Lab Soft News

Back-Channel Tweeting at Medical Conferences

The number of new uses for microblogging that continue to surface is a pleasant surprise. For today's note, I will focus on what is being referred to as back-channel tweeting at conferences. One of my main challenges of managing such conferences is to make them more interactive by stimulating input from the attendees. Part of this problem is that many of them don't want to approach the microphones and ask questions during the Q and A sessions. Now comes Twitter to help solve this problem (see: How to Present While People are Twittering). Below is an excerpt from the article with boldface emphasis mine with emphasis on how speakers need to psychologically adjust to having audiences members tweeting during a lecture:

People used to whisper to each other or pass hand-scribbled notes during presentations. Now these notes are going digital on Twitter or via conference-provided chat rooms. Up until now, this back-channel has been mainly confined to the Internet industry and technology conferences....So the next time you present at a conference, instead of being confronted by a sea of faces looking at you, you may be phased by a sea of heads looking down at their laptops. The challenge is how to adapt to presenting with the back-channel. As a presenter, the idea of presenting while people are talking about you is disconcerting. But to balance that, there are huge benefits to the individual members of the audience and to the overall output of a conference or meeting.

• It helps audience members focus
• The audience gets more content
• Audience members can get questions answered on the fly
• The audience can participate
• The audience can innovate
• You don’t have to be physically present to participate
• You can connect with people
• You can do something else

Yes, presenting with the back-channel is challenging. Prepare yourself for what it will be like. We’re used to having eye contact with our audience and using that eye contact and audience reaction to measure how well we’re engaging the audience. Now when you say something brilliant, instead of nods of appreciation, there will be a flurry of tapping. Here’s the positive spin: The typing means you’re provoking interest.

Stimulated by this article, I have set up a Twitter account (labinfotech) so that I can solicit tweets from the conference registrants during the upcoming Lab InfoTech Summit. While sitting in the audience, I can monitor this account using the browser on my cell phone and repeat some of them from the podium for those not following the back-channel on Twitter. I am hoping this this new conduit will be less intimidating for attendees than walking to the microphone and asking a question or making a comment.

For me, an interesting aspect of this new way to solicit input at conference is that the limit of 140 characters for tweets. I doubt that this will be a barrier. Also, the input from conference registrants can obviously be in the form of both questions and comments. This allows the opportunity to tap into the accumulated experience and knowledge of the entire audience rather than that of only the faculty members. It will also be possible to install a gadget in Lab Soft News so that the readers of this blog not attending the conference can see a feed of the tweets being generated real-time at the event.

38 Exhibitors to Participate in the Upcoming Lab InfoTech Summit

It's not too late to register for the Lab InfoTech Summit that will take place on March 16-18, 2009, at the Venetian Hotel in Las Vegas.This will be the 27th consecutive year for this conference with a continuing focus on clinical lab software including LIS, AP-LIS, middleware, lab portal, blood bank, decision-support, patient identification, instrument interfaces, and LIMS products. Also included will be digital pathology and in-vitro instrument displays. The conference brochure provides details about all of the lectures and workshop to be presented. On-line registration is also available.

Below is a complete list of the participating exhibitors at the conference. No other pathology or laboratory event has such a broad array of companies or products. If your lab is contemplating a purchase of this type in the upcoming months, browsing the Lab InfoTech Summit exhibitor space will make this task much easier and allow efficient comparison shopping.

Corporate Underwriters
Atlas Medical - www.atlasmedical.com
Beckman Coulter - www.beckmancoulter.com
McKesson - www.mckesson.com
SCC Soft Computer - www.softcomputer.com
Siemens Healthcare Diagnostics - diagnostics.siemens.com
Sunquest Information Systems - www.sunquestinfo.com
Technidata America Medical Software - www.technidata-web.com

