Neil Armstrong: "Houston, uh...Tranquility base here. The Eagle has landed."

Those were the first chilling words from Neil Armstrong. Later would come his more famous, "That's one small step for man; one giant leap for mankind."

As a young Air Force officer, I was lucky enough to meet Neil Armstrong. He gave a lecture to a group of junior officers from all four branches of the military about the role of "calm courage" in leadership. In essence, he said, courage is not the absence of fear, but rather the strength and determination to overcome it. Preparation, study and practice are the foundation for courage. "Fearlessness", he said, was "short ‘for foolish ego’". He said “My greatest achievement was not walking on the moon, but rather landing on the moon.” Then he told the story.  Here's the NASA video and audio recording of the 15-minute descent of Armstrong and Aldrin, landing the Eagle.

He took us through a minute-by-minute tour of this recording, describing the background and details of what was happening and what he was thinking about-- "There were all sorts of things going wrong, not according to plan, but the public never really knew anything about it, especially at the time." As best my memory can recall, here’s the story that he told:

At 7:45 you’ll hear the crew say, “Program Alarm” then “”1202” which was the specific alarm code. That’s the beginning of multiple alarms and confusion.

At 8:06, you’ll hear Armstrong impatiently insist, after no feedback from Mission Control, “Give us a reading on the 1202 program alarm.”

At 8:12, Mission Control, “Roger, we’re go on that alarm.” But, they weren’t 100% confident, as was revealed later.

I’m not sure when, but at some point in the above, Armstrong took over manual flight control. At 9:38, he tries to go back into auto control and it seems to hold.

At 11:38 you’ll hear Aldrin call out a “Program Alarm” and “1201”. That was the beginning of another series of similar alarms and confusion about the status of the flight control computer, notably the descent radar system. The crew and Mission Control had never seen these types of alarms in the simulator; they were scrambling to decide whether to abort the landing or not. As I recall him telling the story, the descent radar was placed in the wrong mode, which overloaded the flight control computer and caused the LEM to overshoot the primary landing zone by several miles and burn more fuel than planned. Neil Armstrong again took over manual flight control and was having a hard time finding a place to land, fearful that they would land on the edge of a crater or boulder and the LEM would tip over. So, imagine this… Armstrong manually flying, with Aldrin peering out the window for a clear spot and providing “eyeball” callouts of altitude and drift. 

At 14:20, you’ll hear someone in the background at Mission Control callout "60 seconds" and at 14:50, "30 seconds". That's Mission Control warning the crew that they had only 30 seconds of fuel left in the LEM propulsion system. Armstrong soon landed and they quickly went through their engine shut down procedures… with only 14 seconds of fuel remaining. They were supposed to land with at least one minute of fuel remaining, to ensure that they could safely return to the orbiting Command Module, Columbia. 

After landing and shutting down engines, Armstrong utters his famous words, "Houston, uh...Tranquility base here.  The Eagle has landed." Mission Control then says "Roger, Tranquility, we copy you on the ground. You gotta bunch of guys about to turn blue. We're breathing again. Thanks a lot." Then Armstrong replies, “Thank YOU” which always makes me chuckle to hear. In Armstrong’s thanks, you sense his acknowledgement of Mission Control’s role, plus his genuine Ohio, midwestern small town courtesy, as if he’s having dinner at someone’s house…not having just landed on the moon.

Apollo 11 was one of humanity's greatest achievements. It brought the world together at a time in the 1960s when the world seemed like it was coming apart. But Apollo 11 was also a hair-width away from one of humanity's greatest tragedies. Imagine how we would have felt if the Eagle had landed, but without enough fuel to takeoff and return to the Command Module. Two astronauts would have died a very slow and gruesome death, and we would have never looked up at the moon the same way, again. Neil Armstrong's calm, cool, courage, along with Aldrin’s teamwork, and calm heads in Mission Control, were the difference in that hair-width boundary.

