text:
Q: Unable to load library tesseract in R library(tesseract) # for OCR

Results in error:
Error: package or namespace load failed for 'tesseract' in dyn.load(file, DLLpath = DLLpath, ...):

unable to load shared object '/dhlib/tesseract/libs/tesseract.so':
  libtesseract.so.4: cannot open shared object file: No such file or directory

In addition: Warning message:
package 'tesseract' was built under R version 4.0.5

Any ideas on how to solve this?


text:
Q: Prometheus - PromQL - filter by dict attribute I am trying to get memory usage by K8S PODs in particular states only:
sum(container_memory_usage_bytes{kube_pod_status_phase{phase="Pending"}})

but am getting an error: "parse error: unexpected left brace '{'"
What's the correct syntax?

A: if you want to calculate sum memory usage  in kube_pod_status_phase:
sum(container_memory_usage_bytes) by (kube_pod_status_phase)
or if you want to sum all memory usage :
sum(container_memory_usage_bytes)

redpajama_set_name: RedPajamaStackExchange


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text:
Edmonton teen sets Canadian record at Rubik's Cube speedsolving event
17-year-old Kyle Santucci breaks national mark at the inaugural Rockies Rager in Canmore.
Jordan Small
1 / 1 Banff's Daniel Eaton competes in the skewb challenge at the Rockies Rager Fall 2022. It was Canmore's first ever official Rubik's Cube speedsolving competition at the Canmore Recreation Centre on Saturday (Oct. 8). JUNGMIN HAM RMO PHOTO
CANMORE – The average person solves their first Rubik's Cube in three hours, but for a group of speed-competitors in Canmore, solving takes less than three minutes to do – when blindfolded.
Quickly spinning the mind teasers and matching up colours, it was no problem for dozens of problem-solvers at the inaugural Rockies Rager, a Rubik's Cube speedsolving competition, at the Canmore rec centre on Saturday (Oct. 8), where a national record was broken.
Edmonton's Kyle Santucci, a teen with lightning-quick hands, set the national record in 3x3 cube, averaging 5.93 seconds over five solves. Santucci's fastest time matches one already set, but because his is most recent, the teen now holds the record.
Edmonton's Kyle Santucci solves a skewb at the 2022 Rockies Rager, a Rubik's Cube speedsolving competition, in #Canmore. Earlier in the competition, the lightning-quick Santucci tied a national record in 3x3x3 cube, averaging 5.93 seconds. pic.twitter.com/ymacRI9nOq
— Jordan Small (@jordiesmall) October 9, 2022
The 17-year-old also holds the Canadian record for fastest single solve in 3x3 cube – 4.26 seconds – achieved earlier this year.
"I've gotten a lot faster recently and I know I'm really capable of it," said Santucci. "That's basically what I average overall, but I was just so nervous in-competition and I finally got it and I'm real happy about it."
The world record for fastest single cube solve is 3.47 seconds set by China's Yusheng Du in 2018.
In Canmore, the teen, who has been involved in speedsolving competitions for seven years, won gold in 3x3 cube and 3x3 cube single hand, and third in the skewb and 2x2 cube.
"[Today] could have been better, but I got the national record, so I'm happy about it," he said.
Although Santucci impressed with the record-setting day, results from other competitors at the Rockies Rager had the room on the edge of their seats.
Canada's Danny Buschert won first place in skewb, an eight-corner and six-piece centre cube, at a time of 2.74 seconds. Canada's Lucas Kuczaj won the clock final, a two-sided puzzle with nine clocks, at 5.11 seconds; and Canada's Carson Deibert won the 2x2 cube with a top time of 3.07 seconds.
The 2022 Rockies Rager Rubik's Cube speedsolving competition in #Canmore pic.twitter.com/qVJ8p9xLQU
Bow Valley's Anthony Finnigan and Daniel Eaton qualified to the second round of the 3x3 cube challenge, earning personal best single solve times that day of 25.66 and 30.18, respectively.
However, it was USA's Matthew Dickman, who when blindfolded, took the Rubik's Cube competition to a whole other level.
Without the use of his eyes while solving, Dickman was the only competitor in the finals to complete all three solves with a fastest time of just over 80 seconds.
Before each attempt, participants are allowed a few minutes to look over the cube with little multi-coloured square stickers. With 125 competitions under his belt, the speedsolving veteran said memorization of where each sticker is and needs to go, is key to the blindfolding solve.
"When you're blindfolded, you solve it piece by piece," said Dickman. "A lot of people will either think of words, adjectives, verbs, or they'll come up with stories often times if they're doing a long session of memorization.
"Usually it's not solved, but sometimes you'll end up lucky. A lot of it is memorizing sequences of letters, associating with different words or sounds."
The world record fastest 3x3 blindfolded solve is 14.51 seconds, set this year by USA's Tommy Cherry.
About the Author: Jordan Small
Jordan Small joined the Outlook in 2014 and covers the vast world of sports in the Bow Valley. A Barrie, Ont. native, he also wrote for RMO's Mountain Guide section and the MD of Bighorn beat.
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redpajama_set_name: RedPajamaCommonCrawl


My TGO Challenge was planned to take place between the May 11th to the 23rd. Thirteen days of what I could only hope to be great hiking in the Scottish Highlands. This is my trip report covering my start in Shiel Bridge on the west- to my finish at Dunnottar Castle, Stonehaven, on the east coast.
My trip started well before the actual challenge. Down in the southern parts of Sweden I boarded a bus up to Stockholm and Arlanda Airport. I stayed the night at an hotel close to it. I arrive in Edinburgh the next day just before lunch I went to one of the museums, checked a few exhibitions and used their bathroom to change from my travel clothes into hiking gear, shorts and leggings, and a long-sleeved tee… Then I went to the post office and forward all of my travel clothes to Montrose before starting the hunt for alcohol (fuel). This sent me off to a few different stores before actually finding any. My train for Inverness was leaving at 5pm so I had plenty of time dine and stock up on food for the first three days of hiking.
I spent the night in Inverness and had a short walk to the bus station where I met up with a few other Challengers. We arrive at at Shiel Bridge at around 11am as the bus was about 40 minutes late out of Inverness. This far everything had been late and delayed. My bus to the airport in Sweden, the plane to Edinburgh, the transfer from the airport, the train to Inverness and now this. I started to see a pattern.
After a quick bathroom break most of us set off at 11:45. I put my right foot in the water just outside the Kintail Lodge. The weather is good, the sun is out and there's a slight breeze.
When I get closer to the stalkers path up Ben Attow I meet a man that also a part of the TGO Challenge. We chat a while before I take off up the Munro, he's headed to the youth hostel. The wind started to pick up as I came to the first cairn off the stalkers path onto the lower plateau. Soon the rain got at it too. Getting to the top was quite exhausting, battling the wind and the ground was very wet. At the top I have to take refuge in the makeshift wind shelter and swap into my rain gear. It's really windy at this point and I have to stop several times on my way here and hold on to all my gear and go down to a knee not to get pushed over by the wind.
My map says I'm to decent down the north east ridge but it's too windy and dangerous. I have to turn back to the peak after about a 150m decent. Back at the shelter again, a quick break and then going back the way I came up.
The walk to the youth hostel is windy and rainy but not rough in any way and I make good time. I pitch the tent and make some food before going inside for a cup of tea and meeting up with a few other challengers.
After a cold and rainy night, I sleep in and let the morning sun dry the outside of my tent. After 10am I'm off to the Affric Kintail Way and meet many challengers along the way.
As I reach the loch I meet up and hike alongside Barbara for at least 30 minutes. Listening to stories from former crossings and received a tip or two about local waterholes in different towns. She is the oldest woman on the challenge. It's hard to believe that she's 81 years old, hiking fast and with a steady pace, she's on her 13th crossing. This makes me think that if I just take care of myself, I can hike for many years, something that felt very surreal before seeing her still going strong.
Further up the road I stop at Cougie for about an hour. I order toast with jam and a beer. A few more challengers comes in as I'm about to leave and I linger a little longer just to socialize.
When I come up at Plodda Falls where I've planned to camp for the night I see a sign "no camping allowed". Bugger… I continue up the path east of Hilton Lodge and soon find a good spot as the forest comes to an end. I pitch my tent and sit and watch the sunset and enjoy the beautiful weather.
Another rainy night and a cold morning. I start hiking around 9 and soon catch up with a few I met yesterday. The rain started to let up after 1.5 hours and the sun came out and stayed for the whole day. Not too warm, just perfect.
It's easy hiking to Fort Augustus but the hard gravel roads were painful for many hikers. I caught up with Byron on the last accent and we hike together for the last hour to Morag's Lodge. Alan, a hiker that I met on the first evening at the youth hostel is already there.
We dry out our gear in the sun on the lawn outside the lodge before going down to Londis to resupply. When I come back I get word about free sandwiches. Apparently a group tour that should have stopped by never made it and they'd ordered sandwiches. Yummy! I down two of them and they're accompanied by a couple of ale.