Gold Exhibitors
Antek HealthWare - www.antekhealthware.com
Aperio - www.aperio.com
Apollo PACS - www.apollopacs.com
ARUP Laboratories - www.aruplab.com
BioImagene - www.bioimagene.com
Blue Iris - www.blueiris.com
CareEvolve - www.careevolve.com
Cerner - www.cerner.com
Dako - www.dako.com
Data Innovations - www.datainnovations.com
Dawning Technologies - www.dawning.com
Extract Systems - www.extractsystems.com
GE Healthcare Information Technologies - www.gehealthcare.com
General Data - www.general-data.com
Healthvision - www.healthvision.com
In-Vitro Industry Connectivity Consortium (IIEE)
IMPAC - www.impac.com
mTuitive - www.mtuitive.com
Nikon - www.nikoninstruments.com
Olympus America - www.olympusamerica.com
Omnitech Labs - www.omnitechlabs.net
Orchard Software - www.orchardsoft.com
PathView Systems - www.pathview.com
Roche Diagnostics - www.roche.com/diagnostics
Schuyler House - www.schuylab.com
Seacoast Laboratory Data Systems - www.sldsi.com
STARLIMS - www.starlims.com
Sysmex - www.sysmex.com
TELCOR - www.telcor.com
Ventana Medical Systems - www.ventanamed.com
Wyndgate Technologies - www.wyndgate.com

Journalist Provides Advice about Search Engine Optimization

In a previous note, I raised the topic of Google juice (see: Snap Google Quiz on a Tuesday Morning), which is a term for describing influence with the Google crawler. It can be assessed by the ranking of you or your blog on the Google search engine retrieval page (SERP). The topic of personal search engine optimization arose in a recent article in the Wall Street Journal by a reporter named Julia Angwin (see: It's a New Me (As Seen on Google). Below is an excerpt from it with boldface emphasis mine:

For years, I winced at what popped up when I Googled my name. The top result of a search on "Julia Angwin" was an article I wrote for The Wall Street Journal in 2005 after I. Lewis "Scooter" Libby was indicted for leaking the name of CIA operative Valerie Plame....I hated seeing the story at the top of the list for a number of reasons....Mysteriously, this article had become my hallmark online, showing up in my top-five search results for years....So a few months ago, I began trying to figure out how I could knock that story -- and a few others, while I was at it -- out of my search results. It was the beginning of a long and arduous introduction into the murky art of search-engine optimization, or SEA....My first thought was to try to remove the unwanted article from my SERP. But search-engine expert and consultant Danny Sullivan advised me that it is extremely difficult to remove items from Google search results....Still, Google does encourage people to boost their results by creating content about themselves....The best way to do that, he advises, is to create original compelling content about yourself that is easily accessed by Google and earns links from authoritative and relevant Web sites. For details, I turned to WSJ.com's search-engine-optimization consultant Alex Bennert, who advised me to bury the annoying article underneath more favorable material, such as my social-networking profiles on LinkedIn, Facebook and MySpace, as well as blogging site Twitter....These interlinkages are key to understanding Google's page-ranking system. Google rates Web sites, in part, by how many links they have from other credible Web sites.

All very interesting. It's recommended that the best way to neutralize or counteract a prominent ranking for information you're not happy with on the web is to generate additional appealing content and linkages. This will act as a kind of distraction for the Google crawler whose name is Googlebot. Particularly appealing for Googlebot is what is referred to above as interlinkages. This advice is consistent with my prior understanding about how to make your blog more interesting for Google: provides lots of new information for the crawler to digest and make it interesting enough and with enough links so that readers link to your blog and from your blog. In other words, publish the highest quality blog material with the greatest appeal for the largest number of readers. If you join LinkedIn and Twitter, you can post the URL of your blog in your personal profiles. You can also create an RSS feed of your blog into these sites. This promotes interlinkages from other sites to your blog.

So why is all of this relevant and interesting? Well, to start, it's a fact of life that many people are highly motivated to improve their SERP using SEO techniques. This would hardly have been a major concern a mere three to four years ago. For many people today, including Julia Angwin, their identify on the web is of vital concern to them. Put another way, their public identity and SERP are tightly linked.

More on IICC: Promoting Connectivity between LISs & Lab Instruments

I published a note last July announcing the kick-off meeting of the IVD Industry Connectivity Consortium (IICC) that was held at the AACC annual conference (see: IICC Kickoff Meeting Scheduled for July 28 at the AACC Conference). The IICC is a not-for-profit task force of IVD companies that are collaborating on a common mission. The mission is to create and ensure adoption of a connectivity model to reduce the complexity and variability of data exchange between IVD and hospital/lab information systems. The IICC Core and Supporting members consist of the following: Abbott Diagnostics, Beckman Coulter, Becton Dickinson, BioMerieux, Ortho Clinical Diagnostics, Roche Diagnostics, Siemens Healthcare Diagnostics, Data Innovations, and NTE SA.

