Health care

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

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.

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.

This web frame explores very significant example real world complex adaptive systems (CAS). It explains how the examples relate to each other, why we all have trouble effectively comprehending these systems and outlines the items we see as key to the system and why. By understanding these summaries you can better frame the interdependencies of important events such as war in Iraq, new iPhone releases or a cancer diagnosis and see how they are impacting you. Example systems frame
Dietrich Dorner argues complex adaptive systems (CAS) are hard to understand and manage. He provides examples of how this feature of these systems can have disastrous consequences for their human managers. Dorner suggests this is due to CAS properties psychological impact on our otherwise successful mental strategic toolkit. To prepare to more effectively manage CAS, Dorner recommends use of: Effective iterative planning and Practice with complex scenario simulations; tools which he reviews. Complexity catastrophes
E. O. Wilson reviews the effect of man on the natural world to date and explains how the two systems can coexist most effectively. Adaptive ecology
Barton Gellman details the strategies used by Vice President Cheney to align the global system with his economics, defense, and energy goals. US vds alignment
Kevin Kruse argues that from 1930 onwards the corporate elite and the Republican party have developed and relentlessly executed strategies to undermine Franklin Roosevelt and the New Deal. Their successful strategy used the credibility of conservative religious leaders to: Demonstrate religious issues with the New Deal. Integrate the corporate elite and evangelicals. Use the power of corporate advertising and Hollywood to reeducate the American people to view the US as historically religious and the New Deal and liberalism as anti-religious socialism. Focus the message through evangelicals including Vereide and Graham. Centralize the strategy through President Eisenhower. Add religious elements to mainstream American symbols: money, pledge; Push for prayer in public school Push Congress to promote prayer Make elections more about religious positions. Following our summary of his arguments RSS frames them from the perspective of complex adaptive system (CAS) theory. Strategy is the art of the possible. But it also depends on persistence. Inventing Christian America
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. Financial WMD
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. Aligned justice
Jonathan Powell describes how the government of, the former UK Prime Minister, Tony Blair, actually operated. Powell was Blair's only chief of staff. Mechanics of power
H. A. Hayek compares and contrasts collectivism and libertarianism. Libertarianism
David Bodanis illustrates how disruptive effects can take hold. While the French revolution had many driving forces including famine and oppression the emergence of a new philosophical vision ensured that thoughtful leaders were constrained and conflicted in their responses to the crisis. Voltaire's disruptive network
An epistatic meme suppressed for a thousand years reemerges during the enlightenment. It was a poem encapsulating the ideas of Epicurus rediscovered by a humanist book hunter. Greenblatt describes the process of suppression and reemergence. He argues that the rediscovery was the foundation of the modern world. Complex adaptive system (CAS) models of the memetic mechanisms are discussed. Constraining happiness
Isaacson uses the historic development of the global cloud of web services to explore Ada Lovelace's ideas about thinking machines and poetic science. He highlights the value of computer augmented human creativity and the need for liberal arts to fulfill the process. Complex adaptive system (CAS) models of agent networks and collaboration are discussed. Arts technology & intelligence
Haikonen juxtaposes the philosophy and psychology of consciousness with engineering practice to refine the debate on the hard problem of consciousness. During the journey he describes the architecture of a robot that highlights the potential and challenges of associative neural networks. Complex adaptive system (CAS) theory is then used to illustrate the additional requirements and constraints of self-assembling evolved conscious animals. It will be seen that Haikonen's neural architecture, Smiley's Copycat architecture and molecular biology's intracellular architecture leverage the same associative properties. Associatively integrated robots
Good ideas are successful because they build upon prior developments that have been successfully implemented. Johnson demonstrates that they are phenotypic expressions of memetic plans subject to the laws of complex adaptive systems (CAS). Developing ideas
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: The evolving global scientific network. The Bell telephone network. And 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. Strategic innovation
Roger Cohen's New York Times opinion about the implications of BREXIT is summarized. His ideas are then framed by complex adaptive system (CAS) theory and reviewed. BREXIT
Scott Galloway argues that Apple, Amazon, Facebook and Google are monopolists that trade workers for technology. Monopolies that he argues should be broken up to ensure the return of a middle class. Following our summary of his arguments, RSS comments on these arguments assuming they relate to a complex adaptive system (CAS). While Scott's issue is highly significant his analysis conflicts with relevant CAS history and theory. Monopoly job killers
The IPO of Netscape is defined as the key emergent event of the New Economy by Michael Mandel. Following the summary of Mandel's key points the complex adaptive system (CAS) aspects are highlighted. New economy