I got up in good time before breakfast at 07:30. Continental breakfast, ish. Porridge and toast with beans for me. I'm off around 8:45 and headed down towards the canal. The sun is up and it's quite warm. I don't know what I was thinking but seeing the town and probably suffering from sunstroke I take a wrong turn and ended up on a sightseeing tour of the canal before I got back on track. A few kilometers extra just an hour into the day, a good start! I pass the church burial yard exiting Fort Augustus and got on General Wades road through the Corrieyairack Pass. I decided to take an older path up the hill and after tree trunk climbing and some uphill heather bashing, I met up with Paul that just came down the top on the 'main road'.
We hike together to Blackburn Bothy where he stopped for tea. Just as we came up on the bothy a man comes out on the trail in front of me, sporting a Üla pack and Altras. I take up the chase and soon catch up to him. His name is Stefan and he's also a first timer on the TGO.
We have a similar pace and we hike together and stop at Garva Bridge where we setup camp. A few others come in to the campsite a little later, Brian, Alan and Rory. About one hour later a guy crosses the bridge. He comes up to me and shakes my hand "I read your blog!" he says with a big smile. His name Itai and lives France.
It was a good evening with laughter and chatting until after the sun set.
In the morning me, Stefan and Rory sets off together. We have the same route for the day and apparently even some parts of the next days.
We walk into the Laggan Stores Coffee Bothy and stay for a while with a few other challengers. Then we're on our way to Newtonmore.
We reach Ali and Sue's, organizers, at 3pm and I book a room at the hostel and pick up my maps that I had sent there before hand. I even meet up with a fellow Swede. Stefan has got a reservation at another place and Rory talks me into going to a bothy to shorten our next day. So I cancel my reservation. We're not leaving just yet, not before picking up some food at the grocery store and having a meal at the pub.
We get to the bothy and it's completely empty. I get a fire going and we stay up till half past 10, chatting in the warmth of the fire.
I wake up as Rory starts shifting around in his sleeping bag. I look at the window to my right and it's completely fogged up, condensation running down one side of it as the sun hits the window. It's damp and a little chilly.
Last night we decided that we wanted to get an early start to make up some miles before the sun gets up. The weather forecast says warm sunny days until the weekend when the temperature will drop. Going down from about 20C to 10C.
It's 5am and we have a quick breakfast and start hiking toward Tormie Bridge up by Kingussie. We part ways a little further up the road as he's off to Aviemore and through the Lairig Ghru while I'm going to the Glen Feshie stopping at the Glen Shiel Bothy.
I arrive at the bothy just before 10am. I'm greeted by a lovely family that's currently taking care of the last bits and pieces of the restorations. I get a cup of tea and have lunch with them. The bothy is really a five star one.
Stefan walks in the door about an hour and a half later. He started from Kingussie this morning. We stay for a while and I've decided to tag along with him towards White Bridge where he'll camp. My day is actually done, my planning says that I should camp here at the bothy, but my body feels good so I thought I might as well do two days in one.
We push on and get to White Bridge but we don't like the camping spots that it offers, hard packed ground and sheep. We decide to go a little further and we find a really good spot just outside Glen of Dee.
It's been a long day and we're both tired, about 48km today.
The tents come up fast and we go to get some water. Dinner is getting ready but mine isn't too tasty as I've managed to burn some of my instant soup… Black flakes floats around in my pot… Good job! I guess it works as a type of odd seasoning. I'm to hungry to care so I eat it anyway.
The night was cold. The grass was covered in frost in the morning, so at least 0 degrees last night. We cook breakfast and Stefan sorts my feet out and kill my heel blisters.
We walk into Braemar around lunch time. Beer and burgers for both of us. I've booked myself into the youth hostel and he's got another reservation so he's off to that. I do some shopping at Co-op, 5 days worth of food, all the way to Stonehaven.
Before going to dinner I clean my socks and long sleeved hiking shirt. One could think that the green shirt has given colour to the water because it's everything else but clear. I meet up with Paul and Paul and a couple from Holland. We have drinks and food at the hotel before going to bed.
I wake up just before 8 and start to get myself ready. Paul is also up getting his backpack in order. I take my stuff and head down to The Bothy cafe for second breakfast.
Sitting there in the sun I finally decide to go up Lochnagar. For the past few days I've been thinking and quite determined to skip it. But last night during dinner they convinced me that I should do it, I'm a head of schedule, don't be lazy.
It's a bit of road walking before you get to the parking lot where the trail starts. There are plenty of people in front of me and we all come to the lodge at the same time.
There are two guys just outside the fence, Bill and George, they're putting up a sign "T.G.O. tea" and an arrow pointing at the stone houses.
Apparently I'm the first Challenger to get there this year. After about 20 minutes or so Scott walks in through the door. I've actually met Scott and we had dinner together in Newtonmore. We have a chat and then we're off. He to Jocks Road and I'm up the other side toward Lochnagar.
The climb is quite easy and with a slight breeze and the sun at my back I'm up on the plateau faster than I expected. When I reach the top there's actually cell reception and I manage to call home and give them the grand FaceTime tour of the top.
I start heading down toward the Queens estate and it's a very steep decent and my feet are really feeling it. But I just put that away because the views are just stunning. I reach the house at Loch Munich and have some snacks and air my feet on the lawn.
I make up my mind to push a little further to Shielin of Mark bothy. I go fast on the gravel road and Spittal of Glenmuick is in front of me in no time.
I start the climb toward the bothy and after some encounters with heather and peat I'm there. There are also three women from Holland here and a few hours later, three more hikers in from Aberdeen join us. I let them have the bothy so I sleep outside in my tent by the burn.
The sun woke me up around 6am. Shining straight into my tent. I pull down my buff over my eyes and manage to fall asleep. At 8 the tent is too hot, I need to get up. I start to get out of my sleeping clothes that consists of a merino t-shirt with more holes in it than I can count. An R1 fleece and my tights and shorts. On my feet I have a pair of short down booties.
I break down the tent and just before I'm to set off one of the Hollanders comes down to me and offers me a piece of banana cake that I happily accepts.
At 09:45 I start walking and set my compass almost straight east up the hills. There's a large rock or similar that I aim for. The ground isn't too wet and I make good progress. I come to the ridge and find the land rover tracks and I go left to see the Muckle Cairn.
Then I go back and down towards Glen Lee and past the stables, which is a beautiful decent down all the way to Loch Lee.
I arrive at St. Drostan's at around 1pm. The old church sits just at the outskirts of Tarfside. The two route vetters/organizers Anne and Alan has just arrived a few minutes earlier and are surprised to get a TGOer so soon after getting there. I get offered tea and toast, I also book a room for the night, shower and food!
Not too long after, Roger Smith and his wife arrives. It's nice to meet the one who you've corresponded with via e-mail to get the most out of my planned route. I get to ask Roger about my planned descent down Ben Attow as I believe I miss understood his directions and he says that what I tried to do is quite hard even in good weather and that he meant that I should have followed the ridge all the way toward the youth hostel just as I suspected, in hindsight.
Paul arrives after a few hours. We have dinner around the big table in the kitchen, two challengers and six vetters. After dinner Scott shows up and he's had a rough day via Mount Keen. Heather and peat bog sums his day up pretty well. He also decides to stay the night at the church.
When dinner is over Roger Smith and Alan goes through the list of retirements from the challenge. Number after number, sheet after sheet. You really start to notice it's not all that easy.
– We've got one AWOL.
The whole room shuts down. Everyone is quiet.
The vetters look at each other, they can't do anything about it, it's just facts.
Conversations are on the topic about routes and how this can happen and the mood is definitely changed. They're expecting an update later tonight about the rest of the list. Challenge Control is currently busy handling the situation.
My alarm rings at seven and I drowsily walk to the kitchen. Breakfast. I meet Scott in the hallway and when I get to the kitchen Paul is already there. I have tea and toast.
Paul leaves first. He has to finish in St. Cyrus today, a pretty tough road walk for him. Scott and I have the same route over the hills and Mount Battock so we leave about 30 minutes after Paul.
We start the climb and it's a nice morning with overcast and the sun shines through in the distance. The climb up Craig Soales is steep and the wind is picking up. We get to the top and stop to enjoy the views and take some photos.
It's getting cold when we stand still as we're both in shorts and base layer shirts. When we start the accent up Mount Battock the wind is really picking up and we guesstimate 45mph or there about. After another kilometer Scott stops and asks if we're to put on our wind trousers and I agree. Smart move!
We continue up toward Mount Battock and at this point the wind hits us sideways and I have to lean into the wind not to loose my footing. As we reach the top we both hurry into the wind shelter and sit down. Sitting on the small bench everything is very quiet compare to the howling wind that hits the stone walls. Scott offers me some homemade trail mix and I happily accepts. Going down the wind is at our backs and it's quite easygoing but you really need to hold on to your trekking poles because the wind is eager to steal them from us.
When we arrive at Charr Bothy, which is where Scott is staying for the night we have some snacks and a cup of coffee. I'm to continue on into the Fetteresso Forest to setup for a short 19km (actually 27km) walk into Stonhaven and Dunnottar Castle tomorrow. He's looking at almost a 40km day so after some contemplating on his part he decides to tag along. I got a nice tip from Anne, one the vetters, last night about a good camping spot and that's what I've drawn fresh lines on my map towards.
After a nice walk through forests and up Cairn Kerloch past the wind farms, we end up at a sort of meadow. Not to many spots to pitch at but we manage to find two good ones. We both start to boil water and enjoy an evening meal by the burn and stay up chatting till 8pm.