The IICC will address the transmission of orders and results between IT systems and IVD analyzers but will not attempt to distinguish among the different types of IT systems (e.g. LIS, middleware). It will partner with existing standards organizations to select baseline standards and develop guidelines for usage. Out of scope for the organization but a potential future effort will be the following: (1) calibration data; (2) operator information; (3) process status monitoring; and (4) types of IVD testing.

The Executive Committee of the IICC consists of the following individuals: President, Mojgan Lefebvre, (Corporate Vice President & CIO, BioMerieux); Chief Technology Officer, Eric Olson (Vice President of Informatics and eBusiness, Siemens Diagnostics); Treasurer & Secretary, Scott Goss, (Global Marketing Director Automation & Informatics, Abbott Diagnostics); Chief Marketing & Adoption Officer (Under Recruitment); and Provider Review Committee Chair: Jay Jones, PhD, Director of Chemistry and Regional Labs, Division of Laboratory Medicine, Geisinger Health System.

Representative of the IICC have agreed to participate as an exhibitor at the the upcoming Lab InfoTech Summit, which will be held on March 16-18, 2009, at the Venetian Hotel in Las Vegas. At that time, IICC representatives will be available to discuss the mission of the group in greater detail with conference registrants. If any of the readers of this note are interested in joining the IICC as a member, please communicate with Scott Goss who is the Secretary/Treasurer of the group (scott.goss@abbott.com).

Update on Dubai Healthcare City -- Not So Good

I posted a few previous notes about Dubai Healthcare City. Now comes an update from "Ms. Adventure" provided by Mr. HIStalk. Below is her status report:

Since there seems to be so much interest in what is happening over in Dubai, I thought I would let everyone know what the latest news is and the effects of the economic crisis in this country. Many construction projects have been put on hold indefinitely. Yes, that includes many of the new hospital construction projects. In the Dubai Healthcare City, the University Hospital construction has been halted for a period of 18 months ( it might as well be indefinitely). With the halting of construction, 60 clinical planning and non-clinical projects employees were laid off, and only six were retained for management purposes (C-suite). The new Epic Systems contract is also under investigation, as there are charges of corruption in the management and acquisition of University Hospital HIS system. In other areas of the Healthcare City, over 100 people were laid off. In Dubai overall, 1,500 people per day are cancelling their visas and returning to their home country. As they are leaving, they are also leaving their debt behind. So who is left in Dubai and where is all the excitement? Looks like Cerner is going strong, working on their project for the Ministry of Health (14 hospitals and 60 clinics) named Wareed....I have been in this region over 10 years and sadly I will be returning home soon. I must say that in one short year things have changed so much, from a thriving and booming town to a town that may not have a tomorrow.

A Closer Look at the Standard Clinical Laboratory Reference Ranges

A mandatory companion to any lab test result is the reference range. It consists of both the upper and lower limits of normality for that patient for that test. If a result falls outside of this range, it is considered abnormal and may require further investigation. Reference range will vary by sex and by age. There is also evidence in the literature that the test set-point for an individual may change permanently after an acute illness but such individual variations are not taken into consideration by a lab since they have no detailed knowledge of such longitudinal changes for the  patient. Dr. Tony Killeen made some observations about reference ranges in a recent blog note (see: More on reference ranges). I list it below with boldface emphasis mine

I recently referred to an editorial in the Annals of Clinical Biochemistry that outlines ways to establish reference ranges and their attendant advantages and disadvantages. The authors of an editorial in January’s Clinical Chemistry (55:15-17, 2009) advocate “a new way of thinking about the relationship between biomarker measures and clinical decision-making”. They envisage the use of lab results to generate a prediction of risk of disease, which actually sounds a lot like existing likelihood ratios. These predictions will be based on data other than simply a lab measurement. For example, they might include the patient’s family and social histories, results of imaging studies, and even the patient’s desire for treatment. A result might be of the form that given the results of the lab studies, imaging, history etc. the patient has X% risk of having heart disease, cancer, etc. Certainly I agree with the assessment that traditional reference ranges have important limitations. To move beyond reference ranges to presenting the clinician with more useful data, specifically data that integrate findings from the history, physical exam, imaging, treatment desires etc. will take a lot of effort, much of which will be informatics related.

Here's a definition of likelihood ratio that is referred to above: Likelihood ratio is the likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that the same result would be expected in a patient without that disorder.

