Disrupting health care
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Disrupting health care

Summary
US is the United States of America.   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 (
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 to these arguments suggests that the current
This page describes the organizational forces that limit change.  It explains how to overcome them when necessary. 

power hierarchy can effectively resist these progressive forces

The Innovator's Prescription
In Christensen, Grossman and Hwang's book "The Innovator's Prescription" they apply Christensen's theory of
This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
disruptive innovation
to make US is the United States of America.   health care affordable.  Health care, legal services and higher
Salman Khan argues that the evolved global education system is inefficient and organized around constraining and corralling students into accepting dubious ratings that lead to mundane roles.  He highlights a radical and already proven alternative which offers effective self-paced deep learning processes supported by technology and freed up attention of teams of teachers.  Building on his personal experience of helping overcome the unjustified failing grade of a relative Khan:
  • Iteratively learns how to teach: Starting with Nadia, Leveraging short videos focused on content, Converging on mastery, With the help of neuroscience, and filling in dependent gaps; resulting in a different approach to the mainstream method. 
  • Assesses the broken US education system: Set in its ways, Designed for the 1800s, Inducing holes that are hidden by tests, Tests which ignore creativity.  The resulting teaching process is so inefficient it needs to be supplemented with homework.  Instead teachers were encouraging their pupils to use his tools at home so they could mentor them while they attended school, an inversion that significantly improves the economics. 
  • Enters the real world: Builds a scalable service, Working with a real classroom, Trying stealth learning, At Khan Academy full time,  In the curriculum at Los Altos, Supporting life-long learning. 
  • Develops The One World Schoolhouse: Back to the future with a one room school, a robust teaching team, and creativity enabled; so with some catalysis even the poorest can become educated and earn credentials for current jobs. 
  • Wishes he could also correct: Summer holidays, Transcript based assessments, College education;
  • Concludes it is now possible to provide the infrastructure for creativity to emerge and to support risk taking. 

Following our summary of his arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Disruption is a powerful force for change but if its force is used to support the current teachers to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the current educational network? 

education
are high cost markets that have not disrupted in the US.  They argue that with appropriate regulatory reform hospitals, physician's practices, chronic care services, the reimbursement process, the pharmaceutical, medical device & diagnostics industries, medical education and the value delivery networks, will all
This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
disrupt
improving care and lowering costs. 

They see the mixed public/private network in the US as conducive to disruption, since no one has total control.  They see total public control of health care as reducing the potential niches where disruption can start. 

They argue that four characteristics are required for
This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
disruption
:
  1. This page discusses the physical foundations of complex adaptive systems (CAS).  A small set of rules is obeyed.  New [epi]phenomena then emerge.  Examples are discussed. 
    Regulations and standards
    that facilitate change.
  2. Tools and the businesses that produce them have evolved dramatically.  W Brian Arthur shows how this occurred.
    Sophisticated technologies
    that simplify and transform niche access. 
  3. Low-cost, innovative business models.  These include a value proposition, profit formula, and resource requirements. 
  4. Economically coherent
    The complex adaptive system (CAS) nature of a value delivery system is first introduced.  It's a network of agents acting as relays. 

    The critical nature of hub agents and the difficulty of altering an aligned network is reviewed. 

    The nature of and exceptional opportunities created by platforms are discussed. 

    Finally an example of aligning a VDS is presented. 
    value network

The technologies Christensen, Grossman and Hwang see as supporting health care disruption include:
They see medical practice progressing over time as the understanding of a disease becomes more accurate:
Disrupting health care's hospital businesses
The hospital business model is an aggregate.  Historically the hospital started as a 'job shop' which allowed
This page uses an example to illustrate how:
  • A business can gain focus from targeting key customers,
  • Business planning activities performed by the whole organization can build awareness, empowerment and coherence. 
  • A program approach can ensure strategic alignment. 
expertise
and specialized resources to be centralized and applied intuitively to the diagnosis, and treatment, of each patient.  As medical science improved, its models of certain diseases diagnosis and treatment could be supported by iterative processes.  These 'chain' business models were added to the aggregate.  Any patient is a target customer!  All treatments are made services.  There is a separate fee for each service.  Christensen, Grossman and Hwang argue that the aggregate is error prone and inefficient increasing costs dramatically.  Costly aspects of the hospital are typically subsidized by more profitable treatments.  The net effect of regulation, contracting, pricing models and reimbursement policies is to trap hospital businesses in this inefficient state.  Hospitals avoid competition with low cost businesses through protective regulation.  Christensen, Grossman and Hwang advocate three disruptive phases to improve the efficiency of the hospital business:
  1. Separating the different hospital business models to form coherent: intuitive; empirical diagnosis, and treatment; businesses arguing that it will reduce costly overheads and subsidies. 
  2. Subsequent disruption within the coherent businesses.  Value chains include high capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital). 
    diagnostic equipment.  As the medical device business model disrupts it will drive the hospital model to disrupt too. 
  3. Final disruption across business model types.  
Specialist intuitive job shop hospitals, such as Texas Heart which focuses on cardiovascular disease and
This page discusses the benefits of bringing agents and resources to the dynamically best connected region of a complex adaptive system (CAS). 
centralizes
all appropriate expertise into teams are noticeably lower cost, than general hospitals.  The low diagnosis error rate is a significant component of this reduced cost. 