The night had been calm and warm. I guess being camped in the Fetteresso Forest the trees help to retain the heat. I slept really good, the sound of the wind turbines in the distance wasn't as disturbing as I first found them. Rather soothing actually.
When I get out of my tent Scott was already sitting outside enjoying the morning sun, scribbling something into a book. I eat a few breakfast bars while I break down the tent. We filter some water and then we were back on the trail. The forest was still and the sun trickling through the tight knitted canopy and the birds receipted a well known tune.
The forest is littered with small tracks and bigger logging roads. Unfortunately we're soon on to the latter. As we're about to exit the forest and onto the tarmac a cuckoo said goodbye. There's always a cuckoo close to camp for whatever reason.
We have a quick stop, coffee break, just before hitting the road and mixing with the vehicle on it. Not too long after we have our eyes on Stonehaven in the distance and I say that it looks like there's smoke coming out from the forest. When we get closer it's quite obvious that it's not a fire but rather a pretty dense fog rolling in from the North Sea.
When we get closer to Dunnottar Castle it's soaked in the fog and visibility is poor. The temperature has also plummeted. Previously it was a really warm day. There's a lot of people here, feels really busy compared to the hills.
– So this is what it feels like?
He responds with something like "aye". I think he's just as empty as me. It's low tide and we go out on the sharp rocks covered in seaweed and kelp. Scott takes off his boots and socks and puts his feet in and I take his picture.
– I think so, he says with a grin on his face.
I put my hand in just to be sure and we start walking back up to beach and follow the coast into Stonehaven.
My route that was logged from my Spot Gen 3 tracker. There are more tracker points but this was the only way I could export it. The map/track functionality on their web is not the best in the world. Their iOS app is better but then you can't get an image you can actually zoom in on and showcase it as one.
I saw this just as I came home and much of what's in it could also be what I experienced during the challenge. You should watch it too, it starts at 1:04.


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text:
Welcome to your Red Folder
Firm Strategy
Portfolio Value Creation
Sector Strategy
Advanced Retail Buying
Omnichannel Strategy
Public Sector & Government
Telco Digital Transformation
The future of healthcare--there's an app for that
New technologies are transforming healthcare, promising better data, lower costs and higher quality for all.
By Chuck Farkas and Tim van Biesen
It's 3 AM. Alan awakes from a deep sleep and sits upright in his bed. Since his heart attack and surgery the year before, he has been hyperaware of changes in his heart rate, and he is feeling discomfort in his chest. Alan attaches to his smartphone a digital tool that his payer, CareCo, gave him after his discharge. The Smartheart device produces an ECG in a few seconds and uploads it to an on-call nurse at CareCo.1 Understanding that it is the middle of the night, she sends a text message to Alan's phone. "Alan, I see you have sent me an ECG reading. Are you ok?" Alan texts back, "I'm not sure. I am feeling heaviness in my chest." The nurse monitors Alan's vitals for a few minutes and asks him a few questions. She sees that the ECG is normal but suggests that she set up an appointment with Alan's internist, Dr. Lisa Hodgkins, for the next day. The nurse uses the ZocDoc app to set up the appointment and lets Alan know about the timing.2 She also advises Alan to wear his IneedMD, an at-home monitoring device that will send readings to her every half hour for the remainder of the night.3
In the morning, using videoconferencing on his laptop, Alan talks to Dr. Hodgkins, who conferences in a cardiologist in another office. Based on the ECGs Alan has been sending them for a few weeks and the database on patients like Alan, the doctors confidently adjust his medication to a lower-cost but equally effective generic drug. Dr. Hodgkins uses her tablet to send the prescription to Alan's pharmacy. Within an hour, Alan has a new prescription with a "GlowCap," which will send him a message on his smartphone or sound an alarm if he fails to take his medication at the right time. It also alerts his physician via a report if he misses any doses.4 Because of this digital technology, Alan avoids an ER visit in the middle of the night and a long stressful drive to his physician the next day.
This is not a true story, but it is also not science fiction. All of these digital tools are either available right now or will be soon—SHL Telemedicine's Smartheart device, the IneedMD monitoring glove, the videoconferencing tool, the physician's tablet, the ZocDoc tool for online scheduling, the electronic health record (EHR) and the GlowCap. Because of the proliferation of digital tools flooding the marketplace, it is easy to conclude that the digital revolution in healthcare has taken off and is gaining altitude. The promise of these tools is that their prudent use can help flatten healthcare spending and potentially even hold it at 18% of GDP by 2020. But that will not happen without considerable effort, expense and commitment (see Figure 1).
All stakeholders have something to gain—and lose— by embracing digital technology. If we assume that digital tools can be a disruption to traditional practice, it is not a big leap to conclude that such technology has the potential to change the setting of where and how care is delivered, how data will be collected and used, how care may be managed against well-defined standards of care, how drugs and devices will be evaluated by payers, and how patients themselves may use the new integrated information to choose providers and treatments. The advent of digital health can provide the information and connectivity to enable all those stakeholders to address these challenges in a more creative way.
In the next decade, digital health will facilitate three fundamental shifts in healthcare: bending the cost curve, increasing the speed and value of innovation, and enhancing outcomes and quality of care. Much like the digital transformation of the financial services industry decades ago, there will be winners and losers in the new digital age. Some companies will catch the wave soon enough to reap significant savings; others will wait and be left behind. Even without being an early adopter, you can take action now to ensure that you not only survive but thrive (see Figure 2).
Bending the cost curve
Let's start with a hypothetical payer, CareCo, that sees the wave of innovation and does not want to be left behind. The company has conducted a digital health diagnostic to determine its priorities and benchmark itself against its competitors. CareCo realizes that digital technology can fundamentally change the delivery of healthcare and focuses on four major opportunities to increase the efficiency of its integrated payer business:
Improving its administrative efficiency (potential savings of ~$200 per member per year, or PMPY)
Managing high-cost patients more effectively (~$700 PMPY)
Linking patients to high-quality providers (~$1400 PMPY)
Matching patients to optimal sites of care (~$200 PMPY)
Improving administrative efficiency
CareCo already uses a variety of tools to reduce administrative costs: Automatic scheduling allows patients to schedule appointments via email or online, kiosks streamline on-site patient check-ins and e-billing facilitates online claims filing and bill pay. Patients can view their tests and email their physician via an online portal. Staff who previously spent time on back-office filing are free to work on direct patient care. CareCo provides incentives for its extensive provider network to use electronic health and electronic medical records (EHR and EMR). A recent study showed that while only 25% of physicians are "on target" to meet the federal standards for using these records, 66% of the survey respondents use some form of EHR system to manage clinical information.5
In addition, the data-rich environment enables CareCo to better understand outcomes and identify subsets of patients that respond to specific therapies. This information creates value not only for the payer, but also for manufacturers designing new drugs and products for specific populations.
We estimate that digital health technologies like these can reduce administrative costs by up to 10%, for an overall reduction in PMPY costs of $200.6
Managing high-cost patients more effectively
Patients like Alan, who start out with an acute-care episode like a heart attack, become chronic-care patients as they manage their disease over time. Analysts estimate that 1% of patients drive 30% of healthcare costs.7 For this reason alone, CareCo has provided Alan and his physician with a variety of tools to maintain his health and keep him out of the hospital. And even simpler device-free tools have allowed integrated systems, like the Henry Ford Health System in Detroit, to reduce expected hospital readmissions for heart failure patients by 36%.8 Henry Ford uses Tel-Assurance, a care coordination tool that can be either phone- or Web-based, which has been readily accepted by its diverse patient population. These high-cost patients become extremely attractive targets for the kinds of monitoring tools that medical technology and pharmaceutical companies have started to introduce, and they create an opportunity for suppliers to go beyond a specific pill or device and create a more comprehensive approach to treatment.
Digital health can also help providers and payers identify high-risk patients who have not yet experienced an acute-care episode by using predictive modeling9 and data from patients' EHR to pinpoint those who need extra reminders to take their medication, and engaging them in ways to monitor their own progress and health.
Implementing digital health to manage high-cost patients can generate PMPY savings of approximately $700 or around 7%.10
Linking patients to high-quality providers
We know that physicians and hospitals differ dramatically in their quality and cost, and the highest-cost providers are not always the highest quality.11 Even the most basic of procedures can vary dramatically in cost. The state of Maine publishes the average cost of 30 common medical procedures online. Data show that Anthem Blue Cross Blue Shield HMO members can pay anywhere from $537 to $3,151 for a colonoscopy, depending on whether the procedure is done in a doctor's office, a freestanding surgicenter or an outpatient surgery unit attached to an acute-care hospital.12 One of the reasons for the variation in price is the lack of transparent and accessible information for patients or employers about these variations. But price variation also reflects a widely held but erroneous belief that hospitals always provide a higher quality of care for even the most basic procedures. As digital technology begins to standardize care and technology in all settings of care, and as long as quality is equivalent, the price of care will drive utilization to the lower-cost settings.
