Sunday, April 19, 2015

Antitrust and the Brit

And now the Brit at the Guardian takes after Google. He states:

For all their promise of openness and equality, the technologies of the internet also promote the creation of giant companies. The question facing us as a society is what trade-offs we make: does the bigger danger lie in allowing the creation of unalloyed corporate power, or instead in curbing technology’s potential to prevent it? The question could become moot: in practical terms, if Google trounces the EU on all counts after several years, few other competition authorities will want to take on the company, and they may even be deterred from pursuing other internet behemoths. A decade or so without a challenge may make a new normal near irreversible.

This is not a logical argument, it is a crie de coeur, French is always a good way to bemoan the Brits,  especially those who appear to be totally ignorant of monopolies. Just because a company has a large market share does not make it a monopoly. Perhaps it is just better! And oh by the way it is free!

One could not do what one creats today without Google. Yahoo is a cacaphony of ads, nonsense, and useless blather. Bing is Microsoft, incomprehensible and insulting. Google, well it just works. So the Brits now want it dead! Yes, those same characters who, after the Danes, came and occupied the last vestige of intellectual acumen in the 11th century with the near imbecile of a King, John!

Perhaps we should return to a court with Henry VIII and the beheading of spouses, or perhaps they can take that out of the History books, except perhaps Wolf Hall, or whatever that is.

Saturday, April 18, 2015

Antitrust and the Danes

The Irish can still recall the Danes invading in the 800s, driving up the Shannon, destroying and plundering, the monasteries and massive libraries of documents, driving the then both religious and educated into ever present terror. Then when Henry II arrived and he gave Ireland to his somewhat less than competent son John, it began a thousand year occupation which seems to continue to the present. Yet to a reasonable degree it was the Danes and their ships that destroyed what could have been a few hundred year leap on civilization.

Now to antitrust. This has always been a rather messy quagmire. I have written extensively on the topic and it may be worth an examination. One need look at just two cases; IBM and AT&T. At the time the dropping of IBM was totally correct. There was competition, just look at IBM today, going through another metamorphosis. On the other hand AT&T was also correct. It was a Government sanctioned monopoly that actually stifled any competition. I examined this in detail in 1990. Had DOJ not broken up AT&T we most likely would still have black rotary dial phones and would be leasing them for $1,000 per month!

Now to the Dane and Google. In a sense Google is akin to the Irish monks, providing knowledge universally, along with some of their services, but it is the knowledge that counts. Then comes the Dane, not on a long boat this time but with the power of the EU, that mighty fortress that seem just two shakes from collapse.

As the NY Times notes:

Last year, as Ms. Vestager was leaving her job as Denmark’s minister of the economy, she gave her successor a hand-knit toy elephant — she often works on them during staff meetings — noting that the animals “bear no grudge, but they remember well.”

Sounds like the Danes and their long boats! Off to the monasteries and their libraries, burn them down!

The Times continues:

In Brussels last Wednesday, she filed formal antitrust charges against the company, saying that the search engine giant had abused its market dominance by systematically favoring its own comparison shopping service over those of its rivals. If Google fails to refute the charges, the company could face a fine of more than 6 billion euros.

 Google has competition. It is not an AT&T, perhaps it may become an IBM, but never an AT&T. Technology changes daily, regulators look backward, and project forward their worst visions. The Times continues:

That direction was filing formal charges, called a statement of objection, accusing Google of favoring its own comparison shopping service, called Google Shopping. In practical terms, the commission found that when a consumer used Google to search for shopping-related information, the site systematically displayed the company’s own comparison product at the top of the search results — “irrespective of whether it is the most relevant response to the query,” Ms. Vestager said in a commission-issued statement about the charges.

 The Dane does not seem to understand that the mechanism used is how Google pays for the service. It is a service, it costs money, and frankly anyone else can build their own such service. There is no monopoly, there is no barrier to entry, it is not AT&T preventing any competition. The Dane seems to be clueless about the world of business, but then most likely did her ancestors as they pillaged up the Shannon, past my ancestors. This may just be 21st Century pillage, again the Danes!

Friday, April 17, 2015

The EHR and Its Performance

The NY Times bemoans the status of the EHR. As it states:

The ability to transfer electronic medical records from one doctor or hospital to another is essential to the smooth functioning of the health care system and to providing the best possible care to patients. Yet all too often these transfers are being blocked by developers of health information technology or greedy medical centers that refuse to send records to rival providers. This will not be an easy problem to fix, but some possible approaches were detailed in a report to Congress last week from the Office of the National Coordinator for Health Information Technology, a unit of the Department of Health and Human Services.

