Health care
This page describes the organizational forces that limit change.  It explains how to overcome them when necessary. 

Power& tradition holding back progress
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. 
Be responsive to market dynamics
This page uses the example of HP's printer organization freeing itself from its organizational constraints to sell a printer targeted at the IBM pc user. 
The constraints are described. 
The techniques to overcome them are implied. 
Overcome reactionaries
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The complexity, M. Mitchell Waldrop describes a vision of complexity via:
  • Rich interactions that allow a system to undergo spontaneous self-organization
  • Systems that are adaptive
  • More predictability than chaotic systems by bringing order and chaos into
  • Balance at the edge of chaos 
of the health care network

Summary
The complexity and problems of the US is the United States of America.   Health network is described in terms of 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. 

The network:
Introduction
The current US is the United States of America.   health care network is both costly and underperforming.  There are major systemic issues that result in proximate problems described in 2006 in
Donald Barlett and James Steele write about their investigations of the major problems afflicting US health care as of 2006. 
Barlett and Steele's Critical Condition



Since 2006 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 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. 
has changed the situation but due to the underlying causes the problems persist. 

To understand the nature of the systemic problems and future trends health is viewed as a large set 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
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
structures within the US nation state interacting with each other.  If one compares America to the human body the public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
  • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
system, health care network and the
Matt Taibbi describes the phenotypic alignment of the American justice system.  The result he explains relentlessly grinds the poor and undocumented into resources to be constrained, consumed and ejected.  Even as it supports and aligns the financial infrastructure into a potent weapon capable of targeting any company or nation to extract profits and leave the victim deflated. 

Taibbi uses five scenarios to provide a broad picture of the: activities, crimes, policing, prosecutions, court processes, prisons and deportation network.  The scenarios are: Undocumented people's neighborhoods, Poor neighborhoods, Welfare recipients, Credit card debtors and Financial institutions.

Following our summary of his arguments, RSS comments on them framed by complex adaptive system (CAS) theory.  The alignment of the justice system reflects a set of long term strategies and responses to a powerful global arms race that the US leadership intends to win. 

justice system
together seem analogous to our extensive immune system has to support and protect an inventory of host cell types, detect and respond to invaders and maintain the symbiont equilibrium within the microbiome.  It detects microbes which have breached the secreted mucus barrier, driving them back and fortifying the barrier.  It culls species within the microbiome that are expanding beyond requirements.  It destroys invaders who make it into the internal transport networks.  As part of its initialization it has immune cells which suppress the main system to allow the microbiome to bootstrap.  The initial microbiome is tailored by the antibodies supplied from the mother's milk while breastfeeding.  The immune system consists of two main parts the older non-adaptive part and the newer adaptive part.  The adaptive part achieves this property by being schematically specified by DNA which is highly variable.  By rapid reproduction the system recombines the DNA variable regions in vast numbers of offspring cells which once they have been shown not to attack the host cell lines are used as templates for interacting with any foreign body (antigen).  When the immune cell's DNA hyper-variable regions are expressed as y-shaped antibody proteins they typically include some receptor like structures which match the surfaces of the typical antigen.  Once the antibody becomes bound to the antigen the immune system cells can destroy the invader. 
.  Just as a deficient or over active immune system is dangerous to the complete body's health the same is true of the health care network's impacts on the nation. 

The significant feedback networks and agents affecting the US is the United States of America.   health care CAS include:

America supports two opposed ideas of democracy:
Johnson & Kwak argue that expanding the national debt provides a hedge against unforeseen future problems, as long as creditors are willing to continue lending.  They illustrate different approaches to managing the debt within the US over its history and of the eighteenth century administrations of England and France. 

The US embodies two different political and economic systems which approach the national debt differently:
  • Taxes to support a sinking fund to ensure credit to leverage fiscal power in: Wars, Pandemics, Trade disputes, Hurricanes, Social programs; Starting with Hamilton, Lincoln & Chase, Wilson, FDR;
  • Low taxes, limited infrastructure, with risk assumed by individuals: Advocated by President's Jefferson & Madison, Reagan, George W. Bush (Gingrich); 
Johnson & Kwak develop a model of what the US government does.  They argue that the conflicting sinking fund and low tax approaches leaves the nation 'stuck in the middle' with a future problem.  And they offer their list of 'first principles' to help assess the best approach for moving from 2012 into the future.  