Ed Conway argues that Bretton Woods produced a unique set of rules and infrastructure for supporting the global economy. It was enabled by the experience of Keynes and White during and after the First World War, their dislike of the Gold Standard, the necessity of improving the situation between the wars and the opportunity created by the catastrophe of the Second World War. He describes how it was planned and developed. How it emerged from the summit. And he shows how the opportunity inevitably allowed the US to replace the UK at the center of the global economy. Like all plans there are mistakes and Conway takes us through them and how the US recovered the situation as best it could. And then Conway describes the period after Bretton Woods collapsed. He explains what followed and also compares the relative performance of the various periods before during and after Bretton Woods. Following our summary of his arguments RSS comments from the perspective of Complex Adaptive System (CAS) theory. Conway's book illustrates the rule making and infrastructure that together build an evolved amplifier. He shows the strategies at play of agents that were for and against the development and deployment of the system. And The Summit provides a key piece of the history of our global economic CAS. Bretton woods
A key agent in the 1990 - 2008 housing expansion Countrywide is linked into the residential mortgage value delivery system (VDS) by Paul Muolo and Mathew Padilla. But they show the VDS was full of amplifiers and control points. With no one incented to apply the brakes the bubble grew and burst. Following the summary of Muolo and Padilla's key points the complex adaptive system (CAS) aspects are highlighted. Housing amplifiers
Satyajit Das uses an Indonesian company's derivative trades to introduce us to the workings of the international derivatives system. Das describes the components of the value delivery system and the key transactions. He demonstrates how the system interacted with emerging economies expanding them, extracting profits and then moving on as the induced bubbles burst. Following Das's key points the complex adaptive system (CAS) aspects are highlighted. Derivative systems
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
Robert Gordon argues that the inventions of the second industrial revolution were the foundation for American economic growth. Gordon shows how flows of people into difficult rural America built a population base which then took the opportunity to move on to urban settings: Houses, Food in supermarkets, Clothes in department stores; that supported increasing productivity and standard of living. The deployment of nationwide networks: Rail, Road, Utilities; terminating in the urban housing and work places allowing the workers to leverage time saving goods and services, which helped grow the economy. Gordon describes the concomitant transformation of: Communications and advertising Credit and finance Public health and the health care network Health insurance Education Social and welfare services Counter intuitively the constraints introduced before and in the Great Depression and the demands of World War 2 provide the amplifiers that drive the inventions deeply and fully into every aspect of the economy between 1940 and 1970 creating the exceptional growth and standard of living of post war America. Subsequently the rate of growth was limited until the shift of women into the workplace and the full networking of voice and data supported the Internet and World Wide Web completed the third industrial revolution, but the effects were muted by the narrow reach of the technologies. The development of Big Data, Robots, and Artificial Intelligence may support additional growth, but Gordon is unconvinced because of the collapse of the middle class. Following our summary of Gordon's book RSS frames his arguments from the perspective of complex adaptive system (CAS) theory. American growth
Carl Menger argues that the market induced the emergence of money based on the attractive features of precious metals. He compares the potential for government edicts to create money but sees them as lacking. Following our summary of his arguments RSS frames his arguments from the perspective of complex adaptive system (CAS) theory. With two hundred years of additional knowledge we conclude that precious metals are not as attractive as Menger asserts. Government backed promissory notes are analogous to: Other evolved CAS forms of ubiquitous high energy transaction intermediates and Schematic strategies that are proving optimal in supporting survival and replication in the currently accessible niches. Emergence of money
Eric Beinhocker sets out to answer a question Adam Smith developed in the Wealth of Nations: what is wealth? To do this he replaces traditional economic theory, which is based on the assumption that an economy is a system in equilibrium, with complexity economics in which the economy is modeled as a complex adaptive system (CAS). He introduces Sugerscape to illustrate an economic CAS model in action. And then he explains the major features of a CAS economy: Dynamics, Agents, Networks, Emergence, and Evolution. Building on complexity economics Beinhocker reviews how evolution applies to the economy to build wealth. He explains how design spaces map strategies to instances of physical and social technologies. And he identifies the interactors and selection mechanism of economic evolution. This allows Beinhocker to develop a new definition of wealth. In the rest of the book Beinhocker looks at the consequences of adopting complexity economics for business and society: Strategy, Organization, Finance, & Politics & Policy. Following our summary of his arguments, RSS explores his conclusions and aligns Beinhocker's model of CAS with the CAS theory and evidence we leverage. Economic complexity
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 Wal-Mart 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. Globalization from cotton
Health care
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. Improving wellbeing
Donald Barlett and James Steele write about their investigations of the major problems afflicting US health care as of 2006. Problems of US health care