The problem, as we have noted over the past several years is several fold:

1. First, the Government directed the process. The same group who did the portal for ACA. In addition in my opinion the management team were politically selected not professionally selected.

2. The system should have been patient centered and not practice centered. Namely the system should have take advantage of a secure cloud based approach minimizing physician costs and overhead and allowing single points of collection and correlation. Unfortunately we have a plethora of systems which will be outdated and underused.

3. The system should be multimedia enabled. Now it is merely a text file system with some adjunct access for radiologists and perhaps pathologists. Other multimedia elements are piecemeal and unconnected.

4. The system should provide a customizable dashboard. If the patient is a Type 2 Diabetic one should see their BMI changes as well as HbA1c and others. If the patient has COPD the same.

The problem is NOT the vendors. The problem was in my opinion the very people who created this mess. We noted as such six years ago, but alas, it is this Administration.....And tens of billions of tax money has been spent and added costs to practices...not to mention physicians typing while not examining the patient!

Ad Hoc Propiter Hoc

It is always amazing to see what amounts to research. In a recent MIT News release there is a study that alleges to show that people raised in well off families are smarter than those in poor families because of the difference in income. At least that appears to be the gist, an academic study to justify income transfer and the elimination of income disparity. (This is funded by the Gate Foundation, somewhat ironic.)

The article states:

A new study led by researchers at MIT and Harvard University offers another dimension to this so-called “achievement gap”: After imaging the brains of high- and low-income students, they found that the higher-income students had thicker brain cortex in areas associated with visual perception and knowledge accumulation. Furthermore, these differences also correlated with one measure of academic achievement — performance on standardized tests. “Just as you would expect, there’s a real cost to not living in a supportive environment. We can see it not only in test scores, in educational attainment, but within the brains of these children,” says MIT’s .... Professor in Health Sciences and Technology, professor of brain and cognitive sciences, and one of the study’s authors. “To me, it’s a call to action. You want to boost the opportunities for those for whom it doesn’t come easily in their environment.”

Now I think of Faraday,  orphaned and apprenticed as a bookbinder. His work was prolific and established the basis for our electromagnetic world today. One can go across MIT alumni and see all too many who came from what they would call less advantaged homes. In fact MIT was where one achieved from humble beginnings as compared to Harvard where one achieved from family pedigrees. I would hazard to say many MIT alums did more intellectually for society than Harvard. After all we had fewer politicians and that alone is an achievement.

But I suspect the facts belie the conclusions above. I think of the many MITES students I worked with and befriended. Talk of hard times. Yet look at them now! Could they have done better? Frankly I believe that they did what they did because they had been challenged, not despite it. Probably the one of whom I am most proud went from a Mississippi rural area to heading a major investment fund in Africa!

Also one must remember all the well off kids that go nowhere. The "real cost" is in my opinion a political statement and lacks any factual reality.

The Selfie

There is an article in The Guardian discussing the Millennials and how they bemoan their situation in life. The rather self absorbed author writes:

Life is often referred to as a “highway”, to borrow from Tom Cochrane, and for my generation that hasn’t changed. “Adulthood today lacks a well-defined roadmap”, writes Steven Mintz, in his forthcoming book The Prime of Life. “Today, individuals must define or negotiate their roles and relationships without clear rules or precedents to follow”. This is especially true for us millennials, who are the product of a terrible economy that has required us to hit the emergency button in our lives. But it’s becoming evident that we have been given a roadmap to a road that we are not even on and then are blamed for going in the wrong direction.

But this self absorbed statement is bettered by the photo atop the article, which is a collection of these individuals engaged in the Selfie. This in many ways defines them. They look inward, at themselves, and they see what they may not like. Albeit adoring themselves and their small worlds captured in this image or video, they are not looking outward.

Now they bemoan a "terrible economy". Are you nuts! My parents in the 30s had no economy to speak of, and survived on jobs at $14 per week. You could not even pay you cell phone bill with that. How about Viet Nam and the 60s, for a male you had almost a 50:50 chance of going there as cannon fodder for Johnson. Equally you had the military say at Kent State killing innocent students and there was no justice for that event.