They conclude the question is still political.  They hope it can be resolved with an awareness of their detailed explanations.  They ask who is willing to push all the coming risk onto individuals. 

Following our summary of their arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Historically developing within the global cotton value delivery system, key CAS features are highlighted. 

Hamiltonian and Jeffersonian
.  Different states support one or the other.  But where they meet at the federal level an effect has been to allow health care costs to grow.  The opposing political goals of the Democrats and Republicans have limited the strategies that can be applied to managing health care costs, which will grow dramatically as the baby boomers retire.  Without change the growing cost of health care will significantly impact the US fiscal health with a massive
Johnson & Kwak argue that expanding the national debt provides a hedge against unforeseen future problems, as long as creditors are willing to continue lending.  They illustrate different approaches to managing the debt within the US over its history and of the eighteenth century administrations of England and France. 

The US embodies two different political and economic systems which approach the national debt differently:
  • Taxes to support a sinking fund to ensure credit to leverage fiscal power in: Wars, Pandemics, Trade disputes, Hurricanes, Social programs; Starting with Hamilton, Lincoln & Chase, Wilson, FDR;
  • Low taxes, limited infrastructure, with risk assumed by individuals: Advocated by President's Jefferson & Madison, Reagan, George W. Bush (Gingrich); 
Johnson & Kwak develop a model of what the US government does.  They argue that the conflicting sinking fund and low tax approaches leaves the nation 'stuck in the middle' with a future problem.  And they offer their list of 'first principles' to help assess the best approach for moving from 2012 into the future.  

They conclude the question is still political.  They hope it can be resolved with an awareness of their detailed explanations.  They ask who is willing to push all the coming risk onto individuals. 

Following our summary of their arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Historically developing within the global cotton value delivery system, key CAS features are highlighted. 

national debt
(Oct 2016). 

America has integrated its political, financial and health care networks.  It provides great
To benefit from shifts in the environment agents must be flexible.  Being sensitive to environmental signals agents who adjust strategic priorities can constrain their competitors. 
flexibility
, but also allows the development is a phase during the operation of a CAS agent.  It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents.  That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment.  Smiley includes examples of the developmental phase agents required in an emergent CAS.  In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult.  In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete. 
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. 
infrastructure
and
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 amplifiers
with positive returns, W Brian Arthur's conception of how high tech products have positive economic feedback as they deploy.  Classical products such as foods have negative returns to scale since they take increasing amounts of land, and distribution infrastructure to support getting them to market.  High tech products typically become easier to produce or gain from network effects of being connected together overcoming the negative effects of scale.  .  Hence these need careful
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. 
regulation
.  But
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
emergent
This page discusses the strategy of confusing the control system of a complex adaptive system (CAS). 
parasites
can distort the control systems to their advantage.  The result is that a
Charles Ferguson argues that the US power structure has become highly corrupt. 

Ferguson identifies key events which contributed to the transformation:
  • Junk bonds, 
  • Derivative deregulation, 
  • CMOs, ABS and analyst fraud,
  • Financial network deregulation,
  • Financial network consolidation, 
  • Short term incentives
Subsequently the George W. Bush administration used the situation to build a global bubble, which Wall Street leveraged.  The bursting of the bubble: managed by the Bush Administration and Bernanke Federal Reserve; was advantageous to some. 

Ferguson concludes that the restructured and deregulated financial services industry is damaging to the American economy.  And it is supported by powerful, incentive aligned academics.   He sees the result being a rigged system. 

Ferguson offers his proposals for change and offers hope that a charismatic young FDR will appear. 

Following our summary of his arguments, RSS comments on them framed by complex adaptive system (CAS) theory.  Once the constraints are removed from CAS amplifiers, it becomes advantageous to leverage the increased flows.  And it is often relatively damaging not to participate.  Corruption and parasitism can become entrenched. 

small powerful elite
use the regulations and controls to improve their situation: Academics, Physicians; while undermining the nation. 

The resurgent globalization strategy results in
This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
disintermediation
of low skill, high wage workers in the US encouraging 'local' focus strategies leveraging:
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
, Health care; with the side effect of pushing politically controlled funds from public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
  • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
and towards health care. 

