Re: [genomics] Proposal to create an "Imaging Group" in OSEHRA

Tom Munnecke- Major depressive disorder and the depression in bipolar disease *cannot be "cured" by going for a hike*. These are chronic, debilitating diseases, that impact an individual, their families and our society in horrific ways. There are worse than many other chronic diseases, because they are diseases of brain and behavior. I understand the point that you are trying to make about the transactional model, but, unfortunately, you are perpetrating an obsolete myth that individuals with psychiatric disease could just get better by "pulling themselves up by their bootstraps." Modern neuroscience research has shown us, probably more than anything else, that these are as serious as diseases of the heart, liver or kidney, but once again, the stigma of these diseases persist. And they are diseases, not "disorders." I would agree that the draft DSM-5 has attempted to split psychiatric diagnoses into too many potential CPT codes for reimbursement - edged on by idiots (IMHO) like Dr. Drew Pinsky of TV fame, who pushed to have "sex addiction" included in DSM-5 as a disease. Maybe we should suggest that PTS or TBI can be cured by exercise - this is a laughable notion. Kind regards - Gerry Higgins, Ph.D. On Thu, Mar 8, 2012 at 1:03 PM, Tom Munnecke wrote: > re: things not happening being the most important.. yes, a very big > topic. It gets to the core of prevention and health. If someone cures > their depression by doing lots of hiking, rather than getting a > prescription for an antidepressant, there is no transaction, no DRG, no > income for anyone (except perhaps a shoe company). There are no "outcomes" > to assess, and no way to know if this prevented a heart attack, diabetes, > or whatever. So how does one do a cost/benefit analysis of hiking? > > The transactional model of health care is based on the things done - RIM > talks about everything starting with an activity. The elegant solution - > dissolving problems before they are manifest - is not visible to the > system. > > My "bucket list" of things to do for VistA that never got implemented was > a system I called "pendex" or pending index of things expected around a > patient. This state would be held in a container I called an "ensemble" - > or people, things, knowledge, and agents seeking to accomplish some health > care goal, which I called a "transformation." Ensembles were a way of > decoupling the architecture from the organization chart or agency - a way > of moving to a model of personalization. > > Alas, the world seems to be moving away from this concept into > mega-turbo-hyper centralization :( > -- > Full post: > Manage my subscriptions: > > Stop emails for this post: > >


I didn't mean to perpetuate a myth

Tom Munnecke's picture

Gerry, I am very aware of the severity of psychiatric problems.   I was one of the first computer specialists to be hired by Ted O'Neill when VistA was first getting started, and to protect our positions from the centralists who were trying to shut us down, I was given a staff role support the psychiatry service at Loma Linda VA.  I had an office with one door (which I kept locked) adjoining the psych ward, so I got to listen to a lot of what was happening there, (whether I wanted to or not).  I also attended the psychiatry staff meetings, and got to know quite a few psychiatrists well.  I also got introduced to the work of psychiatrist Milton Erickson - and found his thinking on linguistics and indirection  inspiring in the design of the VistA "speech community".

I wasn't trying to suggest that exercise could cure severe depression, but rather come up with an example of how a self-initiated healthy behavior could improve heatlh but be invisible to the transaction-processing apparatus that is the core of our health IT architecture today.

I've run across these issues in so many contexts that I've come up with two terms to describe what I'm talking about.  Malgnosis is a way of understanding a system by what is failing and how to repair it.  Benegnosis is a way of understanding a system by what is positive and life affirming.  If we are dealing with linear systems in which the whole is exactly equal to the sum of the parts, these ways of knowing are essentially the same - fix what's wrong and we have a working system.  Diagnose what's wrong with a toaster (say, a bad cord), fix it, and we have a fully functioning toaster again.

But when systems reach a level of complexity such that the whole is more than the sum of the parts, these two ways of knowing diverge.  Understanding what's wrong with a dissected cat is not necessariy help us understand live cats.  "Fixing" a lost tail on a cat by trying to reattach it is probably not going to help the cat.  The benegnositic perspective of cats is no longer "negating the negative" of the malgnostic understanding.

My take on much of the problems is that we are facing cat-like problems, but are using toaster-like thinking to try to solve them.

I brought this up recently at Eric Topol's "Future of Genomic Medicine" conference in La Jolla with regard to Scripps Wellderly project.  The are studying the genetic makeup of folks who have lived long, healthy lives.  They mentioned looking for the "absence of variations" in the genomics of their population... an example of "negating the negative."  But understanding the positive effects of resilience, adaptability, self-efficacy are far harder to "diagnose" than the occurance of clinical systems.

This opens up lots of interesting issues, particularly relating to today's social media... I've been flogging Jonas Salk's Vision for Creating an epidemic of health for a long time now... and I find the interesection between genomics and social networks fascinating.

The whole issue I'm trying to address is that our health IT architecture efforts are hugely biased towards tracking the disease/fixit/consumption model.