The Turing Test Falls: Implications for Health Care Decision Support

In the futuristic movie Blade Runner, Detective Rick Deckard's (played by Harrison Ford) skill at "retiring" renegade robotic replicants depends on a series of trick questions that are designed to detect an "empathic" response. While the soulless robots routinely fail the test, the highly advanced Nexus-6 models still seem to be eerily human. While Deckard violently terminates three of the robots, lingering questions over just what is "human" leads him to fall for vulnerable sexy replicant Rachael.

While the Population Health Blog ponders that, along comes the news that a Russian chatbot computer passed the Turing test. More than 30% of the humans who engaged in a text-only "conversation" with the program thought it was being controlled by a 13 year old boy. Not only was the computer able to organize facts and sentences, it also responded with the subtle nuances that underlie typical "human" communication.

While the PHB is weirded out, it is not surprised. In the book The Second Machine Age, authors Erik Brynjolfsson and Andrew McAfee note the doubling of computers' processing power can be likened to the ancient story of doubling wheat seeds on the squares of a chess board.  They point out that the amount of wheat (or processing power) can be grasped until you get to the "second half" of the board: that's when the amounts become staggering and the implications start getting weird.

They point out that computing power has now entered that second half. Quadruped "mule pack" machines can carry payloads across unfriendly landscapes, entire factories can manufacture complex items at a fraction of the cost and Watson can win Jeopardy matches. 

And now, Turing has fallen.

This is good news for health care.  "Second half" decision support in electronic health records is better able to focus on a more likely differential diagnosis, suggest a more accurate series of tests and tailor treatment at the point of care. The good news is that medicine will finally become faster, better and cheaper.  While some may fret about the loss of the "human touch" (or jobs) in this brave new world of the doctor-patient relationship, Brynjolfsson and McAfee point out that when human intelligence is combined with the resources of high performing information technology, the product is better than either alone.  For example, a chess master plus a high-end chess program can beat either alone. 

The same will be true in medicine: smart doctors plus nuanced health information technology will be better than either alone.

Just like in Blade Runner. Thanks to each other, both Deckard and Rachael are better... humans.

Image from Wikipedia

More Big Insights on Big Data

Given the data, what are her chances of
getting breast cancer?

Unable to sate its big appetite for big data insights, the Population Health Blog glommed onto the New England Journal's just-published article on "Learning from Big Data."

As noted previously, "big data" is the use of statistical associations ("predictors") in a) large and b) disparate data sets  to gain insights at the individual level ("outcomes"). For example, a physician could know the likelihood - based on demographic, clinical and economic inputs - that a particular patient won't fill a prescription. As an other example, the PHB spouse could know the likelihood - based on prior active-passive behaviors, incentives and maternal upbringing - the likelihood, despite numerous reminders, that her husband will "forget" to take out the trash.

It's important to recall that big data is not about causality. Just because living in a certain zip code is an independent predictor of obesity (for example) doesn't mean living in [insert name of town] causes residents to be fat. Big data is "agnostic" about the cause, but that doesn't mean Big Data Architects (BDAs) can't use the information.

According to the author, the road from the promise to the reality of big data will be lined with:

1. generalizability, or being confident that the populations used in big data studies are similar to the populations where their lessons are being applied. Propensity matching or scoring is a good step in that direction;

2. automation, so that multiple questions can be answered simultaneously by many users;

3. "data refreshes," so that associations can be retested on repeated basis as new data come on line;

4. ease-of-use, so that even an orthopedist could use the software and understand the outputs.*

Politically, we'll also need to get

5. the owners of data warehouses - including the electronic health record vendors and insurers - to agree on either a) common data formats or b) methods that allow for the interpretation of data regardless of the format. An example of the latter the use of an order, entry or insurance claim for supplemental oxygen therapy as a marker of poor health status.

6) a resolution of our absolutist privacy "impasse.""De-identification" of patients' information makes it possible, but never guaranteed, to keep personal health information secure.

*okay, the New England Journal author didn't poke fun at the orthopedists by saying that, but the PHB couldn't resist. By the way, one way to do this would be to have the outputs be in pictures.

Image from Wikipedia

DITCH THE BITCH

Life is hard and challenges are put in our path almost daily.  It is those life events that occur over several days, months, or even years that can zap the crap out of us.  I realize that it can be difficult to remain positive or refrain from “bitching” for lack of a better word about the circumstances of life that can bring us down.  I have journeyed through the ups and downs of what has felt like huge ocean waves and have been brought to my knees on several occasions, and yes, I am guilty of a bitch or two or more. It can feel frustrating, hurtful, painful, and unfair when we are tossed into the sea of confused human emotion and circumstances.

