Thursday, December 31, 2015

Uncertain Health in an Insecure World – 70

“So What?”

Throughout 2015, a Microsoft Cloud ad touted the world-wide connectivity of some 450 million fanatics to Real Madrid football, positing that “It is not the device that is mobile… It is You!

So what?” is the Real question.

On the threshold of 2016, an idea remains pervasive that good health is a gift of better healthcare. In truth “It’s not the system of care that brings health… It is You!

So what?” is it that keeps humankind trapped in the era of imprecision medicine.

Despite technology triumphs and access upgrades, most patients still fly blind through a flawed healthcare system. This is partly because the experience dis-empowers patients and dis-intermediates physicians.

 “So what?” can be done to connect purported innovations with perceived needs.

Modern medicine’s current whack-a-mole approach to disease detection is wasteful. For example, the cost of false-positive mammograms performed on American women exceeds >US$4B per year!! Could this have anything to do with the huge number of imaging sites offering this basic diagnostic service?

Generalist physicians often function like epidemiologists. Their point-of-care clinical decisions can be enhanced by simply adding one or two data points. For example, public health information about the local prevalence of beta-hemolytic strep cultures and antibiotic prescribing patterns could reduce defensive medicine’s sore throat over-treatment bias, and the rise in drug resistance.

Specialist physicians frequently apply aggregated randomized clinical trial (RCT) and registry data to patient care. Unfortunately, many patients just don’t respond. Despite statistically significant data showing a cohort treatment’s benefit, averaged RCT responses are not a great predictor of individual patient responses.

So what?” can be done. Views vary…

Enter two experts.

Michael Porter and Thomas Lee have proposed a new strategy to “fix” struggling healthcare systems around the world (Harvard Business Review, October 2013). They suggest a laser-like focus on the needs of the patient, and more rational service delivery in the right locations. They warn that there are no “magic bullet” solutions to the systemic problems and entrenched forces negatively impacting healthcare value for patients.

The lack of precision in the maintenance of wellness is even more shocking.

Enter one visionary.

Leroy (Lee) Hood founded the Institute for Systems Biology in 2000, when he and others at the University of Washington became convinced that RCT’s alone could not reflect the complexity of individual disease biology. Their novel P4 paradigm – Predictive, Preventive, Personalized and Participatory – aggregates billions of human data points in the Cloud, reflecting the genomic and environmental factors characterizing illness and wellness at the organismic level.

Of note, the genetic risk of illness is not a disease state.

But if early-onset Alzheimer’s risk can be identified before the transition from organismic illness into clinical disease, an intervention to delay the onset could be very useful. For example, in early prion brain disease, arachidonic acid metabolic and calcium signaling changes in the glutamate receptor ionotropic N-methyl D-aspartate 1 (GRIN 1) protein superfamily (below) might offer interventional targets.

A new age registry study – the 100K Person Wellness Project – has been underway in Seattle Washington since 2014. So far, one hundred and seven “well pioneers” have had their genomes sequenced, and their gut microbiome, clinical, proteomic, metabolomic, and Fitbit gyroscopic little data moved to the Cloud. Up there, 107 ‘N=1’ dense data experiments have yielded >35,000 correlations designed to establish each individual’s genetic risk for sixty diseases. Resulting high- or low-risk genetic probability markers have revealed several actionable possibilities. Wellness coaching opportunities to encourage personal behavior changes were available for 70% of this cohort. For example, when hemochromatosis homozygous subjects with arthritis proactively pursued weekly blood drawing, they were restored back to normal health (i.e., wellness).

That’s “So what!” These well pioneers actually took back control of their individual health!