Glenn Steele & David Feinberg review the development of the modern Geisinger healthcare business after its near collapse following the abandoned merger with Penn State AMC. After an overview of the business, they describe how a calamity unfolding around them supported building a vision of a better US health care network. And they explain: How they planned out the transformation, Leveraging an effective governance structure, Using a strategy to gain buy in, Enabling reengineering at the clinician patient interface. Implementing the reengineering for acute, chronic & hot spot care; to help the patients and help the physicians. Geisinger's leverage of biologics. Reengineering healing with ProvenExperience. Where Geisinger is headed next. Following our summary of their arguments RSS comments on them. We frame their ideas with complex adaptive system (CAS) theory. E2E insured quality care
Robert Pearl explains the perspectives of a health care leader and son who know that the current health care network interacts with human behavior to induce a poorly performing system that caused his father's death. But he is confident that these problem perceptions can be changed. Once that occurs he asserts the network will become more integrated, coordinated, collaborative, better led, and empathetic to their patients. The supporting technology infrastructure will be made highly interoperable. All that will reduce medical errors and make care more cost effective. Following our summary of his arguments RSS comments on them. We frame his ideas with complex adaptive system (CAS) theory including synergistic examples of these systems in operation. The health care network is built out of emergent human agents. All agents must model the signals they perceive to represent and respond to them. Pinker explains how this occurs. Sapolsky explains why fear and hierarchy are so significant. He includes details of Josh Green's research on morality and death. Charles Ferguson highlights the pernicious nature of financial incentives. Bad medical models
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. Disrupting health care
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. Complexity checklists
Friedman and Martin leverage the lifelong data collected on 1,528 bright individuals selected by Dr. Lewis Terman starting in 1921, to understand what aspects of the subjects' lives significantly affected their longevity. Looking broadly across each subject's: Personality, Education, Parental impacts, Energy levels, Partnering, Careers, Religion, Social networks, Gender, Impact from war and trauma; Friedman and Martin are able to develop a set of model pathways, which each individual could be seen to select and travel along. Some paths led to the traveler having a long life. Others were problematic. The models imply that the US approach to health and wellness should focus more on supporting the development and selection of beneficial pathways. Following our summary of their arguments RSS comments from the perspective of CAS theory. The pathways are most applicable to bright individuals with the resources and support necessary to make and leverage choices they make. Striving to enter and follow a beneficial pathway seems sensible but may be impossible for individuals trapped in a collapsing network, starved of resources. Promoting longevity
Gawande uses his personal experience, analytic skills and lots of stories of innovators to demonstrate better ways of coping with aging and death. He introduces the lack of focus on aging and death in traditional medicine. And goes on to show how technology has amplified this stress point. He illustrates the traditional possibility of the independent self, living fully while aging with the support of the extended family. Central planning responded to the technological and societal changes with poorly designed infrastructure and funding. But Gawande then contrasts the power of bottom up innovations created by experts responding to their own family situations and belief systems. Gawande then explores in depth the challenges that unfold currently as we age and become infirm. He notes that the world is following the US path. As such it will have to understand the dilemma of integrating medical treatment and hospice strategies. He notes that all parties involved need courage to cope. He proposes medicine must aim to assure well being. At that point all doctors will practice palliative care. Complex adaptive system (CAS) models of agency, death, evolution, cooperation and adaptations to new technologies are discussed. Agent death
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. Malaria
Peter Medawar writes about key historic events in the evolution of medical science. Medical science events
Using John Holland's theory of adaptation in complex systems Baldwin and Clark propose an evolutionary theory of design. They show how this can limit the interdependencies that generate complexity within systems. They do this through a focus on modularity. Modular designed systems
Lou Gerstner describes the challenges he faced and the strategies he used to successfully restructure the computer company IBM. Compartmented systems
Grady Booch advocates an object oriented approach to computer software design. Object based systems
Bertrand Meyer develops arguments, principles and strategies for creating modular software. He concludes that abstract data types and inheritence make object orientation a superior methodology for software construction. Complex adaptive system (CAS) theory suggests agents provide an alternative strategy to the use of objects. Software construction
Tools and the businesses that produce them have evolved dramatically. W Brian Arthur shows how this occurred. Tools
Matt Ridley demonstrates the creative effect of man on the World. He highlights: A list of preconditions resulting in Additional niche capture & more free time Building a network to interconnect memes processes & tools which Enabling inter-generational transfers Innovations that help reduce environmental stress even as they leverage fossil fuels Memetic trading networks
Brynjolfsson and McAfee explore the effects of Moore's law on the economy. They argue it has generated exponential growth. This has been due to innovation. It has created a huge bounty of additional wealth. But the wealth is spread unevenly across society. They look at the short and long term implications of the innovation bounty and spread and the possible future of technology. Following our summary of their arguments RSS comments from the perspective of CAS theory. Brilliant technologies