Disrupting primary care businesses
The primary care business model is an aggregate.  Like general hospitals they offer to treat any problem for their patients.  Primary care physicians have been:
The reimbursement process based on Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare includes:
  • Benefits
    • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • Eligibility
    • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. 
    • Persons under 65 with disabilities who receive SSDI. 
    • Persons with specific medical conditions:
      • Have end stage renal disease or need a kidney transplant. 
      • They have ALS. 
    • Some beneficiaries are dual eligible. 
    • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
processes has generally rewarded specialists and under paid primary care, limiting the number of newly qualified doctors who are opting for primary care. 

Christensen, Grossman and Hwang suggest that the primary care practice should focus on first line intuitive medicine, aiming to disrupt the simpler engagements from more expensive hospitals.  Distributed diagnostic technologies (PoCT) allows:
  • Immediate diagnosis in the PCP office, an ambulance, the home, the field or in hospital rather than waiting for the lab.  It includes over the counter: glucose monitoring and pregnancy testing and professional: critical care, infectious disease (HIV, Chlamydia), cardiac monitors, diabetes, lipids, coagulation and hematology; with 'over the counter' providing the largest market and infectious disease PoCT the fastest growth.  Devices range from: sticks and small hand-helds, to bench top versions of laboratory devices.  Timely diagnosis allows rapid treatment.  Predictive personalized and preemptive medicine can be designed based on PoCT.  It is difficult to deliver a: timely - within 5 minutes - flexible, cost effective - $20 for infectious disease, accurate, easy to use, safe; PoCT device.  PoCT patients require tests to be free or appropriate while clinicians want to maximize simplicity and coverage.  Diagnostics [will] include:
    • Operator interface
    • Bar code identification
    • Chemical reactors (large sample diagnostics: Early LOC, LFS; and molecular diagnostics: LOC, Paper-based;) which only require a small amount of blood.  Preparation of the sample avoiding contamination have been major challenges often requiring a laboratory-like facility.  
      • Molecular diagnostic sample amplification: PCR, LAMP, RCA;
    • Optical or electochemical probes
    • Low cost imaging devices
    • Reagent storage
    • Networking and storage
, expert systems and telemedicine is the use of remote health care.  It includes telepharmacy and clinical telehealth for stroke and psychiatry.  It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors. 
are viewed as enabling the disruption.  All other aspects of the current business will detract from this activity and are more optimally deployed in other business models. 

Christensen, Grossman and Hwang expect rules based diagnosis and treatment to be more cost effectively deployed by a 'chain' business model with low cost nurse practitioners, which will consequently disrupt the primary care aggregate business. 

While some argue that primary care physicians are the natural gate keeper of the health care network (PCMH) The Patient-centered medical home describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems.   The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes.  The PCMH was promoted as a way to incent more PCP which had been seen as a low reward role by medical students.  HCI3 argues this use of PCMH is flawed.  PCMH is driven by the medical home models of the ACA.  In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care.  It is focused on treating the whole person.  It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications.  It must ensure extended access and availability of its services and patients preferences about access.  It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools.  Many argue that to be effective it must be connected to a 'medical neighborhood'.  The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.  , Christensen, Grossman and Hwang advocate a facilitated 'network' supported by an open digital personal health record