CareCo shares data on quality with all its network physicians via the clinical decision support (CDS) systems, which it has distributed to standardize care based on evidence-based protocols. At Virginia Mason Medical Center in Seattle, for example, the implementation of robust CDS systems has decreased the use of advanced imaging by nearly a quarter without compromising outcomes.13 And CDS systems can reduce adverse drug events from drug interactions by 50%.14
Increased scrutiny of the effectiveness of expensive procedures will also create an opportunity for medical technology companies. In an environment where "smarter" devices can transmit every heartbeat from a patient's remote device to a central place for monitoring and evaluation, the availability of more accurate, real-time data will enable providers to deliver better quality care. On the other hand, the same real-time data may cause providers and institutions to evaluate the effectiveness of a procedure or device more rigorously than before. For example, knee arthroscopy is one of the top 10 outpatient procedures today, with more than 650,000 surgeries performed every year. Recent studies show that by applying CDS systems and other tools, up to 44% of those surgeries could be deemed unnecessary.15 In a price-competitive environment, medical technology companies face a significant challenge to differentiate their products in a number of ways. One option is to create "appropriate use" guidelines that enable surgeons to justify the use of the device and the company to hold price, while affirming the importance of evidence-based decision making. The burden of proof will remain with the manufacturer to demonstrate value and benefit.
Implementing digital health to link patients to low-cost, high-quality providers and eliminate unnecessary procedures can generate PMPY savings of approximately $1,400 or about 15%.16
Matching patients to optimal sites of care. Digital health initiatives will help to funnel patients to the most appropriate, cost-effective sites of care, reducing both hospital costs and in-office physician appointment costs.
Avoided hospital visits will generate the largest savings. We estimate that around 20% of total ER visits are for conditions that could be treated at a doctor's office or walk-in retail clinic at a fraction of the cost of the emergency room, for annual PMPY savings of about $100.17 Many such complications could have been avoided had the patient's vital signs been continuously monitored while the patient was recovering at home. In cases like Alan's, the value of remote monitoring tools that track a patient's vitals can be worth about $40 in PMPY savings.18
In the primary care setting, we estimate PMPY savings of approximately $30 by replacing routine in-office visits with video chat and instant messaging.19 A pharmaceutical company developed an iPhone application that can test a patient's vision and send a picture of the patient's eye to the doctor to check for signs of infection.20 This saves both the patient and the doctor time and enables patients who use drugs that require monitoring to be examined remotely. Tools like this engage patients in the management of their own care and make it easier for doctors to track and monitor the progress of each patient, demonstrating their value and encouraging patient compliance.
CareCo's digital health journey does not happen overnight, but the reward is substantial: By aggressively implementing digital health and using it to drive care coordination and cost savings, CareCo reduces PMPY costs by some $2,500, for overall savings of 25% compared with companies that have no digital health initiatives in place.
Bending the cost curve is only one of the transformational changes that will come from the digital revolution. Digital technology can also allow manufacturers, payers and providers to deliver on their promise to increase the speed and quality of their research.
Increasing the speed and value of innovation
Of the many challenges facing manufacturers, the most significant are the cost and pace of innovation. A recent Forbes article suggests that the cost of an average drug developed by a major pharmaceutical company is not around $1 billion as usually cited, but closer to $4 billion and can be as high as $11 billion.21 At a time when the pressure to innovate is high, the new digital world offers manufacturers a variety of opportunities to conduct research and development in a different way. Processes such as "crowdsourcing," where a company reaches out to new and broader communities for ideas for solutions, can speed up and enhance the research process. Eli Lilly was one of the first to use crowdsourcing via the Web to broaden its research reach,22 and Harvard Medical School has used InnoCentive's crowd-sourcing capability to solve scientific problems around Type 1 diabetes.23 Collaborative data sharing, such as Sage Bionetworks, which is creating large repositories of data for research purposes, is another way to accelerate the pace of innovation.24 The digital revolution is already creating better data to drive more evidence-based decision making on the front end of innovation.
Imagine a global pharmaceutical company called PharmaCo that is focusing on next-generation drugs for heart disease. The company is running a Phase III trial for a new drug for heart disease and decides digital tools can improve the process. PharmaCo uses a well-defined screen to recruit Dr. Johnson as an investigator through Sermo.25 He begins the search for subjects by posting a message describing the trial on a specially designated area of the healthcare social network PatientsLikeMe.26 His assistant scans profiles on the website to identify especially promising potential subjects and sends them individual messages describing the new study. The company next contacts the payer, CareCo, to mine its database and reach out to Dr. Hodgkins and Alan, her patient. Web-based recruitment can result in a nearly two-thirds reduction in recruitment time compared with traditional office-based methods and can allow the drug company to save 60% of marketing spending.27 Within two to three months, the company has filled the trial and is ready to begin treatment.
Once the trial is under way, Dr. Johnson receives daily reports on the trial's progress, compiled and sent to him by a virtual clinical research associate (CRA)—a customized computer program that parses and prioritizes data from patients' self-reports and costs a fraction of a traditional CRA. It utilizes real-time patient feedback and analyzes adverse events and patient dropouts. It also identifies subjects who are higher risks for either and alerts Dr. Johnson to these cases so that he can intervene where appropriate. As a result, he reduces the dropout rate by 30% so that more than 80% of all subjects complete the trial.28
Dr. Johnson keeps in close touch with Alan's physician, Dr. Hodgkins, who in turn keeps Alan informed about all aspects of the trial, without either of them having to travel to the site. Alan's data are integrated with the data of the other patients, and the trial proceeds swiftly and smoothly. Fully integrated, the digital tools can shorten trial timelines by a third and reduce costs by nearly 15%.
These tools also are an asset for in-line products, creating more accurate outcomes data through real-time monitoring, better patient satisfaction through new forms of patient engagement and gaming that drive adherence, and new methods to integrate sites of care for patients with chronic disease. The companies that are first to introduce these tools will have a distinct competitive advantage.
Enhancing outcomes and quality of care
Beyond reducing costs and increasing the speed of innovative products to market, digital technology can improve outcomes and quality of care for patients in a number of significant ways. "Patient engagement" as a term of art is both overused and underutilized, but there is little doubt that providing a patient with high-quality care is enhanced by the adoption of new digital tools by the patient, as well as the suppliers, payers and providers who serve them.
For Alan, rapid treatment of his heart symptoms improves his quality of life by reducing the need for an unnecessary ER visit. The daily burden of managing his complex health regimen will be eased by digital health tools that can automate many of the tasks—such as recording his heart rate on a minute-by-minute basis or tracking his prescription adherence—activities that he would either have to do manually or not at all. Adherence is a key to good outcomes, and simple medication reminders have been shown to increase adherence to medications from 50% up to 96%.29
When acute episodes do occur, digital health can enable better outcomes through higher-quality treatment. Armed with real-time data analysis from remote monitoring tools, health professionals can respond to acute events rapidly, which improves outcomes. Every 30-minute decrease in time-to-treatment reduces mortality risk by 7.5%.30
Decreases in mortality and reductions in adverse drug events and surgical complications are all possible with more engaged patients, better information and providers who willingly embrace digital technology (see Figure 3). But as we noted in the introduction, there are real barriers to adoption that we cannot ignore.
Barriers to adoption—they are real and they are daunting
The adoption of new and exciting digital tools in healthcare must be accompanied by a sober and practical assessment of the barriers to adoption. There are three basic types of barriers: participant adoption barriers, organizational barriers, and policy and regulatory barriers.
As a sector, healthcare does not have a track record of proactively adopting new technology, and in fact, has low levels of investment in IT compared with other data-driven industries such as financial services.
Concerns over the cost of IT systems and the need to secure extremely sensitive patient health data partially explain these low levels of investment. However, new technologies are becoming both less expensive and more secure than legacy IT. For example, Bain analysis suggests that by 2014, cloud technology will have reduced costs by 30% to 40% compared with legacy IT.31 And security concerns may fade as highly secure cloud-based systems are developed and tested, as is currently happening in other sensitive industries.
We believe there will be two waves of adoption of digital health by providers. The first wave has already begun. Some providers are already using mobile technologies such as tablets and smartphones. In fact, in 2012, penetration of smartphones is estimated at 81% among physicians vs. only 48% in the general population.32 The availability of broadband and the integration of tablets into many medical schools' curricula will only accelerate. These tools require little up-front investment and are easy to use.
The second wave of adoption will require substantial external incentives. The early adopter effects are greater here, as these systems require substantial investment and interoperability to achieve their full potential. For example, EHR adoption was low before billions of dollars in federal stimulus funding and the prospect of reimbursement penalties created significant financial incentives for adoption.33
In the short term, the healthcare industry is likely to adopt only the "quick wins"—the easy-to-use, convenient technologies that do not require significant business model changes—and thus they will realize only 20% of the total potential value of digital health. In order to capture the remaining 80% of digital health's potential value, companies will need to implement some quick wins and then use the incremental margins to increase IT spending by up to 5% of revenue (see Figure 4).
Organizational barriers will also pose challenges. Virtually every healthcare company is doing something related to digital technology, e.g., establishing a website, providing customers with information online, providing opportunities for online ordering and scheduling or social networking. These efforts are likely to be scattered across the organization, with each department or product team squeezing out a nod to digital technology from a piece of the marketing budget. The digital approach becomes fragmented and underpowered and fails to capture the full potential of a more integrated approach. What each organization needs is a more centralized approach, one that has its own budget, is separate from the IT department, is coordinated across the organization and has senior executive endorsement.
The remaining barriers to adoption relate to public policy about reimbursement and regulation and are much more difficult for an individual company to address and resolve.
