Hammerbacher, Sinai and Minerva…

Top piece on Sinai’s vision. Everything’s lined up there except the doctors – hmmm…. They’ll need some amazing insights to bust through the inertia, but expect they’ll glean them…

http://www.fastcoexist.com/3022050/futurist-forum/in-the-hospital-of-the-future-big-data-is-one-of-your-doctors

In The Hospital Of The Future, Big Data Is One Of Your Doctors

December 5, 2013 | 7:30 AM

From our genomes to Jawbones, the amount of data about health is exploding. Bringing on top Silicon Valley talent, one NYC hospital is preparing for a future where it can analyze and predict its patients’ health needs–and maybe change our understanding of disease.

The office of Jeff Hammerbacher at Mount Sinai’s Icahn School of Medicine sits in the middle of one of the most stark economic divides in the nation. To Hammerbacher’s south are New York City’s posh Upper East Side townhouses. To the north, the barrios of East Harlem.

What’s below is most interesting: Minerva, a humming supercomputer installed last year that’s named after the Roman goddess of wisdom and medicine.

It’s rare to find a supercomputer in a hospital, even a major research center and medical school like Mount Sinai. But it’s also rare to find people like Hammerbacher, a sort of human supercomputer who is best known for launching Facebook’s data science teamand, later, co-founding Cloudera, a top Silicon Valley “big data” software company where he is chief scientist today. After moving to New York this year to dive into a new role as a researcher at Sinai’s medical school, he is setting up a second powerful computing cluster based on Cloudera’s software (it’s called Demeter) and building tools to better store, process, mine, and build data models. “They generate a pretty good amount of data,” he says of the hospital’s existing electronic medical record system and its data warehouse that stored 300 million new “events” last year. “But I would say they are only scratching the surface.”

Could there actually be three types of Type 2 diabetes? A look at the health data of 30,000 volunteers hints that we know less than we realize. Credit: Li Li, Mount Sinai Icahn School of Medicine, and Ayasdi

Combined, the circumstances make for one of the most interesting experiments happening in hospitals right now–one that gives a peek into the future of health care in a world where the amount of data about our own health, from our genomes to ourJawbone tracking devices, is exploding.

“What we’re trying to build is a learning health care system,” says Joel Dudley, director of biomedical informatics for the medical school. “We first need to collect the data on a large population of people and connect that to outcomes.”

To imagine what the hospital of the future could look like at Mount Sinai, picture how companies like Netflix and Amazon and even Facebook work today. These companies gather data about their users, and then run that data through predictive models and recommendation systems they’ve developed–usually taking into account a person’s past history, maybe his or her history in other places on the web, and the history of “similar” users–to make a best guess about the future–to suggest what a person wants to buy or see, or what advertisement might entice them.

Through real-time data mining on a large scale–on massive computers like Minerva–hospitals could eventually operate in similar ways, both to improve health outcomes for individual patients who enter Mount Sinai’s doors as well as to make new discoveries about how to diagnose, treat, and prevent diseases at a broader, public health scale. “It’s almost like the Hadron Collider approach,” Dudley says. “Let’s throw in everything we think we know about biology and let’s just look at the raw measurements of how these things are moving within a large population. Eventually the data will tell us how biology is wired up.”

Dudley glances at his screen to show the very early inklings of this vision of what “big data” brought to the world of health care and medical research could mean.

On it (see the figure above) is a visualization of the health data of 30,000 Sinai patients who have volunteered to share their information with researchers. He points out, in color, three separate clusters of the people who have Type 2 diabetes. What we’re looking at could be an entirely new notion of a highly scrutinized disease. “Why this is interesting is we could really be looking at Type 2, Type 3, and Type 4 diabetes,” says Dudley. “Right now, we have very coarse definitions of disease which are not very data-driven.” (Patients on the map are grouped by how closely related their health data is, based on clinical readings like blood sugar and cholesterol.)

From this map and others like it, Dudley might be able to pinpoint genes that are unique to diabetes patients in the different clusters, giving new ways to understand how our genes and environments are linked to disease, symptoms, and treatments. In another configuration of the map, Dudley shows how racial and ethnic genetic differences may define different patterns of a disease like diabetes–and ultimately, require different treatments.