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 versus guilds
Amy Chua and Jed Rubenfeld's New York Times opinion based on The Triple Package is summarized. Their ideas are then framed by CAS theory and reviewed. What drives success
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. Warrior groups
Through the operation of three different food chains Michael Pollan explores their relative merits. The application of complex adaptive system (CAS) theory highlights the value of evolutionary testing of the food chain. Natural systems
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. Insect superorganisms
Computational theory of the mind and evolutionary psychology provide Steven Pinker with a framework on which to develop his psychological arguments about the mind and its relationship to the brain. Humans captured a cognitive niche by natural selection 'building out' specialized aspects of their bodies and brains resulting in a system of mental organs we call the mind. He garnishes and defends the framework with findings from psychology regarding: The visual system - an example of natural selections solutions to the sensory challenges of inverse modeling of our environment; Intensions - where he highlights the challenges of hunter gatherers - making sense of the objects they perceive and predicting what they imply and natural selections powerful solutions; Emotions - which Pinker argues are essential to human prioritizing and decision making; Relationships - natural selection's strategies for coping with the most dangerous competitors, other people. He helps us understand marriage, friendships and war. These conclusions allow him to understand the development and maintenance of higher callings: Art, Music, Literature, Humor, Religion, & Philosophy; and develop a position on the meaning of life. Complex adaptive system (CAS) modeling allows RSS to frame Pinker's arguments within humanity's current situation, induced by powerful evolved amplifiers: Globalization, Cliodynamics, The green revolution and resource bottlenecks; melding his powerful predictions of the drivers of human behavior with system wide constraints. The implications are discussed. Computationally adapted mind
The complexity of behavior is explored through Sapolsky developing scenarios of our best and worst behaviors across time spans, and scientific subjects including: anthropology, psychology, neuroscience, sociology. The rich network of adaptive flows he outlines provides insights and highlight challenges for scientific research on behavior. Complex adaptive system (CAS) theory builds on Sapolsky's details highlighting the strategies that evolution has captured to successfully enter niches we now occupy. CAS behavior
Consciousness has confounded philosophers and scientists for centuries. Now it is finally being characterized scientifically. That required a transformation of approach. Realizing that consciousness was ill-defined neuroscientist Stanislas Dehaene and others characterized and focused on conscious access. In the book he outlines the limitations of previous psychological dogma. Instead his use of subjective assessments opened the window to contrast totally unconscious brain activity with those including consciousness. He describes the research methods. He explains the contribution of new sensors and probes that allowed the psychological findings to be correlated, and causally related to specific neural activity. He describes the theory of the brain he uses, the 'global neuronal workspace' to position all the experimental details into a whole. He reviews how both theory and practice support diagnosis and treatment of real world mental illnesses. The implications of Dehaene's findings for subsequent consciousness research are outlined. Complex adaptive system (CAS) models of the brain's development and operation introduce constraints which are discussed. Conscious access
Reading and writing present a conundrum. The reader's brain contains neural networks tuned to reading. With imaging a written word can be followed as it progresses from the retina through a functional chain that asks: Are these letters? What do they look like? Are they a word? What does it sound like? How is it pronounced? What does it mean? Dehaene explains the importance of education in tuning the brain's networks for reading as well as good strategies for teaching reading and countering dyslexia. But he notes the reading networks developed far too recently to have directly evolved. And Dehaene asks why humans are unique in developing reading and culture. He explains the cultural engineering that shaped writing to human vision and the exaptations and neuronal structures that enable and constrain reading and culture. Dehaene's arguments show how cellular, whole animal and cultural complex adaptive system (CAS) are related. We review his explanations in CAS terms and use his insights to link cultural CAS that emerged based on reading and writing with other levels of CAS from which they emerge. Evolved reading
Read Montague explores how brains make decisions. In particular he explains how: Evolution can create indirect abstract models, such as the dopamine system, that allow Life changing real-time decisions to be made, and how Schematic structures provide encodings of computable control structures which operate through and on incomputable, schematically encoded, physically active structures and operationally associated production functions. Receptor indirection
Richard Dawkin's explores how nature has created implementations of designs, without any need for planning or design, through the accumulation of small advantageous changes. Accumulating small changes
Russ Abbott explores the impact on science of epiphenomena and the emergence of agents. Autonomous emergence
Terrence Deacon explores how constraints on dynamic flows can induce emergent phenomena which can do real work. He shows how these phenomena are sustained. The mechanism enables the development of Darwinian competition. Constraint based phenomena

