Enciclopèdia de gestió sanitària

 Elgar Encyclopedia of Healthcare Management

 Una enciclopèdia amb aquest índex.

PART I SCENARIOS
1 Big data and artificial intelligence 2
2 Disruptive technology innovations 6
3 Genomics 8
4 Globalization 11
5 Medical tourism 13
6 Precision medicine 16
7 Robotics 19

PART II BASIC MODELS OF HEALTH SYSTEMS
8 Beveridge model 22
9 Bismarck model 24
10 Market-driven model 26

PART III EVOLUTION OF THE PHARMA AND MEDTECH INDUSTRY

11 Market access 30
12 Digital therapeutics 33
13 Biotech 36

PART IV FOUNDATIONS OF HEALTH ECONOMICS

14 Baumol’s cost disease 40
15 Disease mongering 42
16 Moral hazard in health insurance 44
17 Quasi-markets 46
18 Supplier-induced demand 48

PART V FUNDING

19 Payment mechanisms 51
20 Sources of funding 55
21 Tariff vs price 57

PART VI HEALTH POLICY PRINCIPLES

22 Equality and equity 60
23 Universalism 62
24 Well-being 64

PART VII INVESTMENT ANALYSIS

25 Business planning of healthcare services 69
26 Sources of funding for investments 71

PART VIII LEVELS OF CARE

27 Acute, sub-acute and post-acute care 77
28 Chronic care 79
29 Home care and community care 83
30 Hospital 86
31 Long term care 91
32 Prevention 93
33 Screenings 97
34 Primary healthcare 101
35 Secondary vs tertiary vs quaternary care 104

PART IX NEW PARADIGMS

36 Access to healthcare 108
37 Co-production 110
38 Demedicalization 113
39 Evidence-based medicine 115
40 From compliance to concordance 119
41 Gender medicine 121
42 Global health 123
43 Health literacy 125
44 Initiative medicine 127
45 Integrated care 130
46 Population health management 133
47 Skill mix and task shifting in healthcare 136
48 Value-based vs

PART X PLAYERS

49 Boundaryless hospital 142
50 Community and country hospital 144
51 Intermediate and transitional care settings 147
52 Primary care center 150
53 Research hospital 152
54 Teaching hospital 154

PART XI TRENDS

55 Business models 157
56 Decentralization and devolution in healthcare 159
57 Multidisciplinarity and inter- professionality 161
58 Telemedicine 164
59 Vertical and horizontal integration (hub and spoke network) 168

PART XII BEHAVIOURS:

CHALLENGES TO LEADING HEALTH ORGANIZATIONS

60 Accountability 173
61 Accountable care plan and organization 174
62 Iatocracy, professional bureaucracy and corporatization 177
63 Political arena 180
64 Professional vs managerial culture 182
65 Professionalism 184
66 Stakeholder management 186
67 Teamwork 187
68 Turf wars 189

PART XIII PRACTICES

69 Change management 193
70 Disaster management 195
71 Leadership and leadership styles 199

PART XIV ROLES

72 Case manager 203
73 Clinical engineer 205
74 Clinical leader 208
75 Controller 211
76 Family and community nurse 215
77 General practitioner 218
78 Hospitalist 220
79 Medical director 223
80 Operations manager 225
81 Pharmacist 228
82 Quality and risk manager 233

PART XV TOOLS SYSTEM AND

PROCESS: DISEASE MANAGEMENT

83 Clinical governance 237
84 Guidelines and protocols in healthcare systems 239

PART XVI INNOVATION MANAGEMENT

85 Clinical trial 243
86 Health technology assessment 246

PART XVII OPERATIONS

87 Electronic clinical records 251
88 Patient flow logistics 253
89 Patient management 256
90 Supply chain 258
91 Techniques for process and organizations improvement: lean management in healthcare 261

PART XVIII ORGANIZATION

92 Clinical service lines 264
93 Converging trends in hospital transformation 267
94 Divisionalization, clinical directorates and Troika model in healthcare 271
95 Organizational culture 273
96 Organizational design and development for healthcare organizations 276
97 Patient-centered hospital and health organization 281

PART XIX PEOPLE

98 Clinical and professional engagement 285
99 Great Place to Work® 288
100 Magnet hospital 291

PART XX PERFORMANCE

101 Balanced scorecard in healthcare organizations 294
102 Budgeting (financial vs operational) 298
103 Customer satisfaction 301
104 DRG and case mix index 303
105 Length of stay 305
106 Performance measurement and management systems 307
107 PROMs and PREMs 310
108 Strategic control 313

PART XXI PLANNING

109 Strategic planning 318
110 Strategy making 320

PART XXII PROCUREMENT

111 Centralized procurement 324
112 Innovation procurement 327
113 Managed entry agreements (MEA) 330
114 Value-based procurement 333

PART XXIII QUALITY

115 Accreditation in healthcare 337
116 Audit 340
117 Quality management 343

L'envelliment i els serveis de salut

 Silver Opportunity: Building Integrated Services for Older Adults around Primary Health Care

Malgrat que organitzar els serveis segons edat esdevé una forma inusual d'afrontar el problema de la salut en general, a la pràctica es fa i a determinades edats passen determinats esdeveniments singulars. Si ens referim a l'envelliment, per si mateix no hauria de ser objecte d'un enfocament diferencial, però l'impacte de la cronicitat és quan més es manifesta.