These are just a handful of small examples of what could be done with more data on patients in one location, combined with the power to process it. In the same way Facebook shows the social network, this data set is the clinical network. (The eventual goal is to enroll 100,000 patients in what’s called the BioMe platform to explore the possibilities in having access to massive amounts of data.) “There’s nothing like that right now–where we have a sort of predictive modeling engine that’s built into a health care system,” Dudley says. “Those methods exist. The technology exists, and why we’re not using that for health care right now is kind of crazy.”

While Sinai’s goal is to use these methods to bring about more personalized diagnoses and treatments for a wide variety of diseases, such as cancer or diabetes, and improve patient care in the hospital, there are basic challenges that need to be overcome in order to making this vision achievable.

Almost every web company was born swimming in easily harvested and mined data about users, but in health care, the struggle has for a long time been more simple: get health records digitized and keep them private, but make them available to individual doctors, insurers, billing departments, and patients when they need them. There’s not even a hospital’s version of a search engine for all its data yet, says Hammerbacher, and in the state the slow-moving world of health care is in today, making predictions that would prevent disease could be just the icing on the cake. “Simply centralizing the data and making it easily available to a broad base of researchers and clinicians will be a powerful tool for developing new models that help us understand and treat disease,” he says.

Sinai is starting to put some of these ideas into clinical practice at the hospital. For example, in a hint of more personalized medicine that could come one day, the FDA is beginning to issue labels for some medicines that dictate different doses for patients who have a specific genetic variant (or perhaps explain that they should avoid the medicine altogether). The “Clipmerge” software that the hospital is beginning to now use makes it easier for doctors to quickly search and be notified of these kinds of potential interactions on an electronic medical record form.

On the prediction side, the hospital has already implemented a predictive model called PACT into its electronic medical record system. It is used to predict the likelihood that a discharged patient will come back to the hospital within 90 days (the new health care law creates financial incentives for hospitals to reduce their 90-day readmission rate). Based on the prediction, a high-risk patient at the medical center now might actually receive different care, such as being assigned post-care coordinator.

Eventually, there will be new kinds of data that can be put in mineable formats and linked to electronic patient records, from patient satisfaction surveys and doctors’ clinical notes to imaging data from MRI scans, Dudley says.

Right now, for example, the growing volumes of data generated from people’s fitness and health trackers is interesting on the surface, but it’s hard to glean anything meaningful for individuals. But when the data from thousands of people are mined for signals and links to health outcomes, Dudley says, it’s likely to prove valuable in understanding new ways to prevent disease or detect it at the earliest signs.

A major limitation to this vision is the hospital’s access to all of these new kinds of data. There are strict federal laws that govern patient privacy, which can make doctors loathe to experiment with ways to gather it or unleash it. And there are many hoops today to transferring patient data from one hospital or doctor to another, let alone from all the fitness trackers floating around. If patients start demanding more control over their own health data and voluntarily provide it to doctors, as Dudley believes patients will start to do, privacy could become a concern in ways people don’t expect or foresee today–just as it has on the Internet.

One thing is clear: As the health care system comes under pressure to cut costs and implement more preventative care, these ideas will become more relevant. Says Dudley: “A lot of people do research on computers, but I think what we’re hoping for is that we’re going to build a health care system where complex models … are firing on an almost day-to-day basis. As patients are getting information about them put in the electronic medical record system there will be this engine in the background.”

 

JESSICA LEBER

Clinical analytics delivering results…

Two excellent factoids in support of clinical analytics:
1. Kaiser Permanente: “Today you have a 26% lower chance of dying in one of our hospitals than you do in other hospitals,” said Dr. Mattison, adding that Kaiser is starting to lower its mortality rate much faster than the national average. “A lot of this is directly rated to how we use data and integrate data,” he said.
2. University of Pittsburgh Medical Center has slashed readmission rates by 37% since it began using analytics to predict which patients were more likely to be readmitted to the hospital within 30 days.
The source WSJ posts are paywalled, but UPMC are using the Microsoft solution I was working on. Interestingly, it only requires administrative data to deliver its impact.
In discussions with WentWest Medicare Local, they have access to GP data and hospital data, which would start to fillout the picture in an amazing way…

Wednesday, December 11, 2013

There Is A Real Sting In The Tail In These Great Reported Results From The Use Of Analytics In Healthcare.