Disrupting health care of chronic diseases
The most costly chronic diseases are to a very significant extent induced by the success in treating formerly lethal diseases (diabetes is the leading cause of blindness, limb amputations and kidney failure.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
, congestive heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands.  There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation.  Treatments include: digoxin; , asthma is inflammation of the airways resulting in their narrowing, swelling and generating additional mucus which inhibits breathing.  Its prevalence doubled in the US between 1980 and 2000.  Diagnosis: Propeller Health; Treatments include: Xolair;
, 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.  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; and coronary is an AMI. It can induce cardiac arrest.  Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI.  Risk factors include: taking NSAID pain killers (May 2017).  There is uncertainty about why AMI occur.  Alternative hypotheses include:
  • Plaques started to gather in the coronary arteries and grew until no blood flow was possible.  If this is true it makes sense to preventatively treat the buildup with angioplasty. 
  • Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot.  If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors. 
) and the reimbursement evolved amplifier rewarding treatment rather than wellness is a health care oriented employer based strategy for reducing health care costs and encouraging wellbeing.  Wellbeing has traditionally been a focus of public health.  .  The situation is made worse by sufferers' problematic behaviors, such as smoking, over eating and drinking, being decoupled by delays in feedback from the damaging results.  Christensen, Grossman and Hwang conclude that together these forces require active inducement of wellness behaviors.  They argue that only facilitated network business models, with membership schemes are incented to promote wellness.  They see the Kaiser Permanente business structure as able to construct value chains and business models which benefit from incenting its customers to focus on wellness (Oct 2015). 

Christensen, Grossman and Hwang see chronic diseases needing multiple business models for successful treatment.  These are: a diagnosis business, a treatment allocation business and a treatment adherence business.  The latter is so different it should be handled separately.  However, it is also vital that the patent successfully transitions between the separate businesses.  Christensen, Grossman and Hwang view the employer as well placed, and incented, to manage their employees' transition. 

Christensen, Grossman and Hwang argue that patients are best supported financially by a catastrophic insurance policy plus a health savings account is
  • An employee health savings account which uses a person's health score to calculate the costs of reimbursement and insurance coverage necessary to cope with expected medical costs.  HSAs are an expansion of MSAs that existed in 20 states since the 1990s.  HSAs were enacted as part of MPDIMA.  Each HSA has an insurance policy to handle the risk of catastrophic illness.  Policy holders can withdraw funds untaxed when they are used for paying eligible medical costs including: long-term-care insurance premiums and medical care during retirement.  Employer contributions can be diverted to increased insurance payments if the employee's actions result in a low health score.  HSAs are federally tied to HDHPs.  It is argued that HSAs are very useful to the wealthy as a tax shield.  The poor would depend on the catastrophic insurance limiting the financial impact of cancer treatment or major surgery.  Or it is a
  • Hospital service area - a local health care market for hospital care as used in the Dartmouth Atlas.  
, which accrues cash when treatments are limited to typical essential needs.  They also see opportunities in the increasing information captured about patients actions by pharmacies and shops.  They see these being used by businesses, interested in reducing health care costs, and insurers to detect unhealthy choices and reward healthy ones. 

Disrupting health care value networks
Christensen, Grossman and Hwang review the current value network supporting flows through the US is the United States of America.   health care network.  Physicians and hospitals are independent for-profit businesses.  They are financed by reimbursement from employers, insurance companies and the US Government.  The network is constrained by regulation.  Access to practice medicine is regulated by a guild, composed of physicians.  It can maintain control because reimbursement has been made conditional on the practitioner having a guild issued license.  Patient access to hospitals is controlled through contracts between hospitals and insurers.  The large general hospitals obtain exclusive contracts since they match the overall coverage required by insurers, limiting competition by specialist hospitals.  Treatment is constrained by reimbursementMedicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare includes:
  • Benefits
    • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • Eligibility
    • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. 
    • Persons under 65 with disabilities who receive SSDI. 
    • Persons with specific medical conditions:
      • Have end stage renal disease or need a kidney transplant. 
      • They have ALS. 
    • Some beneficiaries are dual eligible. 
    • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
contracts drive alignment with insurers and suppliers over prices and preferred treatment options.  Disruptive businesses must avoid this highly controlled value network to succeed. 

Christensen sees over-seas markets, corporate orchestrators (such as G.E. and J. & J.), US employers and fixed fee health care providers, like Kaiser, as able to support niches outside of the constraints of the current value network, linking disruptive business models and low cost technologies to aligned value networks.  For employers to support niches they may need to integrate their businesses with a health care business.  While that seems contrary to 'focusing on the core' business Christensen asserts that any offer which helps a customer do his job more effectively or at lower cost is 'core'.   Controlling employee health care costs is viewed as supporting such an offer. 

Christensen sites an example of a company, that setup its own primary care clinics and directly employed physicians.  The medical group sold its services to other companies in the area.  It also significantly reduced the impact of escalating health care costs on the company.  Since the owning family included a doctor, he was able to take on the leadership 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. 
of the medical group. 

Disrupting health care reimbursement
Reimbursement sustains, and shapes the current US is the United States of America.   health care network.  Christensen, Grossman and Hwang view its disruption as essential to obtaining affordable care.  They regard reimbursement as enforcing
H. A. Hayek compares and contrasts collectivism and libertarianism. 
central planning
throughout the network.  Each agent in the network aligns to capture profits and avoid losses. 

