Category Archives: entrepreneurship

Artificial intelligence meets the C-suite

Artificial intelligence meets the C-suite

http://www.mckinsey.com/Insights/Strategy/Artificial_intelligence_meets_the_C-suite

Jeremy Howard: Today, machine-learning algorithms are actually as good as or better than humans at many things that we think of as being uniquely human capabilities. People whose job is to take boxes of legal documents and figure out which ones are discoverable— that job is rapidly disappearing because computers are much faster and better than people at it.

In 2012, a team of four expert pathologists looked through thousands of breast-cancer screening images, and identified the areas of what’s called mitosis, the areas which were the most active parts of a tumor. It takes four pathologists to do that because any two only agree with each other 50 percent of the time. It’s that hard to look at these images; there’s so much complexity. So they then took this kind of consensus of experts and fed those breast-cancer images with those tags to a machine-learning algorithm. The algorithm came back with something that agreed with the pathologists 60 percent of the time, so it is more accurate at identifying the very thing that these pathologists were trained for years to do. And this machine-learning algorithm was built by people with no background in life sciences at all. These are total domain newbies

 

Artificial intelligence meets the C-suite

Technology is getting smarter, faster. Are you? Experts including the authors of The Second Machine Age, Erik Brynjolfsson and Andrew McAfee, examine the impact that “thinking” machines may have on top-management roles.

September 2014

artThe exact moment when computers got better than people at human tasks arrived in 2011, according to data scientist Jeremy Howard, at an otherwise inconsequential machine-learning competition in Germany. Contest participants were asked to design an algorithm that could recognize street signs, many of which were a bit blurry or dark. Humans correctly identified them 98.5 percent of the time. At 99.4 percent, the winning algorithm did even better.Or maybe the moment came earlier that year, when IBM’s Watson computer defeated the two leading human Jeopardy! players on the planet. Whenever or wherever it was, it’s increasingly clear that the comparative advantage of humans over software has been steadily eroding. Machines and their learning-based algorithms have leapt forward in pattern-matching ability and in the nuances of interpreting and communicating complex information. The long-standing debate about computers as complements or substitutes for human labor has been renewed.

The matter is more than academic. Many of the jobs that had once seemed the sole province of humans—including those of pathologists, petroleum geologists, and law clerks—are now being performed by computers.

And so it must be asked: can software substitute for the responsibilities of senior managers in their roles at the top of today’s biggest corporations? In some activities, particularly when it comes to finding answers to problems, software already surpasses even the best managers. Knowing whether to assert your own expertise or to step out of the way is fast becoming a critical executive skill.

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Managing in the era of brilliant machines: An interview  

Managing in the era of brilliant machines: An interview

In this interview with McKinsey’s Rik Kirkland, Erik Brynjolfsson and Andrew McAfee explain the organizational challenge posed by the Second Machine Age.

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Yet senior managers are far from obsolete. As machine learning progresses at a rapid pace, top executives will be called on to create the innovative new organizational forms needed to crowdsource the far-flung human talent that’s coming online around the globe. Those executives will have to emphasize their creative abilities, their leadership skills, and their strategic thinking.

To sort out the exponential advance of deep-learning algorithms and what it means for managerial science, McKinsey’s Rik Kirkland conducted a series of interviews in January at the World Economic Forum’s annual meeting in Davos. Among those interviewed were two leading business academics—Erik Brynjolfsson and Andrew McAfee, coauthors of The Second Machine Age: Work, Progress, and Prosperity in a Time of Brilliant Technologies (W. W. Norton, January 2014)—and two leading entrepreneurs: Anthony Goldbloom, the founder and CEO of Kaggle (the San Francisco start-up that’s crowdsourcing predictive-analysis contests to help companies and researchers gain insights from big data); and data scientist Jeremy Howard. This edited transcript captures and combines highlights from those conversations.

The Second Machine Age

What is it and why does it matter?

Andrew McAfee: The Industrial Revolution was when humans overcame the limitations of our muscle power. We’re now in the early stages of doing the same thing to our mental capacity—infinitely multiplying it by virtue of digital technologies. There are two discontinuous changes that will stick in historians’ minds. The first is the development of artificial intelligence, and the kinds of things we’ve seen so far are the warm-up act for what’s to come. The second big deal is the global interconnection of the world’s population, billions of people who are not only becoming consumers but also joining the global pool of innovative talent.

Erik Brynjolfsson: The First Machine Age was about power systems and the ability to move large amounts of mass. The Second Machine Age is much more about automating and augmenting mental power and cognitive work. Humans were largely complements for the machines of the First Machine Age. In the Second Machine Age, it’s not so clear whether humans will be complements or machines will largely substitute for humans; we see examples of both. That potentially has some very different effects on employment, on incomes, on wages, and on the types of companies that are going to be successful.

Video

Putting artificial intelligence to work: An interview with Anthony Goldbloom and Jeremy Howard

Machine-learning experts Anthony Goldbloom and Jeremy Howard tell McKinsey’s Rik Kirkland how smart machines will impact employment.

Jeremy Howard: Today, machine-learning algorithms are actually as good as or better than humans at many things that we think of as being uniquely human capabilities. People whose job is to take boxes of legal documents and figure out which ones are discoverable— that job is rapidly disappearing because computers are much faster and better than people at it.

In 2012, a team of four expert pathologists looked through thousands of breast-cancer screening images, and identified the areas of what’s called mitosis, the areas which were the most active parts of a tumor. It takes four pathologists to do that because any two only agree with each other 50 percent of the time. It’s that hard to look at these images; there’s so much complexity. So they then took this kind of consensus of experts and fed those breast-cancer images with those tags to a machine-learning algorithm. The algorithm came back with something that agreed with the pathologists 60 percent of the time, so it is more accurate at identifying the very thing that these pathologists were trained for years to do. And this machine-learning algorithm was built by people with no background in life sciences at all. These are total domain newbies.

Andrew McAfee: We thought we knew, after a few decades of experience with computers and information technology, the comparative advantages of human and digital labor. But just in the past few years, we have seen astonishing progress. A digital brain can now drive a car down a street and not hit anything or hurt anyone—that’s a high-stakes exercise in pattern matching involving lots of different kinds of data and a constantly changing environment.

Why now?

Computers have been around for more than 50 years. Why is machine learning suddenly so important?

Erik Brynjolfsson: It’s been said that the greatest failing of the human mind is the inability to understand the exponential function. Daniela Rus—the chair of the Computer Science and Artificial Intelligence Lab at MIT—thinks that, if anything, our projections about how rapidly machine learning will become mainstream are too pessimistic. It’ll happen even faster. And that’s the way it works with exponential trends: they’re slower than we expect, then they catch us off guard and soar ahead.

Andrew McAfee: There’s a passage from a Hemingway novel about a man going broke in two ways: “gradually and then suddenly.” And that characterizes the progress of digital technologies. It was really slow and gradual and then, boom—suddenly, it’s right now.

Jeremy Howard: The difference here is each thing builds on each other thing. The data and the computational capability are increasing exponentially, and the more data you give these deep-learning networks and the more computational capability you give them, the better the result becomes because the results of previous machine-learning exercises can be fed back into the algorithms. That means each layer becomes a foundation for the next layer of machine learning, and the whole thing scales in a multiplicative way every year. There’s no reason to believe that has a limit.

Erik Brynjolfsson: With the foundational layers we now have in place, you can take a prior innovation and augment it to create something new. This is very different from the common idea that innovations get used up like low-hanging fruit. Now each innovation actually adds to our stock of building blocks and allows us to do new things.

One of my students, for example, built an app on Facebook. It took him about three weeks to build, and within a few months the app had reached 1.3 million users. He was able to do that with no particularly special skills and no company infrastructure, because he was building it on top of an existing platform, Facebook, which of course is built on the web, which is built on the Internet. Each of the prior innovations provided building blocks for new innovations. I think it’s no accident that so many of today’s innovators are younger than innovators were a generation ago; it’s so much easier to build on things that are preexisting.

