect.
Sharing, conversation, collaboration, collective action are rungs on a ladder: How much does an individual have to work to coordinate with the group?
Sharing. E.g., Delicious.com has urls, users and tags. It lowers the difficulty of sharing, so the social effects are practically unintended. It’s “me-first” collaboration (cf. Stowe Boyd).
Tagging systems let you share and then aggregate, reversing the traditional order. E.g., the mermaid parade in Coney Island. Since Flickr added tagging in 2005, you can click mermaidparade and get all the photos. The photographers weren’t coordinated ahead of time. Sharing has become a platform for coordination, rather than vice versa.
The next rung up the ladder is conversation, i.e., people actually synchronizing with one another. Clay shows a “communty of practice” at Flickr: High Dynamic Range photography at Flickr. Pre-Web, it would have taken 5-7 yrs from a pro photographer figuring it out to people in the street doing it. At Flickr, it took 3 months because when a photo went up, people could talk and ask how it was done. People post photos, etc. The medium becomes the platform for a community practice where people help one another get better. No commercial incentive.
That’s an example of “every url is a link to a community.” The discussion can turn into a group sharing resources. Clay points to bronzebeta.com, a Buffy site. It came after the Bronze bulletin board shut down. The fans raised money for new software to create their own bronze. They told the designers not to give it any features: no ratings, no identity mgt. They just wanted the system they used to have, a very basic discussion board.
He also points to Aegisub, a project that required a division of labor. It was a huge collaborative effort without a commercial motivation, or an anti-commercial motivation. Their success resulted in making themselves unnecessary.
The fourth rung is collective action. That’s coming. Three stories:
In Jan, 1999, a Northwest flight was stuck on the tarmac fo 7.5 hours. NW signs a toothless bill of passenger rights. Same thing happened last year and it resulted in legislation. What happened? Kate Hanni was on the second plane. She googled for articles about the flight. She comments on all of them, in detail. At the end of each comment, she asked others on the flight to contact her. She’s coopted the media and turned them into sites for coordination. She goes around to legislators’ offices. William James, the philosopher, once said “Thinking is for doing.” We have brains because we’re deciding between courses of action. Now publishing is for acting.
Second, flash mobs started as a critique of hipster culture. The guy who started them said he could get people to do anything at all if you tell them that it’s a protest against the bourgeoisie. It spread to Belarus: They’d go to a square in Minsk eating ice cream in January. Cops arrested them. It was illegal to form groups in October Sq. The kids turned the joke on hippies into a genuine form of dissident action. They provoked the government into reacting, and documented it. Media led to collective action, and the action led to more media. They thought publicity would make a difference, but the West turned out not to care much about Eastern European dictatorships. The tools are very different when deployed in high or low freedom environments. (They’d also done a flash mob where people walked around October Sq smiling.)
Third, a group ran around Palermo putting up stickers protesting the prominence of the Mafia. It was a big story. Now they’re reversing it. They put up a Web site at which businesses can agree to refuse to pay the protection money. If an individual business were to do this, the Mafia would act. They also let citizens search the site for businesses who’d signed.
So, ridiculously easy group forming improves sharing, convesation, collaboration and collective action. Clay is watching now and in the future to see how collective action evolves, for that is the hardest but could be the most important.
Q: Privacy?
A: Privacy cuts across all of this. The higher up the ladder you go, the more important it matters. For sharing, privacy doesn’t matter much, but if we’re going to converse, I at least need a handle. To collaborate, I need to know more. But if we’re going to bind ourselves in collective action, then identity becomes really important. [Hmm. That last point seems wrong. In some collective action, we don’t need to know much about others. E.g., a flash mob of kids eating ice cream.] Privacy isn’t all or nothing. Under what circumstances do we want people in a collective action to know one another, but not be known by others. The big change in privacy is not in opt-in or opt-out; it’s that we’ve lost “don’t ask.”
Q: Yochai Benkler is working on whether you can explain this other than by enlightened self-interest?
A: There’s a growing literature on explaining behavior via social motivations. Behavioral economics is unambiguous about the ultimatum game: People will refuse deals that seem unfair, even if they’re in their interest.
Q: But social cohesion is to my benefit …
A: What you’d really like to be in a group that produces public goods but not have to contribute. But the willingness of people to spend resources to keep social cohesion going cannot be rolled up just to individual enlightened self-interest. [Missed some of that. Sorry.]
Q: What are the downsides you see?
A: I used to be a cyber-utopian. That view broke for me. I was teaching a class at NYU on social software. One of my students was a community manager for a magazine for teenage girls. They were shutting down the health and beauty boards because we can’t get the pro-anorexia girls to shut up with tips about how to avoid eating. I was thinking this isn’t a side effect of the Net. It was an effect. Ridiculously easy group forming for anorexics. Now, we have to move to a publish-then-filter world. That pattern suggests we’re moving the media world from decision to reaction. We can’t stop the pro-anorexia groups from forming. All we can do is watch and act.
A: My nightmare is that the advertising budget for print shrinks and we lose newspapers in mid-size American cities. We lose investigative journalism. Every city under a million goes back to endemic civic corruption. The newspaper industry is not ready now to talk about how to save investigative journalism as we lost print.
Q: [couldn’t hear it]
A: The social media being used in the presidential campaign is less social than before. Obama excels at fund raising, and public-created media. But no one has proposed a policy wiki. No one has proposed the lateral conversation among supporters. (I’m an Obama supporter.) There may be an opportunity in the first 100 days to do social production of shared ideas, which the campaign has not done so far. But I don’t think it can get there without creating a profound cognitive dissonance among the voters.
Have you looked at the mechanics of collective action?
A: The things that are working now are hard to fake, non-professional surprises. Someone has done something you couldn’t do with a fake grassroots campaign. Most email campaigns to the Senate are of zero value because they’re too easy to fake. [Hmm. It’s not that they’re hard to fake. It’s that they had a cost.] The thing that worries most is the need to be surprising, because surprise is a wasting asset, because you can’t be surprising three times in a row.
Q: [me] Why did you choose the axis of groups that take actions? I can feel I’m a member of the Group That Likes Obama without actually doing anything…
A: I’m interested in the trade-off between individuals and groups. At what point can you not explain behaviors through individual psychology. I was irked by businesses that think they have communities instead of cusomters. The dividing line is between people who change their behavior because they’re in a group and those who don’t.
Q: Mobile streaming and virtual worlds. How do they fit into collective action?
A: The change in things we can do via mobiles will be far broader. And I don’t think there is such a category as virtual worlds. All successful virtual worlds are games.
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