The US population has accepted a right to any current treatment.  Doctors are incented to provide as many profitable services as possible.  For major employers reimbursement, and associated tax policies provide incentives for employees to stay with the organization. 

To transform the reimbursement process into a driver of health care disruption Christensen, Grossman and Hwang advocate two architectures:
  1. Integrated capitation is a global payment for all care for a patient during a specified time period.  It forces the provider of care to take a high risk.  Managing the risk implies successful population health management. 
    - for use by fixed fee health care providers such as Kaiser Permanente
  2. High deductible catastrophic insurance + health savings account is
    • An employee health savings account which uses a person's health score to calculate the costs of reimbursement and insurance coverage necessary to cope with expected medical costs.  HSAs are an expansion of MSAs that existed in 20 states since the 1990s.  HSAs were enacted as part of MPDIMA.  Each HSA has an insurance policy to handle the risk of catastrophic illness.  Policy holders can withdraw funds untaxed when they are used for paying eligible medical costs including: long-term-care insurance premiums and medical care during retirement.  Employer contributions can be diverted to increased insurance payments if the employee's actions result in a low health score.  HSAs are federally tied to HDHPs.  It is argued that HSAs are very useful to the wealthy as a tax shield.  The poor would depend on the catastrophic insurance limiting the financial impact of cancer treatment or major surgery.  Or it is a
    • Hospital service area - a local health care market for hospital care as used in the Dartmouth Atlas.  
    for other situations. 
In each case the architecture stimulates a focus on wellness is a health care oriented employer based strategy for reducing health care costs and encouraging wellbeing.  Wellbeing has traditionally been a focus of public health.  , and limiting treatments. 
Disrupting the pharmaceutical industry
Pharmaceutical products now limit the deaths, which prior to these products, were induced in vast numbers by bacterial and viral infections.  But this remarkable achievement has resulted in more people surviving long enough to suffer from chronic diseases.  As science has captured a better understanding of drug treatment the development of new drugs have become associated with a costly trial process to control the introduction of systemic drug treatments which cause harm in some subset of the population. 

Currently the US is the United States of America.   prices drugs so that the GLOBAL pharmaceutical industry is financed to support end-to-end value creation and delivery.  That worldwide investment explains one huge aspect of the current cost of US health care. 

Christensen, Grossman and Hwang are excited by the transition from intuitive to precision medicine.  This offers the possibility for accurate targeting of drugs to patients who will benefit, and away from others who will not, or who will be harmed.  That suggests the potential for a lower cost iterative cycle based development and trial process.  The precision medicine must include a sensor which can provide the targeting.  It must also result in an effective drug that acts specifically on a defective pathway.  The accurate targeting of precision drugs implies they are unlikely to be blockbusters, a business model which requires substantial resources to produce the product, but also generates outsize returns if it converts a majority of its potential market into customers.  

In consequence Christensen argues that diagnosis, trial and mechanism based targeting of drugs should be the profit points in the future pharmaceutical industry.  But they point out the major US pharmaceutical companies are actually retreating from those areas to the currently profitable points.  Their huge size, built to leverage scale economies, becomes a business model constraint and an issue with fewer blockbuster opportunities.  To leverage their huge investments in current drugs they are marketing direct to consumers which may match a future control point in a disrupted system. 