Jeremy Howard: I think people are massively underestimating the impact, on both their organizations and on society, of the combination of data plus modern analytical techniques. The reason for that is very clear: these techniques are growing exponentially in capability, and the human brain just can’t conceive of that.

There is no organization that shouldn’t be thinking about leveraging these approaches, because either you do—in which case you’ll probably surpass the competition—or somebody else will. And by the time the competition has learned to leverage data really effectively, it’s probably going to be too late for you to try to catch up. Your competitors will be on the exponential path, and you’ll still be on that linear path.

Let me give you an example. Google announced last month that it had just completed mapping the exact location of every business, every household, and every street number in the entirety of France. You’d think it would have needed to send a team of 100 people out to each suburb and district to go around with a GPS and that the whole thing would take maybe a year, right? In fact, it took Google one hour.

Now, how did the company do that? Rather than programming a computer yourself to do something, with machine learning you give it some examples and it kind of figures out the rest. So Google took its street-view database—hundreds of millions of images—and had somebody manually go through a few hundred and circle the street numbers in them. Then Google fed that to a machine-learning algorithm and said, “You figure out what’s unique about those circled things, find them in the other 100 million images, and then read the numbers that you find.” That’s what took one hour. So when you switch from a traditional to a machine-learning way of doing things, you increase productivity and scalability by so many orders of magnitude that the nature of the challenges your organization faces totally changes.

The senior-executive role

How will top managers go about their day-to-day jobs?

Andrew McAfee: The First Machine Age really led to the art and science and practice of management—to management as a discipline. As we expanded these big organizations, factories, and railways, we had to create organizations to oversee that very complicated infrastructure. We had to invent what management was.

In the Second Machine Age, there are going to be equally big changes to the art of running an organization.

I can’t think of a corner of the business world (or a discipline within it) that is immune to the astonishing technological progress we’re seeing. That clearly includes being at the top of a large global enterprise.

I don’t think this means that everything those leaders do right now becomes irrelevant. I’ve still never seen a piece of technology that could negotiate effectively. Or motivate and lead a team. Or figure out what’s going on in a rich social situation or what motivates people and how you get them to move in the direction you want.

These are human abilities. They’re going to stick around. But if the people currently running large enterprises think there’s nothing about the technology revolution that’s going to affect them, I think they would be naïve.

So the role of a senior manager in a deeply data-driven world is going to shift. I think the job is going to be to figure out, “Where do I actually add value and where should I get out of the way and go where the data take me?” That’s going to mean a very deep rethinking of the idea of the managerial “gut,” or intuition.

It’s striking how little data you need before you would want to switch over and start being data driven instead of intuition driven. Right now, there are a lot of leaders of organizations who say, “Of course I’m data driven. I take the data and I use that as an input to my final decision-making process.” But there’s a lot of research showing that, in general, this leads to a worse outcome than if you rely purely on the data. Now, there are a ton of wrinkles here. But on average, if you second-guess what the data tell you, you tend to have worse results. And it’s very painful—especially for experienced, successful people—to walk away quickly from the idea that there’s something inherently magical or unsurpassable about our particular intuition.

Jeremy Howard: Top executives get where they are because they are really, really good at what they do. And these executives trust the people around them because they are also good at what they do and because of their domain expertise. Unfortunately, this now saddles executives with a real difficulty, which is how to become data driven when your entire culture is built, by definition, on domain expertise. Everybody who is a domain expert, everybody who is running an organization or serves on a senior-executive team, really believes in their capability and for good reason—it got them there. But in a sense, you are suffering from survivor bias, right?

You got there because you’re successful, and you’re successful because you got there. You are going to underestimate, fundamentally, the importance of data. The only way to understand data is to look at these data-driven companies like Facebook and Netflix and Amazon and Google and say, “OK, you know, I can see that’s a different way of running an organization.” It is certainly not the case that domain expertise is suddenly redundant. But data expertise is at least as important and will become exponentially more important. So this is the trick. Data will tell you what’s really going on, whereas domain expertise will always bias you toward the status quo, and that makes it very hard to keep up with these disruptions.

Erik Brynjolfsson: Pablo Picasso once made a great observation. He said, “Computers are useless. They can only give you answers.” I think he was half right. It’s true they give you answers—but that’s not useless; that has some value. What he was stressing was the importance of being able to ask the right questions, and that skill is going to be very important going forward and will require not just technical skills but also some domain knowledge of what your customers are demanding, even if they don’t know it. This combination of technical skills and domain knowledge is the sweet spot going forward.

Anthony Goldbloom: Two pieces are required to be able to do a really good job in solving a machine-learning problem. The first is somebody who knows what problem to solve and can identify the data sets that might be useful in solving it. Once you get to that point, the best thing you can possibly do is to get rid of the domain expert who comes with preconceptions about what are the interesting correlations or relationships in the data and to bring in somebody who’s really good at drawing signals out of data.

The oil-and-gas industry, for instance, has incredibly rich data sources. As they’re drilling, a lot of their drill bits have sensors that follow the drill bit. And somewhere between every 2 and 15 inches, they’re collecting data on the rock that the drill bit is passing through. They also have seismic data, where they shoot sound waves down into the rock and, based on the time it takes for those sound waves to be captured by a recorder, they can get a sense for what’s under the earth. Now these are incredibly rich and complex data sets and, at the moment, they’ve been mostly manually interpreted. And when you manually interpret what comes off a sensor on a drill bit or a seismic survey, you miss a lot of the richness that a machine-learning algorithm can pick up.

Andrew McAfee: The better you get at doing lots of iterations and lots of experimentation—each perhaps pretty small, each perhaps pretty low-risk and incremental—the more it all adds up over time. But the pilot programs in big enterprises seem to be very precisely engineered never to fail—and to demonstrate the brilliance of the person who had the idea in the first place.

That makes for very shaky edifices, even though they’re designed to not fall apart. By contrast, when you look at what truly innovative companies are doing, they’re asking, “How do I falsify my hypothesis? How do I bang on this idea really hard and actually see if it’s any good?” When you look at a lot of the brilliant web companies, they do hundreds or thousands of experiments a day. It’s easy because they’ve got this test platform called the website. And they can do subtle changes and watch them add up over time.

So one of the implications of the manifested brilliance of the crowd applies to that ancient head-scratcher in economics: what the boundary of the firm should be. What should I be doing myself versus what should I be outsourcing? And, now, what should I be crowdsourcing?

Implications for talent and hiring

It’s important to make sure that the organization has the right skills.

Jeremy Howard: Here’s how Google does HR. It has a unit called the human performance analytics group, which takes data about the performance of all of its employees and what interview questions were they asked, where was their office, how was that part of the organization’s structure, and so forth. Then it runs data analytics to figure out what interview methods work best and what career paths are the most successful.

Anthony Goldbloom: One huge limitation that we see with traditional Fortune 500 companies—and maybe this seems like a facile example, but I think it’s more profound than it seems at first glance—is that they have very rigid pay scales.

And they’re competing with Google, which is willing to pay $5 million a year to somebody who’s really great at building algorithms. The more rigid pay scales at traditional companies don’t allow them to do that, and that’s irrational because the return on investment on a $5 million, incredibly capable data scientist is huge. The traditional Fortune 500 companies are always saying they can’t hire anyone. Well, one reason is they’re not willing to pay what a great data scientist can be paid elsewhere. Not that it’s just about money; the best data scientists are also motivated by interesting problems and, probably most important, by the idea of working with other brilliant people.

Machine learning and computers aren’t terribly good at creative thinking, so the idea that the rewards of most jobs and people will be based on their ability to think creatively is probably right.

About the author

This edited roundtable is adapted from interviews conducted by Rik Kirkland, senior managing editor of McKinsey Publishing, who is based in McKinsey’s New York office.