Two very interesting reports appeared a week or two ago.
December 5, 2013, 7:12 PM ET

Data Helps Drive Lower Mortality Rate at Kaiser

REDWOOD CITY, CALIF. — Kaiser Permanente’s use of data analytics is helping it lower hospital mortality rates and look for ways to diagnose illnesses earlier. John Mattison, chief medical information officer at Kaiser spoke, Thursday, at VentureBeat’s Data Science Summit in Silicon Valley. Dr. Mattison predicts that by the year 2020, ten times more medical research will be generated by analyzing vast quantities of medical data than by conventional models of clinical research.
Over the past several years, Kaiser Permanente’s hospitals in southern California – the region with the most members — have enjoyed a lower mortality rate than the national average, according to data from the Centers for Medicare and Medicaid Services. “Today you have a 26% lower chance of dying in one of our hospitals than you do in other hospitals,” said Dr. Mattison, adding that Kaiser is starting to lower its mortality rate much faster than the national average. “A lot of this is directly rated to how we use data and integrate data,” he said.
Kaiser Permanente has some advantages in data collection over other medical providers because it provides physician, hospital and pharmacy services as well as health insurance to patients. All of those records are electronic. When a patient visits a Kaiser hospital, their entire health record, including doctor visits and medications, is immediately available. Kaiser can easily track patient outcomes after hospital procedures because patients see their doctors within the Kaiser system for follow-up visits. It’s a closed loop and all of that information resides in one place.
The informatics department at Kaiser, which is growing, looks at medical studies as well as information from its anonymized pool of information about patient outcomes to make implementable recommendations that it sends to physicians and hospitals through information alerts. One of the most high profile examples of this happened about a decade ago when Kaiser looked at its database of 1.4 million members and discovered that patients who took Vioxx were more likely to suffer a heart attack or sudden cardiac death than those who took a competing medication. Physicians were resistant to these alerts in the early years but the culture has changed and the informatics department continues to get requests for more of these alerts, said Dr. Mattison.
More here:
We also had this appear on the very same day.
December 5, 2013, 10:32 AM ET

Analytics Helps UPMC Slash Readmission Rates

University of Pittsburgh Medical Center has slashed readmission rates by 37% since it began using analytics to predict which patients were more likely to be readmitted to the hospital within 30 days.
That represents considerable savings for the hospital in terms of providing urgent care, let alone saving the hospital from potential penalties levied by the Centers for Medicare and Medicaid Services for failing to lower those rates.
The trouble for most hospitals is that they’re geared up for the “average patient,” whereas no one is actually an average patient. The role of analytics at UPMC is to determine most precisely which course of treatment will be most effective for each individual.
“Analytics helps you determine who you should focus on,” said Dr. Pamela Peele, chief analytics officer for the UPMC Insurance Services Division during a visit to CIO Journal offices.
According to Dr. Peele, the factors that hospitals should pay attention to are “jaw-dropping.” Far from the actual health of the patient, those factors have to do with how patients used care in the past – what services they’ve received over time and whether the use of the services has been “lumpy or smooth” over time.
Lots more here:
What we have here are very positive reports of the value of analytics in improving hospital and health system performance at the level of the most important measure – improved clinical outcomes.
The sting in the tail is that both the organisations involved are very strategic users of Health IT and have been evolving and improving their Health IT infrastructures over decades. They also have integrated environments where EHR data from both hospitals and ambulatory systems is easily accessible as well as the billing / insurance information and all that can be used for analysis.
For Australian Hospitals they have no access to the GP records and Medicare Payment records – so it now becomes very tricky to obtain such benefits.
It is really only those organisations that hold relevant ambulatory, hospital and insurance information which is easily accessible, and that also have a very advanced IT infrastructure that can replicate this. I wonder are the gurus and NEHTA and DoH working out how these sorts of benefits can be replicated in Australia or is the plan to mine the PCEHR to do a very second best effort?
Time will tell I guess.
David.

 

 

Upworthy, flow, dopamine…

This is actually about behaviour change, flow and dopamine…  vulnerable, manipulable moments in conscious life being exploited by new online offerings like upworthy. Downloadable crack. Hope it starts being used more for good…

http://bigthink.com/21st-century-spirituality/this-cat-may-have-just-saved-canada-you-wont-believe-how

This Cat May Have Just Saved Canada. You Won’t Believe How.