I agree that it would be highly desirable to provide a likelihood ratio by patient for various lab test results. The challenge of providing such a service is that it requires additional information about the patient that is not commonly stored in the laboratory information system (LIS). Hospital EMRs are theoretically an aggregation point for all clinical information for a patient. However, most such systems struggle to acquire and publish the more common clinical data elements. To suggest that they could handle more complex tasks such as the calculation of lab likelihood ratios by patient goes far beyond their capabilities.

I am an advocate for the integration of pathology, lab medicine, and radiology into the unified specialty of diagnostic medicine. I have posted a number of previous notes about this subject. Furthermore, I believe that it is inevitable that information processing for such a merged specialty will occur in a vertical cloud where all diagnostic data including images will be stored, aggregated, and analyzed. Since the processing power in such a cloud is almost unlimited, it would be very possible under such a scenario to provide likelihood ratios with any test result. In the future, most biomarkers will be reported out as large panels of test results called IVDMIAs. Such reporting will be particularly demanding of computing power. In upcoming notes, I will discuss this idea of a vertical diagnostic cloud in more detail.

Cleveland Clinic Partners with Minute Clinic in Retail Health Services

I have posted a number of previous notes about walk-in clinics located in pharmacies and also in big-box stores. In one such note (see: Health Systems Launch Walk-In Clinics), I suggested that health systems might be wise to launch their own walk-in clinics as an extension of their ambulatory care activities. Apparently these walk-in clinics are now being categorized as retail healthcare. We now learn that the Cleveland Clinic seems to be doing the next best thing -- creating a strategic relationship with MinuteClinic, a subsidiary of CVS. (see: Cleveland Clinic partners with MinuteClinic, links EMRs). Below is an excerpt from the article with boldface emphasis mine:

Cleveland Clinic, a pioneer in the use of healthcare information technology, has entered into a clinical collaboration with MinuteClinic, the largest provider of retail healthcare in the country. As part of the collaboration, Cleveland Clinic and MinuteClinic will fully integrate their electronic medical records systems to streamline communication around all aspects of a patient's care. Each Cleveland Clinic-affiliated MinuteClinic will have access, with patient consent, to a patient's Cleveland Clinic MyChart electronic medical record, which includes medical history, prescriptions, treatments and health maintenance information. At the patient's request,MinuteClinic will share its patient information with other Cleveland Clinic-affiliated locations in northeast Ohio via the MinuteClinic EMR for MinuteClinic patients who have been treated in those locations. MinuteClinic is a subsidiary of the CVS Caremark Corp. It has 500 clinics in 25 states. Under the agreement, Cleveland Clinic will share responsibilities at several locations inside select northeast Ohio CVS pharmacy stores...."We are pleased to be working with one of the leading medical institutions in the United States to expand access to basichealthcare needs in the Cleveland community," said Chip Phillips, MinuteClinic's president. "Through this agreement, Cleveland Clinic's family physicians will serve as a valuable resource to our MinuteClinic nurse practitioners in northeast Ohio and we look forward to collaborating with Cleveland Clinic on a range of patient education and preventive services."

The most interesting part of this particular article is that it emphasizes EMR integration between the Cleveland Clinic and MinuteClinic. Such integration apparently consists first of providing MinuteClinic employees access to the Cleveland Clinic personal health record (PHR) called MyChart with the permission of the patient visiting the MinuteClinic. Not a lot of technology at work here. On the other side of the coin, Cleveland Clinic physicians will have access to the MinuteClinic EMR. There is also a brief reference to shared responsibilities between the Cleveland Clinic and MinuteClinic at several locations, but this is not spelled out in detail.

I must add, however, that the relationship between Cleveland Clinic and MinuteClinic is far from clear at this point. Another report (see: Cleveland Clinic to supervise MinuteClinics in Greater Cleveland CVS pharmacies) indicates that Cleveland Clinic physicians will have supervisory responsibility at some of the walk-in clinics. Below is an excerpt from it:

The Cleveland Clinic is no longer content with merely providing care at its hospitals.The nonprofit health system plans to announce a partnership with CVS/pharmacy...that will give the Clinic further reach into the Greater Cleveland community. Under terms of the deal, the Clinic will be paid to provide medical oversight of already operating MinuteClinics at nine CVS pharmacies in northeast Ohio. The Clinic will assign a physician to supervise each one.