The two largest areas of digital health value creation— reduced acute episodes through care coordination for patients with chronic conditions and matching patients with low-cost, high-quality providers—may require more significant reimbursement reform to be widely adopted.
Care coordination may require a more rapid implementation of bundled payments that reward providers for investing in the primary care of chronic-care patients to avoid acute episodes. While this type of payment is one of the elements of health reform, it is not yet widespread and may take a decade to fully implement.
Matching patients with low-cost, high-quality providers will depend on comparable quality data and will require increased competitive pressure before payers willingly make changes to their networks, policies and product design. Change will not come without integrated and more accessible data about provider performance—data that are not easily available today.
Finally, regulatory barriers continue to loom large in the minds of payers and providers considering these new technologies. However, as the need to slow the growth of healthcare costs becomes more and more critical, we believe that regulators will clear the regulatory roadblocks and approve technologies that can help to bend the cost curve. While the security and privacy of patient data will remain of paramount concern to patients, we believe that regulators will continue to provide more clarity in regards to HIPAA34 privacy and security regulations and will show more flexibility on legislative issues such as "standing authorization" to enable data to be shared when it can improve a patient's care.
Who will be the winners and losers in the digital transformation? (See Figure 5)
There are early signs that many patients rapidly adopt the new digital tools when they are available. Patients may not realize the extent to which the quality of care differs from provider to provider, but the digital revolution will certainly speed up their access to integrated data, quality providers, more tools to manage their own health and communities to help them manage their disease state through gaming, social media or other innovative forms of engagement. How quickly will these new tools become commonplace? How will it effect the way patients take responsibility for their health?
Physicians and other providers
If digital health can reduce the time physicians and other providers spend on administrative tasks, they will be clear winners. Easy access to one another's expertise and patient information can elevate the practice of medicine from an art to more of a science—and even make it more fun for the practitioners. The new standardization will, however, cause a certain loss of autonomy for physicians. As physicians aggregate into larger practices, they will lose some of their professional decision- making power over individual treatment decisions.
Will the benefits of greater access to patients and more information outweigh the loss of autonomy?
Brick-and-mortar providers
In almost every scenario, the use of evidence facilitated by digital technology will reduce the need for hospital beds and put pressure on community hospitals and academic medical centers (AMCs) to do more with less. Hospitals will experience tremendous competitive pressure to adopt the latest health information technology (HIT), and the cost of HIT will only drive down their already small margins. We believe AMCs will be at an initial advantage, with greater margins to invest in those new technologies. But as community hospitals catch up, digital health will begin to level the playing field between the state-of-the-art facilities at AMCs and the community hospitals through adoption of standards of care. Will digital health accelerate the ability of community hospitals to capitalize on their low-cost position to gain share?
The line between payer and provider is becoming increasingly blurred. In light of market trends, payers will have to fundamentally shift their business model, and digital health will be a critical component of getting there. Will payers play a small role and cede much of care management to providers? Or in a future that requires IT infrastructure to enable treatment, are payers in the best position to become the IT provider that powers the whole system? Will payers maintain their transactional role? Or can they play a broader role in care management?
The digital revolution has the potential to turn the world upside down for pharmaceutical companies. With easier access to data, all products will be reviewed more carefully and thoroughly by public and private payers. In the past, data about patients came mainly from clinical trials. With the advent of tools that can transmit individual patient data quickly and accurately, the challenge will be to speed the process of research and development so that these companies can create better drugs on a faster timeline. When companies do create a better product, digital technology will enable a more rapid commercialization of the product. But success for pharmaceutical companies will depend on their ability to demonstrate real clinical as well as economic benefit to those who are paying the bill. Can pharmaceutical companies get ahead of the curve of digital adoption and maintain a seat at the table?
Medical device companies
The adoption of digital health will be an opportunity and serious challenge for the medical device industry as well. To the extent that the digital revolution speeds the creation of smarter devices that provide real clinical and economic benefit, there will be many business opportunities—better tools for patient monitoring and tools to keep patients out of hospitals and emergency rooms. However, like pharmaceutical companies, medical device companies will have even more pressure to prove the value of their products because the data will tell payers if a product is worth it. Medical device companies will have to create more compelling outcomes-based research, as well as lower costs to maintain sales in an environment in which procedure volume is likely to decline. There will be advantages in inventory tracking and reduction in salesforce through digital tools, as well as better access to information for patients and providers. But overall, digital health will likely begin a move toward standardization, not differentiation, of devices. More and more decision making is already shifting to institutional procurement and away from the prior decision makers—physicians. How can medical device companies use digital health to continue to differentiate their products and compete in the new digital arena?
Is it all worth it?
Healthcare is at a tipping point, and part of the transformation of healthcare will be digital health. Like the financial services industry, these new tools will provide better access, quality and innovation at a lower cost of service. Once these tools are in place, customers will demand them. Can you imagine choosing a bank without automated tellers or the ability to monitor and pay your bills online? Investing in these technologies is compelling, regardless of your sector, and we believe those who take advantage of these tools will be the biggest winners.
Chuck Farkas is a partner with Bain & Company and a leader in the firm's Healthcare practice. Tim van Biesen is a partner with Bain & Company and leads Bain's Healthcare practice in the Americas. This report was prepared by Chuck Farkas, Tim Van Biesen and Sonali Madia Patel. The authors would like to thank Reynold Strossen, Trae Wallace, Kristin Heintz and Erin Yu for their research.
How IT transformed banking
Beginning with the introduction of the ATM in 1967, financial services companies have invested in transformative IT systems, which have revolutionized the industry's cost structure, products and consumer experience. IT has drastically reduced costs, from $4.00 per interaction conducted in person in a branch to $0.08 per interaction through a smartphone app. IT has also enabled innovation, such as the E*TRADE Internet trading platforms; consumer engagement, as seen with the success of www.mint.com's financial management tools; and quality, observed through the real-time availability of accurate information on financial markets worldwide.
To fund these investments, the financial services industry significantly increased its spending on IT. In the early 1990s, before the Internet revolution, financial services spent roughly 3% of revenue on IT, according to a Gartner report. In the mid-1990s, as the industry invested in the first generation of Internet systems, its IT spending increased to 10% of revenue. By 2000, spending had stabilized at a "maintenance" level of roughly 6% to 8% of revenue. Healthcare spends only 3% of revenue on IT today, and to achieve the same gains in cost reduction, innovation, consumer engagement and quality as financial services, it may need to increase spending to a similar degree.
A day in the life of the...
Digital health won't just transform the back office. It will change the daily lives of people throughout the healthcare system—from doctors, nurses and clinical investigators to patients, including both the seriously ill and the very healthy.
To hear Bain & Company partners discuss how digital health will transform the day in the life of each of these stakeholders, go to: www.bain.com/digitalhealth
A host of digital technologies, many of them tablet based and Internet enabled, will make doctor-patient interactions more efficient and aid doctors with surgical preparation, pharma details and even their own continuing medical education.
Operating room nurse
From setting up for surgery to tracking equipment and approving medical devices, surgical ward nurses can rely on many new technologies to reduce costs and improve patient care.
Community health worker
The emerging markets healthcare sector is a natural fit for mobile platforms, as large mobile usage and high smartphone penetration promise to bring better quality care to poor and remote areas.
Clinical investigator
Technology can improve drug trial participation rates, monitor compliance and reduce costly drop-outs, while speeding regulatory decisions and new trial launches.
Acute care patient
Digital health technologies can detect emergencies, transmit data from patients on their way to the emergency room, minimize costly transfers and allow patients to be discharged earlier by monitoring them remotely for post-treatment complications.
Chronic care patient
Remote monitoring, social media and even gaming can improve medication adherence and speed intervention for patients with conditions that can quickly become dangerous and expensive if not controlled.
Healthy patient
Digital health isn't only for the sick. Exercise monitors, calorie trackers, fitness-oriented social networks and other digital technologies can help the healthy stay that way.
1 Brian Dolan, "FDA clears Smartheart mobile ECG device," MobiHealthNews, April 17, 2012, accessed April 19, 2012, http://mobihealthnews.com/17031/fda-clears-smartheart-mobile-ecg-device/.
2 ZocDoc is an online scheduling tool. Accessed March 28, 2012, http://www.zocdoc.com/.
3 IneedMD is a glove that sends ECG information to a physician or remote location, accessed March 28, 2012, http://medgadget.com/2010/09/self_administered_12_lead_ecg_glove_for_athome_monitoring.html.
4 "How GlowCaps work," accessed March 28, 2012, http://www.vitality.net/glowcaps_howglowcapswork.html.
5 California HealthCare Foundation, "Study finds physicians slow to transition to electronic records," iHealthBeat, February 22, 2012, accessed March 28, 2012, http://www.ihealthbeat.org/articles/2012/2/22/study-finds-physicians-slow-to-transition-to-electronic-records.aspx#.
6 Interview with Darshan Mahajan, president of the State Medical Board of Ohio, December 2011; Bain analysis.
7 Peter Crooks, "Managing High-Risk, High-Cost Patients: The Southern California Kaiser Permanente Experience in the Medicare ESRD Demonstration Project," The Permanente Journal, Kaiser Permanente, Spring 2005/Vol. 9, No. 2, accessed April 11, 2012, http://xnet.kp.org/permanentejournal/spring05/highrisk.html.