For whatever reason, the impact of this story didn't hit me until later, when I worked for TRW. I was lucky enough to sit in on another related lecture, in honor of the Apollo 11 25th anniversary, and listen to some of the TRW engineers who were in Mission Control for Apollo 11. They designed and built the descent engines for the Lunar Module ("LEM"). They knew the untold story of the near disaster that I heard from Armstrong, years before. 

Armstrong was not comfortable with the attention he garnered from what is still the greatest adventure of humankind.  He could have been the total opposite...the most arrogant man in the world, yet he was humbled.  I wish we had more corporate and political leadership who were uncomfortable in those roles-- the reluctant leaders, pushed into their role, not pushing others out of the way to get there.

We had our share of trouble in the 60s and 70s, when Apollo brought the world together.  Even with those problems, I think there was always an underlying sense of confidence in ourselves—in America-- and from the rest of the world that the US could eventually overcome any challenge. We need to get that attitude back.  We need to earn it back.

Update to this blog: A dear friend, Susan Pollack, found a detailed write-up about this story that you can read here: Apollo 11's Scariest Moments: Perils of the 1st Manned Moon Landing.

Hacking a Nuclear Conferencing System

On my LinkedIn profile, there’s a blurb in my bio that generates some fun conversations.  That blurb is:  “In 1988, he hacked into the national nuclear warning system from a public pay phone.”  At the request of several friends and colleagues, here’s the story behind that blurb…

From 1983-1991, I was an information systems officer in the US Air Force, the last two years of that in the reserves.  My entire career was centered on nuclear warfare operations, supporting what was then known as the Strategic Air Command (SAC).  The pinnacle of that job was serving as a member of the battle staff on an aircraft known at the Looking Glass.  There were 14 of us who functioned as airborne CIOs, primarily managing the battle staff information systems on the plane and the vast array of information systems that were ground and space-based, associated with nuclear warfare.  As an Airborne Launch Control Officer, the CIO was also responsible for “turning keys” with the Operations Controller to launch all 1,000 nuclear ballistic missiles in the US inventory.  Lynda Sabin, to this day a dear friend, was also one of those 14 officers and now she, too, is in healthcare analytics.  Interesting coincidence.  The Wikipedia write-up is available here, but in short, the Looking Glass aircraft and battle staff were responsible for assuming command of all US nuclear forces in the event of war, and managing that war from the safety and survivability of the air-- in a nuclear war, not much would be left of ground-based command centers like the Pentagon.  The Looking Glass was the anchor in a larger “World Wide Airborne Command Post” organization that consisted of numerous aircraft operating from bases around the world that were connected by a global wireless network.

That global wireless network between the orbiting aircraft was also connected to wireless ground entry points that were managed by AT&T.  These ground entry points took our wireless signal for voice and data traffic and routed it via landlines to SAC and other military forces, as well as the White House.  There were two very critical voice conferencing systems that operated on isolated AT&T ground networks:  the SAC Operational Conferencing System (SOCS, pronounced sox) and the Joint Chiefs of Staff Alerting Network (JCSAN, pronounced jay-san).  SOCS was the voice conferencing system used primarily to manage SAC nuclear forces in the event of an emergency—i.e., Air Force bombers, cruise missiles, and intercontinental ballistic missiles.  JCSAN was the voice conferencing system used to manage nuclear and other military operations from the Pentagon, including the nuclear forces associated with the Army and Navy, but Air Force, too.  AT&T provided the circuits and technical support for each of these physically isolated and independent networks.

As those who have served will attest, life in the military can be summarized as hours and hours of pure boredom interrupted by moments of shear terror.  During those hours of boredom, I would read and study everything I could find—the latest intelligence reports, force status reports; military plans, especially the President’s “Black Book” and the Single Integrated Operational Plan, or SIOP, which were the massive handbooks for nuclear warfare and reconstitution of US society after a nuclear exchange.  I would also study the configuration of the information systems that we were tasked with managing, and along with our IS teams, we would quiz each other on the trivia and nuances of those configurations. 