In order to more widely apply P4 approaches, new technologies are needed. These include 3rd generation DNA sequencing (cheaper, faster), peptide protein capture agents (for ELISA assays on micro-sized blood samples), dynamic personalized data (individualized Clouds), selected reaction monitoring (SRM) assays for targeting blood proteins (reflecting specific cellular network perturbations in lung cancer, PTSD, etc.), and single instrument multiplex diagnostics for micro RNA’s and RNA sequencing (based on existing scientific evidence).  
Some companion diagnostics are now available for home use. But patients still have to go to the doctor for treatment.

So what?”, then, is the value of all this testing… to You?

Real value lies in information collected and modeled being actionable at an individual level.

We in the Square begin 2016 full of hope, but with many unresolved “So what?” questions. 

Tuesday, December 22, 2015

Uncertain Health in an Insecure World – 69

“War is Over?”

When John Lennon and Yoko Ono released Happy Xmas (War is Over) in December 1971, the song was both inspirational, and aspirational. The Harlem Community Choir sang back up to lyrics set to the traditional English ballad, Skewball. In the pre-social media era, Lennon had learned the hard way how to do political and social advocacy. “Now I understand what you have to do – Put your message across with a little honey.

So this is Christmas (2015), and what have you done?”

And in Syria, war isn’t over.

Of the 12 million refugees displaced inside Syria or fleeing that morass, half are less than 18 years old, and 40% are children under the age of 12. Nearly 80% of these child refugees have experienced a death in the family, 60% have seen someone beaten or shot, and 30% have been kicked, shot at or physically hurt. Some 12,000 children have died since 2011. But it’s the emotional trauma that endures, with PTSD levels 10-times the prevalence among other children around the world. The resulting mental health sequelae will follow them whatever country of asylum they reach.

Many organizations and countries have done something.

Save the Children, UNHCR, UNICEF, USAID, and 30+ other governmental, non-governmental and religious agencies are all doing their level best to respond to the Syrian refugee crisis. Children “living” in makeshift camps suffer from illnesses like diarrhea and cholera, malnutrition and abuse. Many are exploited as fighters, human shields or non-combatant supporters. With another bitter winter coming to the region, for these poorly clothed children, things will only get worse.

Jesus Christ was born 10 miles south of Jerusalem, in Bethlehem, just 140 miles from Damascus.

On March 4, 1966, John Lennon casually commented to British journalist Maureen Cleave that, “We’re more popular than Jesus now.” And while the 24 year-old Beatle noted that “Jesus was all right”, he also predicted that “Christianity will go.” Unlike some blatantly unapologetic Christian U.S. politicians making ISIS fear-infused hateful statements about Muslims, John and Beatles manager Brian Epstein had to eat the proverbial carpet of apology.

Barrel bombs dropped from Syrian army helicopters kill more civilians than ISIS (above).

Fear of these airborne attacks in al-Assad opposition neighborhoods has fueled this largest human exodus since World War II. In the view of Kenneth Roth, Human Rights Watch executive director, this governmental terrorism of the Syrian population, “Is a recruitment bonanza for ISIS because the group can claim to be standing up to these atrocities.” The global community has lined up against or with the al-Assad regime. The European Union talks about addressing the mysterious “root causes” of migration to Europe, while remaining largely passive. Also seemingly impotent, the UN Security Council has repeatedly called for an end to “indiscriminant employment of weapons in populated areas… such as the use of barrel bombs.

With Russia, Iran continues to back the al-Assad regime, making these war crimes possible.

Two millennia ago, three wise men traveled from the East to worship one newborn King of the Jews. Balthasar, Melchior and Gaspar were from ancient Persia, now modern Iran. After the origination of Christianity among Jewish Aramaic-speaking Semitic peoples of Judah (Israel, Palestine and Jordan), it quickly spread through modern day Syria, Lebanon, Iraq, Iran and Turkey. From there, like modern refugees (below), Christianity migrated into Greece, Armenia, Georgia, the Caucasus and the Balkans.

Syriac Christianity, centered in Antioch and along the eastern Mediterranean coast – the Levant – believes there were as many as twelve wise Magi!