The
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
emergence
and
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
evolution
of US is the United States of America.   based science oriented doctors, hospitals and communities is described by Robert Gordon.  He explains how doctors obtained self-regulatory power which aligned the interests of doctors, pharmacists, hospitals and drug companies.  Doctors' power continued to expand until the AHA is the American_hospital association. 
pushed back.  The medical profession was criticized for being paternalistic.  The profits from hospital systems' is the owner of a set of hospitals and other owned infrastructure and employer of direct staff.   business success were invested in grand buildings that signalled, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance.  In eukaryotic cells signalling is used extensively.  A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form.  Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell.  Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state.  Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals.  Cell signalling is reviewed by Helmreich.  Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors.  In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation.  To be credible signals must be hard to fake.  To be effective they must be easily detected by the target recipient.  To be efficient they are low cost to produce and destroy. 
status is a publically accepted, signal that one possesses assets: wealth, beauty, talent, expertise, access & trust of powerful people; to be able to help others. 


As health care has become more specialized it has been necessary to respond with additional tools to help with coordination: Complexity checklists
Atul Gawande writes about the opportunity for a thirty per cent improvement in quality in medicine by organizing to deploy as agent based teams using shared schematic plans and distributed signalling or as he puts it the use of checklists. 

With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates the effects of complexity and how to organize to cope with it. 

Following the short review RSS additionally relates Gawande's arguments to its models of complex adaptive systems (CAS) positioning his discussion within the network of US health care, contrasting our view of complexity, comparing the forces shaping his various examples and reviewing facets of complex failures. 
described
by Atul Gawande;

America's current health care insurance legislation and regulations institutionalize yearlong contracts between the network and the subscribers.  But many national health issues require longer term strategies.  While piecemeal solutions exist: Geisinger, Intermountain, Kaiser; the yearly cycles help drive the health care network towards a short term focus. 

In
Deaton describes the wellbeing of people around the world today.  He explains the powerful benefit of public health strategies and the effect of growth in material wellbeing but also the corrosive effects of aid. 

Following our summary of Deaton's arguments RSS comments from the perspective of complex adaptive system (CAS) theory.  The situation he describes is complex including powerful amplifiers, alignment and incentives that overlap broadly with other RSS summaries of adaptations of: The biosphere, Politics, Economics, Philosophy and Health care. 

The Great Escape
Angus Deaton reveals that most of the critical health issues should be best handled as public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
  • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
problems.  However, they are sustained within our nation state by the
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
properties identified in last three paragraphs and
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
evolved
properties of our brains discussed by Sonia Shah as they pertain to community responses to our long chronic
In this page we summarize the arms race between hosts and their parasites.  The deadly nature and adaptive pressure of the relationship is introduced.  How the slowly reproducing hosts cope is described.  Cultural hosts and parasites are discussed. 

arms race
with malaria.  Evolved properties explained in Thinking Fast and Slow by Daniel Kahneman.  The consequent inadequate public health response results in these health issues being diagnosed and treated by the health care network. 

Scientific advances offer the potential for new cheaper, less invasive, and more effective ways to understand, diagnose and treat health problems.  But Gordon shows that after defeating Infectious diseases and providing some powerful tools for CVD is cardiovascular disease which refers to:
  • Conditions where narrowed and blocked blood vessels result in angina, hypertension, CHD and heart attacks and hemorrhagic/ischemic strokes.  Mutations of the gene PCSK9 have been implicated in cardiovascular disease.  Rare families with dominant inheritence of the mutations have an overactive protein, very high levels of blood cholesterol and cardiac disease. Other rare PCSK9 mutations result in an 88% reduced risk from heart disease.  Inflammation is associated with cardiovascular disease (Aug 2017). 
; the other strategies: Politically driven war-on-cancer; and general shift
Deaton describes the wellbeing of people around the world today.  He explains the powerful benefit of public health strategies and the effect of growth in material wellbeing but also the corrosive effects of aid. 

Following our summary of Deaton's arguments RSS comments from the perspective of complex adaptive system (CAS) theory.  The situation he describes is complex including powerful amplifiers, alignment and incentives that overlap broadly with other RSS summaries of adaptations of: The biosphere, Politics, Economics, Philosophy and Health care. 

from public health
to technology driven research and health care, has been: Costly, Undermined by the revealed chronic issues from living longer; of apparently limited benefit.  And these changes additionally introduce confidentiality and complexity issues for doctors and patients.  Augmented intelligence enables the achievement of goals in the face of obstacles.  The goals are sub-goals of genes' survival and reproduction and include:
  • Obtaining and eating food
  • Sex
  • Finding and maintaining shelter
  • Fighting for resources - in the preferred hunter gatherer environment loss of resources was critical while possession was often transient. 
  • Understanding the proximate environment
  • Securing the cooperation of others
: Watson; may help with the increasing complexity if the additional analysis can be effectively leveraged by the providers. 

