Bad medical models
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Bad medical models

Summary
Robert Pearl explains the perspectives of a health care leader and son who know that the current health care network interacts with human behavior to induce a poorly performing system that caused his father's death.  But he is confident that these problem perceptions can be changed.  Once that occurs he asserts the network will become more integrated, coordinated, collaborative, better led, and empathetic to their patients.  The supporting technology infrastructure will be made highly interoperable.  All that will reduce medical errors and make care more cost effective. 

Following our summary of his arguments RSS is Rob's Strategy Studio comments on them.  We frame his ideas with complex adaptive system (CAS) theory including synergistic examples of these systems in operation.  The health care network is built out of emergent human agents.  All agents must model the signals they perceive to represent and respond to them.  Pinker explains how this occurs.  Sapolsky explains why fear and hierarchy are so significant.  He includes details of Josh Green's research on morality and death.  Charles Ferguson highlights the pernicious nature of financial incentives. 

Mistreated Why we think we're getting good health care--and why we're usually wrong
In Robert Pearl's book 'Mistreated' he:

Pearl notes that doctors are extensively trained, including years of rigorous practice, so that they are competent to diagnose and treat medical problems:
But Pearl asserts that inside each doctor lurks a persistent sense of terror:  success in the role requires judgment, skill and luck!  Physicians fear making a mistake that harms a patient.  They agree to 'First, do no harm.'  But practice long enough and there will be a life-threatening mistake: a problem diagnosis, causing a major infection, or committing a technical error.  He describes a set of system problems:

Pearl reviews the mental models of patients too:
Pearl concludes that our decisions aren't logical and context matters greatly.  Our minds distort our perceptions.  Disease and death are feared and alter the choices we make for our health care.  And big participants in health care: insurance companies, drug manufacturers; contribute to the distortion and negative impacts. 


Pearl reviews the impact of the major
Plans are interpreted and implemented by agents.  This page discusses the properties of agents in a complex adaptive system (CAS). 
It then presents examples of agents in different CAS.  The examples include a computer program where modeling and actions are performed by software agents.  These software agents are aggregates. 
The participation of agents in flows is introduced and some implications of this are outlined. 
agents
in US is the United States of America.  
The complexity and problems of the US Health network is described in terms of complex adaptive system (CAS) theory. 

The network:
  • Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US: high tax with safety net or low tax without.  The emergence of a parasitic elite supported by tax policy, further constrains the choices available to improve the efficiency and effectiveness of the network.  
    • The US is optimized to sell its citizens dangerous levels of: salt, sugar, cigarettes, guns, light, cell phones, opioids, costly education, global travel, antibacterials, formula, foods including endocrine disrupters;
    • Accepting the US controlled global supply chain's offered goods & services results in: debt, chronic stress, amplified consumption and toxic excess, leading to obesity, addiction, driving instead of walking, microbiome collapse;
  • Is incented to focus on localized competition generating massive & costly duplication of services within physician based health care operations instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  • Is amplified by the legislatively structured separation and indirection of service development, provision, reimbursement and payment. 
  • Is impacted by the different political strategies for managing the increasing cost of health care for the demographic bulge of retirees.  
  • Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  • Includes a legislated health insurance infrastructure which is:
    • Costly and inefficient
    • Structured around yearly contracts which undermine long-term health goals and strategies.  
  • Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR products deep within the hospital systems. 
health care
on perceptions and network operation, relative to comparable external networks and how they are perceived:

Commonly accepted ideas are highly robust, but are sometimes wrong and can always be improved.  Pearl explores some notable examples:

In part two Dr. Pearl describes his 'dull but effective' solutions: ACA transforming perceptions, Pearl's four major shifts, Understanding the current systems failings and what people want and need; which he judges have the potential to change perceptions and alter behavior for the better. 