Bloomberg: Big Data Knows You’ve Got Diabetes Before You Do

 

http://www.bloomberg.com/news/2014-09-11/how-big-data-peers-inside-your-medicine-chest.html

Did You Know You Had Diabetes? It’s All Over the Internet

Photographer: Rick McFarland/Bloomberg

The headquarters of Acxiom Corp. in Little Rock, Arkansas. The Acxiom list was compiled by various sources, including… Read More

Photographer: Joshua Roberts/Bloomberg

An electronic medical records system.

Photographer: Joe Raedle/Getty Images

An elderly man reached for medication in Florida.

Photographer: Joe Raedle/Getty Images

An elderly woman with her medication in Maine.

The 42-year-old information technology worker’s name recently showed up in a database of millions of people with “diabetes interest” sold by Acxiom Corp. (ACXM), one of the world’s biggest data brokers. One buyer, data reseller Exact Data, posted Abate’s name and address online, along with 100 others, under the header Sample Diabetes Mailing List. It’s just one of hundreds of medical databases up for sale to marketers.

In a year when former National Security Agency contractor Edward Snowden’s revelations about the collection of U.S. phone data have sparked privacy fears, data miners have been quietly using their tools to peek into America’s medicine cabinets. Tapping social media, health-related phone apps and medical websites, data aggregators are scooping up bits and pieces of tens of millions of Americans’ medical histories. Even a purchase at the pharmacy can land a shopper on a health list.

“People would be shocked if they knew they were on some of these lists,” said Pam Dixon, president of the non-profit advocacy group World Privacy Forum, who has testified before Congress on the data broker industry. “Yet millions are.”

They’re showing up in directories with names like “Suffering Seniors” or “Aching and Ailing,” according to a Bloomberg review of this little-known corner of the data mining industry. Other lists are categorized by diagnosis, including groupings of 2.3 million cancer patients, 14 million depression sufferers and 600,000 homes where a child or other member of the household has autism or attention deficit disorder.

The lists typically sell for about 15 cents per name and can be broken down into sub-categories, like ethnicity, income level and geography for a few pennies more.

Diaper Coupons

Some consumers may benefit, like those who find out about a new drug or service that could improve their health. And Americans are already used to being sliced and diced along demographic lines. Lawn-care ads for new homeowners and diaper coupons for expecting moms are as predictable as the arrival of the AARP magazine on the doorsteps of the just-turned 50 set. Yet collecting massive quantities of intimate health data is new territory and many privacy experts say it has gone too far.

“It is outrageous and unfair to consumers that companies profiting off the collection and sale of individuals’ health information operate behind a veil of secrecy,” said U.S. Senator Jay Rockefeller, a West Virginia Democrat. “Consumers deserve to know who is profiting.”

Senators’ Attention

Rockefeller and U.S. Senator Edward Markey, a Democrat from Massachusetts, introducedlegislation in February that would allow consumers to see what information has been collected on them and make it easier to opt out of being included on such lists. In May, the Federal Trade Commission recommended Congress put more protections around the collection of health and other sensitive information to ensure consumers know how the details they are sharing are going to be used.

The companies selling the data say it’s secure and contains only information from consumers who want it shared with marketers so they can learn more about their condition. The data broker trade group, the Direct Marketing Association, said it has its own set of mandatory guidelines to ensure the data is ethically collected and used. It also has a website to allow consumers to opt out of receiving marketing material.

“We have very strong self regulation, we have for more than 40 years,” said Rachel Nyswander Thomas, vice president for government affairs for the DMA. “Regardless of how the practices are evolving, the self-regulation is as strong as ever.”

Yet the ease with which data is discoverable in a simple Google search along with Bloomberg interviews with people who showed up in one such database suggest the process isn’t always secure or transparent.

Open Access

Dan Abate said he never agreed to be included in any list related to diabetes. Two other people on the same mailing list said they didn’t have diabetes either and weren’t aware of consenting to offer their information.

In Abate’s case, neither he nor anyone in his family or household has diabetes and the only connection he can think of for landing on the list are a few cycling events he participated in for a group that raises money for the disease.

“I could understand if I was voluntarily putting this medical information out there,” Abate said. “But I don’t have diabetes, and I don’t want my information out there to be sold.”

Bloomberg found the diabetes mailing list on the website of Exact Data in a section for sample lists that included dozens of other categories, like gamblers and pregnant women. The diabetes list contained 100 names, addresses and e-mails. Bloomberg sent e-mails to all of them, and three consented to interviews. There were no restrictions on who could access the list, available on search engines like Google.

Online Surveys

Exact Data’s Chief Executive Officer Larry Organ said the list posted on its website shouldn’t have included last names and street addresses, and the company has since deleted any identifiable information. He said the data came from Acxiom and Exact Data was reselling it.

The Acxiom list was compiled by various sources, including surveys, registrations, or summaries of retail purchases that indicated someone in the household has an interest in diabetes, said Ines Gutzmer, a spokeswoman for the Little Rock, Arkansas-based company. While Gutzmer said consumers can visit the Acxiom website to see some of the information that has been collected on them, she declined to comment about how any one individual was placed on the list.

Acxiom shares rose less than 1 percent, to $18.66 at the close of New York trading. The company has lost 29 percent of its value in the past 12 months.

Sharing Information

One of the more common ways to end up on a health list is by sharing health information on a mail or online survey, according to interviews with data brokers and the review of dozens of health-related lists. In some cases the surveys are tied to discounts or sweepstakes. Others are sent by a company seeking customer feedback after a purchase. The information is then sold to data brokers who repackage and resell it.

Epsilon, which has data on 54 million households based on information gathered from its Shopper’s Voice survey, has lists containing information on 447,000 households in which someone has Alzheimer’s, 146,000 with Parkinson’s disease, and 41,000 with Lou Gehrig’s disease. The Irving, Texas-based company provides survey respondents with coupons and a chance to win $10,000 in exchange for information on their household’s spending habits and health.

The company will share with individual consumers specific information it has gathered, said Jeanette Fitzgerald, Epsilon’s chief privacy officer.

Suffering Seniors

KBM Group, one of the largest collectors of consumer health data based in Richardson, Texas, has health information on at least 82 million consumers categorized by more than 100 medical conditions obtained from surveys conducted by third-party contractors. The company declined to provide an example of the surveys. KBM uses the information for its own marketing clients, and sells it to other data brokers, said Gary Laben, chief executive officer of KBM.

“None of our clients wants to engage with consumers or businesses who don’t want to engage with them,” he said. “Our business is about creating mutual value and if there is none, the process doesn’t work.”

Data repackaging is extensive and pervasive. The Suffering Seniors Mailing List help marketers push everything from lawn care to financial products. It consists of the names, addresses, and health information of 4.7 million “suffering seniors,” according to promotional material for the list. Beach List Direct Inc. sells the information for 15 cents a name. Marketed as “the perfect list for mailers targeting the ailing elderly,” it contains a breakdown of those with diseases like depression, cancer and Alzheimer’s, according to its seller’s website.

Clay Beach, the contact on Beach List’s website, did not return calls and e-mails over the past month.

‘Confidential’ Clients

Little is known about who buys medical lists since data brokers say their clients are confidential, Rockefeller said at a hearing on the issue in December.

Promotional material for the Suffering Seniors data found by Bloomberg on Beach List’s website initially included a list of users. The names of those users have since been removed.

One customer was magazine publisher Meredith Corp. (MDP), which used the list in a test for a subscription offer for Diabetic Living magazine, said Jenny McCoy, a spokeswoman. Other users have included the American Diabetes Association, which said a small portion of names from the list was given to one of its local chapters, and Remedy Health Media, a publisher of medical websites.

Magazine Advertising

Remedy Health may have used the list to advertise one of its magazines, which has been defunct for several years, said David Lee, the company’s executive vice president of publishing.