The HCIT is health care information technology.  The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets.  Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; 
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. 
infrastructure amplifier
has been legislated, standardized, regulated and funded by the government.  The result has been to push proprietary, costly, 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.  
vendors' systems deep into the health care network agent's operations creating additional silos!  Leverage of the Internet has been constrained by its lacking ubiquitous architected security and identity facilities.  

The US population associated antibiotics are compounds which kill bacteria, molds, etc.  The first antibiotic discovered was penicillin.  Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying.  Antibiotics are:
  • Economically problematic to develop and sell. 
    • Congress enacted GAIN to encourage development of new antibiotics.  But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D. 
    • Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.  
    • C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.  
    • F.D.A. has simplified approval standards.  It is working with industry to limit use of antibiotics in livestock. 
    • BARDA is promoting public-private partnerships to support promising research.
  • Impacting the microbiome of the recipient.  Stool banking is a solution  (Sloan-Kettering stool banking).  
  • Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016). 
  • Monitored globally by W.H.O.
  • Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).  
    • Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015). 
with effective scientific health care.  The association has been supported by health care driven signalling, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance.  In eukaryotic cells signalling is used extensively.  A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form.  Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell.  Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state.  Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals.  Cell signalling is reviewed by Helmreich.  Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors.  In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation.  To be credible signals must be hard to fake.  To be effective they must be easily detected by the target recipient.  To be efficient they are low cost to produce and destroy. 
by legisator supported drug industry messages through advertisers. 

The health care network has signalled, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance.  In eukaryotic cells signalling is used extensively.  A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form.  Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell.  Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state.  Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals.  Cell signalling is reviewed by Helmreich.  Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors.  In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation.  To be credible signals must be hard to fake.  To be effective they must be easily detected by the target recipient.  To be efficient they are low cost to produce and destroy. 
that technological innovation will provide the personalized focus 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.  
to improve outcomes and drive down costs.  Christensen asserts that the niche structure of the US health care network can be leveraged to drive innovation is the economic realization of invention and combinatorial exaptation. 
up and costs down via
This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
disruption
Brynjolfsson and McAfee note the exponential growth of multiple
This page discusses the benefits of bringing agents and resources to the dynamically best connected region of a complex adaptive system (CAS). 
centralized
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
technologies which makes
The agents in complex adaptive systems (CAS) must model their environment to respond effectively to it.  Samuel modeling is described as an approach. 
modeling
the future trends particularly difficult.  The heart damaging side-effects of Herceptin highlight a challenge to technology oriented 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.  


Patients of a health care network suffer from acute and chronic types of problem.  It is helpful to analyze the two problem types separately. 

Acute problems are critical to define and address immediately.  The patient, if still conscious, is likely to be focused on the problem and getting well as soon as possible.  Public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
  • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
& medicine have been successful at combating many acute problems.  Sometimes the problems are cured.  Or they may become chronic problems. 

Chronic problems are viewed as ever present and of low priority.  Our associative minds reduce the priority of repetitive issues.  Many of these problems are induced by abundance and toxicity generated by our
Sven Beckert describes the historic transformation of the growing, spinning, weaving, manufacture of cotton goods and their trade over time.  He describes the rise of a first global commodity, its dependence on increasing: military power, returns for the control points in the value delivery system(VDS), availability of land and labor to work it including slaves. 

He explains how cotton offered the opportunity for industrialization further amplifying the productive capacity of the VDS and the power of the control points.  This VDS was quickly copied.  The increased capacity of the industrialized cotton complex adaptive system (CAS) required more labor to operate the machines.  Beckert describes the innovative introduction of wages and the ways found to mobilize industrial labor. 

Beckert describes the characteristics of the industrial cotton CAS which made it flexible enough to become globally interconnected.  Slavery made the production system so cost effective that all prior structures collapsed as they interconnected.  So when the US civil war blocked access to the major production nodes in the American Deep South the CAS began adapting. 

Beckert describes the global reconstruction that occurred and the resulting destruction of the traditional ways of life in the global countryside.  This colonial expansion further enriched and empowered the 'western' nation states.  Beckert explains how other countries responded by copying the colonial strategies and creating the opportunities for future armed conflict among the original colonialists and the new upstarts. 