SOCS and JCSAN were supposed to be physically separate networks from AT&Ts public telephone switching systems.  All three—the public telephone network, SOCS and JCSAN were supposed to have an “air gap” between them.  Under certain emergency situations, the air gap could be manually closed, like patching two servers together or bypassing a firewall with a hardwire connection.   The air gap and physical separation were a very deliberate design.  SAC had its need for a conferencing system to manage SAC specific-issues and the Pentagon had its need for managing more global issues across all of the military branches by using JCSAN. In the worst case communications scenario, if the President or National Command Authority needed to communicate to military forces from a public telephone, the public telephone network could be manually connected to JCSAN and SOCS.  Like a separate highway, AT&T’s publicly switched telephone networks were supposed to be completely separate from both the SOCS and JCSAN, with the exception of a drawbridge that could be lowered in an emergency to allow traffic to travel among the three.  But, over a period of several months studying and quizzing members of my IS team, I saw what I thought was an oddity in the design of the AT&T networks that could allow public access to the SOCS and JCSAN networks-- a backdoor that was open… a drawbridge that was already lowered.

For several of those boring nights aboard the Looking Glass, I studied the JCSAN, SOCS, and private telephone network configurations and occasionally talked to AT&T engineers in the ground entry points, asking them questions that focused on the oddity that caught my attention-- I see a way to connect AT&T’s public telephone system into the JCSAN, without manual intervention—without the patch cord across the air gap that separated them.  No, that’s not possible.  Naturally, when you start to see something like I was seeing—when the pattern in the puzzle first emerges-- you can’t believe what you’re seeing.  You keep telling yourself that you misunderstand something… surely it can’t be so. And that’s what I did for weeks… I wrestled in disbelief.

I mentioned what I thought I saw—this backdoor-- to a few colleagues and teammates, but none of them really took it seriously because even I didn’t believe it completely.  But the more I thought about it, the more I looked at the puzzle, the more I was convinced that the backdoor existed.  My mind wouldn’t let it go… and there was only one way to confirm it or prove that I was wrong—try to hack the backdoor.  If I were right and the door opened, it would mean uncovering a big stinky mess associated with one of the most important information systems assets in the US military.  The JCSAN was connected to the “red phone” in the Oval Office and Situation Room.  If I were wrong and the hack failed, it would go unnoticed—a failed hack of no significance.  But that’s not something you “just try” in the military as a young officer.  If you uncover that big stinky mess, it’s going to splatter on a lot of people’s toes, all the way up the ladder.  But if I didn’t uncover it and reveal the problem, what if someone else did?  What if one of the “bad guys” found it and kept it a secret until there was a national emergency… and then they exploited it and disrupted our ability to manage US nuclear forces?  This was in 1987 and ’88, when the Cold War was on steady simmer and the stability of the Soviet Union was just beginning to unravel.  We weren’t sure who would be in charge of Soviet nuclear weapons nor what their state of leadership mind might be.  And I was only 28 years old at the time… it was a stressful burden and decision at a young age, but in a twisted way, the burden was captivating.

One night, at the conclusion of a Looking Glass flight, a group of us from the battle staff went to a local watering hole—Gilmore Lake Tavern—near Bellevue, Nebraska, not far outside the gates of SAC Headquarters in Omaha.  During idle conversation over beer, I mentioned finding what appeared to be a backdoor to the JCSAN, through the public telephone network.  To some of the teammates at Gilmore’s Tavern that night, it was old news—I had told them before—and they lightheartedly dismissed it.  To other teammates, it was just another crazy scheme from The Beave (they nicknamed me The Beaver, as in Ozzie and Harriet’s son, because of the 1950’s flattop haircut that made me look more like 18 than 28 years).  Major Chuck Horton, a dear friend, laughed and bet me a pitcher of beer that I was wrong.  No way was there a backdoor to the JCSAN.  It’s time to put The Beave’s rumor to rest.  Put up or shut up Sanders.  Open the door or quit talking about it.