A growing source of data fodder are website registration forms that ask for health information in order for a user to access the site or receive an e-mail newsletter.

One such site is Primehealthsolutions.com, which provides basic health information on a variety of conditions. It makes money by collecting data on diseases its users have been diagnosed with and medications they are taking, which people disclose when signing up for the site’s e-mail newsletter.

The site has more than three dozen lists for sale, including a tally of 2.2 million people with depression, 267,000 with Alzheimer’s, 553,000 with impotence, and 2.1 million women going through menopause.

Jason Rines, a co-owner of Prime Health Solutions, said he will share the lists only with those marketing health-related products, like pharmaceutical or medical device makers.

Purchasing Trail

Acxiom said it uses retail purchase history or magazine subscriptions to make assessments about whether someone has a particular disease interest.

Health data collection is troubling to people like Rebecca Price, who has early-stage Alzheimer’s disease. While she now makes no secret of her disease and serves as a member of the Alzheimer’s Association’s early stage advisory group, that wasn’t always the case. Price, a 62-year-old former doctor, said she initially didn’t even tell her husband of her condition for fear word would get out and harm her personally and financially.

“It is a very, very personal diagnosis,” Price said.

Social media is another potential way information can be collected on patients, said Dixon, of the World Privacy Forum, who warns patients to be more careful about what they share on sites like Facebook.

“Don’t ‘like’ the hospital website or comment ‘thank you for the great breast cancer screening you gave me,’” she said. “Under the Facebook policy that is public information and it is in the wild and if someone goes to that site and pulls it off, it is totally public.”

Facebook Policy

While it would be possible for data miners to scrape ‘likes’ and public comments from Facebook Inc. (FB)’s social network, the company said such practice is against company policy and, if discovered, would be blocked.

“We don’t allow third-party data providers to scrape or collect information without our permission,” said Facebook spokeswoman Elisabeth Diana. “Third-party data providers that work with Facebook don’t collect personally identifiable information and are subject to our policies.”

For consumers who want to know what list they may be on, there are limited options. KBM for example doesn’t have the technological capabilities to look up an individual by name and tell them what lists they are on, though they can purge a name from all their lists if requested to do so, said CEO Laben.

Acxiom started a website last year that allows people to view some of the information it has on them. Those who choose to can correct or remove their data.

Epsilon’s Fitzgerald says the best way for consumers to protect themselves is to be more aware of where they are sharing their information and pay more attention to website privacy policies.

“If people are concerned, don’t put the information out there,” Fitzgerald said. “Consumers would be better served if they were educated more on what is going on on the web.”

(A previous version of the story mistated the name of the Direct Marketing Association and corrected the spelling of Facebook spokeswoman Elisabeth Diana.)

To contact the reporters on this story: Shannon Pettypiece in New York atspettypiece@bloomberg.net; Jordan Robertson in San Francisco atjrobertson40@bloomberg.net

To contact the editors responsible for this story: Rick Schine at eschine@bloomberg.net Drew Armstrong

What Uber for healthcare might look like

Interesting take on imagining the future of healthcare.

http://www.kevinmd.com/blog/2014/08/uber-health-care-will-look-like.html

What the Uber of health care will look like

 

Medallion owners tend to fall into two categories: private practitioners and fleet owners. Private practitioners own their own car, have responsibility for maintenance, gas and insurance, and tend to use the cash flow to live while allowing the medallion to appreciate over the course of their career. They then cash out as part of their retirement plan.

Fleet owners have dozens of medallions; they lease or buy fleets of automobiles and often have their own mechanics, car washes and gas pumps. They either hire drivers as employees or, more often, rent their cars to licensed taxi drivers who get to keep the balance of their earnings after their car and gas payments.

In London, taxi drivers have to invest 2 to 4 years of apprenticeship before they can take and pass a test called “The Knowledge.” However, like NYC, finally getting that a licence to operate a Black Cab in London is a hard-working but stable way to earn a living.

Now imagine that someone comes along that can offer all the services of the NYC yellow cab or the London Black Cab directly to the general public, but does not have to own the medallion, own the car or employ the driver. With as much as 70% lower overhead, they provide the same service to the consumer; in fact they are so consumer friendly that they become the virtual gatekeeper for all the taxi and car service business in the community.

How, you ask? Outsourcing the overhead and just-in-time inventory management; they convince thousands of people to drive around in their own cars with the promise of a potential payment for services driving someone from point A to point B. All these drivers have to do is meet certain standards of quality and safety. This new company does all the marketing and uses technology to make the connection between the currently active drivers and those in need of a ride; they provide simple and transparent access to a host of cars circulating in your neighborhood, let you know the price and send a picture and customer rating of the driver, all before he or she arrives, and they process the payment so no money ever changes hands.

This is the premise behind Uber, a very disruptive take on the taxi business. As a recent article in Bloomberg noted, the slower rate of growth in medallion value is already attribute to the very young company; a recent protest by Black Cab drivers in London resulting in an eight-fold increase in Uber registrations.

Now imagine that a new health care services company comes to your community offering population health management services on a bundled payment or risk basis. They guarantee otherwise inaccessible metrics of quality and safety to both large employers and individual consumers. They employ only a handful of doctors, but do not own any hospitals, imaging centers or ambulatory care facilities.

However, they are masters at consumer engagement, creating levels of affinity and loyalty usually found with consumer products and soft drinks. They use a don’t make me think approach to their technology, seamlessly integrating analytics and communications platforms into their customers lives, and offer consumers without a digital footprint a host of options for communications, including access to information and services via their land lines or their cable TV box. They leverage high-level marketing analytics to determine who will be responsive to non-personal tools for engagement, like digital coaching, and who requires a human touch.

Care planning is done based on clinical stratification and evidence; population specific data is used to determine the actual resources required to achieve clinical, quality and financial goals. (A Midwest ACO has more problems with underweight than obesity, do they need to maintain their bariatric surgery center?) Physicians serve as “clinical intelligence officers,” creating standing orders across the entire population, implemented by non-clinical personnel; they also create criteria for escalation and de-escalation of services and resource allocation based on individual patients progress towards goals. They employ former actors and actresses as health coaches and navigators, invest heavily in home care and nurse care managers and use dieticians in local supermarkets to support lifestyle changes (while accessing and analyzing the patients point-of-purchase data to see what they are really buying).

The primary relationship between patients and their health systems is with a low cost, personal health concierge: Primary care physicians are only accessed based on predetermined eligibility criteria and only with those physician who agree to standards of quality and accountability are in the network. Multi-tiered scenario planning for emergencies is built into the system. For professional resources only required on an as-needed basis, such as hospital beds, surgeons and medical specialists, access is negotiated in advance based on a formula of quality standards and best pricing but only used on a just-in-time basis.

They are not a payer, although a professional relationship with them is on a business-to-business basis. They are a completely new type of health system, guaranteeing health and well being, transparent in their operations and choosing their vendors based on their willingness and ability to achieve those goals. In doing so, they significantly reduce the resources necessary to achieve goals for quality of care and quality of health across the entire population; they treat quality achievement as an operational challenge and manage their supply chain accordingly.

Am I suggesting this a new model of care? No, I am personally an advocate for physician-driven systems of care. But this kind of system is very possible, and there are companies working on models of national ACOs using many of these principles.

The Uber of health care will have much less to do with the mobile app; and far more to do with creating value by minimizing overhead, designing flexible operations, supporting goal-directed innovation and bringing supply-chain discipline to the idea of resource-managed care delivery. It will involve embracing models of care delivery that leverage emerging evidence on non-clinical approaches to health status and quality improvement, and focusing on designing goal-directed interactions between people, platforms, programs and partners.

I can hear more than a few of you creating very good reasons why it wont work (“You can’t put an ICU bed out to bid!”), but these scenarios are very doable. If we want to revitalize the experience of care for patients and professionals, we must be willing to acknowledge and embrace dramatically different, often counter-intuitive, new operating models for care that will require new competencies, forms of collaboration and reengineering the roles and responsibilities of those who comprise a patients’ health resource community.