Completing the adaptive shifts Beckert describes the advocates for industrialization in the colonized global south and how over time they joined the global cotton CAS disrupting the early western manufacturing nodes and creating the current global CAS dominated by merchants like Walmart pulling goods through a network of clothing manufacturers, spinning and weaving factories, and growers competing with each other on cost. 

Following our summary of Beckert's book, RSS comments from the perspective of CAS theory.  The transformation of disconnected peasant farmers, pastoral warriors and their lands into a supply chain for a highly profitable industrial CAS required the development over time: of military force, global transportation and communication networks, perception and representation control networks, capital stores and flows, models, rules, standards and markets; along with the support at key points of: barriers, disruption, and infrastructure and evolved amplifiers.  The emergent system demonstrates the powerful constraining influence of extended phenotypic alignment. 

global supply chain
or our poorly adapted responses to it.  The toxic impact of smoking is an important example.  Some chronic diseases have
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
co-evolved
with us.  As such our mental and immune responses are entrenched.  But these responses cannot take into account the effects and requirements of medical treatment. 
Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles mosquitoes and Plasmodium.  250 - 500 million people are infected each year with malaria and one million die. 
Sonia Shah's study of malaria
is illustrative.  For most sufferers malaria is a chronic, intermittent problem.  It is just the sort of issue that people ignore unless they present symptoms at which point they seek treatment until the symptoms subside.  Like most chronic problems a more rigorous long term strategy is required but, when it exists, is not judged significant enough by the sufferer relative to other current activities. 

There are a number of important 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. 
types occurring in the health care network.  They include: the access transaction, the treatment transaction, the payment transaction and the off-label transaction

US health care access transaction
The access transaction controls patient access to the costly health care resources. 

There was little access to health care services in the US during the early 20th century.  As the reputation of doctors and hospitals improved during the 1920s the cost-of-care began to rise and insurance coverage became necessary resulting in the
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
emergence
of the access transaction. 
The shift by 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. 
to reimbursing 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.  
for DRG is a diagnosis-related group.  It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits.  The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides.  It assumes patients within a grouping are clinically similar.  Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities.  For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed.   coded procedures introduced a powerful care provision profit amplifier (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.  ) which encouraged the insurers to further constrain access. 
The group practice is an integrated health care organization with salaried physicians and bundled pricing.   Early examples included Kaiser Permanente and the Mayo Clinic. 
counteracted this FFS trend but HMO legislation is the Health Maintenance Organization Act of 1973 which amended the PHSA to provide assistance for the creation of HMOs including:
  • Money for development
  • An override of specific restrictive state laws
  • A mandate offered to specific employers to offer an optional HMO plan as part of their employee benefits package. 
ignored the beneficial aspects of group practice while similarly limiting policy holder access to only specific doctors. 