Primary Navigation

In this page we explain how to use the site.
There are two main starting points:

The example systems frame and
The presentation frame.
And then there is how we use the site.

The site uses lots of click through. That's so that you can see the underlying principles that are contributing to the system being discussed. We hope that as you internalize and reflect on the principles the system should appear in a new light. At this site clicking is good!

Opportunities

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.

Theory

This web frame explores very significant example real world complex adaptive systems (CAS). It explains how the examples relate to each other, why we all have trouble effectively comprehending these systems and outlines the items we see as key to the system and why. By understanding these summaries you can better frame the interdependencies of important events such as war in Iraq, new iPhone releases or a cancer diagnosis and see how they are impacting you.

Examples

This page presents a search result list covering each linked region of rob's strategy studio.

Search

Rob's Strategy Studio aims to celebrate and illuminate complex adaptive systems (CAS) just as an art studio does art.

By way of introduction it notes the complex interactions that led to the partnership that discovered the DNA double helix and genetic code.

The page introduces the RSS vision 'I act, therefore I think' approach and the RSS mission.

It describes how many key aspects of the world are CAS including businesses.

Finally the page explains each of the framed pictures displayed at the studio including the other aspects explored in this vision frame.

Vision

This page introduces the programs that the Adaptive Web Framework (AWF) develops and uses to deploy Rob's Strategy Studio (RSS).
The programs are structured to obey complex adaptive system (CAS) principles. That allows AWF to experiment and examine the effects.
A production program generates the web pages.
A testing system tests the production program. It uses a framework to support the test programs. This is AWF's agent programming framework as described in the agent-based programming presentation.
An example of the other AWF agent-based programs that are also described in the frame is the virtual robot.
Finally a strength, weaknesses, opportunities and threats assessment is presented.

Perl

This page introduces a series of asymmetries which encourage different strategic approaches.
The differences found in business, sexual selection, gamete structure, as well as in chess encourage escalations in the interactions.
And yet the systems including these asymmetries can be quite stable.

Asymmetries

This web frame includes a set of presentations about complex adaptive systems (CAS)

Presentations

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 (

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 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.
, 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
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. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
products deep within the hospital systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. .