Pearl reviews the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
  • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
    • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
    • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
    • Children, allowed to, stay on their parents insurance until 26 years of age. 
  • Medicare solvency improvements. 
  • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
  • A requirement that chain restaurants must report calorie counts on their menus. 
:

Pearl's four pillars of transformation - a well-integrated EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
system can support a health care transformation.  Empowered clinical staff can respond to signals from and inconsistencies in the patient's health record by identifying problems and enabling corrective action.  That depends on the system and culture as much as the staff's personality, work ethic or values.  The whole team has to be incented to fix the patients broad problems.  FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.   reimbursement is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
  • Fee-for-service,
  • Per Diem,
  • Episode of Care Payment, 
  • Multi-provider bundled EPC,
  • Condition-specific capitation,
  • Full capitation.  
and disconnected specialists undermine this integrated empowered team strategy.  Pearl asserts that four shifts can together create a more efficient and effective model of care delivery:
  1. A team of physicians working together on your behalf.  Pearl argues that there are three types of health care venue today: 
  2. Aim for people to stay healthy, which is better and cheaper.  Pearl notes that FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.   does not reward doctors and hospitals for optimal care, just to do more.  Pearl wants incentives to reward preventing problems, improving quality, maximizing safety and minimizing cost. 
  3. Effective interoperable technology is essential to fully enable responsive, convenient, well informed care.  10 million EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    s provides a database which supports predictions of which: Hospital patients will require subsequent ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
    admission so early intervention can remove this possibility; Patients will return to the ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
    after discharge, so their release can be delayed while their recovery is monitored.  But only a handful of US hospitals apply advanced data analytics, leaving problems hidden.  The data can differentiate between situations where watchful waiting is best and surgery is required.  Pearl laments that EHR interoperability is held back by business constraints.  And hospitals also need to augment the EHR with all the data about the patient gathered at other sites.  Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis.  The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass.  Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms.  Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS.  For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
    • Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature. 
    • Analytics tools (BI) for PHM will be hard to develop.  
      • Complex data models must include clinical aspects of the patient specific data, including disease state population wide.  
      • A key aspect is providing clear signals about the nature of the data using data visualization. 
    • Data communication with the ability to exchange and transact.  HIEs and EMPI alliance approaches are all struggling to provide effective exchange. 
    • Data labeling and secure access and retreival.  While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool.  Silos imply that the security architecture will need to be robust. 
    • Raw data scrubbing, restructuring and standardization.  Even financial data is having to be restandarized shifting from ICD-9 to -10.  The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process. 
    • Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data. 
    • Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure.  The integration of the EHR into a big data collection tool is key. 
    helps doctors determine which clinical approaches best match a situation.  Pearl notes that Kaiser has provided a million virtual doctor visits a month.  But most hospitals still don't offer these capabilities.  Insurance policies and state medical boards have constrained action but are slowly shifting.  Pearl discusses
    This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
    Clayton Christensen
    's
    US healthcare is ripe for disruption.  Christensen, Grossman and Hwang argue that technologies are emerging which will support low cost business models that will undermine the current network.  Applying complex adaptive system (CAS) theory to these arguments suggests that the current power hierarchy can effectively resist these progressive forces. 
    disruption of healthcare
    as an enabler of change. 
  4. Physicians must be trained to be effective leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a leadership methodology based on the three-circles model. 
    .  As CEO of a major Kaiser medical group and a member of the Stanford business school faculty Pearl's experience led him to conclude leaders must touch their colleague's heart, brain and guts.  Pearl explains:
Pearl views his four pillars as a vision to strive for.  In particular he hopes politicians will use the vision as a way to improve the competitive advantage of American business and so will support legislation that encourages such a transformation. 


Pearl explains what he, doctors, patients; everyone wants and needs - he loves: sports, team sports in particular and baseball most, because of its happy associations with his father and his childhood.  And he adds baseball, like our bodies, requires every agent to work together to succeed.  Similarly teamwork generates the best results in health care. 
Recently Pearl laments baseball and health care have become overly profit oriented to the detriment of pleasure and fulfillment. 