I didn’t respond for a few minutes, percolating on whether it was worth calling his bet or not.  A pitcher of beer was meaningless; the challenge of the bet was about the risk of adventure.  While I percolated, so did the beer that I’d been drinking and the liquid courage soon overtook the inhibitions.

The dialing sequence to the backdoor was in the breast pocket of my flight suit.  I’d been carrying it around with me for about a month.  I pulled it out, looked at Horton and said, “OK, here we go.  Let’s see what happens.”  He laughed and stayed in his chair.  No one else at the table was paying much attention.  I walked across the bar to the pay phone, put in a quarter, and started dialing the sequence, traversing my way across AT&T’s publicly switched network.  Click, click, click… I would enter a public network switch, get a dial tone, and dial into another.  As I recall, I traversed about 12 switches and networks.

And then I reached what I predicted was the backdoor—the switch that bridged the public telephone system with JCSAN.  I paused like I was standing in front of a real door, stared at it, took a breath, and dialed the last sequence.  If the sequence was wrong, I would get another dial tone into an unknown switch, like opening a door into a an empty room; or I would get a trunk busy signal indicating a dead end…the dead end air gap between the public system and the JCSAN.  If the door opened, I would set off a worldwide alert, known as a warble tone, in all of the US military’s major command centers, including the Pentagon.  The battle staffs of those command centers would pick up their “red phone”, join the conference call, and prepare to receive emergency action messages (EAMs) or other instructions from the Joint Chiefs of Staff or National Command Authorities.

A warble tone went off.  The backdoor was open.  The command centers started answering—This is NORAD. This is NMCC.  This is CENTCOM. This is Space Command…and so on.  

I wasn’t prepared.  I hadn’t actually thought completely through the scenario—“What if the door opens?”  I sat there with the black handset from the Gilmore Lake Tavern phone in my hand, pressed to my ear, stunned for a few seconds, speechless. I looked across the bar at Horton and mouthed the words, “Holy &#*%!”, my eyes wide open. He leaned forward in his chair with a frown of concern.  Then I silently mouthed a second time, “Holy &#*%!”.  Horton’s jaw dropped and his eyes popped. 

A waitress walked by, glanced and smiled at me and then Horton, wondering about the exchange of all the odd facial gestures.  She looked back at me quizzically and paused just long enough to become a party to the event that was unfolding.  I reacted instinctively, like a 12-year old caught red handed in a serious prank—and handed the phone to her.

She looked at me, “What…?  Who is it?  What do you want me to do?”

I said the first thing that popped in my head. 

“Say ‘Hello, General’.” 

“Say ‘Hello, General’?” 

“Yes, say ‘Hello General’.” 

And that’s what she said, “Hello General”.  Her voice came across loud and clear to every US major command center and nuclear battle staff in the world.   I grabbed the phone back, now in a panic, and stuck it to my ear.  My mind racing with oh my god, what have I done??  There was total, stunned silence on the other end.  After a few seconds, someone finally asked, “Who is this?  Who convened this conference?”

Slam.  I hung up the phone and stood there staring at it.  Sanders, you’ve gone a little too far this time, was the voice inside my head.  The waitress asked me, “Who was that?” but I couldn’t respond.  I looked at Horton and shook my head, side to side.  I walked across the bar, back to the table, slowly, eyes wide, mouth tightly closed. 

“It worked”, I told Horton. 

“No way”, he said without excitement, only stern denial. 

“Oh yes—it worked.” 

I told him what happened.  He responded,  “You can’t tell anyone you did this.  Don’t say a #$%&* word about this to anyone!” 

It was a sleepless night, excited like an explorer who stumbled on an important but forbidden discovery.  I wanted to talk about it, but knew quiet discretion was the wiser choice.