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:

Prices vary tenfold! They depend on who you work for. The poorest pay the highest prices.
Medical decisions are taken by for-profit business employees. Medical assessments are made by clerical staff. Hospital patients are
discharged
- have costly handoff problems reviewed by project BOOST. When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue. Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs. Discharge information can include:
- Patient info
- Behavioral summary
- Treatment history
- Medical history
- Treatment objectives
- Insurance policy
- Discharge plans
early overriding the judgments of doctors.
Preventative care is discouraged.
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.
is encouraged. Huge numbers of people die from medical mistakes.
More than 48 million Americans don't have health insurance. 18,000 die each year. Many have to be treated in expensive emergency wards 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).
.
More than 10 million Americans are under insured. They risk bankruptcy is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
when treated by the health care network.
Thirty years of government policy has pushed for cost reductions within the health care network. Each strategy has failed to reduce costs, while creating distortions. A huge, costly billing and administrative infrastructure has developed. Doctors are encouraged to
overtreat
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.
and focus on profitable specialties.
This presentation reviews just-in-time manufacturing with analysis based on complex adaptive system (CAS) theory.

Just-in-time manufacturing methodologies, misapplied to hospitals, starved the network of resources, inducing chaos provides an explanation for the apparently random period between water droplets falling from a tap. Typically the model of the system is poor and so the data captured about the system looks unpredictable - chaotic. With a better model the system's operation can be explained with standard physical principles. Hence chaos as defined here is different from complexity. within the complex operations.

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 ruling making expansion an optional state government decision.
Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
Medical home models.
Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
Qualifications for ACOs. Organizations must:

Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
Participate in the MSSP for three or more years.
Have a management structure.
Have clinical and administrative systems.
Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
Demonstrate it meets HHS 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 (Sunshine Act).
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

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.

networks and

agents affecting the US is the United States of America. health care CAS include:

The overall US is the United States of America. economy is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. and its main food network is based on augmentation with fossil fuels which (initially empowered Rockefeller, Senator Aldrich & the oil companies and subsequently)

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.

amplified the
Through the operation of three different food chains Michael Pollan explores their relative merits. The application of complex adaptive system (CAS) theory highlights the value of evolutionary testing of the food chain.

food production network:

Power of the elites is increasing and trapping 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).
. Since the 1980s tax adjustments have driven income and capital to the elites (Dec 2017). This encourages focusing capital on whims and allows many poor areas to collapse.

Positive return economics, 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.
has driven resources and monopoly power to the 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.
of networked high technology companies. These companies are pushing to enter the medical and
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?
educational
networks:

Incentives to teachers are increasing the complexity of the educational network (Sep 2017).

Being the only super power allows the elites to focus on overpowering one another, and limits their dependence on the rapidly aging majority.
Wealthy is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. 'New Democrats' accept the benefits and costs of globalization.
This page reviews Christensen's disruption of a complex adaptive system (CAS). The mechanism is discussed with examples from biology and business.

Disintermediation of the poor is the unfortunate cost of leveraging a global workforce. Health care investments offer a way to improve the health of the gross population as long as cost inflation can be contained. But the local jobs associated with health care and education and the voter hostility to cost management signals, 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.
: premiums, 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; limits the effectiveness of the cost management strategy.
Powerful Republicans counter the problematic demographic trends with a focus on:

The power to nominate: President; and subsequently appoint:

Members of the judiciary, instantiates the contragrade flows of judiciary influences subsequent interpretation of the constitution.
Appointees to the executive branch regulators.

Regulation to enforce a competitive market in health care has repeatedly failed.

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
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
competition

Between new and incumbent insurers
Between insurers and hospitals

Predatory incentives shift political and system focus from low cost highly effective public health strategies to high cost inefficient health care strategies

Employment opportunities for health care workers encourage Democratic politicians to support health care based strategies
Profit cascades from sale of products including toxic components, align industry and politicians, 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, to focus on supportive legislation and reduced regulation: EPA is the Environmental Protection Agency of the Federal government.
; generating subsequent health problems for hospitals to diagnose and treat.
Infrastructure development opportunities encourage Democratic and Republican politicians to support health care based strategies
Doctor & hospital presence removes constraints on business development and community growth.
Incentives and increased complexity drive specialization of doctors and hospitals. Long costly training constrains the choices of medical students ensuring remuneration is a focus of their career decisions.