Steven Merahn is director, Center for Population Health Management, Clinovations. He blogs at MedCanto.

Outsource physician behaviour change to the experts: Big Pharma

So pay for performance doesn’t work. This is hardly surprising when you see the compromise and mediocrity forced upon policy makers to get ideas through. There have been instances of success in health care. Indeed, one could argue that the exemplary success of big pharma in changing physician behaviour has provided a rod for its own back. Why not harness this expertise in getting under the skin of doctors, and pay big pharma sales outfits to guide physician practice in constructive directions, rather than being distracted by flogging pills that don’t really work that well anyway, and potentially harm? Might have a chat with Christian.

http://www.nytimes.com/2014/07/29/upshot/the-problem-with-pay-for-performance-in-medicine.html

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“Pay for performance” is one of those slogans that seem to upset no one. To most people it’s a no-brainer that we should pay for quality and not quantity. We all know that paying doctors based on the amount of care they provide, as we do with a traditional fee-for-service setup, creates incentives for them to give more care. It leads to increased health care spending. Changing the payment structure to pay them for achieving goals instead should reduce wasteful spending.

So it’s no surprise that pay for performance has been an important part of recent reform efforts. But in reality we’re seeing disappointingly mixed results. Sometimes it’s because providers don’t change the way they practice medicine; sometimes it’s because even when they do, outcomes don’t really improve.

The idea behind pay for performance is simple. We will give providers more money for achieving a goal. The goal can be defined in various ways, but at its heart, we want to see the system hit some target. This could be a certain number of patients receiving preventive care, a certain percentage of people whose chronic disease is being properly managed or even a certain number of people avoiding a bad outcome. Providers who reach these targets earn more money.

The problem, one I’ve noted before, is that changing physician behavior is hard. Sure, it’s possible to find a study in the medical literature that shows that pay for performance worked in some small way here or there. For instance, a study published last fall found that paying doctors $200 more per patient for hitting certain performance criteria resulted in improvements in care. It found that the rate of recommendations for aspirin or for prescriptions for medications to prevent clotting for people who needed it increased 6 percent in clinics without pay for performance but 12 percent in clinics with it.

Good blood pressure control increased 4.3 percent in clinics without pay for performance but 9.7 percent in clinics with it. But even in the pay-for-performance clinics, 35 percent of patients still didn’t have the appropriate anti-clotting advice or prescriptions, and 38 percent of patients didn’t have proper hypertensive care. And that’s success!

It’s also worth noting that the study was only for one year, and many improvements in actual outcomes would need to be sustained for much longer to matter. It’s not clear whether that will happen. A study published in Health Affairs examined the effects of a government partnership with Premier Inc., a national hospital system, and found that while the improvements seen in 260 hospitals in a pay-for-performance project outpaced those of 780 not in the project, five years later all those differences were gone.

The studies showing failure are also compelling. A study in The New England Journal of Medicine looked at 30-day mortality in the hospitals in the Premier pay-for-performance program compared with 3,363 hospitals that weren’t part of a pay-per-performance intervention. We’re talking about a study of millions of patients taking place over a six-year period in 12 states. Researchers found that 30-day mortality, or the rate at which people died within a month after receiving certain procedures or care, was similar at the start of the study between the two groups, and that the decline in mortality over the next six years was also similar.

Moreover, they found that even among the conditions that were explicitly linked to incentives, like heart attacks and coronary artery bypass grafts, pay for performance resulted in no improvements compared with conditions without financial incentives.

In Britain, a program was begun over a decade ago that would pay general practitioners up to 25 percent of their income in bonuses if they met certain benchmarks in the management of chronic diseases. The program made no difference at all in physician practice or patient outcomes, and this was with a much larger financial incentive than most programs in the United States offer.

Even refusing to pay for bad outcomes doesn’t appear to work as well as you might think. A 2012 study published in The New England Journal of Medicine looked at how the 2008 Medicare policy to refuse to pay for certain hospital-acquired conditions affected the rates of such infections. Those who devised the policy imagined that it would lead hospitals to improve their care of patients to prevent these infections. That didn’t happen. The policy had almost no measurable effect.

There have even been two systematic reviews in this area. The first of them suggested that there is some evidence that pay for performance could change physicians’ behavior. It acknowledged, though, that the studies were limited in how they could be generalized and might not be able to be replicated. It also noted there was no evidence that pay for performance improved patient outcomes, which is what we really care about. The secondreview found that with respect to primary care physicians, there was no evidence that pay for performance could even change physician behavior, let alone patient outcomes.

One of the reasons that paying for quality is hard is that we don’t even really know how to define “quality.” What is it, really? Far too often we approach quality like a drunkard’s search, looking where it’s easy rather than where it’s necessary. But it’s very hard to measure the things we really care about, like quality of life and improvements in functioning.

In fact, the way we keep setting up pay for performance demands easy-to-obtain metrics. Otherwise, the cost of data gathering could overwhelm any incentives. Unfortunately, as a recent New York Times article described, this has drawbacks.

The National Quality Forum, described in the article as an influential nonprofit, nonpartisan organization that endorses health care standards, reported that the metrics chosen by Medicare for their programs included measurements that were outside the control of a provider. In other words, factors like income, housing and education can affect the metrics more than what doctors and hospitals do.

This means that hospitals in resource-starved settings, caring for the poor, might be penalized because what we measure is out of their hands. A panel commissioned by the Obama administration recommended that the Department of Health and Human Services change the program to acknowledge the flaw. To date, it hasn’t agreed to do so.

Some fear that pay for performance could even backfireStudies in other fields show that offering extrinsic rewards (like financial incentives) can undermine intrinsic motivations (like a desire to help people). Many physicians choose to do what they do because of the latter. It would be a tragedy if pay for performance wound up doing more harm than good.

John Perry Barlow: Which side of history do you want to be on?

“The main thing here is for people to recognize that what we’re doing is creating the foundations of the future in a very fundamental way.

I mean we’re building the future that we all might want or all might not want, depending on our current vested interests.

I think it takes a really crummy ancestor to want to maintain his current business model at the expense of his descendant’s ability to understand the world around them.

And if you really want to figure out which side you’re on, ask yourself what’s going to make you a better ancestor?

John Perry Barlow
Co-founder, Electronic Frontier Foundation

Interviewed in the feature documentary “Downloaded” aired on SBS.

Google founders on their distaste for health data regulators

 

http://www.forbes.com/sites/davidshaywitz/2014/07/04/google-co-founders-to-healthcare-were-just-not-that-into-you/

David ShaywitzContributor

I write about entrepreneurial innovation in medicine.

Opinions expressed by Forbes Contributors are their own.

PHARMA & HEALTHCARE  17,430 views

Google Co-Founders To Healthcare: We’re Just Not That Into You

At his yearly CEO summit, noted VC Vinod Khosla spoke with Google co-foundersSergey Brin and Larry Page (file under “King, Good To Be The”).

Towards the end of a wide-ranging conversation that encompassed driverless cars, flying wind turbines, and high-altitude balloons providing internet access, Khosla began to ask about health.

Specifically, Khosla wondered whether they could “imagine Google becoming a health company? Maybe a larger business than the search business or the media business?”

Their response, surprisingly, was basically, “no.”  While glucose-sensing contact lenses might be “very cool,” in the words of Larry Page, Brin notes that,

“Generally, health is just so heavily regulated. It’s just a painful business to be in. It’s just not necessarily how I want to spend my time. Even though we do have some health projects, and we’ll be doing that to a certain extent. But I think the regulatory burden in the U.S. is so high that think it would dissuade a lot of entrepreneurs.”