The next day, “the incident” was the topic of discussion all over our squadron, and apparently SAC headquarters, too.… and probably all over the military command centers and the Pentagon, as well.  A few of my SAC and Looking Glass teammates knew that I had been talking about this backdoor for quite some time.  They knew it was most likely me behind the incident—they would glance at me in a knowing way-- but they didn’t say a word.  A formal investigation was launched.  I wasn’t involved in the investigation, nor was I quizzed or implicated.  To this day, I don’t know what became of the situation.  I heard that AT&T was summoned to explain, but I don’t really know.   I purposely laid low, no interest in attracting attention to myself, but rather satisfied in the confidence that the backdoor would be closed.

I never had any interest in testing the backdoor again, assuming that it had been closed, but also feeling like I’d used one of my nine lives the first time-- no need to risk another. Over time, as the seriousness of the incident subsided and the military became more concerned about other matters, such as the demise of the Soviet Union, the incident became more openly discussed, often times with a sense of humor about a significant but ultimately harmless caper.  I didn’t openly discuss and fully admit to being the culprit until a couple of years after I resigned from the Air Force and was working for TRW where the incident became a small badge of honor among a cult of similarly mischievous “kids”.  Later, our team at TRW, led by Ron Gault, was hired by the National Security Agency to conduct counter espionage and threat analysis on the entire US nuclear command and control system; those hours of boring study on the Looking Glass paid off nicely under the NSA project.

There are pros and cons to an obsessively curious personality.  I’ve had an interesting life because of that curiosity, but it can push you to the borders of trouble, too.  In this case, it was more than curiosity that pushed me into the incident.  I couldn’t stand not knowing if that backdoor would open or not, and my somewhat impetuous side pushed me to indulge that curiosity in a very unusual setting—Gilmore Lake Tavern.  It would have been just as easy to test the backdoor in a controlled and official Air Force setting, which crossed my mind.  But, the sense of adventure in opening that door by myself, without any supervision, was far more appealing.  The color in life comes from unusual events and settings.  As the janitor for the Liberty Bell museum in Philadelphia told me one time, “If it weren’t for the crack, it would just be a bell and it wouldn’t mean a thing to nobody.”

Sometimes, if life doesn’t do it for you, you have to put a crack in the bell.  J

The Emperor's New Data Model

That was the title of the post to a LinkedIn group ("Healthcare Data Warehousing Association") by my friend and colleague, Dr. Jonathan Einbinder, of Partners Healthcare.  Here's a copy and paste of his post and my response.

Dr. Einbinder:  "In real-world terms, how is a comprehensive healthcare data model (e.g. like the ones provided by Oracle or IBM), helpful in moving forward an analytics agenda? Seems to me that potential value lies in providing a standard target for ETL and in building (or acquiring) content/reports on top of the model. That is the idea, anyway. In pragmatic terms, I wonder if it makes more sense to focus on standardizing a few key dimensions... (anyone remember IHC's Common Data Bus). I would like to hear how other provider organizations approach this."

Dale Sanders: The comprehensive enterprise data model sounds great, in theory, but it fails miserably in practice. I've lived it first-hand and watched it second-hand numerous times now. Of course you know my bias for the Intermountain (IHC) bus architecture, but that bias comes from a good place...pragmatic common sense. 

The origins of the bus approach go back much further than Intermountain (IHC), actually, back to an Air Force project that I worked on in the early 1990s. The bus architecture emerged after the failure of a $60M data warehouse project to pull 450 source systems into a common analytic model for nuclear weapon systems management. It took three years and 200 consultants to develop the enterprise model and ETL for that project. The ETL was so complicated, we spent all of our time maintaining and fixing the problems. When a new source system was introduced, the ETL scripts took months to write; there was no agility. When we exposed the enterprise data model to the analysts, they stared blankly because they had lost all familiarity with the content of their source systems, even though we had a very robust metadata repository, showing all the mappings-- the analysts simply didn't recognize the "enterprise" representation of their data. Finally, the number of analytic use cases that required an enterprise model was less than 2%. We tracked, measured and surveyed the need, post facto.