The commercialization of each significant stage of life of the US population has both improved
wellbeing
is described by Angus Deaton as all the things that are good for a person:
- Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. Life expectancy as a measure of population health, highly weights reductions in child mortality.
and gradually increased the
Barriers are particular types of constraints on flows. They can enforce separation of a network of agents allowing evolution to build diversity. Examples of different types of barriers and their effects are described.

barriers to success. Education and health care have become essential services and a source of significant debt. The proximate environment has become more uncertain 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. and
stressful
is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
for the majority.

The connection of Amazon's ecommerce network to the pharmaceutical sub-network introduces the possibility of
This page reviews Christensen's disruption of a complex adaptive system (CAS). The mechanism is discussed with examples from biology and business.

disruption.

The US population now associates health problems with technological solutions provided by the health care network. Health care agents: Politicians, Academics, NIH is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. , Drug companies, Hospitals, Physicians, Pharmacists; reinforce this view.

The
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS). The mechanism and its emergence are discussed.

evolved
dopamine
is a synaptic signal supporting generalized goal-directed behavior & anticipation of reward. Its significance is that the receptors that detect the signal are of the slow acting type and are used to alter (modulate) the response of fast acting dopaminergic neural circuits in which the receptors are deployed (LTP). The signal detects significant changes including predictions of models and actual results which differ unexpectedly. The dopamine network architecture is designed to signal the possibility of any type of reward: Norm violation punishment, Winning a lottery, & Misfortune of an envied competitor. Dopamine signalling:
- Rescales continuously to accommodate the range of intensity offered by different stimuli. So dopamine's responses to any reward habituate. GABA is released by some tegmental neurons to induce habituation.
- Reflects the anticipation of reward. It supports establishment of a relationship between a signal, working for a reward and obtaining the reward, but subsequently dopamine is mainly released encouraging the work, right after the signal supporting anticipation of the reward. Anticipation requires learning and is reflected in hippocampus activity. That explains context dependent cravings. And the learning architecture means reliable cues become rewarding. The accumbens supports willpower. And dopamine
- Promotes goal-oriented behavior needed to obtain & likely to achieve the reward - through the dopamine projections to the prefrontal cortex. That makes dopamine central to:
- Is lowered by certain gene variants which induce: less dopamine in the synapse, fewer receptors, lower responsiveness of receptors; associated with (as tiny effects in hugely varying social scenarios): sensation seeking, risk taking, attentional problems, extroversion; where:
Read Montague explores how brains make decisions. In particular he explains how:
- Evolution can create indirect abstract models, such as the dopamine system, that allow
- Life changing real-time decisions to be made, and how
- Schematic structures provide encodings of computable control structures which operate through and on incomputable, schematically encoded, physically active structures and operationally associated production functions.
goal based reward system
offers the health care network a highly profitable, self-reinforcing product -- opioids -- with demand which becomes self-reinforcing. Drug manufacturers have obtained large profits from over-subscription, but like the triangular opium trade of prior centuries, the results have been highly destructive for many patients.

The addictive nature of opioids combined with 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: EPAEDE is the ensuring patient access and effective drug enforcement act of 2016. It allows patients' access to necessary medications including opioid painkillers (Sep 2015). And it constrains the powers of the DEA to intervene (May 2016). It establishes a process for federal agencies to go through before a distribution center can be shut down. Sponsors include Senators Orrin Hatch and Sheldon Whitehouse and Representatives Tom Marino and Peter Welch.
; supports huge protected profits and
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.
issues.

The adoption of an authoritarian white uniform:

Integration of health products with marketing networks have transformed the populations attitude to cleanliness. The
Kevin Kruse argues that from 1930 onwards the corporate elite and the Republican party have developed and relentlessly executed strategies to undermine Franklin Roosevelt and the New Deal. Their successful strategy used the credibility of conservative religious leaders to:
- Demonstrate religious issues with the New Deal.
- Integrate the corporate elite and evangelicals.
- Use the power of corporate advertising and Hollywood to reeducate the American people to view the US as historically religious and the New Deal and liberalism as anti-religious socialism.
- Focus the message through evangelicals including Vereide and Graham.
- Centralize the strategy through President Eisenhower.
- Add religious elements to mainstream American symbols: money, pledge;
- Push for prayer in public school
- Push Congress to promote prayer
- Make elections more about religious positions.
Following our summary of his arguments RSS frames them from the perspective of complex adaptive system (CAS) theory. Strategy is the art of the possible. But it also depends on persistence.
strategic coordination
of: Finance, Government, Marketing, News, Entertainment; supports and
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.

controls this flow.