DECEMBER 10, 2013, 4:37 PM
Bt-cat

Last Friday, Guelph resident Andrew McPherson’s cat, Tutu, appears to have achieved the impossible. Local residents claim their small town will never be the same again, and the future of Canada now seems certain.

Ok, so this article has nothing to do with a mystical cat or the sleepy suburb an hour outside of Toronto, but if you’re reading this, your curiosity was piqued. And there’s good reason.

Part of it is what is now dubbed the Upworthy-style headlines. Started in March 2012 by ex-employees of Move On and The Onion, the viral media site clocked an incredible 87 million unique visitors last month. The site’s headline aesthetic—a mini-story that makes clicking through irresistible—has been cloned by numerous websites attempting to create their own clickbait.

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While The Atlantic’s Robinson Meyer recently explained the analyticsbehind the massive surge in Upworthy’s traffic, what is really interesting is why the titles are so seductive. It all has to do with our SEEKING system.

While not usually considered an emotional system in our brain, Estonian-born American neuroscientist Jak Panksepp argues that SEEKING is a function of the main instinctual-emotional system in humans in The Archaeology of Mind. We need to be in this mode in order to chase a romantic partner, find food, get to work in the morning…even get out of bed in the morning.

While such regular activities seem everyday, it is in this enormous neural pathway—from the midbrain to the Lateral hypothalamus into the medial frontal cortex—that dopamine is released. And without dopamine, we would have no motivation to do anything in life.

Yet what makes this system even more incredible is not that dopamine is released during gratification, but several seconds before we’re gratified. That is, while we’re engaged in seeking, our anticipation of an event—the first sip of beer, the moments before you undress a partner, the build up before the beat drops—forces dopamine to be released.

Relating this pathway to music, Ohio State university music researcherDavid Huron writes,

As we listen to music our anticipation builds, which generates pleasurable experiences for the listener. When a stimulus is anticipated, a positively-valenced emotional response arises.

This is why disappointment ensues if you’re expecting a beat to drop and it doesn’t—or if you click through an article about nationalistic Canadian cats to find out it has nothing to do with feline life.

The anticipation phase could also help explain the ‘magical’ experience one encounters when engaged in what Hungarian psychology professorMihály Csíkszentmihályi calls Flow: a runner’s high, being immersed in a novel, any moment when your complete and total reality is present in one focused effort.

When musicians, athletes, actors and chess players describe being in Flow experiences, they claim the impetus for action was not consciously initiated. Their movements seem to flow like a river with no consciousness of how they were moving or acting. Neuroscientist and author Sam Harrissays, “This experience has been at the core of human spirituality for millennia.”

The tiny squirts of dopamine we receive when hearing the ding of a text message or seeing a snazzy headline taps into that same anticipatory neural system. If the content matches our expectations, we feel satisfied, and depending on how much it blows us away—Zach Galifianakis Says Everything You Want to Say to Justin Bieber Right to His Face is one great example—we can then feel inspired, outraged and a whole host of other emotions. This is the brilliance of Upworthy: tapping into our ancient neural networks of anticipation and gratification.

Image: Renata Apanaviciene/shutterstock.com

Fox vs. Hedgehog

Source: http://bigthink.com/experts-corner/beware-the-one-trick-hedgehog

Beware The One Trick Hedgehog

DECEMBER 9, 2013, 12:00 AM
Unnamed-1

There are two kinds of experts and we often don’t use them wisely. The differences between foxes and hedgehogs, and Newton and Darwin, can show when a diversified portfolio of experts is advisable. This year’s Nobel Prize committee in economics evidently agrees: It rewarded the apparently “opposing” theories of Eugene Fama (efficient markets) and Robert Shiller (animal spirits), which pit reason against passion.

Philip Tetlock did the relevant experiment, getting established experts to make 82,000 predictions about political and economic trends and tracking their accuracy. He found differences in thinking style that could predict who’d predict better. Tetlock classified experts using the aphorism “The fox knows many things, but the hedgehog knows one big thing.

Hedgehogs think the world follows simple rules, and prefer a grand unified theory. Convinced they possess the One True Theory, they confidently and zealously defend it. This encourages a closed mindset which is more prone to confirmation bias (squeezing evidence into the theory and discounting what doesn’t fit).