This small part of our little blue orb, known in Arabic as al-Sham (the Sh in Da’esh), is now part of the Islamic State of Iraq and the Levant (ISIL).

The Levant has long been a hotbed of religious strife, whatever we’ve called the area.

In the Levant, despite many wise men and well-meaning saviors, there’s always something deadly happening to create martyrs.

But children... Seriously? 

Reflecting on 2015's uncertain health in an insecure world, we and those walking with us in the Square from around the world still aspire to…

“A very merry Christmas and a happy New Year,
Let’s hope it’s a good one without any fear.

Tuesday, December 15, 2015

Uncertain Health in an Insecure World – 68


Eric Clapton’s I Shot The Sheriff refrain, “One day the bottom will drop out…”,  brings to mind the finality of irrevocable acts.

The World tells us when enough is enough, in its own, none too subtle ways. Unfortunately, the hardest thing to do, beyond listening, is to actually hear what it is saying.

The World does not speak our 6,500 languages… any of them. It talks to us in tongues. We translate with numbers that humans can measure – vital signs, of a sort – air temperature, sea level, ozone depletion, red tides, epidemics, droughts and deaths.

During this week’s global climate summit in Paris (COP21), delegates from 196 countries who have been listening hard for what seems like too many years (since the Kyoto Protocol of 1997), many of the same people who fumbled at Copenhagen in 2009, finally spoke… as one. Their final agreement on curbing fossil fuel use is designed to restrain the rise in average global temperature to “well below” +2 degrees Celsius above pre-industrial levels (or +3.6 degrees Fahrenheit in the one country still using that scale).

In Obamacare terms, this warming projection is like “bending the curve” of cost expenditures in order to achieve healthcare system sustainability. As noted by U.S. President Barack Obama, the Paris plan is “a turning point for the world… the best chance we have to save the one planet that we’ve got.

How does one translate these temperature targets into global ecosystem terms?

Big data driven predictive analytic models have shown that between 2050 and 2100, the Paris accord’s limits on greenhouse gas emissions will achieve a new equilibrium – when trees, soil and oceans can naturally absorb what human activity is generating. John Schellnhuber of Germany’s Potsdam Institute for Climate Research calls this positive tipping point “net zero.

The top greenhouse gas-emitters – China, U.S., EU, India, Russia, Indonesia, Brazil and Japan – made 2030 pledges to shift from carbon-intensive fuels in favor of renewable energy sources such as wind and solar.

Of course, countries can view this multi-trillion dollar drive to reduce emissions very differently. China, for example, is in the midst of its own post-industrial revolution. China is also the #1 carbon-based fuel user, at 2,972 millions of metric tons of oil equivalents, generating 66% of its energy from coal burning (below).

Beijing, a city of 20 million souls, spent most of the past week under a red alert due to extremely high particulate level smog. Widespread industrial coal burning causes poor air quality in China’s cities on a regular basis, but last week’s levels were an “Airpocalypse.” The handshake with the Devil made by the Chinese Communist Party in return for breakneck economic growth is paying negative ecologic returns. 

What does the bottom falling out look like?

By the year 2100, the United Nations Intergovernmental Panel on Climate Change (IPCC, est. 1988) estimates a 20 inch sea level rise. Expert opinions differ on these numbers – the U.S. National Academy of Sciences (est. 1863) predicts a rise ranging from 16 to 56 inches, depending on how we humans listen and respond to Earth’s queues. According to scientists and journalists at Climate Central (est. 2008), including some Weather Channel veterans, this places some 280 million peoples’ houses at risk of becoming submerged.

The U.S. Environmental Protection Agency (EPA, est. 1970) says that ocean levels have already risen 8 inches since Europe’s Industrial Revolution, circa 1870. Pacific islands like Nauru in the Marshall archipelago (above) and many other vulnerable countries are threatened right now. Bangladeshi farmers have created floating agricultural rafts from straw, rice stubble and water hyacinth in response to ever worsening flooding.

