I am about to write a review of Epubor, a utility to strip Digital Rights Maintenance DRMs from a number of encoded electronic books. In particular, I would like to convert Kindle books (including their new KFX format) as well as Kobo books into epub, so that from Adobe Digital Editions (ADE), you can transport the epub version to some device of your choosing. The other methods I have tried DeDRM and the Calibre plug-ins, are really quite clumsy and don't work with KFX, far as I can tell. So it Epubor can convert any format into epub, glory hallelu! Keep your eye on this, for the review, whenever I get a license from them.... Ernie

XX hybridization - are males doomed?

It seems to me that cloning just reproduces the genome, whereas sexual hybridization with haploid gametes results in diploid cells with a combinant genome...the biological mechanism that ensures diverity, variation and sucess in adapting to environmental changes.

Bacteria (and viruses) swim in an ether of pieces of nucleic acid and fragments of protein, and are able to pick up these fragments and incorporate them into their own genome - these plasmids are like the spread of memes using twitter in the twether.

So outside of the usual haploid fusion through biological whole organism mating, we humans have introduced ICS, in vivo fertilization....and in fact, we can scrub sperm of surface proteins, and even extract its genetic material and introduce that into an egg, to achieve fertilization which can then be completed through surrogate wombs.

What we have not yet done, is to take the genetic material from a diploid ovum, introduce that into another ovum and produce a diploid XX zygote. Of course, if the sperm contains the haploid X chromosome, the resulting gamete will be XX, but why not the genetic material from another ovum?

Curiously, I have not been able to find anything about this ovum-ovum hybridization idea on the Internet....my conspiracy theory friends say that first, if I can think of it, it's being done somewhere (meme theory), and secondly, that it would be done by the backing of billions of dollars guaranteeing total security (like Manhattan Project)...

Others more technical say its something about telomeres....and it will come. If and when it comes, we can see three kinds of zygotes - XY from female and male haploid cells, XX from female and male haploid cells, and XX from female and female haploid cells. Clearly, since an ovum is always X, no YY zyogtes are possible.

Will this then be the demise of the human male? The fundamental tenet of evolutionary adaptability will have been met with hybridization from two genomes - through ovum-ovum fertilization.....and any Ys of interest can be kept in the freezer for use with the same technique.

Merely a biotechnology question on my part, but there may be some social consequences if the technology is feasible.

Patient as expert

The context for "patient" is a person who feels ill, and needs others to arrive at an improvement. The steps in scientific medicine are: urgent care-diagnosis-treatment, over time. The need for others varies with time and with the nature of the tools needed for improvement. If a "cure" has only cognitive elements, then surgeons, interventional radiologists would not be needed, and DIY stents would be available over-the-counter. There may always be a need for others with more knowledge, skills, or experience at various points along the journey.
Providers have studied to acquire this set of knowledge, skills and experience over numerous subjects. Most patients call on a subset of this information space with a need for one or two entities, diagnoses, paradigms, syndromes. The more specific the illness state, the more readily a patient can become an expert on it, to a depth exceeding the harassed GP who needs to have several hundred diagnostic entities and care patterns at hand and in mind.

The partnership between patient and provider is highly contingent on social relationships of respect, trust and acceptance of the other's knowledge. A provider who respects and trusts the patient's knowledge can defer all choices and decisions to the other, often seen when one doctors treats another, with no perceived need for recommendations.

The limiting factor of patient as expert is that true expertise is not just knowledge of a subject, but also knowledge of the subject's connections to all related subjects. What might be called wisdom increases as the boundaries of what one does not know comes more sharply into focus.

For the healing process to work well between the person who is ill, and all his or her assistants (providers), trust, respect, and acceptance of what the others know need to be mutually acknowledged.

Health2.0 could crunch physicians

Well, I am a physician in general practice, and I saw 58 people today in seven hours in the clinic. Now I ask myself, with every one of these visits, whether it was a necessary visit, and from the patient's point of view, I would have to say yes. So I spent seven and a half minutes per patient, which includes listening and talking, examination, writing notes, writing prescriptions, writing lab and imaging orders, writing referrals, calling the emergency, calling the pharmacy. Not all these apply to each patient, but at least three or four of them do.

Some of the patients waited for an hour, some more....that's because it's a first come first serve no appointment clinic. We don't turn people away. So from the patient's point of view, there's a lot of wasted time sitting around. Even if one got into the queue, left and came back an hour or two later, there would still be a sense of makeshift time. And all this for an average of less than six minutes with the physician.