Consumers typically request access
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. 
indirectly
during visits with PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the low FFS leverage of the PCP compared to specialists. 
s and subsequent referrals.  The access transaction is validated during appointment scheduling and registration is either:
  • Restrictive cardiomyopathy, a rare disease where scar tissue makes the heart muscle rigid and reduces the efficiency.  Or
  • Revenue Cycle Management aligns treatment with reimbursement.  Customer service will be involved.  IT will architect the core billing, decision support and ad-hoc services, constructed by RCM vendors, into systems to support RCM.  The Hospital's central business office will aim to maximize cash recoveries.  As per Deming mistakes in the RCM pipeline result in rework and lost cash flow and revenue of between 4 - 12%.  The staff must be trained and fully engaged in the design and operation of the pipeline.  The front end processes are best placed to capture all the information needed to make the cycle successful.  The activities include:
    • Scheduling and Appointments - where visits and procedures are booked and demographic and insurance information is collected.  If this information is incorrect it is likely the claims will not forward to third party payers.  When resources and their states are accurately known an optimal set of plans can be constructed to efficiently and effectively flow patients through the system.  But that is difficult to guarantee because of a number of interrelated problems:
      • Scale - as the number of resources increases the ability of a central scheduling system to represent all of them accurately and reliably becomes impossible. 
      • Ubiquity - a CAS strategy for ensuring availability is to have an over-abundance of equivalent resource that can be used for schedule allocation.  But often these resource levels are set by local decision makers who all respond at about the same time to imposed funding changes.  The effect is to suddenly and unpredictably undermine the guarantee of over-abundance.  Sometimes the assumption of equivalence also fails as in the desire of a patient to see only a specific surgeon. 
      • Changes can ripple through the plans requiring coordination meetings and notifications or guaranteed receipt of status updates. 
    • Verification checks for:
      • Referral - Is there PCP authorization?  Is the PCP referred service covered by the patient's plan,
      • Authorization - obtain Insurance authorization if required, and
      • Pre-certification - is there 'need' for inpatient care or other care before admission by the MCO.  Otherwise could introduce problems including not obtaining/verifying the insurance name, number and eligibility, not securing pre-certification and pre-authorization with time limits, not copying the insurance card, not checking for secondary coverage, not detecting expired referral or authorization,
    • Pre-registration - provide advice about their financial obligations and what documents to bring to the procedure.  If there is a copay or an outstanding payment to be paid these should be processed,
    • Registration - some patients are scheduled outside of the main admitting process (by OP clinic or E.D.) and this must be detected and the scheduling verification and pre-registration process be performed,
    • Time of service payments - co pays and self pays,
    • Coding - identify diagnosis (ICD 9 -> ICD-10 codes) and treatment (CPT) activities and charges for the episode.  More than 80% of hospital cases are coded in error. 
    • Demographics and billing data entry - enter charges and adjust capitated charges,
    • Patient statements - submit primary and secondary claims (following HIPAA formats) with or without involvement of a clearinghouse, produce patient statements including time of service, outstanding balance, charged amount with codes, insurance details, forms used (UB 92/04 and HCFA 1500).  A paper based claims filing has a rejection rate of 30%.  Duplicate claim payment rates of 1 - 2% of medical expenses are common.  Duplicate claims detection is often not part of the process.  Payer's goals are in conflict with Provider goals.  
    • Collections and payment posting - Post all payments and adjustments and deposit money into the bank,
    • Denials and appeals - resubmission and appeal of claims, denial analysis and bad debts and write offs.  To reduce denial rates and appeals the reimbursement contracts payer processes and actual denials must be analyzed and understood. 
    • Account follow up - Patient inquiries, resubmission of claims and issue refunds. 
    • Financial counseling;
, from health insurance companies.  The company's profits improve if they can limit access, so they deploy
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 amplifiers
which encourage their clerical staff to limit access.  The cost savings for the insurer may not balance the additional costs to the overall network of complications of delayed or missed treatment.  Consumers of health care vary.  Some are part of an
E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can take hold.  Various social insects have developed strategies which have allowed them to capture the most valuable available niches.  Like humans they invest in specialization and cooperate to subdue larger, well equipped competitors. 
enterprise and use bundling
to leverage health care benefits.  Others are individuals who get costly and limited coverage.  Some consumers do not have insurance coverage.  They are forced to use costly treatment transactions and risk financial ruin. 

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). 
regulations provide a partial relaxation of the access transaction constraints. 

Unfortunately, the patient being emergently complex makes the access transaction difficult to get correct, even though its setup by a skilled doctor. 

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 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. 
expanded patient access to health care services by mandating insurance coverage.  But with the law's conflicting goals of increasing access while reducing overall costs, cost sharing is the requirement for patients to pay a portion of the cost of their health care services.  Such out-of-pocket payments include: copayments, deductibles and coinsurance. 
constraints were consequently added to the access transaction: Copayments is a fixed payment for a covered service after any deductible has been met.  It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services.  As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016);
, Deductibles, Network limitations - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans.  This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans.  By limiting the number of providers/doctors offered in the plans the few that are included should get more business.  Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers).  In large cities narrow networks are even more common.  Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills.  There are problems induced by narrow network constraints:
  • Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts.  Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running.  If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.  
  • Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016). 
; which remains complex and compromised.  And the transaction's constraints can be gamed by service developers, distributors, doctors, providers or pharmacies, who remove the patient's cost constraints so as, to gain access to more treatment and payment transactions. 