In a typical disruptive transition foreign low cost generic manufacturers, in China and India, are initiating R&D is research and development. 
programs as they attempt to capture more of the low profit areas of the world health care market.  For the US pharmaceutical companies the vice is tightening, since their focus on current profitable markets is all but assured to mean missing the next blockbuster drug while investing huge sums in R&D of the currently owned market segment. 
Disrupting the medical device and diagnostic equipment industry
Advanced technologies are miniaturizing and reducing the costs of equipment.  Christensen, Grossman and Hwang expect this to encourage distributed deployment (Personalized medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient.  Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease.  The take-up of personalized medicine benefits from the focus on genomics detailed by the NIH director Francis Collins and includes:
  • NCCN intensive cell therapies
  • Direct to consumer genomic testing
  • Direct to consumer diagnostics
  • Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.  
: Diagnostics, Direct-to-consumer, Liquid biopsy uses a tiny blood sample used for diagnostic testing.  Often the testing is based on using DNA sequencing to detect DNA in the blood from cancer cells.  By identifying the mutations in a patient's tumor accurate treatments can be selected, and recurrence can be detected.  But aging generates many similar mutations which could lead to false positives in a broad screening test.  Research and development is ongoing (Jun 2016). 
, Molecular imaging allows the visualization of cellular function and molecular processes, allowing more precise and earlier diagnosis of disease.  It extends traditional imaging by:
  • Using biomarkers including nano sensors, which interact chemically with their surroundings, to image particular targets and pathways.  
  • Providing quantitative data on the imaged process or function enabling nanomedicine.  
  • Extending mass spectrometry with MALDI to allow rapid (relative to sequencing or x-ray crystallography), low cost analysis of proteins, bacteria and viruses. 
, Personal genomics, theranostics is a combination of diagnostics and therapy that are seen as key in personalized medicine.  Theranostic nanoparticles can be designed to have multiple capabilities: both imaging and carrier; to support diagnosis, drug delivery and monitoring of therapeutic response.  ; Nanomedicine is the application of nanotechnology to medicine (May 2016).  Commercial applications are focused on research and clinical tools for drug delivery, therapies, in vivo imaging, neuro-electronic interfaces, other nanosensors, and eventually cell repair machines!!  There are issues with determining toxicology etc. 
: Research 2016;).  Integration of computer controls and communications should allow less skilled operators to use the equipment. 
Disrupting medical education
Medical and nursing schools still reflect their design in the early 1900s.  The methods take no account of our understanding of iterative execution and improvement processes.  Christensen explains that
This presentation reviews just-in-time manufacturing with analysis based on complex adaptive system (CAS) theory. 
the process
was highlighted at Toyota where people are trained to perform a role until they can execute it expertly.  With such agents performing the lean production process continuous improvement, and high awareness of the plans and actions, expertise is sustained.  Medical schools are still implementing mass production techniques.  Students are expected to learn the theory months or years prior to practicing the role.  The quality control is based on a final exam and malpractice checks while practicing.  Quality cannot be guaranteed. 

Additionally medical students are not trained in team work or process improvement.  They are unlikely to experience all of the needed roles while an intern is a medical graduate in their first year of residency. 
, due to there being a limited number of patients with the relevant problems.  Christensen, Grossman and Hwang view simulators as offering the potential to improve the learning process for medical schools as it has done for airline pilots. 

While medical schools are unlikely to make such dramatic changes overnight Christensen, Grossman and Hwang see them as being disrupted by oversees schools that already supply US is the United States of America.   health care with primary care doctors to make up for the short fall from US schools. 
Disruption of health care and regulatory reform
Christensen, Grossman and Hwang accept that incumbents will be protected by the US is the United States of America.   regulatory infrastructure.  However they argue that there are niches where regulations do not reach.  From these bridgeheads low cost disruptive businesses can build strength, until they become valuable enough to become part of the regulatory goals.  At that point the current incumbents will disrupt. 

Incumbents will be keen to use regulatory pressure to undermine the disruptive business models. 

Christensen, Grossman and Hwang note that regulators often strive to replace monopolies with forced competition.  They warn that if the new competitors are forced to participate in the current network they will lose to the incumbent 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. 


Breakthrough research is typically undermined by the alignment processes of the academic research community.  As such it should be supported by government policy and investment.  Once seeded into industry government's role should be to tilt the playing field to ensure the industry gains competitive strength.  But they argue democracies usually struggle to do this. 

With little likelihood that health care industries and value networks will be restructured by government, Christensen, Grossman and Hwang see fixed fee providers such as Kaiser as important niches where disruption can start. 


The application of
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
represents
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.  The emergence of a parasitic elite further constrains the choices available to improve the efficiency and effectiveness of the network. 
  • 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. 
US health care
as a system of
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
collaborating to utilize a set of
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
emergent
niches. 

Christensen, Grossman and Hwang stress how technologies that reduce cost, and simplify catalyze disruption.  We view disruption's effect a little differently.  It contributes at all stages of the innovation is the economic realization of invention and combinatorial exaptation. 
cycle between
This page discusses the benefits of bringing agents and resources to the dynamically best connected region of a complex adaptive system (CAS). 
centralized
, distributed and
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. 
networked
agent structures.  The steam engine centralized artisan industrial activities, leveraging the power of coal.  The internal combustion engine and electric motor enabled more distributed configurations.  In each case the previous technologies, businesses and value chains were disrupted, in Schumpeter's wave of creative destruction.  The situation is not definitive.  Cloud computing centralizes the administration and operation of computing services, networks their application and undermines Microsoft's Windows business.  If the amplifiers that support Microsoft's business fail or reverse it may not have the free cash to restructure and then as it seeks profits the windows business could be disrupted. 