8 Bernie Monegain, "Henry Ford reduces hospital admissions with remote monitoring," Healthcare IT News, September 9, 2009, accessed March 28, 2012, http://www.healthcareitnews.com/news/henry-ford-reduces-hospital-admissions-remote-monitoring.
9 Companies like OptumHealth have developed programs such as eSync that combine "medical claims and pharmacy data, lab results, self-reported data and behavioral and segmentation information" to predict a population's medical needs and conditions before they occur and calculate the value from interventions such as increasing Rx adherence to evidence-based medicine, accessed March 28, 2012, http://www.optumhealth.com/content/attachments/110107_Value%20Driver%20White%20Paper.pdf.
10 Interview with Bain team and following sources, accessed March 28, 2012, http://www.cms.gov/reports/downloads/mccall_mgh_cmhcb_final_2010.pdf; http://xnet.kp.org/permanentejournal/spring05/highrisk.html; https://www.cms.gov/NationalHealthExpendData/downloads/proj2010.pdf.
11 David C. Goodman, Elliott S. Fisher, Chiang-Hua Chang, "Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries," The Dartmouth Institute for Health Policy and Clinical Practice, September 28, 2011, http://www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf.
12 Andrew Conte and Luis Fabregas, "Costs can vary widely for same medical procedures," Pittsburgh Tribune Review, September 25, 2011, accessed March 28, 2012, http://www.pittsburghlive.com/x/pittsburghtrib/news/s_758618.html.
13 CC Blackmore, RS Mecklenburg, GS Kaplan, "Effectiveness of clinical decision support in controlling inappropriate imaging," Journal of the American College of Radiology 8:1 (January 2011): 19–25, http://www.jacr.org/article/S1546-1440(10)00389-3/abstract, accessed March 28, 2012, http://www.ncbi.nlm.nih.gov/pubmed/21211760.
14 Bain interviews.
15 Vonda J. Sines, "Unnecessary Surgery: The Four Most Common Unwarranted Operations," accessed April 9, 2012, http://voices.yahoo.com/unnecessary-surgery-four-most-common-unwarranted-428454.html?cat=5; J. Bruce Moseley, et al., "A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee," The New England Journal of Medicine 347:2 (July 11, 2002): 81–88.
16 Bain analysis.
17 National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables, accessed April 24, 2012, http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf; Sadeq Chowdhury and Steven Maclin, "Statistical Brief #318: Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings, 2008," March 2011, accessed April 24, 2012, http://meps.ahrq.gov/mepsweb/data_files/publications/st318/stat318.pdf.
18 James E. Mansfield Jr., Dennis Callahan, "Benefits of over-the-counter heartburn medication to consumers and the healthcare system," NielsenHealth, December 7, 2008; National Ambulatory Medical Care Survey, Centers for Disease Control and Prevention's National Center for Health Statistics, 2008; www.teladoc.com.
19 Expert interview; ibid James E. Mansfield and Dennis Callahan, "Benefits of over-the-counter heartburn medication to consumers and the healthcare system," NielsenHealth, December 7, 2008, accessed April 24, 2012, http://www.chpa-info.org/media/resources/r_5333.pdf; Health Care and Business: Using new technologies to reduce costs, improve access and increase employee satisfaction, Teladoc, accessed April 24, 2012, http://www.teladoc.com/pdfs/Telehealth-Special-Report.pdf.
20 The "EyeSnapi" application was invented by Palo Alto ophthalmologist Harvey Fishman, Ph.D., http://abclocal.go.com/kgo/story?section=news/health&id=8110799.
21 Matthew Herper, "The Truly Staggering Cost of Inventing New Drugs," Forbes, February 10, 2012, accessed April 24, 2012, http://www.forbes.com/sites/matthewherper/2012/02/10/the-truly-staggering-cost-of-inventing-new-drugs/.
22 Charles Babcock, "Eli Lily Uses Web to Broaden Drug Research Reach," Crowdsourcing.com, September 14, 2011, accessed April 24, 2012, http://www.crowdsourcing.org/document/eli-lilly-uses-web-to-broaden-drug-research-reach/6615.
23 Eliot Van Buskirk, "Harvard-Based Crowdsource Project Seeks New Diabetes Answers—and Questions," Wired, February 3, 2010, accessed April 9, 2012, http://www.wired.com/epicenter/2010/02/crowdsourcing-rewires-harvard-medical-researchers-brain/.
24 Sage Bionetworks is a new medical research organization that works through partnerships with other research organizations to gather data and provide training in research methodology, accessed March 28, 2012, http://sagebase.org/info/faqs.php.
25 Sermo is an online resource for physicians to engage in discussions about clinical issues, accessed March 28, 2012, http://www.sermo.com/.
26 PatientsLikeMe is an online resource for patients to share experiences and gather data about their treatment, accessed March 28, 2012, http://www.patientslikeme.com/.
27 Patient Safety Institute and First Consulting Group, "Economic Value of an Electronic Health Information Exchange (EHIX) Network," May 2007, accessed April 9, 2012, http://www.ptsafety.org/resources/PSI_Pharma_Value_White_Paper.pdf.
28 Ibid.
29 GlowCaps presentation, accessed April 24, 2012, http://www.vitality.net/docs/pharma_presentation.pdf.
30 Giuseppe De Luca, Harry Suryapranata, Jan Paul Ottervanger and Elliott M. Antman, "Time Delay to Treatment and Mortality in Primary Angioplasty for Acute Myocardial Infarction," American Heart Association, accessed April 24, 2012, http://circ.ahajournals.org/content/109/10/1223.
31 Bain Research, "Cloud Computing POV: Complete Integrated Materials," (updated January 2012).
32 Manhattan Research, "Physicians and Mobile: Profiling Advanced Smartphone Users," 2010, 4; Mark Walsh, "Nielsen: Smartphone Penetration Reaches 48%," Online Media Daily, February 21, 2012, accessed April 9, 2012, http://www.mediapost.com/publications/article/168085/nielsen-smartphone-penetration-reaches-48.html.
33 Edward Fotsch, "Health IT and Rapid Adoption of Electronic Health Records in the US," PDR Network, April 2011, accessed April 9, 2012, http://www.gs1.org/docs/healthcare/news_events/060411/26_Fotsch_EHR.pdf.
34 HIPAA is the Health Insurance Portability and Accountability Act of 1996, accessed April 24, 2012, http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html.
Chuck Farkas
Advisory Partner, Boston
Tim van Biesen
The Cure for Pharma's Commercial Productivity Woes
To earn greater loyalty and raise productivity, figure out what really matters for doctors.
Healthcare's Evolving Payment Landscape
Value-based healthcare providers still need to persuade doctors that they offer better outcomes than fee-for-service models.
The Rise of Telemedicine and Remote Care
Physicians say technology will help them treat more patients remotely.
Digital Manufacturing Technologies Offer Pharma an Efficiency Breakthrough
Pharma leaders are piloting industry 4.0 solutions to tame complexity and cut costs.
US Healthcare Profit Pool to Rise At a Healthy Pace
Profits are forecast to grow 5% a year through 2024, with the fastest growth in medtech and healthcare IT.
Performance Improvement Trimming costs, pumping up output
Performance Improvement Turning bottlenecks into growth opportunities
Organization Creating a regional operating model in medical devices
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Infant asthma is a type of breathing problem that happens to young children all over the world. It involves inflammation of the airways of the lungs after a reaction to one of many substances.
Infant asthma can happen to any child. It is hard to know if your baby has breathing problems, since babies can't tell you how they are feeling.
As a parent, there a few signs and symptoms you can look for. This childhood problem can be treated and managed with the help of your doctor. Every situation is different just like every child is different. But the right treatment can protect your child.
In babies, infant asthma is very subtle and easily missed. Younger children typically have different and more mild symptoms than older ones.
Any allergens in your home can trigger a reaction in your child. You should take note of any breathing problems that your young one has, especially at night. Many infants develop symptoms before the one year milestone.
The key point of any respiratory disease is that an infant's lungs are still developing.
Asthma, which is a chronic breathing problem, can affect the lungs before they have a chance to function properly. If not diagnosed and treated correctly, asthma can permanently damage the delicate tissue of an infant's lungs and cause future problems.
Therefore it is essential to bring a child to the doctor as soon as any breathing problem surfaces.
Although your pediatrician will take a medical history and physical exam, he or she will greatly rely on your description of the symptoms. These signs are subtle and may not appear in the office.
Because their lungs are still developing, babies with asthma can have one or more of the classic asthma symptoms.
Your baby may also appear to have difficulty breathing or may look simply look uncomfortable. A symptom that is harder to see in infants is tightness in their chest. When lungs become filled with mucus and inflamed, it causes a feeling of not being able to breathe. This may translate into poor feeding and failure to grow.
But you have to be careful when it comes to looking at these symptoms in babies. There are different childhood diseases that cause similar symptoms to asthma. Just because your infant have one of these symptoms does not mean he or she have asthma.
For example, bronchiolitis, or inflammation of the lungs, also causes wheezing in babies. This can be mistaken for the wheezing that is frequently seen in asthma.
To be safe, you should go to the doctor if your baby has any breathing problem for no reason. Your doctor is trained in this area and can tell you if it is truly asthma.
Don't be afraid to be wrong. As a parent you are an advocate for child.