US health care treatment transaction
The diagnosis/treatment transaction is more complex than a typical product transaction since there are potentially six interacting complex systems participating. 
  1. The patient is an
    This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
    emergent
    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. 
    system
    .  The patient includes the microbiome, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc.  These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight.  The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system.  The symbiotic relationship must be actively managed.  In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed.    High throughput sequencing allows the characterization of bacterial populations inside guts.  Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers.  If they are borne via cesarean they never receive some of the key bacteria from their mothers.  A variety of diseases may be caused by changes in the microbiome:
    • Eczema can be related to changes in the skin microbiome. 
    • Obesity can be induced by changes to the gut microbiome. 
    setup in a symbiotic is a long term situation between two, or more, different agents where the resources of both are shared for mutual benefit.  Some of the relationships have built remarkable dependencies: Tremblaya's partnership with citrus mealybugs and bacterial DNA residing in the mealybug's genome, Aphids with species of secondary symbiont bacteria deployed sexually from a male aphid sperm reservoir and propagated asexually by female aphids only while their local diet induces a dependency.  If the power relations and opportunities change for the participants then they will adapt and the situation may transform into separation, predation or parasitism. 
    relationship during development is a phase during the operation of a CAS agent.  It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents.  That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment.  Smiley includes examples of the developmental phase agents required in an emergent CAS.  In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult.  In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete. 

  2. The disease could be an invasive pathogen, also an emergent system, or a problem with the operation of cellular agents that on aggregate make up the patient. 
  3. The treatment of a bacterial pathogen may be an evolved bactericide such as penicillin.  Such a treatment can result in destruction of the pathogen with few apparent side effects for the patient.  But
  4. The doctor may be an independent agent working with support and infrastructure from a
  5. Health care provider, part of the health care system.  Surgery, with its dependence on antibiotic are compounds which kill bacteria, molds, etc.  The first antibiotic discovered was penicillin.  Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying.  Antibiotics are:
    • Economically problematic to develop and sell. 
      • Congress enacted GAIN to encourage development of new antibiotics.  But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D. 
      • Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.  
      • C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.  
      • F.D.A. has simplified approval standards.  It is working with industry to limit use of antibiotics in livestock. 
      • BARDA is promoting public-private partnerships to support promising research.
    • Impacting the microbiome of the recipient.  Stool banking is a solution  (Sloan-Kettering stool banking).  
    • Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016). 
    • Monitored globally by W.H.O.
    • Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).  
      • Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015). 
    sterile procedure and opioid based pain management is an iterative process, overseen by a doctor, to limit a patient's pain.  The process is doctor prescribed, RN managed, pharmacist validated, and patient administered.  The process may be coordinated by pain management specialists.  Pain management is central to modern surgery where it is supported by hospital infrastructure.  It is central to the perioperative process.  It is a major aspect of ED operations.  It has been extended out to discharged patients with chronic long term pain where it can lead to opioid dependency.  Treatments include: Opioids including: Fentanyl, Morphine, OxyContin, Percocet; NSAIDs, Cannabinoids, Acupuncture, Massage, CBT, and Mindfulness.  , has broad side effects which are slowly being characterized. 
  6. Government administrators and regulators attempt to
    The agents in complex adaptive systems (CAS) must model their environment to respond effectively to it.  Samuel modeling is described as an approach. 
    model
    , influence and constrain the health care system to conform to the current rules and parameters specified by the US is the United States of America.   and state legislatures.  As such businesses, seeking profits, and participating directly and indirectly in the health care system adapt and seek attractive niches.  Parasitic behaviors is a long term relationship between the parasite and its host where the resources of the host are utilized by the parasite without reciprocity.  Often parasites include schematic adaptations allowing the parasite to use the hosts modeling and control systems to divert resources to them.   emerge from the availability of model and control structures that can be influenced. 

Historically the diagnosis/treatment transaction was between a patient suffering from a disease, and a doctor who proposed to help 'manage' the disease, as described by Peter Medawar.  The financial power was limited.  The ability of the doctor to affect the disease outcome was minimal, but the patient probably didn't fully understand that.  There was little financial opportunity to encourage legal action.  Early treatment regimes were best avoided!  And even today some treatments deliver more harm than good!  Patients vary, diagnosis is not perfect, and treatments may be costly, or have unfortunate side effects.  Health care leverages hope for new treatments which can cause dilemmas for doctor and patient.  As ever, the benefit to the doctor and the patient is only related through an
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


The
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
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
that participate in a treatment transaction has evolved and reflects the history, including
This page discusses the impact of random events which once they occur encourage a particular direction forward for a complex adaptive system (CAS). 
frozen accidents
that occurred along the way.  Doctors and nurses have self-regulated positions in the value chain. 

The evolved nature of the agents includes typical memetic operator exploration of the adjacent possible.  Improved models of medical science, diagnosis, and treatment and associated actions have added to agent fitness. 