The perverse incentives of health care are due to imbalances:
Pearl writes that doctors are unhappy with these imbalances, resulting in low personal and professional satisfaction, depression is a debilitating state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, burn-out and suicides.  Practitioners see themselves as embattled and powerless.  Pearl notes that doctors have to cope with the deaths of their patients.  Events that remain vividly with the family and health care professionals, especially when improvements in the system could have changed the outcome.  The environment in which health care is administered has a major impact on clinical quality.  It alters perception which transforms
The complexity of behavior is explored through Sapolsky developing scenarios of our best and worst behaviors across time spans, and scientific subjects including: anthropology, psychology, neuroscience, sociology.  The rich network of adaptive flows he outlines provides insights and highlight challenges for scientific research on behavior. 

Complex adaptive system (CAS) theory builds on Sapolsky's details highlighting the strategies that evolution has captured to successfully enter niches we now occupy. 

behavior
.  Some group practice leaders
This page reviews the inhibiting effect of the value delivery system on the expression of new phenotypic effects within an agent. 
demonstrate
use of inappropriate but lucrative coding and billing which then shifts the perceptions of new members.  Pearl describes examples of loss aversion which are more influential when they are concrete (cash loss) than indirect (credit catalyzes the purchase of homes and durable goods by spreading out the payment into a series and removing the need to obtain the entire purchase price in advance as described by Gordon.  It is supported by an evolved amplifier, including: a clear benefit to the purchaser, a profit stream captured by the lender, enforceable contractual agreements, within a schematic regulatory framework.  Taibbi describes the amplifier's architecture as deployed by Chase.  Nineteenth century US rural purchases were credit based but with a large initial commitment.  Cash purchases increased between 1890 and 1910.  Between 1910 and 1915 cash purchasing shifted back to leveraging credit.  By 1920 credit accounts were offered at department stores.  Installment plans, provided by finance companies: GMAC; with minimal upfront commitments supported the purchase of costly durable items including automobiles. 
).  This type of mental distortion is amplified by health insurance which ensures the cost impact of care is highly indirect.  And since physicians decide the demand for a procedure and its price, while patients have little choice but to pay, supply and demand are decoupled.  Medical research displays similar biases.  Drug and device companies monitor who is using and prescribing their most profitable products.  These doctors are rewarded with food, flattery and friendship. 

Still Pearl concludes the massive scope of the transformational change requires everyone to recognize our health care decisions affect ourselves, our families and our communities.  People want:
Pearl feels that the best health care must provide all these wants as one to its patients.  He asserts this requires the
The complexity and problems of the US Health network is described in terms of complex adaptive system (CAS) theory. 

The network:
  • Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US: high tax with safety net or low tax without.  The emergence of a parasitic elite supported by tax policy, further constrains the choices available to improve the efficiency and effectiveness of the network.  
    • The US is optimized to sell its citizens dangerous levels of: salt, sugar, cigarettes, guns, light, cell phones, opioids, costly education, global travel, antibacterials, formula, foods including endocrine disrupters;
    • Accepting the US controlled global supply chain's offered goods & services results in: debt, chronic stress, amplified consumption and toxic excess, leading to obesity, addiction, driving instead of walking, microbiome collapse;
  • Is incented to focus on localized competition generating massive & costly duplication of services within physician based health care operations instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  • Is amplified by the legislatively structured separation and indirection of service development, provision, reimbursement and payment. 
  • Is impacted by the different political strategies for managing the increasing cost of health care for the demographic bulge of retirees.  
  • Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  • Includes a legislated health insurance infrastructure which is:
    • Costly and inefficient
    • Structured around yearly contracts which undermine long-term health goals and strategies.  
  • Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR products deep within the hospital systems. 
health care network
to work together learning from each other, to reduce medical error and improve coordination.  They will need to have and use integrated information systems to do this.  That will allow them to address social disparities in health outcomes.  Insurers must shift from FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.   to FFV is fee-for-value payment.  It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation.  In each case the risk has shifted from the payer to the providers of care. 
and stop demanding prior authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures.  The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions.  After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization.  This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer.  If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process.  It may take 30 days for the insurer to approve the request.   to do what's right.  The synergies will improve quality and drive down costs. 