A fundamental weakness of the business model for most walk-in clinic is that the nurse clinicians staffing the clinics work with a set of treatment protocols. A referral process is needed to accommodate those patients with serious acute problems not covered by these protocols. One approach for such patients is to say "sorry" and refer them to the nearest hospital emergency departments. With two-way sharing of clinical information and physician staffing of these facilities, referrals to a prestigious health system such as the Cleveland Clinic can be expedited. So, in a nutshell, this budding relationship may go a long way toward patching this weakness. The Cleveland Clinic, in turn, taps into a potentially rich source of referrals for more complex health problems.

The Famous Receive Better (and Worse) Healthcare Than the Rest of Us

In a recent note (see: Carcinoma of the Pancreas in the News; Some Additional Information), I discussed cancer of the pancreas and mentioned the fact that Supreme Court Justice Ruth Bader Ginsburg was being treated for the lesion. Now come news that her lesion was benign but that another smaller malignant lesion was discovered at the time of the operation (see: Justice Ginsburg’s Cancer Treatment Takes Unusual Turn). Below is an excerpt from the article with boldface emphasis mine:

U.S. Supreme Court Justice Ruth Bader Ginsburg was released from Memorial Sloan-Kettering Cancer Center today after she underwent surgery last week to remove a tumor in her pancreas. New details that have emerged about her health aren’t so easy to interpret. First off, the small tumor that was removed, which the court had previously said was “apparently early-stage pancreatic cancer,” turned out to be benign, the court reported in its statement today. But, while removing it, the surgeon found a “previously undetected single, even smaller, tumor,” the court said. That one was malignant....Based on the latest information from the court, [a medical expert] says, he’s “confused.” One reason: It’s not common to perform such difficult surgeries unless the physician thinks there’s a solid chance the tumor slated for removal is malignant....So [the expert] says he would need more information to know why the procedure on Ginsburg took place at all.

The chain of events brings to my mind the issue of the quality of healthcare delivered to the rich and famous, both on the positive and negative side. Everyone knows why the famous receive better care. They generally can afford it or merit it. I suspect that attention to detail in the case of Justice Ginsburg resulted in the extraordinary event of the discovery of not one but two pancreatic neoplasms, one small and the other smaller. The first was reportedly benign and the second one malignant. One can only attribute such news to the very close diagnostic scrutiny provided for her using the best available lab and imaging technologies.

How in the world could such close scrutiny result in bad outcomes or problems? Here's the answer and you may have read it here first because hospitals and physicians tend not to brag about their mistakes and failures. The definition of quality care is that it is delivered by the most skilled physicians and nurses in the best hospitals. Furthermore, good care is also highly dependent on a set of time-tested protocols and procedures designed to minimize failures and mistakes. When treating famous people, such routines and protocols send to get modified out of respect for the individual and to avoid inconveniencing them. This results in mistakes. Famous people also tend to have their electronic medical records stored under a "John Doe" alias to avoid prying eyes. This makes it more difficult to review previous episodes of care and disrupts continuity of care.

When President Reagan was shot, someone in his entourage was smart enough to transport him to an inner-city hospital in Washington, D.C., where treating gunshot injuries was a common event rather than to a suburban hospital with nicer rooms and better views but no experience in handling such cases. If you are rich and famous and admitted to the hospital, you best bet is to tell everyone the following: "Treat me like everyone else." By the way, this almost never happens.

Relationship of Pharmaceutical Companies to Continuing Medical Education

KevinMD, the author of a very successful health blog, posted a recent note posing the controversial question of whether the fact that pharmaceutical companies are now generally banned from providing gifts to physicians is hurting the economy (see: How banning pharmaceutical gifts to doctors may hurt the economy). Below is his note in its entirely with boldface emphasis mine:

Massachusetts is considering implementing some of the toughest laws in the country regulating the pharmaceutical industry from giving gifts of any kind to doctors, and restricting drug company funding. MedPage Today ...reports that one unexpected consequence is that many major physician conferences are pulling out of the city. For instance, the American Academy of Allergy, Asthma & Immunology pulled its 2015 convention out of Boston, citing difficulty finding "sponsorships and to provide education courses under current legal conditions." Millions of dollars will be lost, both in convention revenue and hotel bookings. There's talk that other major physician conferences are bypassing Boston altogether. Will the unintended consequence of hurting the state economy force the government to loosen up their oversight of pharmaceutical gift-giving?