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Foxes believe the world is complex and distrust grand theories. They’re empirically driven, seek locally useful rules, and are open, cautious, eclectic thinkers tolerant of counter arguments. Unwedded to One True Theory they cope better with ambiguity, see the limits of their thinking tools, often qualify their opinions, and more readily adapt to new data.

Tetlock found that foxes fared better than hedgehogs, who barely beat “dart-throwing
chimps.”

Despite that hedgehogs hogged the spotlight. The media love their certain sounding sound bites and flamboyant forecasts. Sadly, the most quoted were the worst predictors and increased
confidence actually decreased accuracy.

Darwin’s greatest lesson applies: Fit to context is key. Hedgehog-experts are good in fields with stable behaviors and known rules. Otherwise, fox-experts are a better bet. This relates to how Newton differs from Darwin. Newton worked with unchanging behaviors. His laws can predict detailed outcomes in simple closed situations. But Darwin dealt with complex systems of changing parts and behaviors; he described the shape of open generative processes (note the cautious foxiness of that plural; “natural selection was the main but not the exclusive means” of evolution. These evolutionary processes have stable tendencies but less predictable specific outcomes.

The closer we get to humans and social sciences, the less Newton-like and hedgehoggy life gets. Economies, full of changing parts and innovative behaviors, need foxy thinking.

Aquinas famously feared “the man of a single book.” And we should be wary of experts with a single model. Models are hedgehog thinking incarnated. With assumptions built into their structure, they can create “model-risk.” Widespread use leads many to overlook the same issues. The dominance of Fama’s big idea possibly had this effect in the last financial
crisis
.

The more we rely on markets, the more important it is to use economic experts wisely. Market-loving hedgehogs tend to downplay the empirical problems of their beloved system. Fixed ideas are risky in a changing world; we’re predictably safer hearing also from market-realist foxes. So should we diversify or concentrate risks?

Illustration by Julia Suits, The New Yorker Cartoonist & author of The Extraordinary Catalog of Peculiar Inventions.

Service presses loved ones’ ashes as a playable vinyl record

Say no more…

http://www.springwise.com/service-presses-loved-ones-ashes-playable-vinyl-record/

Service presses loved ones’ ashes as a playable vinyl record

The UK’s And Vinyly is enabling the recently departed to have their ashes pressed as a vinyl record.

alttext

United Kingdom 6th December 2013 in Weird of the Week.
This is part of a new series of articles that looks at some of the most bizarre and niche business ideas we see here at Springwise.

Remembering loved ones is a highly personal experience, and placing ashes into an urn can be too traditional for some. The first of our Weird of the Week series focused on Holy Smokes, a service that puts ashes into bullets. Now the UK’s And Vinyly is enabling the recently departed to have their ashes pressed as a vinyl record.

Founded by Jason Leach, who also runs a number of record labels such as Subhead, Daftwerk and Death to Vinyl, the service allows anyone to have a loved one’s ashes pressed as a working record, where it can be accompanied by music, the sound of their voice or simply left blank — allowing the pops and clicks to provide an audio representation of the ashes. The ashes are placed onto the raw piece of vinyl before it gets pressed, enabling the ashes to be compressed into the material. Each record comes with personalized artwork — either a simple name and date of birth and death, or a portrait by artist James Hague, who creates his images using ashes mixed into the paint. The GBP 2,000 package gets customers 30 discs with the sounds of their choice, or they can also have a Daftwerk artist record a song about the deceased.

While some may feel uncomfortable handling the ashes of their loved ones, others may cherish the opportunity to connect with them after they die through a very personal artifact. What other unusual ways are there to commemorate the dead?

Website: www.andvinyly.com

Spotted by Denise Kuperman, written by Springwise

Healthways…

http://www.healthways.com  || http://www.healthways.com.au

Christian Sellars from MSD put on a terrific dinner in Crows Nest, inviting a group of interesting people to come meet with his team, with no agenda:

  • Dr Paul Nicolarakis, former advisor to the Health Minister
  • Dr Linda Swan, CEO Healthways
  • Ian Corless, Business Development & Program Manager, Wentwest
  • Dr Kevin Cheng, Project Lead Diabetes Care Project
  • Dr Stephen Barnett, GP & University of Wollongong
  •  Warren Brooks, Customer Centricity Lead
  • Brendan Price, Pricing Manager
  • Wayne Sparks, I.T. Director
  • Greg Lyubomirsky, Director, New Commercial Initiatives
  • Christian Sellars, Director, Access 

MSD are doing interesting things in health. In Christian’s words, they are trying to uncouple their future from pills.