Adds Page,

“We have Calico, obviously, we did that with Art Levinson, which is pretty independent effort. Focuses on health and longevity. I’m really excited about that. I am really excited about the possibility of data also, to improve health. But that’s– I think what Sergey’s saying, it’s so heavily regulated. It’s a difficult area. I can give you an example. Imagine you had the ability to search people’s medical records in the U.S.. Any medical researcher can do it. Maybe they have the names removed. Maybe when the medical researcher searches your data, you get to see which researcher searched it and why. I imagine that would save 10,000 lives in the first year. Just that. That’s almost impossible to do because of HIPAA. I do worry that we regulate ourselves out of some really great possibilities that are certainly on the data-mining end.”

Khosla then asked a question about a use case involving one of my favorite portfolio companies of his, Ginger.io, related to the monitoring of a patient’s psychiatric state.

Responded Page, “I was talking to them about that last night. It was cool.”

That pretty much captures Brin and Page’s view of healthcare – fun to work on a few “cool” projects, but beyond that, the regulatory challenges are just too great to warrant serious investment.

(To be clear, Brin and Page emphasized their personal distance from Google Ventures, which has conspicuously pursued a range of health-related investments.  “Medicine needs to come out of the dark ages,” Google Ventures Managing Partner Bill Maris recently told Re/code.)

On the face of it, it’s pretty amazing that a company that doesn’t think twice about tackling absurdly challenging scientific projects (eg driverless cars) is brought to its knees by the prospect of dealing with the byzantine regulation around healthcare (and more generally, our “calcified hairball” system of care, as VC Esther Dyson has put it).  A similar sentiment has been expressed by VC and Uber-investor Bill Gurley as well; evidently taking on taxi and limousine commissions is more palatable than taking on the healthcare establishment.

Yet others – with eyes wide open – are taking on the challenge.  AthenaHealth’s Jonathan Bush, for instance, is maddened by the challenges of regulatory capture (see my WSJ review of his book here), yet he shows up each day to fight the battle.

Similarly, while I’ve not always agreed with Khosla’s perspective on algorithims, I’ve consistently admired his willingness to enter the fray (see here and here).

This morning on Twitter, he asked whether his willingness to invest in healthcare means he’s courageous (as I suggested) or naïve.

The answer, I imagine, is probably both.  The challenges in healthcare, especially regarding regulation, are real, and disruption is hard to come by.  As Brown University emergency physician Megan Ranney comments, there are “big risks, lots of roadblocks” but also “huge potential for humankind.”

I suspect the key to overcoming the regulatory roadblocks will be making the use cases more persuasive and immediate.  After all, most people have the enlightened self-interest to embrace life-saving innovations (anti-vaxers notwithstanding).

The challenge is that to this point, the benefits of technology generally seem less than persuasive – the tech seems “cool,” as Page and Brin might say, but not exactly convincing.  I’m not just talking about Google Glass (which perhaps defines the genre) and Google’s contact lenses (I’ve not met many experts who’ve bought into this technology), but also approaches like 23andMe.  When they ran up against regulators, there wasn’t exactly an outcry, “this technology has transformed my life and now you’re shutting it down.”  If only.

In contrast, efforts to shut down Uber typically generate far more impassioned protests.  Why? Because it’s immediately apparent to users how Uber improves their lives.  To use the service once is to be convinced.

What healthcare technology needs is to find a way to be similarly indispensable.  Page may cite the potential to save 10,000 lives, but the challenge is to convince anyone this applies to their own N of 1.  More directed examples of instances where technology could immediately impact lives, and could impact more were it not for oppressive regulation, would go a long way to rolling back the regulations that seem to impede progress.

Rather than focusing on the thousands of lives that could be saved in an imagined future, technologists would do well to provide a compelling demonstration of what big data and sophisticated analytics can achieve for the health of discrete individuals in the present, even with current limitations; success here could help innovative entrepreneurs push back on antiquated regulations, and bring healthcare delivery into the modern age while ushering in a new era in biomedical research driven by access to rich coherent datasets.

The truth is, Page is probably right about the underlying opportunity.  In particular, as I’ve long-argued, there’s tremendous potential to be found by thoughtfully combining comprehensive genomic and rich phenotypic data – immediate opportunities to impact clinical care, and the chance for a longer-term impact on scientific understanding.

I’m perhaps more optimistic than Page is, however, both about our collective ability to succeed meaningfully even within the constraints of our existing system, and about the ability of demonstrated success to move even the most intransigent stakeholders.

The Vitality Institute: Investing In Prevention – A National Imperetive

Vitality absolutely smash it across the board…

  • Investment
  • Leadership
  • Market Creation
  • Developing Health Metrics
  • Everything…!

Must get on to these guys…..

PDF: Vitality_Recommendations2014_Report

PDF: InvestingInPrevention_Slides

Presentation: https://goto.webcasts.com/viewer/event.jsp?ei=1034543 (email: blackfriar@gmail.com)

 

From Forbes: http://www.forbes.com/sites/brucejapsen/2014/06/18/how-corporate-america-could-save-300-billion-by-measuring-health-like-financial-performance/

Bruce Japsen, Contributor

I write about health care and policies from the president’s hometown

How Corporate America Could Save $300 Billion By Measuring Health Like Financial Performance

The U.S. could save more than $300 billion annually if employers adopted strategies that promoted health, prevention of chronic disease and measured progress of “working-age” individuals like they did their financial performance, according to a new report.

The analysis, developed by some well-known public health advocates brought together and funded by The Vitality Institute, said employers could save $217 billion to $303 billion annually, or 5 to 7 percent of total U.S. annual health spending by 2023, by adopting strategies to help Americans head off “non-communicable” diseases like cancer, diabetes, cardiovascular and respiratory issues as well as mental health.

To improve, the report’s authors say companies should be reporting health metrics like BMI and other employee health statuses just like they regularly report earnings and how an increasing number of companies report sustainability. Corporations should be required to integrate health metrics into their annual reporting by 2025, the Vitality Institute said. A link to the entire report and its recommendations is here. 

“Companies should consider the health of their employees as one of their greatest assets,” said Derek Yach, executive director of the Vitality Institute, a New York-based organization funded by South Africa’s largest health insurance company, Discovery Limited.

Those involved in the report say its recommendations come at a time the Affordable Care Act and employers emphasize wellness as a way to improve quality and reduce costs.

“Healthy workers are more productive, resulting in improved financial performance,” Yach said. “We’re calling on corporations to take accountability and start reporting health metrics in their financial and sustainability reports.  We believe this will positively impact the health of both employees and the corporate bottom line.”

The Institute brought together a commission linked here that includes some executives from the health care industry and others who work in academia and business. Commissioners came from Microsoft (MSFT);  the Robert Wood Johnson Foundation; drug and medical device giant Johnson & Johnson (JNJ); health insurer Humana (HUM); and the U.S. Department of Health and Humana Services.

The Vitality Institute said up to 80 percent of non-communicable diseases can be prevented through existing “evidence-based methods” and its report encourages the nation’s policymakers and legislative leaders to increase federal spending on prevention science at least 10 percent by 2017.

“Preventable chronic diseases such as lung cancer, diabetes and heart disease are forcing large numbers of people to exit the workforce prematurely due to their own poor health or to care for sick relatives,” said William Rosenzweig, chair of the Vitality Institute Commission and an executive at Physic Ventures, which invests in health and sustainability projects. “Yet private employers spend less than two percent of their total health budgets on prevention.  This trend will stifle America’s economic growth for decades to come unless health is embraced as a core value in society.”

Google Ventures – moving medicine out of the dark ages

Duke story about direct monkey brain implants that allow the control of more than two arms.

Great take on dealing with lagging regulation:

“You shouldn’t ignore the laws. But if you worry as an investor about, “Oh, you shouldn’t invest in any personal genomics companies because there’s a lot of regulations that need to be updated.” Well, you won’t do anything innovative.”