I feel compelled to weigh in on this topic as I have in a previous note because I have participated in, and managed, CME conferences for many years (see: On the Corrosive Influence of Big Pharma on Academic Physicians). Most medical conferences require some monetary support from vendors to succeed. Otherwise, the registration fees would be so high that few physicians would probably attend. However, the participation of vendors such as Big Pharma should be viewed as an opportunity and not a problem. Physicians, like all professionals, need to update their skills constantly and this goal can be achieved, in part, at medical conferences. They can learn much from the conference faculty who are selected on the basis of their expertise and teaching skills. Such faculty members must not be obligated in any way to the sponsoring pharmaceutical companies. Conference registrants can also acquire information from the pharmaceutical company representatives who work the vendor displays that are browsed by conference registrants. A "fire wall" must be placed between the didactic content provided by the faculty and the sales efforts of the vendor representatives. In my experience, such a barrier is not that difficult to erect. The lecture area must be a "no spin" zone.

It strikes me as childish and precipitous for the American Academy of Allergy, Asthma and Immunology to pull a conference that will occur six years in the future for lack of [pharmaceutical] sponsorship. There is a political agenda at work here. I recommend that everyone concerned take some deep breaths. A new modus operandi needs to be developed between the pharmaceutical companies and the professional societies pertaining to the structure, organization, and funding of conferences along the lines described above. This probably won't happen overnight. However, the fact remains that physicians need to attend conferences and the company representatives need an opportunity to interact with them. These interactions may not be as frequent in the physician office settings because of the high cost of such calls. My guess is that medical conferences will continue but with new rules, even in Massachusetts.

Note to Philanthropists: Fund Programs for Changing Unhealthy Behaviors

If you have any extra cash lying around and you want to devote it to a good cause, you might consider using some of it as an incentive to cause individuals in your community to change their unhealthy behaviors. The positive effect of such philanthropy was spelled out in a recent article in the Wall Street Journal (see: More Smokers Quit if Paid, Study Shows).  Below is an excerpt from the article with boldface emphasis mine:

Smokers who are paid to quit succeed far more often than those who get no cash reward, according to a new study that provides some of the strongest evidence yet that financial incentives can help change such behavior....The study, one of the largest of its kind, comes at a time when more employers, schools and other institutions are paying people to do everything from lose weight to improve their grades....For the new study, researchers, led by a team from the University of Pennsylvania, tracked 878 General Electric Co. employees from around the country for a year and a half in 2005 and 2006. Participants, who smoked an average of one pack of cigarettes a day, were divided into two groups of roughly equal size. All received information about smoking-cessation programs. Members of one group also got as much as $750 in cash, with the payments spread out over time to encourage longer-term abstinence....All participants were contacted three months after they enrolled in the study and periodically after that. Those who said they had stopped smoking at any point during the study were asked to submit saliva or urine samples for testing so that their claims could be verified. About 14.7% of the group offered financial incentives said they had stopped smoking within the first year of the study, compared with 5% of the other group. At the time of their last interview for the 18-month study, 9.4% of the paid group was still abstaining compared with 3.6% of those who got no money....According to the federal Centers for Disease Control and Prevention, which helped fund the study, smoking costs companies about $3,400 per smoking employee annually, or about $7.18 per pack of cigarettes, in health-care bills, reduced productivity and absenteeism.

I have posted a number of previous notes about the prevalence of chronic diseases and the fact that many of them are caused by behavioral issues such as smoking, drinking, obesity, lack of exercise, and insufficient exercise. I provided more information about this same topic in recent note dealing with the lack of a preventive medicine infrastructure (see: The Need for a Preventive Medicine Infrastructure in the U.S.). I suggest here that a philanthropic goal with a proven success rate would thus be to donate money to use as an incentive for people to modify their behaviors and improve their health. The influx of such funds on a large scale might also serve as a stimulus for greater development of the preventive medicine infrastructure that I suggested was somewhat lacking. Part of the infrastructure that needs to be developed is the monitoring apparatus to ensure that people who receive payments are sticking to their programs. The rate of recidivism in such programs is high for obvious reasons.

Why, you may ask, should philanthropists participate in such programs? Is this not a logical investment for companies such as General Electric, cited in the article excerpt above. The answer is yes indeed, the return-on-investment is such that this is an attractive investment for companies for their employees. For this reason, I think that donors might target their "investments" in those not included in the workforce such as children, the elderly, and pregnant women. Local or national foundations with a focus on public health and preventive medicine would be the logical recipients. I will try scout around the web to find organizations like this. Please also feel free to comment on this note if you have any suggestions in this regard.