Eventually
US healthcare is ripe for disruption.  Christensen, Grossman and Hwang argue that technologies are emerging which will support low cost business models that will undermine the current network.  Applying complex adaptive system (CAS) theory to these arguments suggests that the current power hierarchy can effectively resist these progressive forces. 
disruption of the current health care businesses
must occur.  But private practice doctors fear what change may bring.  Those near retirement may give up but Pearl hopes they won't because their expertise is needed.  He views reduced medical error as providing the needed cost savings instead of the reduced reimbursements the doctors' fear.  New doctors can choose how they will practice medicine.  But Pearl warns without change cost inflation will induce rationing of care. 

Pearl's assessment is the health care delivery system still needs fixing:
Pearl hopes that once: physicians, politicians, insurance and drug-company executive, patients; understand these system failings they will insist on doing something about it.  That will mean his father's unfortunate death served a purpose. 


This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
CAS theory
views the people and businesses of the US is the United States of America.   health care
This page discusses the effect of the network on the agents participating in a complex adaptive system (CAS).  Small world and scale free networks are considered. 
network
as
Russ Abbott explores the impact on science of epiphenomena and the emergence of agents. 
emergent
Plans are interpreted and implemented by agents.  This page discusses the properties of agents in a complex adaptive system (CAS). 
It then presents examples of agents in different CAS.  The examples include a computer program where modeling and actions are performed by software agents.  These software agents are aggregates. 
The participation of agents in flows is introduced and some implications of this are outlined. 
agents
.  As such they must
The agents in complex adaptive systems (CAS) must model their environment to respond effectively to it.  Samuel modeling is described as an approach. 
model
their proximate environment to operate effectively within it.   Over evolutionary time scales the models have become sophisticated enough to allow us to presume we see reality.  But illusions demonstrate that this is not the case.  We construct our reality from the signals we perceive:

Dr. Pearl's moving and thoughtful book challenges our mental models of good health care.  Hopefully we can integrate his insights into the strategic process used for understanding and improving the US is the United States of America.  
The complexity and problems of the US Health network is described in terms of complex adaptive system (CAS) theory. 

The network:
  • Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US: high tax with safety net or low tax without.  The emergence of a parasitic elite supported by tax policy, further constrains the choices available to improve the efficiency and effectiveness of the network.  
    • The US is optimized to sell its citizens dangerous levels of: salt, sugar, cigarettes, guns, light, cell phones, opioids, costly education, global travel, antibacterials, formula, foods including endocrine disrupters;
    • Accepting the US controlled global supply chain's offered goods & services results in: debt, chronic stress, amplified consumption and toxic excess, leading to obesity, addiction, driving instead of walking, microbiome collapse;
  • Is incented to focus on localized competition generating massive & costly duplication of services within physician based health care operations instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  • Is amplified by the legislatively structured separation and indirection of service development, provision, reimbursement and payment. 
  • Is impacted by the different political strategies for managing the increasing cost of health care for the demographic bulge of retirees.  
  • Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  • Includes a legislated health insurance infrastructure which is:
    • Costly and inefficient
    • Structured around yearly contracts which undermine long-term health goals and strategies.  
  • Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR products deep within the hospital systems. 
health network





























































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This page looks at schematic structures and their uses.  It discusses a number of examples:
  • Schematic ideas are recombined in creativity. 
  • Similarly designers take ideas and rules about materials and components and combine them. 
  • Schematic Recipes help to standardize operations. 
  • Modular components are combined into strategies for use in business plans and business models. 

As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan. 

Finally it includes a section presenting our formal representation of schematic goals. 
Each goal has a series of associated complex adaptive system (CAS) strategy strings. 
These goals plus strings are detailed for various chess and business examples. 
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