An electrical-computer engineer, Scott Birbeck, who was a friend and colleague, but not assigned to this particular project, was watching this disaster from a distance. One day he said to me, "Why don't you guys stop trying to make all the data look the same and just make it look the same only where you have to, like we (EE's) do when we build a bus for a computer? We could care less about the details of the devices on the bus, we just care about how they connect to the bus so they can communicate to everything else. Isn't this basically the same problem?" We went to the white board and started sketching.

The next day, a few of us who were desperately trying to pull this data warehouse disaster from the fire, sat down and defined the format and naming conventions for the "core data elements" required to communicate across the "data bus". It took less than a full day to do that for 450+ source systems. The next day, two of us started adding attributes to the source system data models in the staging area, to reflect these core data elements (previously, we had not allowed analysts to access their data in the staging area, which was another mistake in retrospect). In about a week, we had the ability to query across a large number of the most important source systems using these new foreign keys in the data bus.

Going against the policies of the project manager, we secretly gave analysts direct access to the source system data in the staging area and told them how to take advantage of the new data bus...and away they went. They loved it. Soon, the analysts started asking for extracts of the data from the source systems-- data mart subsets of the data that pertained to their particular analytic need; so we built those, too-- they didn't need nor want to constantly pull data from an enterprise model.

We purposely kept this all very secret until there was enough momentum and support from the analysts behind the new approach that the success could not be denied. We didn't want to take this secretive route, but had no choice because the project manager was dogmatically, egocentrically tied to the enterprise model strategy. He soon left the company and still despises those of us who were involved in the recovery, but the Air Force Colonel who was the executive sponsor loved us, as did the analysts.

In three months, the project went from disaster to heroic. The design is still operating and evolving nicely, now almost 20 years later. Oracle told us that it was their largest data warehouse in the world at the time.

Healthcare Reform Debate Continues

Now the healthcare reform political debate has switched to two topics about whether states should implement: (1) Health Insurance Exchanges (HIE); and (2) Adopt the new formula that determines who is eligible for Medicaid.  The new formula would provide greater coverage for lower income individuals and families.

There should be zero political debate about whether HIE's are good for taxpayers and consumers-- they are.  End of debate.  Insurance companies don't want them because they will eventually drive up competition and drive down premiums.  Many GOP governors don't support HIE's simply because they prefer to oppose anything to do with Obama.

The #2 issue is more complicated and worthy of healthy debate, not along political party lines.  While expanding Medicaid coverage is a good thing to do socially-- providing insurance for those who can't afford to pay seems like the humane thing to do in our country.  The problem is, many states can't afford to fund expanded coverage right now, nor can the federal government.  So... it's the right thing to do socially, but a foolish thing to do financially at this time in history, without a plan to afford the increase in coverage.

Remember: I'm a registered political Independent and have been my whole voting life.

Suggestions About Predictive Analytics

Suggestive Analytics. The power of suggestion meets the power of data. But, before we talk about that, let’s contrast it to the buzz phrase of the day — Predictive Analytics.

I’d like to have a dime for every white paper, blog, journal article and marketing brochure I’ve seen in the past six months that cheer a coming healthcare revolution as a result of “Predictive Analytics.” The only thing more prevalent is the term “Big Data.” The latter fascination and buzz is rooted in Freudian reference, I’m quite sure, so of course every male CIO in healthcare wants it.  J But what of the former — what about predictive analytics?  On what do we base this sudden love affair with predictive analytics?  Not much, I’d say.

Wikipedia has a fairly lengthy definition of “Predictive Analytics.”  As defined there, “Predictive analytics encompasses a variety of statistical techniques from modeling, machine learning, data mining and game theory that analyze current and historical facts to make predictions about future events.”

Seems to me that predictive analytics in healthcare tends to come in two flavors — too easy and too hard — with a neglected middle ground.  Do we really need predictive analytics and Big Data to know that a 32-year old sedentary patient who smokes and has a BMI of 30 is a high risk for multiple chronic diseases?  What about a patient living alone, over 65, post-CABG — do we need Watson to tell us that such a patient is high risk for readmission?  Hardly… and yet we are surrounded by such patients.  The problem isn’t that we don’t know.  The problem is that we don’t intervene.