As Unilever CEO, Paul Polman stated from Paris, “This agreement establishes a clear path to de-carbonize the global economy within the lifetimes of many people alive today.” Outside the boardrooms, protesters in the streets are angered by all the misdirection and obfuscation.

Oddly, the new accord waits until 2020 to take effect, largely so that individual governments – in some 55 countries representing at least 55% of global emissions – can ratify and enact the required standards. The intersection of policy and politics is jobs, and it would be naive to imagine that economies won’t fail and governments won’t fall in pursuit of these Paris ideals.   

We will not dwell on the obvious adverse effects of this carbon fuel cataclysm on human health.

The U.S. Centers for Disease Control and Prevention (CDC, est. 1946) National Center for Environmental Health has surveyed the scientific literature on climate change, together with other natural and human-made stressors The threats to human health and promotion of disease are diverse and patently evident (below), and appear to be intensifying, even in the less extreme North American ecosystem. New public health problems are to be expected from climate-induced disruptions of physical, biological and ecological systems.


Guitar aficionados have nick-named Eric Clapton ‘Slowhand’, because he plays complex rock riffs with such relaxed ease. In his rock classic, The Crossroads, Clapton sings, “I went down to the crossroads, fell down on my knees.

The World is squarely at The Crossroads, right now!

After decades of analytic complexity from scientists and perilous advocacy by activists, COP21 looked too easy. Those who have brought Mother Earth to its knees have been handed one final chance… A reprieve.

Many of us standing in the Square today won’t be here in 2050.

But as the seas rise and cities choke, from this day forward, we are all out of envelopes to tear, and others to blame.

Thursday, December 10, 2015

Uncertain Health in an Insecure World – 67

Golden Fleece

In Greek mythology, soon after his birth, Jason’s life was under threat. His mother Alcimede smuggled him to Mount Pelion, where he was raised by the centaur, Chiron, a trainer of heroes. Once grown, a band of 85 men, the Argonauts, accompanied Jason on his quest to steal the Golden Fleece. Their ship, the Argo, sailed to Colchis where the Golden Fleece (below) was guarded by a dragon. The goddess Hera protected Jason and the Argonauts during their long & perilous journey. In the end, Jason was successful; he returned to Thessaly to ascend the throne of Iolcus.

As in ancient Greece, in modern times, seeking the Golden Fleece is a long & perilous journey.

With increasing digitization of the healthcare ecosystem, electronic health records (EHR) must become mobile to follow the flow of patient care. But healthcare has lagged behind other industries in the use of web technologies. Rob Brull of Carepoint Health in Dallas notes that, “Healthcare has relied on integrating the healthcare enterprise (IHE) and simple object access protocol (SOAP) for (data) transport, which can be cumbersome.” After 20 long years and several versions, Health Level 7 (HL7; below) emerged as the healthcare data exchange and information content modeling standard.

Now, having reached its destination, HL7 remains landlocked. What’s next?

Fast Healthcare Interoperability Resources (FIHR, pronounced “fire”) are new specifications and standards for electronically exchanging healthcare information, based on web industry approaches. This data exchange architecture, spearheaded by Australian software developer Graham Grieve (below) in 2013, is intended to reduce healthcare information technology (HIT) bottlenecks and to offer more granular data access – to achieve true HIT interoperability. Eventually, FHIR will support automated clinical decision-making and other machine-based structured data processing.

FHIR is mapping the uncharted waters of HIT mobility.

FHIR has developed built-in mechanisms for traceability to the HL7 Reference Information Model (RIM), and to other content models. RIM is a large pictorial representation of HL7 (Version 3) clinical data domains that identifies the life cycle of a message or of message groupings. Brull adds, “FHIR uses Representational State Transfer (REST) web API’s. It is more lightweight.” 

REST-ful or not, just what are API’s?