It is very important that parents are aware of this chronic respiratory illness. Although this condition may show differently in babies, there are treatment plans that can them to breathe more comfortably.
Infant asthma differ from child to child and no two asthma attacks are alike. Young children with infant asthma usually have symptoms that are not similar to older children.
Although asthma is best known to develop in children ages 5-12, infants can show signs under the age of one. While some symptoms of infant asthma are mild, others are more severe. It is important to know the difference. You should know so you can find the best treatment for your child.
Your baby may develop a cough, but not all coughs mean your infant has asthma. If your infant has a chronic cough, call your physician. A chronic cough is one that lasts around three weeks or longer. Also, if your infant constantly coughs at nighttime, it may be a concern.
A cough may indicate an infection. About 30% of children with wheezing have respiratory infection that affects breathing. Only your pediatrician can tell the difference.
This is a classic symptom. Infant with asthma tend to make a wheezing noise that sounds like a small whistle. It will be more subtle in a baby so you will have to listen carefully.
Many children under the age of six experience some type of wheezing. Since their small lungs are easily irritated, almost anything can cause the airways of the lungs to constrict. This is a condition that is easily treated with medication.
Your child may suffer with frequent chest colds. But if your child has not gotten better after taking antibiotics for a respiratory infection, return to the doctor as soon as possible. Chronic chest colds are an indication that the lungs are damaged.
Your doctor can determine if your child has asthma and need a management plan. This will treat current symptoms and prevent further attacks.
If your infant makes strange noises after playing or eating, it is a sign that something is wrong. Also, look for things like poor feeding and poor sleeping. Any abnormal behavior should be discussed with your doctor.
Infant asthma is an illness that affects many young children during their early years.
While identifying the exact cause of asthma is difficult if not impossible, it is important to realize that there are some factors that will cause certain babies to have this condition.
The number one cause for infant asthma is viral infections during childhood. Viral infections, such as bronchitis or RSV (Respiratory Syncytial Virus), can cause respiratory problems in infants and make them more susceptible to asthma.
When a viral infection is present, it causes more mucous production and swelling of the airways in the lungs. After this exposure, the lungs become more vulnerable to irritation and swelling.
If your child frequently has colds or infections, you should closely monitor how breathing is, especially at night. Infections tend to weaken the lungs and make it more sensitive to allergens.
Most experts agree that this condition is hereditary, which means an infant has a greater chance of developing asthma if his or her family member has it. Studies have shown that genetics play a role in whether or not a baby develops asthma. Therefore, parents who have asthma have a higher chance of raising a baby who has it.
But this does not mean that every person with asthma will have a child with the disease. It is a matter of chance if your child will develop it.
Smoke and chemicals are major irritants when it comes to the lungs. Environmental smoke or secondhand smoke contains harmful chemicals that can trigger asthma in babies. Since their lungs are small and not fully developed, smoke can damage the delicate lungs in infants.
Infants who live in a household with a smoker or has a mother who smokes has a greater chance of developing severe asthma symptoms. If anyone in your home smokes, then you should consider making it a smoke-free zone.
Other common triggers include mold, dust mites, and animal dander that are found throughout the typical home. Although they are impossible to completely remove, they can be contained or reduced with the right mildew and mold control products.
Proper cleaning is one of the most important weapons of asthma prevention. If you cannot completely remove these allergens, you can detox them so they do not harm your child.
An allergy, which is a disorder of the immune system, produces an overreaction to a substance that your baby smells, eats, or touches. This substance that causes an allergic reaction can also trigger an asthma attack. Therefore, it is important to monitor your baby carefully and see if there is anything that sets off a change in your baby's condition.
Eczema, hives, and swelling are indications of an allergic reaction Even if your child does not scratch, you can imagine the frustration that comes with asthma.
Some allergens such as pollen that cause allergies are also known to trigger an asthma attack. Every asthmatic is different and trigger are based upon environment and genetics. Your pediatrician can evaluate your baby to determine what is causing the attacks.
Infants who are suspected to have asthma should be closely monitored by their physicians.
Since infant asthma is subtle, it cannot be truly be diagnosed in one visit. Regular doctor visits are important because they allow your pediatrician to watch closely over the symptoms. You should also record any changes in your child's behavior.
If it is asthma, your pediatrician can prescribe medication and monitor if it is working correctly.
Certain drugs are not appropriate for infants.
There is no quick fix for infant asthma and close monitoring is part of the asthma action plan to managing it.
You may have to bring your child to the doctor's office for multiple for a physical examination. Over time your pediatrician will develop an asthma action plan to suit your child's needs.
Even though they may not be classic symptoms, there are certain signs that you can watch for in a baby with asthma.
The first signs include fussiness, lethargy, and trouble eating or sleeping.
Infants in respiratory distress tend to have heavy, loud breathing and flaring nostrils. These are signs that the baby is gasping for air.
You may also find rapid breathing and a weak cry. If the skin looks pale or grey or the fingernails turn blue, then the baby is in trouble and need immediate medical care. Call 911 or take your child to the emergency room.
Time is very important when you are dealing with breathing problems.
Parents should be alert to situations that require medical attention.
If your baby is diagnosed, you should always be prepared to go to emergency room if there is trouble. Time is essential when it comes to breathing.
Infant asthma does not have be hazardous to your child's health. If you understand treatments for infant asthma and how it can affect your child's life, you can manage even the worst symptoms.
Treatments for infant asthma do not have to be dangerous. If your child suffers from this respiratory disease, you can feel safe knowing modern medications are based on years of research studies and are considered safe for babies with asthma.
Asthma is a disease of the immune system and lungs, in which the immune system overreacts to allergens and affects the lungs. Some allergens such as pollen can start an allergic reaction and trigger an asthma attack.
It is very important that parents are aware of this chronic respiratory illness.
Although this condition may show differently in babies, there are treatment plans that can them to breathe more comfortably.
The first step to treatment is a proper diagnosis. To treat this illness, your health care provider will need to correctly diagnose it. Identifying this illness is difficult because the symptoms are subtle and your baby cannot verbalize what is wrong.
Every asthmatic is different and the trigger is based on the environment and genetics. Your pediatrician can evaluate your baby to determine what is causing the attacks.
Your doctor will have to perform a physical exam and look for a family history of asthma or allergies.
Medical treatment is prescribed according to the age of the infant and the severity of the symptoms. This will help you and your baby for the long term. If you have any questions or concerns, do not hesitate to call your physician.
Treatments for infant asthma are almost the same as with older children. If your doctor prescribes medication for your child, he or she will discuss the dosage, usage, and possible side effects.
If you may be worried about side effects of some of these medications, don't be. They have been scientifically studied and are deemed safe for babies. Your child's doctor will give the lowest dosage of medication to prevent future attacks.
It is very important that you give medication to your baby when you first see an asthma attack. This will prevent an emergency situation.
If your child has moderate to severe asthma, your doctor may prescribe nebulizers that serve as treatments at home. Medications are given in a liquid form or in a nebulizer treatment. They come in smaller doses and are well tolerated.
A nebulizer treatment is given by a machine that creates a fine mist of medication that usually comes out of a mask. The mask is fitted over the nose and mouth of the infant.
When it comes to babies, nebulizers are very flexible.
Since babies can't hold a mouthpiece, you can use a face mask to send a mist of medication over the face. If you and your baby have a busy schedule, treatments can be given in many different ways. It can be done while your baby is sleeping or playing in the car seat.
Nebulizer treatments usually do not take a long time to complete and relief is usually immediate.
If you want quick relief from infant asthma, then PARI Baby Nebulizer is for your family. This aerosol delivery system is designed specifically for the low inspiratory flow rates of babies and young children. The PARI BABY also adapts to the needs of the patient by allowing treatments to be given in almost any position, such as lying down, sitting in a lap or stroller, or standing.
As a parent, the next step is to understand your options for treatments for infant asthma. You will have to develop a care plan with your doctor that you can perform on a daily basis.
After a thorough examination and diagnosis, your doctor will create a medical plan if your child has it. It will treat current symptoms and stop future attacks so that your baby can breathe comfortably.
The good news is that if your child has infant asthma, you can make adjustments to help relieve symptoms.
Use dust mite covers. Dust mites, which are tiny bugs that like to hide in linen, are known to aggravate asthma symptoms. So it is important remove them from crib bedding and mattresses. When your child sleeps close to dust mites, it is an invitation for trouble. Allergen bedding and dust mite covers can decrease your child's exposure to these troublesome pests.
Buy organic baby bedding. Don't let your baby go to sleep with pesticides and formaldehyde. Made from 100% pure Organic Crib sheets have a luxurious feel. Your baby will love em. All manufacturing and finishing for this natural bedding are achieved without chemical ingredients, dyes, or formaldehyde. So no chemicals to breathe in while sleeping. Without chemicals, there is no potential harm from toxins to your baby while sleeping.
Use cleaning supplies that are hypo-allergic and odor-free. Allergy cleaning products are designed to be allergy-free and do not contain any chemicals that are known to aggravate asthma. Infants are particularly sensitive to chemicals in the home such as cleaning solutions. Hypoallergic products remove these toxin substances and yet continue to provide a clean surface.
Place an air cleaner in your child's room. The main functions of these devices are to clear away allergens and to maintain good air quality. Air cleaners not only remove hidden allergens. They make a more comfortable environment for the whole family.