After some chair swapping, I managed to sit across from Linda Swan from Healthways. It was terrific. She’s a Stephen Leeder disciple, spent time at MSD, would have been an actuary if she didn’t do medicine, and has been on a search that sounds similar to mine.

Healthways do data-driven, full-body, full-community wellness.

They’re getting $100M multi-years contracts from PHIs.

Amazingly, they’ve incorporated social determinants of health into their framework.

And even more amazingly, they’ve been given Iowa to make healthier.

They terraform communities – the whole lot.

Linda believes their most powerful intervention is a 20min evidence-based phone questionnaire administered to patients on returning home, similar to what Shane Solomon was rolling out at the HKHA. But they also supplant junk food sponsorship of sport and lobby for improvements to footpaths etc.

Just terrific. We’re catching up for coffee in January.

Pollenizer’s Universal Pitch Deck – punchy, no faffing…

http://pollenizer.com/universal-startup-pitch-deck

  1. Hi, I’m….
    From….
  2. The problem we’re solving is…
  3. Our solution is…
  4. This is a big opportunity because…
  5. Our target market is…
  6. We will acquire customers by…
  7. We make money by…
  8. Our key competition is…
  9. We’re better because…
  10. Our team is…
  11. What we’ll do next is…
  12. Currently, we are seeking…
  13. To summarise…
  14. Thanks!

RWJF Webinar recording – Transparency in healthcare price, cost and quality

This hour long webinar brings together presenters from a recent RWJF conference of the same name.
Of note:
> 24m 30s: demonstration of a new app (closed beta) “Hospital Adviser Medicare Hip & Knee” developed by Consumer Reports (US equivalent of Choice Magazine) using publicly released de-identified cost CMS government data (if only in AU!!) – tip: don’t get your hip or knee done in NYC
> presentation by Castlight Health – US analytics business providing employees and employers personalised price & quality transparency for procedures/conditions/doctors
> The conference found that transparency is necessary but not sufficient to deliver improvements in care.

> 49m 25s: Value-based pricing – the benefit of the care, not its cost

> 50m: providers don’t have feedback on their own performance (let alone payers and patients) – when providers see their own price competitiveness, they adjust their prices

> 56m: Leapfrong asked how can transparency be applied to over-utilization of procedures? By feedback to providers.

MJA Insight: Hard choices – Will Cairns

  • We cannot continue on our current course without depriving other societal domains that are essential to the long-term wellbeing of our community, such as education, physical infrastructure, aged care, environmental protection, the arts and recreation
  • When we eventually do act we will realise that there are a limited number of ways to constrain the proportion of community resources expended on health care.

    One is for funders to pay less for the things that are done.

    The second, and perhaps the simplest, is to not do things that are of little or no benefit. We could also ensure that, when there is a choice, the less expensive options are used. This is primarily a task for doctors but everyone is responsible.

    The third is to make sure that people do not have treatment that they do not want. This merely supports the right of people to make a choice not to start or persist with treatment that will not bring them sufficient benefit in terms of a quantity of a life of quality as they define it. This also requires community acceptance that individuals have the right to make such choices.

While thoughtful medical practice, systemic support of the right to individual choice and improved efficiency can buy us some time they are unlikely to be sufficient.

Perhaps the complex ecology of gridlocked self-interest means that struggling health systems must collapse and fail before they can be rebuilt, and we will just have to watch while it happens.

Surely a better outcome would be to work towards spending only what we can afford. These are not simple issues and the process might begin with an open discussion of our community values and the goals of health care. The sooner we start that discussion the better.

From: https://www.mja.com.au/insight/2013/47/will-cairns-hard-choices

PYMWYMI App

Had this idea yesterday while thinking about TP’s birthday present.

Wouldn’t it be good if we could convert our respects or displeasures for public figures into something virtuous like goats for people in disadvantaged communities? A “put your money where your mouth is” app that could let anyone pledge any amount of money whenever a public figure either impressed or distressed them? On a regular basis, but at least annually, the public figure with the most respects would be recognised in the media, and be given the privilege of deciding where the money was directed. The most disrespected public figure could be sent to Nauru for a couple of weeks.