So yes, absolutely, the regulations need to catch up with reality. I think as the outcomes of the science with Foundation Medicine, 23andMe, etc., start to become important to people and to patients, people will demand that change. And that’s how it happens.

http://recode.net/2014/06/21/google-ventures-bill-maris-on-moving-medicine-out-of-the-dark-ages/

 

Venture capital funding for the life sciences sector dropped by $5 billion from 2008 to 2012 and was basically flat last year, according to market reports. But the search giant’s venture arm, established in 2009, has steadily plugged money into companies throughout the space, including: 23andMe, Adimab, DNANexus, Doctor on Demand, Foundation Medicine,Flatiron Health, iPierian, One Medical Group, Predilytics, Rani Therapeutics, SynapDx and Transcriptic.

Some of the bets have started to pay off. Foundation Medicine raised $100 million in an initial public offering in 2013. Earlier this year, Bristol-Myers Squibb bought portfolio company iPierian in a deal that could be worth up to $725 million.

The focus on the space at least in part reflects the background of Google Ventures’Managing Partner Bill Maris. He studied neuroscience at Middlebury College and neurobiology at Duke University. In his early career, he was the health care portfolio manager at Swedish investment firm Investor AB.

Maris also took a lead role in the creation of Calico late last year, a Google-backed company focused on delaying aging and the diseases that come with it. (Google has declined to discuss the company, which is run by Genentech Chairman Arthur Levinson.)


“Medicine needs to come out of the dark ages now.”

Bill Maris, managing partner, Google Ventures


Google Ventures generally isn’t taking the old biotech route, betting on companies somewhere along the winding path of developing drugs that may — but probably won’t — someday earn Food and Drug Administration approval. Rather, the firm is focused on companies leveraging the increasingly powerful capacities of computer science, including big data, cloud processing and genomic sequencing, to improve diagnostics or treatments.

In the second part of my two-part interview, which has been edited for space and clarity, Maris discusses the promise of these tools for medicine as well as what’s still standing in the way.

Re/code: Looking through your health-care investments, there’s 23andMe, DNA Nexus, Foundation Medicine, Flatiron. To the degree there’s a common theme, it seems these are all big data plays, using a lot of information and smart algorithms to make advancements in medical research or hit upon more effective treatments. Is that part of your investment philosophy?

Maris: I used to be a health-care investor a long time ago in the public markets. One thing I learned that we tried to apply here is that investing in small molecules, trying to invest in the next treatment, there’s an element of gambling to that.

I’m glad that people started those companies and I’m glad that they have people who specialize in investing in them. But that’s not our specialty, because you have to build a portfolio to make a success overall.

What we try to put into our practice is “invest in what we know,” which is where health care meets technology. In some sense, almost all companies these days need to be big data companies.

Bill Maris, managing director, Google Ventures

Especially when you get around genomics or, like Flatiron, looking for insights across vast amounts of oncology data. These are by definition big data companies that couldn’t have existed 10 or 15 years ago.

Take Foundation Medicine. The tools didn’t exist to actually genotype quickly the way that we can today, and in 10 years it will be even more advanced. So by necessity the companies we’re investing in are in that space, because that’s the forefront.

Clinicians treating patients based on “if you present with these symptoms, I’m going to treat you based on the knowledge in my head?” Those days are either disappearing or will soon disappear, I hope. We can get much better outcomes from people if we understand the genetic basis of the exact cancer that they have, what interventions might be most effective against it, what’s worked in the past and what hasn’t. I think that’s where the future of health care is.

So yes, lots of these are big data companies, in that sense. But that’s a catchphrase, they’re more than that. They’re data-informed companies that are trying to build businesses that are commercially important and, in this case, relevant to patients. That means they’ll get better outcomes, you’ll live longer and be healthier.

Medicine needs to come out of the Dark Ages now.

There is a unique challenge when it comes to data and medicine. Either you have a lot of information that is stored away in paper filing cabinets in doctors’ offices, or you’ve got companies that did studies decades ago that might be of use but they’re either not digitized or they’re holding on to them as intellectual property. So while there’s this great potential, it’s actually really hard to get at it. Can you talk a bit about what needs to happen technologically?

Of course it’s difficult. If it were easy it would be done by now, there would be nothing remarkable about what Nat [Turner] and Zach [Weinberg] are doing at Flatiron. The fact that it’s difficult is what makes it something an entrepreneur needs to tackle — and this isn’t unique, right?

All the information in the world has been pretty dispersed, but Google’s mission has been to organize it and make it universally accessible. That’s kind of a crazy mission and they’re doing okay at it. It takes people with a vision to say, “We’re going to try to organize this and make it accessible to people.” When we do those things, good things will result from that.

Maybe it takes a generation, because doctors will start using the system. Or maybe it just takes one big push, where we’re just going to go into clinicians’ offices and help them get all the data organized and put into electronic formats. Once you’ve done it one time you can gain an infinite number of insights to help your patients, so there’s a good motivation to do that.

Organizing healthcare information is a daunting task, but it is not an impossible task. We’ve had people walk on the moon. This is a lot more doable.

I want to ask about 23andMe. We’ve seen a handful of companies in that space that have closed or haven’t gone anywhere, and 23andMe obviously hit a big wall with the FDA last year.

I don’t know what you’re talking about.

Yeah, I read it somewhere. But that was a big part of their business, can you talk about what their ongoing prospects are and what direction they could steer in?

Yeah, as I understand it, the heredity product is still available and we see big businesses being built there, like Ancestry.com and others.

At the same time, their vision is bigger than that. They’re at an impasse with the FDA right now, but no one has thrown up their hands. Communication is ongoing, they’re trying to work that out, we’re dedicated to trying to resolve that roadblock. And we think it’s a product that is of value to people, so they can look at and understand their own genomic information.

I think the company’s prospects are great, I’ve known [co-founder] Anne [Wojcicki] for almost 20 years now, and she’s nothing if not focused, dedicated and motivated. She’s a believer in this. I think the company has been a little bit ahead of its time.

It’s inevitable that everyone will eventually be genetically sequenced because it’s going to be really important to their health care, to understanding their future and what they’re at risk for. If you believe that, then you believe that there’s probably a big business to be built here because someone has to deliver that information.

So we have a lot of faith in the team.

Taking that case — and given that health care and medical research is moving in this digital direction — do you think there are some regulatory shifts that need to take place?

I think the laws need to catch up with science and reality, and the law is never good at that. It’s always slow.

I mean, look at the patent office. I just saw a patent that Smucker’s has for a peanut butter and jelly sandwich. It’s sort of crazy.

Look at Uber and its regulatory challenges, taxi and limousine commissions trying to stop Uber. When you sit with my job — which is a really fun job to do, kind of a judge at a science fair — it’s really important to look at the technology and how it might benefit people, and not worry about the bureaucracies that might try to impede that.

At the end of the day, what always happens is, the right products for society and the people get out there.

You shouldn’t ignore the laws. But if you worry as an investor about, “Oh, you shouldn’t invest in any personal genomics companies because there’s a lot of regulations that need to be updated.” Well, you won’t do anything innovative.


RELATED ARTICLE

 

So yes, absolutely, the regulations need to catch up with reality. I think as the outcomes of the science with Foundation Medicine, 23andMe, etc., start to become important to people and to patients, people will demand that change. And that’s how it happens.

You studied neuroscience and neurobiology. What are some exciting developments you’re seeing in your own area?

I also think we’re just coming out of these Dark Ages in neuroscience. The forefront of neuroscience is (he points to parts of his head), “Well, this is the learning area, this is memory, this is where the right arm is controlled.” That’s not really how the brain works, it’s this cloud-based understanding.

I forget which neuroscientist said this, but you essentially have a Jennifer Aniston neuron. There are certain pathways in your brain that remember who that is. The more you fill up your brain with those things, the more neurons get used up.

So we’re getting closer to a point, and there are some folks at MIT working on this and other places as well, to really understanding the wiring of the brain. What makes it a whole, what causes consciousness. It’s not just that these cloudy regions all talk to each other.