Virtually all software has to request other software to do something for it. Application program interfaces (API’s) are a set of routines, protocols and tools for building software applications. API’s specify how software components should interact, and are used when programming graphical user interface (GUI) components. An ‘asking’ software program uses a standardized set of API requests that have been pre-defined for the ‘answering’ program. In this way, an API grants access to or opens another application (below).

Josh Walker of the Forrester Research Inc. in Cambridge Massachusetts says that, today, building an application without API’s is “basically like building a house with no doors… (API ) is how you open the blinds and the doors and exchange information” through them.

HIT typically confuses the system of record (which is stable and massive) from the systems of consumption (which are more malleable and smaller). According to former Obama Administration Chief Technology Officer, Aneesh Chopra (above), the processing of these differing types of information requires a lot of “handshakes and handoffs”. Back in olden times (2010), the U.S. government had no solutions for people shopping for healthcare plans. Aneesh recalls that he turned to the private sector to avert a failed launch of Obamacare’s 1.0 website, hiring Ed Mullen (below), a user interface (UI) web design guru from New Jersey, to come to the rescue.

API’s are featured in the Accountable Care Act (i.e., Obamacare) 2015 final rule on healthcare exchange standards for employers, in order to assure that patients have the right to access their personal health information (PHI) and to connect to their PHI using an app of their choice from an app gallery. The U.S. government’s April letter to insurers in the federally-facilitated marketplace (FFM) sets forth a requirement to have a website with an API connection to the FFM, as an alternative to patient portals. This connection flexibly opens up the electronic healthcare system for individuals using mobile devices, or by those using machines with patient permission.

Such specifications are consistent with Obamacare’s stage-3 EHR healthcare system adoption and certification criteria.

These days, innovative start-ups like Stride Health use the government's own data to help employees search for the most cost-effective healthcare insurance plan, one that fits them, in five minutes or less!  Instead of saying to employees, “Here’s the URL to… Atta-boy,” ever-entrepreneurial Uber has partnered with Stride Health to help their drivers choose the best healthcare plans, and save them money (below).

JASON is an independent group of scientists and Nobel laureates, thought leaders who advise the U.S. government on science and technology. One of JASON’s goals is to promote public policies that create an open, interoperable health data infrastructure. JASON’s roots in the Viet Nam War and nuclear proliferation eras once created a close linkage to DARPA. But in its recent 2013-14 reports, JASON decries the lack of EHR interoperability in the current HIT ecosystem, and advocates for policy changes to adopt a new architecture in the U.S. and international EHR meaningful use requirements for healthcare systems.

Enter the modern day heroes…

The Argonaut Project is a private sector initiative intended to rapidly advance industry-wide adoption of modern open interoperability standards. This market-driven core and documentation project is sponsored by modern HIT Argonauts – healthcare insurers, EHR vendors, healthcare systems, major consulting firms and pharmacy distributors. Their quest is to rapidly develop a first-generation FHIR-based API and core data services specification that will enable expanded healthcare information sharing for EHR’s and other HIT’s, based on Internet security standards and architectural patterns & styles.

How will Google or Apple get involved in the guidance of care in chronic diseases, where disease complexity & diversity makes the chances of precision medicine accuracy low?

The combination of FHIR for simple content summaries (encoded using extensible markup language, XML) and REST standards for data transport would bring HIT into alignment with more modern web services approaches used by companies such as Facebook, Yahoo and Google. In the end, as noted by Arien Malec at McKesson’s RelayHealth, “to expose a medication list to authorized parties, the current systems are not designed to do that, and it takes a lot of extra work.” Malec’s good use case example would be to offer mobile app developers access to patient data. “If you are going to do that using FHIR it’s going to be cheaper, faster and better that rolling your own.