What I will share is that “bitching” about it will not change a thing, and in fact, usually makes life feel worse as negative emotions try to take over our very being.  This is when we tend to lash out, make poor choices, and even grab for those comfort foods that are supposed to fix everything when life feels bigger than us.  Life does not come with an “easy” button, but our successes in life are achieved through how well we weather the storms that slap up us in the face and knock us on our butts. 

It is one thing to be physically strong, but I will share that mental strength is what will carry us through life.  Life is “10 percent what happens to us and 90 percent how we respond to it” so if we are bitching about the circumstances and wearing that “why me?” attitude, that eliminates all possibilities to learn and grow from the situation.   “Why or poor” me creates a life of bitterness and resentment, and can scar deep and for many years.  Looking at a situation and saying “I do not like this, BUT what can I learn from this to become a better person” will bless our lives in so many ways.  We will never be able to see the end game and that is where faith comes into the picture.  We can help with the outcome through our attitude however.  If we “Ditch the Bitch” and take on a mental game of “I CAN get through this” no matter what, then you have won already. 

This applies to all areas of life including getting healthy, weight loss, illness, overcoming injury, job loss, and broken relationships just to name a few.  We are all here living a life that we think should happen for us, but we truly do not have control of so many things in this life.  Realizing that we can only control our responses to the uncontrollable is what creates a better self, a healthier and stronger person overall.   Keep in mind that when we are living this journey of life and reaching for goals, it is not in the bitching that the positive stuff happens.  Time to “Ditch the Bitch” and Stay Healthy!

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

StayHealthy!

Darla

Calorie Intake and Body Fatness on Unrestricted High-fat vs. High-carbohydrate Diets

In recent posts, we've explored the association between calorie intake and the US obesity epidemic, and the reasons why this association almost certainly represents a cause-and-effect relationship.  I also reviewed the evidence suggesting that carbohydrate and fat are equally fattening in humans, calorie for calorie.

One valid objection that came up in the comments is that calorie-controlled diets in a research setting may not reflect what happens in real life.  For example, in a context where calorie intake isn't tightly controlled, diet composition can impact calorie intake, in turn affecting body fatness.  This, of course, is true, and it forms one of the central pillars of our fat loss program the Ideal Weight Program.

Some low-carbohydrate diet advocates argue that the obesity epidemic was caused by US dietary guidelines that emphasize a carbohydrate-rich diet*.  The idea here is that the increase in calorie intake was due to the diet shifting in a more carbohydrate-heavy direction.  In other words, they're hypothesizing that a carbohydrate-rich eating style increases food intake, which increases body fatness**.  According to this hypothesis, if we had received advice to eat a fat-rich diet instead, we wouldn't be in the midst of an obesity epidemic.

Fortunately for us, this hypothesis has been tested-- many times!  Which eating style leads to higher calorie intake and body fatness when calories aren't controlled: a carbohydrate-rich diet, or a fat-rich diet?

Short-term Studies

Read more »

Looking Ahead to the Second Enrollment Wave of Obamacare This Fall

Big or small?

The latest just-published edition of Health Affairs has a sobering reminder written by Tricia Brooks ("Open Enrollment, Take Two") that the healthcare marketplace wars will recommence on November 15.

That's when open enrollment starts all over again. While the good news is that more than 7 million people got health insurance through the on-line marketplaces, the bad news is that there are now 7 million people who will have to use the process again to get their insurance renewed.

While Dr. Brooks is generally upbeat and hopes our politicians will put their constituents first, the Population Health Blog asks.... what could possibly go wrong?

What the PHB learned.....

Development work isn't finished yet.  The back-room and behind-the-scenes web machinery dealing with application questions, required consumer notifications and eligibility issues are continuing to get tweaked. In addition, the Feds are working to upgrade the electronic and other processes that are necessary to verify identity and immigration status. Plus, it has yet to be fully integrated with the commercial marketplaces, Medicaid and the CHIP agencies.

It is also possible that during the renewal process, persons who underestimated their income in the process of applying for tax credits may be subject to claw back, and the individual mandate's tax penalty will rear its ugly head.  We don't know how consumers will react.

It also remains to be seen how many consumers will understand the financial assistance or miss the deadline. Look to the Administration launch reprise of a marketing campaign that encourages "tell your friends and family" word-of-mouth.

And then there is no guarantee that many states will want to - or be able to - fully cooperate.

What went unmentioned is the "wild card" of the fall political campaign.  All of the members of the House of Representatives, a third of the Senate and many Governors will be spinning Obamacare.  Thanks to the fog of political war played out our TV screens, individuals may be entering the open enrollment period with a whole new set of opinions and apprehensions.

Stay tuned!

Perspectives on Exercise for Elders

Despite its busy travel schedule, the Population Health Blog had a chance to check out "Lifestyle Interventions and Independence for Elders" (or "LIFE") study that was published online in the May 27 issue of JAMA.