So if a patient could save two hours of travel and wait time, and instead spend fifteen minutes on an eHealth medium with the physician, and get all the things that you want, and HelloHealth promises, that would incur a demand of fifteen minutes of time from the physician. Where would this extra seven and a half minutes come from? Would I have to work fifteen hours a day to see the same 58 people each with fifteen minutes of electronic interaction? Or is there some sense that with eHealth tools, some of the 58 visits would not be needed? It's more likely that with increased communications capability and information, comes more questions and demand for answers. If no visits in a time-slice today are unnecessary, then all 58 visits will continue to be made, either face to face or electronically.

The problem here is that the total time spent waiting among the patient population could be considerably diminished, but if none of the visits were unnecessary, the physician still needs to interact with the same 58 people. While the benefits of eHealth could increase the time per interaction and decrease waiting times for the patient, where would it generate extra time for the physicians in a workday?

With HelloHealth, if each physician were paid for an hour of eVisit with one patient, would first of all this hour mean that six others would not be seen, and secondly, a small but not insignificant point, would the hour's visit cost seven times more than a visit with a physician in a clinic?

These are challenges that need to be faced squarely before we can implement on a population wide basis methods which are asymmetrical - reduce patient waiting time, increase patient interaction times, but without reducing demand on the same pool of physicians who are already struggling to meet the meeds of a population that feel underserviced with insufficient time and care.

Bottom line here - no matter how inefficient the office and wait times seem to be to the patient, the physician works very hard at producing a great clinical encounter in the seven minutes spent with a patient. Sometimes it doesn't work, usually it is satisfactory. It seems unlikely that eHealth, while making things quite a bit better for the patient, could improve the efficiency of the physician to permit more overall service time that would be incurred by the additional demands created by eHealth tools....huis clos

Providers not aligned with market forces

Of the three major categories of players in the health care system - patients, payors and providers, the first two are aligned in their driving interests - better health, lower intensity of interaction with the providers - make up for better quality of life for patients, better profits for payors. The competition among the 160 insurers (plus Medicare) leads to systems which offer better outcomes for employers (and thus patients) - whether this is the Patient Centered Medical Home, or Patient Portals, or Personal Health Records, or EHRs that interoperate and give access to CCRs that are kept in globally accessable PHRs.

These forces also make feasible care managers who would work with patient and provider to ensure that accepted care guidelines for acute or chronic disease are on course, in line with what evidence says would be the best management strategy.

However, these forces do not align with the interests of providers, who after all, are essentially paid for each service rendered, whether in the office, hospital or surgery. These people are not paid for patients or the public to be healthy or disease free.

This is why an integrated system like Kaiser (or the countries with universal care and state-owned facilities) run the risk of conflicting goals in their business model. On the one hand, the payor arm wants to keep patients on a long-term low intensity in demand for provider services; on the other hand, they need to keep the clinics and hospitals open, and to keep doctors, nurses fed. Unless the provider staff share in the retained earnings of the payor, the integration has a strategic challenge to meet.

Physicians who adopt EMRs or EHRs, or who are asked to implement Medical Homes, need to be given ways in which their interests are aligned with those of patients and payors, and not simply at an altruistic or ethical level. Even if the providers are employed by payors.

EC

Health2.0 Spreadsheet of 170 entities

From the speed-dating of one day at Health2.0, I looked at all the websites of companies, people and organizations in the Proceedings, read through all of them, followed some other leads that were of immediacy, and ended up with a spread-sheet that has:

1. Some ontological characterization of the Health 2.0 space
2. Live clicks to web-sites of each one, plus a few secondary sites
3. Commentary (mine) on each one
4. An ontology related to my interest in Personal Health Records, Patient Centered
Medical Home, Patient as Partner, Clinical Portals, Knowledge Portals

Of course, all ontologies are biased constructs, and deserve deconstructing.

These data will the basis of a report on the application of these concepts and technologies to single payor integrated health care systems across other domains, where insurance is not competitive and drivers are different from ours.

A copy of this spreadsheet is available on request to ec.health2.0@gmail.com

I am in the process of sending this to Matthew Holt at Health2.0accelerator / advisors, and it may be that it is available there as well.

EC

Left-handed electrons

Why is it that electrons have a left-handed spin ALL THE TIME? There are some constants about this universe we inhabit that are just plain unbelievable! Makes no particular sense...shouldn't they be random? Like coin flips? What IF they were?