The addictive nature of opioids combined with 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: EPAEDE is the ensuring patient access and effective drug enforcement act of 2016. It allows patients' access to necessary medications including opioid painkillers (Sep 2015). And it constrains the powers of the DEA to intervene (May 2016). It establishes a process for federal agencies to go through before a distribution center can be shut down. Sponsors include Senators Orrin Hatch and Sheldon Whitehouse and Representatives Tom Marino and Peter Welch.
; supports huge protected profits and
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.
issues.

An
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS). The mechanism and its emergence are discussed.

evolved process is
This page discusses the strategy of modularity in a complex adaptive system (CAS). The benefits, mechanism and its emergence are discussed.

modular enough that treatments can be specific. But that is unlikely since evolved innovations leverage addressable templates for a grab bag of strategic tools which may be broadly used.
Genomics combines recombinant DNA, DNA sequencing and bioinformatics to sequence, assemble and analyse genomes. provides an easily understood description of phenotypic implementation. But the understanding of control networks for genes and their products is still limited and probably requires understanding complex adaptive dynamic factors.

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.;
offers health care:

Better integration, coordination and control

Paying for health care was supported by health insurance from early in the twentieth century: Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy.
, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. ; introducing payer driven
Terrence Deacon explores how constraints on dynamic flows can induce emergent phenomena which can do real work. He shows how these phenomena are sustained. The mechanism enables the development of Darwinian competition.

constraints and
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 amplifiers.

Employers are organizing: Health Transformation Alliance; to take advantage of their access to
Big Data
encompasses the IT systems and processes necessary to do population based data collection, management and analysis. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
about best and worst case health care pricing and quality of their employees treatments, to
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.

flow employees to low cost high quality services (Aug 2017).

Price constraints are removed by:

Fixed payments for specific treatments independent of cost enable profit seeking and profit maximization by increasing treatment volume.
Ancillary constraining patient copayments removed (paid) by producers, distributors and operators of treatments, whose profits are tied to treatment volume.
Drug price competition regulated away

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

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);

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

Robert Gordon argues that the inventions of the second industrial revolution were the foundation for American economic growth. Gordon shows how flows of people into difficult rural America built a population base which then took the opportunity to move on to urban settings: Houses, Food in supermarkets, Clothes in department stores; that supported increasing productivity and standard of living. The deployment of nationwide networks: Rail, Road, Utilities; terminating in the urban housing and work places allowing the workers to leverage time saving goods and services, which helped grow the economy.

Gordon describes the concomitant transformation of:

Communications and advertising
Credit and finance
Public health and the health care network
Health insurance
Education
Social and welfare services

Counter intuitively the constraints introduced before and in the Great Depression and the demands of World War 2 provide the amplifiers that drive the inventions deeply and fully into every aspect of the economy between 1940 and 1970 creating the exceptional growth and standard of living of post war America.

Subsequently the rate of growth was limited until the shift of women into the workplace and the full networking of voice and data supported the Internet and World Wide Web completed the third industrial revolution, but the effects were muted by the narrow reach of the technologies.

The development of Big Data, Robots, and Artificial Intelligence may support additional growth, but Gordon is unconvinced because of the collapse of the middle class.

Following our summary of Gordon's book RSS frames his arguments from the perspective of complex adaptive system (CAS) theory.

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, Treatment protocols specified in 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. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!

described by Steele & Feinberg;

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

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

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.;

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. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!

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. Sulfur dye stuffs were found to be effective antibiotics. The first evolved 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 Wal-Mart 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 The MMA prohibits Medicare from directly negotiating drug prices.

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: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
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

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 ruling making expansion an optional state government decision.
Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
Medical home models.
Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
Qualifications for ACOs. Organizations must:

Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
Participate in the MSSP for three or more years.
Have a management structure.
Have clinical and administrative systems.
Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
Demonstrate it meets HHS 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 (Sunshine Act).
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.

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

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

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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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.

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