Use a humidifier to add moisture to the air and relax the lungs. Keeping the level of humidity at a low level in your home not only helps your baby to breathe but can actually eliminate some of the allergens that will bring on an attack. While too much humidity can contribute to bacterial growth, a warm humid environment can be beneficial to your child's health.
Remove carpeting and opt for hardwood flooring. Like the bed, the tuft of the carpet can harbor a great number of pollutants that can lead to an asthma attack. Carpets are a hotspot for dust mites and dust. Even if you vacuum frequently, it is impossible to completely eliminate them completely. Hardwood floors provide an alternate way to quickly remove allergens.
Keep furniture dust-free and vacuum rugs. Dust and smoke are known to trigger attacks and should be controlled as necessary. Dusting and vacuuming should be done on a regular basis to limit your child's exposure to allergens.
Use allergen-free toys for your child to play with. A baby tends to breathe in particles that are close to the face so it is important to have toys that won't set off an attack. Several cleaning products are able to attract the dust and prevent them from settling on surfaces.
Keep family pets outdoors or out of bedrooms. And use pet allergen control products that can remove the dander that can do harm to infants. While pets like to linger in the living room, bedroom, and playroom area, pet dander is a major trigger for infants. Whether it is the saliva or hair that is irritating, it is best to decrease the exposure to these elements.
Remove any signs of mold or mildew at the first sight. Currently there are several mold and mildew products that can eliminate it from your home and prevent asthma symptoms. Several types of mold are extremely dangerous to infants. But fortunately you can remove mold and mildew with special types of cleaners that resist their growth.
Choose nebulizers and kits that are meant for pediatrics. Your doctor will prescribe medications to treat asthma symptoms and to relax your child's airways and reduce swelling and constriction. The best way to administer a baby is through a pediatric nebulizer that turns it into a mist that the baby can easily breathe. The right nebulizer for an infant should allow for a face mask. This way you can give it while he or she is sleeping or sitting in a car seat.
Infant asthma can be successfully managed with the right kind of treatment plan. Once your pediatrician has diagnosed asthma for your child, you can start a safe treatment plan. By using some of the following products, you can develop an asthma action plan to control the symptoms.
Asthma is best known by certain symptoms like wheezing, coughing, and shortness of breath.
If your infant may have one of the common symptoms, it does not necessarily mean that he or she has asthma. It is always best to take your infant to the doctor if you have any questions or concerns about infant asthma.
If your child has infant asthma, the best way to prevent episodes is to avoid triggers that can bring upon attacks. The most common triggers are infections, smoke, dust, pet dander, mold, and pollen. They tend to fill the lungs with foreign particles that an infant's immune system may response to. Keep a list so that you can discuss it with your infant's doctor.
Prevention is a very essential part of asthma management. It provides a layer of protection so that your child does not have to suffer unnecessarily with asthma.
As a parent, you have the power to shield your child from allergens that can set off asthma symptoms. Although these methods seem simple, they can help your child to breathe much easier.


Bin durch Zufall, auf You Tube,zu diesem Video gestossen.
In dieser Radio Talk Show von Art Bell , a la Domian, wird live während der Sendung, in die gesperrte Zone geflogen. Hört sich ziemlich gefaked an , aber weiss da einer mehr über den Moderator und seinen Sendungen auf coasttocost.com?
In Deinem Link mag es ja ein wenig glaubwürdig klingen.
Bei A.Bell geht wohl alles ein wenig mehr in Richtung Entertainment, obwohl einiges schon interessant ist.
* J.C. Webster the Third, or "J.C." – J.C. began calling in 1996, and has since been on the air over 50 times. He features himself to be a Revival Baptist preacher, and believes Art to be "the Devil's Mouthpiece." He has continued to call George Noory and guest hosts. Although some have expressed a disbelief that someone like J.C. could exist, Art Bell and George Noory have repeated their beliefs that J.C. is real, and is neither a "put on" nor a "plant."
* One of Art Bell's Coast to Coast interviews occurred in 1997 with Mel Waters, who discussed what is known as "Mel's Hole" in rural Washington, which is said to be an infinitely deep hole featuring paranormal powers. No such hole has ever been found.
* In the mid to late 1990s, a regular caller named "Fritz" would call in and give his view on various matters.
* In the mid to late 1990s, another regular caller known only as "Charlie Liberal" used to call with his perspectives on current events.
* In April 1996, Bell received a package of what would be known as "Art's Parts". These parts were allegedly pieces of debris from the 1947 Roswell UFO crash. Extensive analysis of the metals indicated they were made of an odd Bismuth material.
* In 2000 and 2001, Bell spoke with John Titor, a self proclaimed time traveler from 2036 who made all kinds of fantastic predictions and discussed time travel.
* In February 2005, Bell received a call from a person calling himself "Oscar" proclaiming to be "the Son of Satan." Oscar had since also called George Noory, but disappeared after a June, 2007 on-air confrontation with J.C.
* One night in 1997, Art Bell received a fax from a woman named Jill who requested he clear a line for her boyfriend, whom she claimed was determined to fly a small plane into Area 51. He cleared the "Wild Card Line," took the man's call, which he broadcast on-air. Bell warned that the U.S. government would either try to force him down or shoot him down and warned, "You'd better turn around now." The caller described military jets arriving to intercept him, then taking fire from the ground before shouting "Oh baby, I think I'm going in! Prepare for anything! Whoohoo!" and the line went dead. Bell traded follow-up faxes with the woman, but never heard again from the man. Bell allows that the call may have been a hoax, but many listeners at the time believed it was genuine. Some even believe that, rather than killing the man, the personnel actually had him work for them.
* At about 11 p.m. PST, Thursday, September 11, 1997, he designated one phone line for Area 51 employees who wanted to discuss the secretive base. Several callers claimed to work at Area 51, but the bizarre highlight of the night came when a seemingly distraught and terrified man claimed to be a former Area 51 employee recently discharged for "medical" reasons. He cited malevolent extraterrestrials at Area 51 ("extra-dimensional beings" who are not "what they claim to be") and an impending disaster that the government knew would take out "major population centers." Midway through this call, Bell's program went off the air for about 30 minutes. After talking to network engineers, the official explanation was that the network satellite had "lost earth lock" or forgotten where the earth was. Network officials were baffled, and the cause remains a mystery.
o This incident formed the basis of the song "Faaip de Oiad" by the rock band Tool, which features said interview (with Art Bell's part cut out), over frantic drumming and buzzing static.
o Another song featuring this call was "They are not what they claim to be ..." by electronic artist The serenity Vortex (previously known as The Boy Flood). It was featured on the main page of Coast to Coast AM in the listers submission section. This version is more purely musical than Tool's but still has a dark edge to it.
o Yet another song featuring the call was "It's Out There and It's Gonna Get You" by experimental Texas-quartet The Paper Chase on their 2006 album Now You Are One Of Us.
o And another song "Planetary Duality I : Hideous Revelation" by the Technical Death Metal band The Faceless that uses what the caller said with fast guitars, drums, and eerie noises dubbed over the callers voice.
* A caller in 2000 named "Daniel Murray" claimed he was a Majestic Agent from Downey, CA.
o This call served as the inspiration for the alternate reality game Majestic.
* In March 2005 a man also called about disturbing events on Kwajalein and Johnston Atoll about a weapon that only targeted certain people and could leave others unhurt. He indicated he had been on both islands (that are US military only) and that these weapons had been tested in 1993. Art lost the call after another voice came on the line with a click saying "Shelton, terminate the call from A-6." Art tried to call the man back but was unsuccessful.
* "Bugs" - Aging farmer who has repeatedly told of his account of shooting and burying two Bigfoot creatures back in the 1970s in the Texas Panhandle, initially thinking they were bears. Bugs has mailed a map of the location of this "burial" to Art Bell, to be released to the public upon Bugs' death. During his first appearance in 1996, Bugs said he had taken a dozen Polaroid photos of the creatures he would be willing to send to Art. None of the alleged photos have yet been made available.
* In 2003, Chris Clements, a freelance writer with the Washington Post, called Art Bell to tell him he had evidence of a financial connection between the Bush family and the Bin Laden's. Clements went on further to tell of how his research showed that 9/11 may have been orchestrated by the Bush family and hinted at proof of a coming police state with secret prisons and the chipping of citizens. Clements promised to forward all of his information to Bell but it was reported that Clements died in a suspicious car crash in the weeks after his call.


It's good when you know the new HTML5 and use them, but there are also tags that are not supported anymore, you should avoid using them and remove them from your content when you do an update.
, instead use  in combination with
foo
.
use css to style a div or span instead of these tags.
<marquee> too got replaced by css, you can set the overflow-style option to marquee.
<acronym> is deprecated too, i guess you may use  instead.
<applet> was already deprecated in HTML4 use <object instead>.
<bgsound> is no more in HTML5, too. Use the <audio> tag instead.
<dir> also isn't available since HTML4, if you want to display a directory listing use the

 list tags.
<frame>, <noframes> and <frameset> are gone for good, but you may still use iframe or maybe in some situations you could load content via AJAX and inject it in your DOM.
<isindex> already deprecated since HTML4.
<tt> which stands for teletype text, it is used to render text using a monospaced font.