At the other extreme are the patient outliers and rare cases.  As much as we would hope and try, no computer algorithm in the near future is going to predict the impending stroke of a 34-year old patient who is a competitive triathlete with no family history of cardiovascular disease, yet we pursue such predictive scenarios and celebrate enormously if we come within a country mile in a randomized trial of pulling it off.  We ignore the forest of high-risk patients that surrounds us, in pursuit of the perfect and isolated tree.

The predictive middle ground of data that we choose to ignore at the point of care is genetic and family history.  Depending on which report you believe, we know of at least 150 genetic and family history markers that have a profound impact on the outcome of care. Think about it — we can predict and manage care with genuine data-driven decisions in these cases, but we ignore this middle ground, in part, because the data is not readily available in EMRs at the point of care (a different problem altogether worth discussing), we ignore these opportunities for the same reason we ignore the forest of “too easy” scenarios.

Predicting clinical outcomes and risk is not the problem.  The problem lies in our inability and unwillingness to intervene — personally, culturally, and operationally — when we see the opportunity. What healthcare system is operationally capable or even culturally willing to assign a caregiver at home to ensure that the 65-year-old post-CABG patient will not be readmitted?  How many women are willing to be tested for BRCA1 and BRCA2 mutations that raise the risk of breast cancer by 60% … and take action if they are affected?  I won’t even talk about our inability to do something about the skyrocketing incidence of obesity and diabetes.  It’s not that we don’t know, it’s that we are generally incapable of intervening.

Does this cynicism mean I have no interest or hope in predictive analytics for healthcare?  No.  We need to continue inching along technically and culturally with the concepts until, someday, the two will intersect.  In the meantime, we should be realistic and look for other analytic opportunities that are within the grasp of healthcare and already surround us in other parts of our lives — which brings me back to this notion of Suggestive Analytics.

I first saw the power of suggestive analytics in a program called the Antibiotic Assistant at LDS Hospital, thanks to colleagues Dave Classen and Scott Evans.  The Assistant is a complex algorithm which predicts and ranks the best course of antibiotic therapy for inpatients, given the profile of their lab, micro and pathology results, and general demographics.  It’s a very impressive, and an early example of predictive analytics.  However, to me, the equally impressive story is its use of suggestive analytics.

When the program was first released, only the predictive efficacy of the rank ordered antibiotic protocols were presented to physicians.  Naturally, physicians always chose the highest ranked protocol, even if the predicted efficacy of the top choice only differed by a tenth of a percentage compared to the second best choice, but that second best choice might be 10 times less expensive than the top choice.  The breakthrough came when Scott and David revealed the cost of those antibiotic protocols to the physicians, thus suggesting to physicians that they also consider cost alongside predicted efficacy when making their decision.  The benefits to clinical outcomes stayed virtually the same, but costs dropped from an average of $123 per dose to $52.

As e-commerce consumers, we are surrounded by Suggestive Analytics.  Amazon was among the first to influence our behavior by using data in this capacity.  They surround our transaction — e.g., buying a book — with data-driven suggestions that affect our purchasing behavior — customer ratings, frequency of purchase by other consumers, commonly bundled and related purchases and products, availability of the product, arrival date of the shipment, new vs. used prices.

Richard Thaler and Cass Sunstein wrote a great book (Nudge:  Improving Decisions About Health, Wealth, and Happiness) that gives example after fascinating example of what amounts to suggestive analytics, even though they never specifically use the term.

The difference between predictive and suggestive analytics is summarized quite easily:  under predictive analytics, Amazon would fill your shopping cart for you, based upon using predictive data mining algorithms.  Under suggestive analytics, you get to fill your own shopping cart.  Would I prefer that Amazon predict my shopping habits for me and streamline the whole process without my intervention?  Absolutely.  Is it reasonably possible in the near future?  Absolutely not.