The personal health record is viewed by Christensen, Grossman and Hwang as critical to successful health care disruption.  Their Indivo personal health record is a Personal Health Record.  Goal is to place patients in control and make them accessible.  Early vision differentiated between standalone PHR and EHR tethered patient portals.  There are various PHR services.  Privacy, security, data integrity, ownership, cost, and quality are all unresolved issues.  Can be loaded onto a cell phone or app but then the health care privacy regulations don't apply.   process is equated with Toyota's manufacturing data process.  We note that the IETF process successfully supported a highly analogous disruption of a set of incompatible business networks with the Internet technologies.  Network effects, 'free programming' and open standards, ensured the power of the Internet amplifier.  The US HITECH the Health Information Technology and Economic and Clinical Health Act 2009.  Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology.  It is assumed that over time use of the new infrastructure will grow exponentially.  HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC.  Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. 
and 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
have driven EHR refers to electronic health records which are a synonym of EMR.  EHRs have 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-patent setting. 
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
s preeminently into the health care network. 

Specialized job shop hospitals combine
This page discusses the benefits of bringing agents and resources to the dynamically best connected region of a complex adaptive system (CAS). 
centralization
with a
This page discusses the interdependence of perception and representation in a complex adaptive system (CAS).  Hofstadter and Mitchell's research with Copycat is reviewed. 
perception and representation
architecture.  The gathering together of the entire costly infrastructure brings the benefits of
This page reviews the catalytic impact of infrastructure on the expression of phenotypic effects by an agent.  The infrastructure reduces the cost the agent must pay to perform the selected action.  The catalysis is enhanced by positive returns. 
amplification
.  However, to sustain the flows through the amplifiers requires ubiquitous resources.  Maintenance of
Flows of different kinds are essential to the operation of complex adaptive systems (CAS). 
Example flows are outlined.  Constraints on flows support the emergence of the systems.  Examples of constraints are discussed. 
queues
and transaction integrity generate costs.  The cost of errors generated by the adhoc 'processes' including rework and compound failures and death are very significant. 

Christensen, Grossman and Hwang argue that disrupting US is the United States of America.   health care can reduce the cost burden, and so will be beneficial.  If the businesses can define
This page reviews the strategy of architecting an end-to-end solution in a complex adaptive system (CAS).  The mechanism and its costs and benefits are discussed. 
end-to-end architectures
they can develop tight processes and the error rate should drop.  The limited success of regulation, public health and politics to limit the growth of chronic problems suggests this may continue to be difficult.  In 2016 maternal deaths are rising in the US for example.  Hospitals depend on throughput to keep doctor's skills honed.  Low volume services will become error prone and inefficient at attracting patients.  But they also argue that the low cost businesses that provide the disruption will be part of a global network.  It is possible that disruption will once again drive US jobs overseas. 

Christensen, Grossman and Hwang include in the business model both resources, and technologies.  We find it more consistent to limit the business model to be a memetic
The agents in complex adaptive systems (CAS) must model their environment to respond effectively to it.  Samuel modeling is described as an approach. 
model
.  The resources and technologies are then included in the flows being transformed by the agents in executing the
Plans emerge in complex adaptive systems (CAS) to provide the instructions that agents use to perform actions.  The component architecture and structure of the plans is reviewed. 
schematic
cascade. 

The modern scientific / medical process acts as a
Plans change in complex adaptive systems (CAS) due to the action of genetic operations such as mutation, splitting and recombination.  The nature of the operations is described. 
genetic algorithm
, iteratively testing a wide range of disease niches and retaining the memetic structures which are most successful.  Indeed the
Peter Medawar writes about key historic events in the evolution of medical science. 
conjectural construction and testing of hypothesis
is
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
evolutionary