The Substitute Medical Applications Reusable Technologies (SMART) collaboration between Harvard and the U.S. Office of the National Coordinator (ONC) for HIT is actively creating an API for substitutable health apps that can run across multiple EHR’s. ‘SMART-on-FHIR’ is a prototype developed to support FHIR’s potential for providing a robust open-architecture health API.

Like ancient explorers, “information altruists” are more likely to openly share their PHI. But if this increases the cost of an insured pool of employees for an employer, it could cost these adventuresome adopters their jobs.

A recent Kaiser-Permanente member survey revealed that 60% would give up some health information privacy if it improved their healthcare. In Amy Edgar’s Robert Wood Johnson Foundation sponsored @FlipTheClinic project, the July 2015 ‘Flip 55’ showed that 16 consecutive patients answered that they did want their hospital EHR discharge summaries sent to them, while 2/3rds of stage-1 EHR adopters stated that nobody asked for or wanted their discharge summaries.

Another disruptive technology disconnect!

Digital Health Advisors” will soon function (via API’s) as trusted navigators to the right healthcare in the right setting at the right time.

Mapping a myth is complicated.

While Greek history scholars agree on the Argonauts' route from Greece to Colchis (green), their return route (orange) has been the subject of a bewildering array of interpretations… of geography... of lost languages… all clouded by fear and ignorance.

We in the Square have long followed the mythic journey of interoperable health information technology. We’ll worry about the route back after we’re there. 

The Golden Fleece is finally within reach… Beware the dragon!  

Wednesday, December 2, 2015

Uncertain Health in an Insecure World – 66

“Stall Point”

Like the AirAsia flight 8501 that crashed last December into the Java Sea, fixed wing aircraft lose lift when climbing skyward too quickly.

Companies confronting a sudden business growth plateau are also said to have hit a “stall point”. Harvard Business Review studies of stalled Fortune 500 firms – good companies like 3M, Apple, Caterpillar, Levi Strauss and Daimler-Benz – show that the root causes are both knowable and preventable. Most such stalls are caused by management’s bad strategy choices and/or poor organizational design. What 1950's economist Joseph Schumpter called the “gales of creative destruction” can easily sink weaker companies, like the Uber Effect tanked the value of New York City Taxi medallions (below).

But is there an innovation stall point?

Eastman Kodak (est. 1888, above) is a business school case study on how not to manage an innovation pipeline. Whether through arrogance or ignorance, the Rochester New York global leader in film-based photography technology failed to commercialize digital photography. Kodak stalled, filing for bankruptcy protection in January 2012. Ironically, photo-sharing app company Instagram was sold in 2012 for US$1B to Facebook. Activist investors second-guessed Instagram’s CEO Kevin Systrom (below) when just eighteen months after his deal with Mark Zuckerberg, the company’s value was estimated at >US$5B.

Innovation is fast becoming an ennui-provoking buzzword.

As a perfect economic storm was brewing in the mid-1990’s, Harvard’s Clayton Christensen’s wrote The Innovator’s Dilemma, advancing the (then) novel management theory of disruptive innovation. Christensen’s disruptive innovation construct helped to explain the failure of respected and (once) well-managed companies.

Clay’s theory has since been much touted, and widely misquoted. 

Recently, his big idea has been called into question in the press and by scholars for being overly simplistic and too one-size-fits-all. One Christensen premise criticized by The New Yorker writer Jill Lepore (The Disruption Machine, June 23, 2014) is “disrupt or be disrupted,” the cliché kernel seized upon by Silicon Valley “upstarts who work at startups.”

If business theories are debatable, and innovation is ubiquitous, where is reality?

The U.S. National Oceanic and Atmospheric Administration (NOAA) satellites and harbor buoys capture gobs of real weather data to feed predictive analytics. I’ve watched scientists at U.S. Department of Energy’s Oak Ridge National Labs in Tennessee (above) manipulate weather forecasting models with Titan supercomputers to simulate global weather patterns and future bad events. TV’s The Weather Channel (TWC) accesses public versions of these big NOAA datasets and complex computer models, converting them into customer-friendly multi-media local marketing products (below).