Predictive analytics is certainly appealing in concept but, right now, it is little more than a marketing term, another adjective of hype.  Our healthcare industry would be better served to borrow concepts from the world of e-commerce and social networking, and embrace a new concept of Suggestive Analytics at the point of care to nudge our behavior in desired directions.

Personal Honesty: Is Facebook the Real You?

Social media, especially Facebook, is among other things, a life experiment for me as an IT professional and "corporate executive". In particular, I'm insatiably curious about the role that social media technology plays in transparency-- breaking down the barriers and often hypocritical behaviors between personal and professional lives that allow for things such as university football coaches to lead double lives as pedophiles; Secret Service agents with the trust of Top Secret clearances to cheat on their spouses with prostitutes; and Board members and executives to conspire and misappropriate money from non-profit healthcare organizations-- i.e., how truthful is the complete circle of our lives? The recent flap over employers asking for Facebook passwords is an interesting twist on personal honesty vs. personal privacy-- should we care if we have no secrets? Does social media reveal the truth and real person in us or not? This study from the University of Texas seems to think so...  Manifestations of Personality in On-Line Social Networks.

None of us hold perfect behavior.  Accepting that, if you are going to make a mistake in personal behavior and organizational leadership, err towards transparency, not secrecy.  Open up your life.  If the worst thing they accuse you of is "too much honesty... too much information", I suspect you'll still get a clear pass through the Pearly Gates.  :-)

Healthcare Change is Here to Stay, Regardless of Supreme Court?

"Do you agree that Change is Here Regardless of Supreme Court's Decision?"

This question was recently posed by Jay Warden of the Camden Group to members of HIMSS.  Copied below was my response.

I believe SCOTUS is going to overturn the individual mandate, but leave the rest of ACA alone for Congress to fix. But, to the question, yes, I believe we finally reached a tipping point in the industry towards what I'm calling Healthcare 2.0, which boils down to bundled payments that put the economic burden of quality and cost control on the provider, neither of which exist under the current fee-for-service model. In the absence of federal pressure to change healthcare if the Affordable Care Act (ACA) is repealed-- partially or completely-- the employers now have the momentum and there's no turning back.

We are seeing a growing trend of direct contracting with providers by self-insured employers, which is disintermediating the insurance companies and their profits from the economic model. The federal individual mandate under ACA was foolish and naive-- and pushed by the insurance companies to line their pockets. We simply aren't the type of society that legislates that sort of thing from the federal level, and trying to do so was like poking a stick in a hornet's nest. But, the ACA is not all bad and I will give the ACA credit for getting the ball rolling. Employers like IBM, Cisco, Intel, Google, Facebook, Apple, WalMart, Ford, et al, are not going to allow the momentum stop. They are taking control of healthcare by squeezing traditional insurance companies like Aetna, BCBS, and United out of the picture and direct contracting for fixed-fee coverage-- or in some cases, hiring and building their own healthcare delivery organizations.

I'm a CIO in a national health system that allows for private and federally insured options and thus provides 98% insurance coverage without an individual mandate. In this model, if you want insurance for broader coverage, you can buy that in the private market. If you want very affordable, basic coverage, you can access that through the federal government or similar products that are legislated upon the private insurance companies. It strikes a very good balance between private market and federal involvement to ensure access and affordability. I'm also a part-owner of a small business that is leveraging new models for self-funded coverage; it's not easy but it is possible. Obama and Congress could have made it easier for all employers by repealing the McCarran-Ferguson Act (MFA) and opening the doors to interstate competition between insurance companies. Legislating insurance that's not affordable is like creating 30 million new criminals. You need to lower the costs of insurance, first, and you can do that by removing the federal laws that protect the insurance companies from open competition. The Obama Administration caved to the insurance lobby by allowing MFA to stand...since the 1940s.

Despite a less-than-perfect federal attempt, the ACA got things rolling and the momentum for healthcare change is hear to stay, thanks to employers who are no longer willing to accept the status quo.