The comparison between a historical treatment transaction and a product sales transaction only becomes legitimate once the product characteristics become unique and complex.  A house sale has some of the flavor.  But still the components of the house are typically commoditized and replaceable.  The house has a design.  An old building that has been remodeled repeatedly seems a closer analogy.  Particularly one with parts that are mostly unique, or at most are only similar to todays functionally equivalent replaceable commodity components.  An over-the-counter foreign currency derivative trade seems an even closer analog.  As such a commercial treatment transaction should be expected to be potentially costly, and of high uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers.  This is different from Risk.   for the participants.  The transaction costs can be economized by integrating the components within an iterative social structure, much like iterative enterprise transactions can have reduced transaction costs. 

US health care payment transaction
The payment transaction issues payments for services provided by agents in the health care network.  The transaction is subject to alterations by the insurance provider issuing the payments, so as to improve profits.  But the decoupling of the payment transaction from the cost of the treatment has promoted overtreatment is the application of unnecessary health care.  It is a complex problem:
  • Overtreatment needs to be adaptive.  As people age their medicine levels typically need to be changed.  Often, as in the case of blood pressure, and blood sugar reduction, they should be reduced to avoid inducing falls (Nov 2015).  
  • Patients with chronic diseases, such as type 2 diabetes, often require different treatment settings.  And again these vary with age. 
  • Patients who have learned a regime, and been told it was successful, may resist instructions to change it.  Some worry that they will impact their health care provider's treatment performance measures. 
.  Only politicians can constrain overtreatment and they are not rewarded for doing so.  Our analysis of the health care network describes the evolution of the payment transaction, 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
constraints involved and key hub agents leveraging the distortions. 

US health care off-label transaction
The off-label transaction disconnects medical product development and testing from where the products can be deployed.  The markets for block-buster products can be expanded without the huge costs of testing.  However, this disconnect removes the
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
that supports the quality improvement process. 

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. 
Christensen, Grossman and Hwang argue
that health care has now reached a point where '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.  
, delivered by an aligned network of agents, can
This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
disrupt
the current US is the United States of America.   health care network.  The nature of the treatment transaction is far more complex than an engineered product transaction.  It is likely that the disruption will be initially significant for the problems and treatments which turn out to be non-adaptive. 

Christensen, Grossman and Hwang argue that the presence of conflicting business models within the hospital and physician businesses limits their overall efficiency and effectiveness generating waste and other costs.  Separation of the 'job-shop', 'chain' and 'network' businesses should be enabled by improved understanding of the disease mechanisms. 

As the market shifts to precision diagnostics uses genomic analysis to diagnose genetic disorders - for example Genomic Health's Oncotype DX & Agendia's MammaPrint.  The desire to see the genetic risk factors identified by such tests should depend on the risk * burden * Possibility of intervention.  Early tests look at only single gene mutations.  Genomic testing can be performed direct-to-consumer.  Data is being collated on the genetic components of most diseases to enable more sophisticated diagnosis in the future such as the OPHG (EGAPP initiative), USPSTF recommendations and NCBI (Genetic test registry).  While there is only limited identification of the significant mutations and limited patient bases misdiagnosis is a problem (Aug 2016). 
and medicines, the target markets of specific products are likely to shrink and off-label strategies will be less valuable to product developers. 

Major disruptions will have to gain market share without encountering regulatory constraints.  But the integrated nature of the health care, financial and political networks reduces the likelihood of this.  Powerful agents are moving to control new niches: point-of-care diagnostics (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


The pervasive influence of parasites is a long term relationship between the parasite and its host where the resources of the host are utilized by the parasite without reciprocity.  Often parasites include schematic adaptations allowing the parasite to use the hosts modeling and control systems to divert resources to them.   leveraged through the political control system on the health care network amplifiers limits the potential of other actions to reduce the growth of problems: Maternal deaths; and costs.  The possibility of political reform seems remote.  While popular movements demand change most of the influential actors are benefiting from the current distortions.  Even the undermining of national competitiveness relative to the cost structure of China, India, Japan and Europe would not necessarily impact the financiers and other elites.  But when the majority of the population is required to align to ensure national survival the political landscape may need/have to accommodate their expectations. 

CAS modeling of the US health care system reveals the opportunities and uncertainties is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers.  This is different from Risk.   inherent in such an extensive network.  It also cautions against assuming the system can be equated with adaptive systems which contain fully architected components.  


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Nature and nurture drive the business eco-system
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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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