Her-2 + breast tumors, grow rapidly because they respond via the human EGF receptor (HER), coded for by the gene 'Her2', to cell growth signal epidermal growth factor (EGF).  Herceptin inhibits the growth of the Her-2+ tumors by inhibiting the EGFR.   are highlighted as examples of precision medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient.  Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease.  The take-up of personalized medicine benefits from the focus on genomics detailed by the NIH director Francis Collins and includes:
  • NCCN intensive cell therapies
  • Direct to consumer genomic testing
  • Direct to consumer diagnostics
  • Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.  
.  Unfortunately it seems to us that this example is illustrative of the difficulty of reaching the Author's implied level of precision in a treatment transaction is an operation which guarantees to complete a defined set of activities or return to the initial state.  For a fee the postal service will ensure that a parcel is delivered to its recipient or will return the parcel to the sender.  To provide the service it may have to undo the act of trying to deliver the parcel with a compensating action.  Since the parcel could be lost or destroyed the service may have to return an equivalent value to the sender. 
Genentech market a humanized mouse antibody is a y-shaped blood transported protein generated by the adaptive immune system's plasma cells, B lymphocytes, to accurately identify and neutralize pathogens such as bacteria and viruses that exhibit a matching antigen. 
specific for the Her-2 cell receptor, in biological cells these proteins are able to span the cell membrane and present an active site which is tailored to interact with a specific signal.  When the receptor pairs with its signal, its overall shape changes resulting in changes in the part internal to the cell which can be relayed by the cells signalling infrastructure.  In neuron synapses one type of receptor (fast) is associated with an ion channel.  The other (slow) is associated with a signalling enzyme chain and modulates the neuron's response. 
, which inhibits its operation.  The original work leveraged a correlation between overabundance of cells and Her-2 gene activity to initiate checking of various cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).   for presence of the Her-2 receptor.  Aggressive metastasizing tumors were found to correlate with the presence of Her-2 receptors.  Genentech were reticent to productize the antibody since it was not known what its mechanism was and so it was possible the treatment would have dangerous side effects.  EGF is epidermal growth factor which signals, via the Ras/Raf/MAP pathway, cell proliferation, differentiation and growth.  It stimulates DNA synthesis in target cells and cell proliferation. 
is a general cellular growth factor are chemical signals which stimulate cellular growth.  In the brain they induce plasticity. 
.  As Genentech feared Herceptin is found to have problematic side effects in the hearts of some patients. 

Christensen, Grossman and Hwang argue that as diagnoses for particular diseases become accurate, current business models will be disrupted.  Value will inevitably shift from performance to ease of use.  However, this transition is not guaranteed.  While growth can be sustained within a network, agent alignment, promoted by amplifiers and supported by barriers will be reinforcing trapped in a local minimum. 

Christensen, Grossman and Hwang show that Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare includes:
  • Benefits
    • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • Eligibility
    • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. 
    • Persons under 65 with disabilities who receive SSDI. 
    • Persons with specific medical conditions:
      • Have end stage renal disease or need a kidney transplant. 
      • They have ALS. 
    • Some beneficiaries are dual eligible. 
    • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
and traditional employer-paid health care decouple the treatment of health care from its cost.  This
This page reviews the strategy of setting up an arms race.  At its core this strategy depends on being able to alter, or take advantage of an alteration in, the genome or equivalent.  The situation is illustrated with examples from biology, high tech and politics. 
evolved amplifier
consequently converts the desires of sick patients and medical practitioners to treat into rapidly increasing cost.  The majority of healthy voters are attracted to the benefit of long term health risk reduction and detached from the cost.  This has an
Rather than oppose the direct thrust of some environmental flow agents can improve their effectiveness with indirect responses.  This page explains how agents are architected to do this and discusses some examples of how it can be done. 
indirect effect
on law maker's decisions about health care policy and politics. 

The adaptive interactions of law makers and business including health care executives have created a series of
This page reviews the strategy of setting up an arms race.  At its core this strategy depends on being able to alter, or take advantage of an alteration in, the genome or equivalent.  The situation is illustrated with examples from biology, high tech and politics. 
evolutionary amplifiers
leveraging: their position to
This page discusses the physical foundations of complex adaptive systems (CAS).  A small set of rules is obeyed.  New [epi]phenomena then emerge.  Examples are discussed. 
structure the regulations and laws
, their protected
The complex adaptive system (CAS) nature of a value delivery system is first introduced.  It's a network of agents acting as relays. 

The critical nature of hub agents and the difficulty of altering an aligned network is reviewed. 

The nature of and exceptional opportunities created by platforms are discussed. 

Finally an example of aligning a VDS is presented. 
value chain
positions, and the helplessness of the sickly poor.  A particularly significant example is the government, and employer subsidized health care of employees of major corporations.  This was designed to encourage good employees to remain working for the corporations.  When US corporations targeted their hiring in the US all participants benefitted from the effects.  But as the US economic network globalized, the US multi-nationals shifted their hiring focus overseas.  This pushed a pool of potential and former US based employees into the self/un-insured.  With the amplifiers still present the self/un-insured desperately seek jobs that aren't there while living in fear is an emotion which prepares the body for time sensitive action: Blood is sent to the muscles from the gut and skin, Adrenalin is released stimulating: Fuel to be released from the liver, Blood is encouraged to clot, and Face is wide-eyed and fearful.  The short-term high priority goal, experienced as a sense of urgency, is to flee, fight or deflect the danger.  There are both 'innate' - really high priority learning - which are mediated by the central amydala and learned fears which are mediated by the BLA which learns to fear a stimulus and then signals the central amygdala. 
of the potentially catastrophic impacts of 'full priced' treatment for major illness. 