A second article bemoans the "following of your dream". It is some student whose life on food stamps as they go about following their dram is decried as not enough:

a twentysomething graduate student, knows something about trying to live on food stamps. One of the so-called millennials, ... took an unpaid internship fresh out of college in 2012 and had to rely on food stamps to help supplement her income. Currently enrolled in graduate school at Oregon State University, ... is making do with $800 a month. “I was following my dreams, which I realized really quickly I could not afford to do. I was working as an intern at the Boston Review [during the week] and was unpaid. I was eating through my savings and applied [for food stamps] because I realized that I was not going to be able to continue pay rent and be able to buy food at the same time,” she said. It was actually Boston Review that had suggested she apply. “I guess other interns they had in the past had done it.”

 If you want to "follow your dream" then you have a price to pay. I should not have to pay your price, I did that when I ate rutabagas and drank powered milk. If you are willing to take an unpaid job then that economic choice has consequences.

Dreams do not an economically stable society make. It appears that the Selfie is a true metaphor for this group, inward focused and self absorbed. Talk of a "lost generation". Yet I look at many of those who have managed to squeak across our borders as at sunrise they line up looking for a days work and then applying themselves for fifteen or more hours and then doing it again and again. Never saw them take a Selfie.

Wednesday, April 15, 2015

Cancer and Outliers

Decades ago I spent a considerable amount of time trying to logically develop a basis for rejecting outliers. When collecting data oftentimes most of the results look like the random variations one would expect, except for those few outliers.

At the time I noted:

When data are taken in many experiments there often are points which bear no resemblance to the actual experiment being performed but arise from other, possibly undefined, sources. These data points are called outliers and the data analyst seeks ways to identify them and accurately reject them from the data base. Statisticians have developed many techniques for recognizing and rejecting outliers, but their approaches have usually been centered upon techniques where time variations in the measurements were absent.

Namely I was concerned about rejection where we had some underlying but possibly uncertain dynamic process governing the system. Outliers can be viewed in many ways:

1. Just a bad data point.

2. A data point which is one of a kind.

3. A data point which represents a significant system underlying it.

Now consider the many new therapies for treating cancers; immunotherapy and pathway control therapy. We often see say 20% of the patients are "cured". The other 80% regress to normal status and do not survive. Are the 20% outliers, and should be rejected or are they representative of a different dynamic system and we should really try to identify that system. Forty years ago I felt the latter. Namely we observe data and if it divides into two distinct terminal states then we have two distinct underlying systems, pathways or immune responses, driving them there.

In Nature this week there is an interesting paper examining this issue. The authors note:

By definition, exceptional responses are rare, which makes them hard to study. Their anecdotal nature seems to contradict the teachings on statistically sound results in biomedical research. In a clinical trial, even if there are several exceptional responders, a drug will fail to achieve approval because it does not improve the health of the majority of patients. This means there has been little incentive for researchers or drug companies to investigate thoroughly why a few people respond so well.

This has typically been the result that these outliers are just bad data. In reality they are good data, great data, but for another reason. Find that reason, namely identify the system that allows the patient to respond. If something works for even one patient, then it is not a failure but a success. Yet the statistical approach to clinical trials means we declare the trial a failure. That was NOT my approach 40+ years ago, and it should not be the case now. Somehow we seem to reject success, small as it may be, rather than ask why.

The Nature article continues:

Vincent Miller, a former MSKCC oncologist, agrees that views about outliers are changing and thinks that many more such individuals might be found. Any oncologist has a handful of patients in whom cancer just melts away with no obvious explanation, says Miller, who is chief medical officer of Foundation Medicine in Cambridge, Massachusetts, a company that performs genomic analysis of samples from people with cancer. In January, the pharmaceutical company Roche, based in Basel, Switzerland, bought a majority stake in Foundation Medicine, which is also involved in the ERI.

 Yes, physicians must learn to think differently. They must go beyond answering what and how, diagnosis and treatment, and start asking why. We now have means and methods to assist in attaining the answer, they are tools from systems identification and analysis.

Finally the article states:

For research on outliers to be of greatest help, the outlier cases must be rigorously selected. Only then can the analysis deliver sound results despite the fact that it remains a profile of only one person, says Friend. Taylor agrees, pointing out that molecular analysis of tumours from patients is increasingly possible and that there is growing acceptance of studying outlier patients. “Nevertheless,” he says, “it requires that we stay focused on exploring the most significant outlier responses to ensure the greatest return for patients.”

 Yes selection helps but we must also use verifiable models of the disease or the putative curative process. If we have some immune response technique, then perhaps it is not a PD-1 problem, but some receptor we do not know yet. Find it, work into the shadows, and assume that it is there and then go looking.