TWC’s parent, The Weather Company, processes 100 gigabytes of big data daily. In April 2015, IBM partnered with NOAA to provide cloud-enabled weather forecasting and climate change models to its customers… data scientists, business professionals and software developers. Drug companies and pharmacies already rely on these weather models to predict when to increase the production of anti-allergy medications. On October 28, 2015, IBM purchased The Weather Company (below), including all of its digital assets and apps… everything except for The Weather Channel!

Innovation only matters if its benefits become widely accessible.

Henry Ford’s 1913 Michigan model-T auto assembly line improved production efficiency from >12 to 1½ hours per car, making driving available to the masses. Eventually, the rest of the U.S. and global auto industry caught up. Now Ford produces cars in Russia, China, India, Brazil, Romania and Thailand.

Since 1925, Bell Labs’ scientists have completely transformed global communications. Despite the U.S. government breakup of AT&T’s monopoly (1984), Bell Labs acquisition by Lucent (1996), and their merger with Alcatel (2007), Bell’s so-called Idea Factory has never stopped producing ideas.

Sure, there were stalls along the way. But we have all been forever changed by Ford and Bell Labs ideas.

In 1914, Thomas J. Watson joined the firm he later led and renamed International Business Machines (IBM, est. 1924). Watson’s IBM built its reputation on mainframe computing hardware and software. At a November 2015 healthcare innovation summit in Boston, an IBM executive described their new cognitive computing technology – Watson – as “The Weather Channel for the internet of things (IoT).” Today, IBM is thinking big about cloud computing… and Big Blue wants to be your IoT company.

However, last week at an IBM Watson Health advisory board meeting, this “really, really, really cool” technology that learns by reading the scientific literature, singing Bob Dylan, scanning medical images and collating personal genomics data, seemed stalled! IBM Watson’s health utilities are still prototypes – minimum viable products (above) – without a broad customer base. Sitting in lower Manhattan with big pharma & healthcare VP’s, patient advocates & physicians, and IBM programmers & marketers, the board struggled to triangulate Watson’s health value. At day’s end, we concluded that Watson was more of a “disruptive technology” than a commercial product.

This distinction – between innovation and disruptive technology – is important.

Disruptive technologies are breakthroughs that change the way people live. If Watson can truly enable the interface of EPIC’s electronic health record with CVS’ pharmacy database with Medtronic’s structured & unstructured medical device data flow, its relational insights will improve patient care and outcomes. Watson could become especially powerful in partnership with big pharma companies like Johnson & Johnson in treating chronic diseases that require daily decisions involving patients’ little data from wearable tech sensors like the Apple Watch (below).

Simplifying, life-enabling information – the equivalent of whether or not to bring an umbrella based on computer modeled local rain chances – quickly weaves itself into the fabric of day-to-day life.

The Galapagos Archipelago is a unique Pacific coast ecosystem, centuries in the making. In the absence of natural predators, species evolve slowly – evolve or fail – and outsiders provoke no fear. As the endangered booby bird dives (below), deftly pivots its wings and stalls onto the rocky shore, adaptation is evident. 

The foggy north Pacific basin called Silicon Valley is another unique ecosystem, one formed over just 50 years. With intense startup competition for risky funding, and “fail fast” fears driving a ruthless urgency among its entrepreneurial inhabitants, wise objects are evident in the channel.

Despite global pressures for speciation and innovation, sadly, neither of these ecosystems can be reproduced elsewhere in the world.

Disruptive technologies survive the natural rise and fall of such ecosystems, and man-made business theories. And like a single species, solo companies can no longer be counted upon to achieve creative disruption.

For lesser innovators, the dilemma, the ultimate stall… extinction… lurks!

In the Square, we choose to parse such distinctions. And if clever innovative ruses can no longer change human reality, then the two terms should not be confused.