Christensen, Grossman and Hwang argue that reimbursement imposes a central planning process on health care pricing instead of a market mechanism.  As Hayek explains in 'The Road to Serfdom' central planning inherently: fails to accurately capture the actual situation, and unfairly allocates resources to favored agents. 

Christensen, Grossman and Huang assert that pharmaceutical products have been transformational to improving life expectancy is a measure of the average life time of a new born baby.  Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group.  There are representational and data capture problems with the model:
  • Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person.  No adjustment can be made for increased wellbeing. 
  • Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
  • Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients.  For life expectancy calculations in subsequent years the impact is ignored.  
  • Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.  
  • Vital registration systems gather accurate data for life expectancy.  But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys. 
.  We see public health strategies following the british enlightenment to have been more significant.  They note the potential of personalized medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient.  Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease.  The take-up of personalized medicine benefits from the focus on genomics detailed by the NIH director Francis Collins and includes:
  • NCCN intensive cell therapies
  • Direct to consumer genomic testing
  • Direct to consumer diagnostics
  • Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.  
, assuming that a new trial process will be developed to enable it.  It also needs new ways to reach applicable patients (Aug 2017) and detect their particular physiologies. 

The pharmaceutical drug development trial process is currently regulated as a series of increasingly broad checks on the effectiveness and safety of the drug.  Once the system moves from evolutionary testing of any potential solution to a chaotically defined problem, to an
This page reviews the strategy of architecting an end-to-end solution in a complex adaptive system (CAS).  The mechanism and its costs and benefits are discussed. 
end-to-end architected
activity targeted mechanistically, the trial would be more effective and less costly integrated into a
Walter Shewhart's iterative development process is found in many complex adaptive systems (CAS).  The mechanism is reviewed and its value in coping with random events is explained. 
Shewhart cycle
.  The check phase implies the development of effective diagnostic
Agents use sensors to detect events in their environment.  This page reviews how these events become signals associated with beneficial responses in a complex adaptive system (CAS).  CAS signals emerge from the Darwinian information model.  Signals can indicate decision summaries and level of uncertainty. 
sensors


Christensen, Grossman and Hwang argue that regulation will be forced to respond to the global transformation that will disrupt the US health care network.  While they may be right, the people with the power to change the rules/laws have a vested interest in sustaining these amplifiers.   In particular their view that attacking monopolists is not important in catalyzing disruption seems questionable.  In situations where mistakes have allowed the connection of disruptive external networks the powerful have typically also been divided. 
Peter Turchin describes how major pre-industrial empires developed due to effects of geographic boundaries constraining the empires and their neighbors' interactions.  Turchin shows how the asymmetries of breeding rates and resource growth rates results in dynamic cycles within cycles.  After the summary of Turchin's book complex adaptive system (CAS) theory is used to augment Turchins findings. 
Tchurchin argues
that this historically results from the forces unleashed during the major periodic down cycle in the system.  Certainly Christensen's oft used example of
Lou Gerstner describes the challenges he faced and the strategies he used to successfully restructure the computer company IBM. 
IBM's mainframe business collapse
, was assisted by a subset of US lawmakers and administrators initiating anti-trust actions against
A government sanctioned monopoly supported the construction of a superorganism American Telephone and Telegraph (AT&T).  Within this Bell Labs was at the center of three networks:
  1. The evolving global scientific network. 
  2. The Bell telephone network.  And
  3. The military industrial network deploying 'fire and missile control' systems. 
Bell Labs strategically leveraged each network to create an innovation engine. 
They monitored the opportunities to leverage the developing ideas, reorganizing to replace incumbent opposition and enable the creation and growth of new ideas. 
Once the monopoly was dismantled AT&T disrupted. 
Complex adaptive system (CAS) models of the innovation mechanisms are discussed. 

AT&T
(creating as a side effect UNIX is a computer operating system.  It is a registered trademark of AT&T. 
and the BSD is Berkeley Software Distribution, an operating system based on UNIX's architecture. 
free software distribution) and IBM which left Digital Equipment Corporation (DEC) and Apple access to market niches. 

The Innovator's Prescription helps bring clarity to the astonishingly complex US health care network.  It offers predictive models of the network and its agents.  It highlights and analyses major problems and proposes adaptive solutions based on disruption.  


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Emerging structure and dynamic forces of adaptation


integrating quality appropriate for each market
 
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. 
Strategy
| Design |
This page uses an example to illustrate how:
  • A business can gain focus from targeting key customers,
  • Business planning activities performed by the whole organization can build awareness, empowerment and coherence. 
  • A program approach can ensure strategic alignment. 
Program Management
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