You can’t do anything without a map. Until you can diagnose something you can never cure it, you can’t understand it. It’s hard to get from here to there without a map. So the first thing to do is to build a model.

When you can map an entire human brain, then you can really understand how it all works.

We don’t even know if everything gets recorded in your brain and your brain is just really good at controlling noise, where it’s just filtering out a bunch of things that you don’t need to think about because you’d just be overloaded. So there are these fundamental questions of neuroscience we just now have the tools to understand.

It’s so far behind, it’s so underfunded, in a way. We as a people and a country spend a lot of money on a lot of things. But we all walk around with this thing in our head and we have no understanding of how it actually works.

Machine-brain interfaces are a way to understand that. There’s a guy at Duke named Miguel Nicolelis, who I worked with and who comes out here every once in a while. He does work where he implants electrodes into brains and he’s now got monkeys who can move cursors on a screen [with virtual arms] and they get a reward of orange juice. Then he thought, “Well, why is the monkey just limited to one [virtual arm]? Maybe I could teach them to move three at once, or four.”

What we are learning from that is, well, we have two legs and two arms, but your brain is actually capable of operating four or six of them if you had them. There’s so much potential.

Here’s what the monkey saw in that experiment:

Relman Obit: the medical-industrial complex

RelmanOnHealthcare

http://t.co/g9LnZnM5ta

“Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there’s only one way to diagnose or treat an illness,” he told the review. “In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

Photo

Dr. Arnold S. Relman in 1979 at The New England Journal of Medicine. He led it for 23 years.CreditAssociated Press
Dr. Arnold S. Relman, who abandoned the study of philosophy to rise to the top of the medical profession as a researcher, administrator and longtime editor of The New England Journal of Medicine, which became a platform for his early and influential attacks on the profit-driven health care system, died at his home in Cambridge, Mass., on Tuesday, his 91st birthday.

His wife, Dr. Marcia Angell, said the cause wasmelanoma.

Dr. Relman and Dr. Angell filled top editorial posts at the journal for almost a quarter-century, becoming “American medicine’s royal couple,” as the physician and journalist Abigail Zuger wrote in The New York Times in 2012.

The couple shared a George Polk Award, one of journalism’s highest prizes, for an article in 2002 in The New Republic that documented how drug companies invest far more in advertising and lobbying than in research and development.

His extended critique of the medical system was just one facet of a long and accomplished career. Dr. Relman was president of the American Federation for Clinical Research, the American Society of Clinical Investigation and the Association of American Physicians — the only person to hold all three positions. He taught and did research at Boston University, the University of Pennsylvania, Oxford and Harvard, where he was professor emeritus of medicine and social medicine.

Early in his career, he did pioneering research on kidney function.

He was also editor of The Journal of Clinical Investigation, a bible in its field, and he wrote hundreds of articles, for both professional journals and general-interest publications. Days before he died, Dr. Relman received the galleys of his final article, a review of a book on health care spending for The New York Review of Books, to which he was a frequent contributor.

In a provocative essay in the New England journal on Oct. 23, 1980, Dr. Relman, the editor in chief, issued the clarion call that would resound through his career, assailing the American health care system as caring more about making money than curing the sick. He called it a “new medical-industrial complex” — a deliberate analogy to President Dwight D. Eisenhower’s warning about a “military-industrial complex.”

His targets were not the old-line drug companies and medical-equipment suppliers, but rather a new generation of health care and medical services — profit-driven hospitals and nursing homes, diagnostic laboratories, home-care services, kidney dialysis centers and other businesses that made up a multibillion-dollar industry.

“The private health care industry is primarily interested in selling services that are profitable, but patients are interested only in services that they need,” he wrote. In an editorial, The Times said he had “raised a timely warning.”

In 2012, asked how his prediction had turned out, Dr. Relman said medical profiteering had become even worse than he could have imagined.

His prescription was a single taxpayer-supported insurance system, likeMedicare, to replace hundreds of private, high-overhead insurance companies, which he called “parasites.” To control costs, he advocated that doctors be paid a salary rather than a fee for each service performed.

Dr. Relman recognized that his recommendations for repairing the health care system might be politically impossible, but he insisted that it was imperative to keep trying. Though he said he was glad that the health care law signed by President Obama in 2010 enabled more people to get insurance, he saw the legislation as a partial reform at best.

The health care system, he said, was in need of a more aggressive solution to fundamental problems, which he had discussed, somewhat philosophically, in an interview with Technology Review in 1989.

“Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there’s only one way to diagnose or treat an illness,” he told the review. “In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

Dr. Relman edited The New England Journal of Medicine from 1977 to 1991. Founded in 1812, it is the oldest continuously published medical journal in the world, reaching more than 600,000 readers a week. Dr. Angell was the editor in 1999 and 2000.

When he took the journal’s helm, interest in health news was booming, and newspapers and magazines competed to be first in reporting new developments. One policy he instituted was to ask general-interest publications not to disclose a forthcoming article in advance, a request almost always honored, albeit sometimes grudgingly.

He also began requiring authors to disclose any financial arrangements that could affect their judgment in writing about the medical field, including consultancies and stock ownership.

Dr. Relman and Dr. Angell met when she was a third-year student and he was a professor at Boston University School of Medicine. They published a paper on kidney disease together in The New England Journal of Medicine, then did not see each other for years.

After he became the journal’s editor, he asked her to come on board as an editor, which she did, abandoning her career as a pathologist. They began living together in 1994 — both were divorced by then — and married in 2009.

They became the ultimate medical power couple, not least because they were gatekeepers for one of the world’s most prestigious medical journals. Their outspoken views further distinguished them.

“Some have dismissed the pair as medical Don Quixotes, comically deluded figures tilting at benign features of the landscape,” Dr. Zuger wrote in The Times. “Others consider them first responders in what has become a battle for the soul of American medicine.”

Arnold Seymour Relman was born on June 17, 1923, in Queens (in an elevator, according to Dr. Angell) and grew up in the Far Rockaway neighborhood. His father was a businessman and avid reader who inspired his son’s love of philosophy. His mother nicknamed him Buddy, and friends called him Bud the rest of his life.

He skipped grades in school and graduated at 19 from Cornell with a degree in philosophy, but he chose not to pursue the field because it “seemed sort of too arcane,” his wife said. He earned a medical degree from the Columbia University College of Physicians and Surgeons at 22. His first marriage was to Harriet M. Vitkin.

In addition to Dr. Angell, he is survived by his sons, David and John, and a daughter, Margaret R. Batten, all from his first marriage; his stepdaughters, Dr. Lara Goitein and Elizabeth Goitein; six granddaughters; and four stepgrandsons.

Last June, Dr. Relman fell down a flight of stairs and cracked his skull, broke three vertebrae in his neck and broke more bones in his face. When he reached the emergency room, surgeons cut his neck to connect a breathing tube. His heart stopped three times.

“Technically, I died,” he told The Boston Globe.

He went on to write an article about his experience for The New York Review of Books, offering the unusual perspective of both a patient and a doctor.

“It’s both good and bad to be a doctor and to be old and sick,” he told The Globe.

“You learn to make the most of it,” he added. “Schopenhauer, the German philosopher, said life is slow death. Doctors learn to accept that as part of life. Although we consider death to be our enemy, it’s something we know very well, and that we deal with all the time, and we know that we are no different. My body is just another body.”

Correction: June 23, 2014 
An earlier version of this obituary misstated where Dr. Relman and his wife, Dr. Marcia Angell, met. They met when she was a student and he was a professor at Boston University School of Medicine, not Harvard Medical School. Because of an editing error, the earlier version also misstated the dates of Dr. Relman’s tenure as editor of The New England Journal of Medicine. He held the post from 1977 to 1991, not from 1977 to 2000. (Dr. Angell was editor in 1999 and 2000.)