Over 14,000 persons over the age of 70 were screened at 8 medical centers for participation in the study.  To be eligible, candidates had to be sedentary (less that 20 minutes a week of regular physical activity), mobile (could walk 400 yards over 15 minutes), without any cognitive impairments and otherwise medically fit.

Participants were randomly assigned to either:

1) The exercise intervention, which consisted of 2 classes per week plus individualized home-based activity 3 to four times a week.  The goal was to achieve 30 minutes of walking daily, 10 minutes of leg lefts using ankle weeks and 10 minutes of balance training.  The cost was $1815 per participant per year.

2) The education intervention, which consisted of weekly workshops for 26 weeks with monthly sessions for follow up.  The classes included 10 minutes upper extremity stretching and flexibility exercises

Of the 1635 who were accepted, 818 were randomly assigned to the "exercise" group, while 817 were assigned to the "education" group. The average age of the participants was 79 years, approximately two thirds were women, 18% were African-American and the average body mass index was a hefty 30.

After an average of 2.6 years, more than half (59%) went on medical leave of variable duration.  Ultimately 63% of the sessions were attended. Loss to follow-up averaged 4% per year. Yet, using an intention to treat analysis, the authors found that ultimately 70% of those in the physical activity group were able to complete the 400 yards vs. 65% in the health education group. 

That 5% difference amounts to a "number necessary to treat" or NNT of approximately 20.

The PHB's takeaways:

1) This was an elegant study that demonstrates exercise for the elderly can lead to a clinically and statistically significant reduction in age-related declines in mobility.  We've intuited that "exercise is a good thing" for grandma, but now we know it.

But there is bad news:

2) Lest anyone believe that this single piece of evidence will prompt the U.S. health care system to cover preventive exercise classes for the elderly: it won't.  Medicare's definition of "medically necessary" is too full of loopholes ("condition," "accepted standards" and "coverage decisions") and is being held hostage by  Medicare's vast and hidebound bureaucracy.

3) The criteria were relatively narrow (already able to walk 400 yards and without any co-morbid conditions) and the exercise program was unique.  Would persons only able to walk 300 yards benefit from a less proscribed version of LIFE?  How about persons with diabetes? We don't know.

4) $1815 per member per year or $151 per member per month, whatever the merits of LIFE, is unaffordable.  If that was 818 persons in an average Medicare Advantage health plan, that's almost $1.5 million in additional expense to ultimately benefit 5%, or about 40 individuals.

5) The bad news is that with or without exercise, about a third (30% and 35%) of otherwise mobile, if sedentary, healthy seniors are destined to experience a significant decline in that mobility. 

Bikini Competition Suit

Last week, I went to order my bikini competition suit at Stakked Couture in Houston, at the recommendation of my trainer and posing coach.  Lining the walls when you walk in is a sample of the type of bikinis they make.  It was explained to me that for the "bikini" division, the women wear bikinis with "connectors" (the blingy side things) as opposed to a "figure" or "bodybuilding" suit, that has the high "V" sides that connect with the bikini top in the back.  I had no idea. 

I had to fill out a form with my measurements, anticipated contest weight (I'm 108 now when I weigh at the gym, but I'm 104 at home first thing in the morning).  I guessed 104 (gym scale) for my contest weight.  

Then, I had to choose my fabric color.  

I originally had in mind that I would wear turquoise, but still wanted to see what they had.  Upon seeing their selection, I knew right away I didn't want pink, orange, or yellow.  I considered purple for a minute, and possibly red, but stuck to my original idea.  Below is a sample of the fabric I choose.  

The salesperson asked, "Do you want a regular bottom or pro bottom?"  "What's the difference?" I replied.  She showed me an example of a regular bottom that was so tiny, I was stunned speechless for a second.  I mean, I knew the bikinis were small, but when I was looking at it in person, I was just in shock.  This freaked me right out into thinking, I better get my ass in shape fast if I'm going to be wearing one of those.  The pro bikini bottoms are even smaller, so I'm going with the regular.

Then, you choose your connectors (they have various styles). I opted to wait until my bikini fitting in two weeks to pick the connectors.  That way, I can see more of how they will look on.  I like the drapey connectors like in the photo below, but she said they make short girls' legs look shorter.  Boo. 

via

I'll probably end up doing something simple like the connectors on Amanda Latona's suit below.

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I'm really nervous to go back for my fitting.  I'm doing everything I can to have no regrets about this bikini prep, so my best just has to be good enough.  I'm also concerned about that crazy spray tan and am considering using a makeup pro to do my makeup- even though I usually like how I do my own.  My posing coach (a black female) keeps reminding me, "you're gonna be my color" and she really wants me to use her makeup artist to do my makeup.  They have makeup artists at the show that you can hire.  

This week is 5 weeks out.  I posted a progress pic on Instagram (@honeywerehome), but I'll do another recap here soon too.  Have a great week!