Per tant, seguint el criteri que el que cal és organitzar els serveis de salut poblacional, també cal dir que certes questions requereixen una atenció particular. I això és el que fa aquest informe del Banc Mundial i que es resumeix a aquesta gràfica. Cal fer una ullada a l'informe sencer perquè això és massa genèric.

Integrated care and population health (2)

 Handbook Integrated Care

On value (once again)

 From value for money to value-based health services: a twenty-first century shift

VBHS cannot be achieved without reorienting existing fragmented models of care towards one that rests on a strong primary health care foundation (19) with an integrated community care component and underpinned by the principle of people coproducing health. This may encompass a shift from inpatient to outpatient and ambulatory care, where appropriate. It requires investment in holistic and comprehensive care, including health promotion and prevention strategies that support people’s health and well-being (20). It further requires effective referral systems, flexible and multidisciplinary provider networks, and participatory monitoring and evaluation strategies.

Nothing new. 

Joaquim Mir

Five levels of care integration

 The importance of understanding and measuring health system structural, functional, and clinical integration

A helpful framework on integrated care from the Health Services Research article:

The framework focuses on how systems are structured and governed, what people who work in the system believe and how they behave, and activities intended to integrate patient care into a single coordinated process within the system. We chose this model because, while there are many different ways to characterize health systems, we wanted to focus on those characteristics that might prove to be meaningful with regard to performance differences.

Hypothetical relationships are depicted in the model using arrows that move from left to right. The five types of integration depicted in the model (structural, functional, normative, interpersonal and process integration) are hypothesized to effect intermediate and ultimate outcomes. From Singer SJ, Kerrissey M, Friedberg M, Phillips R. A Comprehensive Theory of Integration. Med Care Res Rev. 2020;77(2):204, Sage Publications, Inc. 

• Structural integration (physical, operational, financial, or legal ties among operating units within a system)
• Functional integration (formal, written policies, and protocols for activities that coordinate and support accountability and decision making among operating units)
• Process (or clinical) integration (actions or activities intended to integrate patient care across people, functions, activities, and operating units within the system). In our discussion, we refer to this as clinical integration.

Structural and functional integration are under the direct control of system executives. Our intent was to understand the kinds of strategic decisions they were making, why they made them, and how they saw their decisions affecting their goals for their systems. Understanding the organizations that make up the systems and the extent to which systems are structurally and functionally integrated is a vital starting point for understanding whether process/clinical integration is happening within systems, how it is happening, or indeed whether it is even possible.

Two additional types of integration—normative and interpersonal. 

Normative integration refers to sharing a common culture; interpersonal integration refers to collaboration or teamwork.

Profiling complex patients

 Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles

Instead of predictive modeling using costs, this is the right approach from a clinical point of view:

This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles.

And the figures below reflect these results.

Great article.

Figure 1.  Seven Patient Profiles Derived From Latent Class Analysis

 

Figure 2.  Comparison of k-Means Clustering With Latent Class Analysis (LCA)

Table 1.  Baseline and 1-Year Follow-up Characteristics of the Overall Population and by Patient Profile

Table 2.  Key Defining Features and Suggested Management Strategies for the 7 Clinical Profiles of Medically Complex Patients

Integrated care as organizational innovation

Innovative Integrated Health And Social Care Programs In Eleven High-Income Countries 

High-income countries face the challenge of providing effective and efficient care to the relatively small proportion of their populations with high health and social care needs. Recent reports suggest that integrated health and social care programs target specific high-needs population segments, coordinate health and social care services to meet their clients’ needs, and engage clients and their caregivers. We identified thirty health and social care programs in eleven high-income countries that delivered care in new ways. We used a structured survey to characterize the strategies and activities used by these programs to identify and recruit clients, coordinate care, and engage clients and caregivers. We found that there were some common features in the implementation of these innovations across the eleven countries and some variation related to local context or the clients served by these programs.

Needs segmentation, Patient coordination and Engagement are the crucial topics. More details inside the article.

 

Primary Care value and physician compensation

Realising the Potential of Primary Health Care

If Primary Care is so important why so few physicians choose it as specialty for the residency programs?. The answer is that there is a difference in perception of value and compensation. Well, this is only the first answer. High value, high effort and low relative compensation compared to other specialties. Governments should care about it and about integrated care is finally organised. This is what OECD report says:

These new models of organisation should be more widely adopted to move away from the traditional and reactive solo-practice model. While there is no one-size-fits-all model of organisation, an integrated model of primary health care often meets the following four characteristics:
 Multi-disciplinary or inter-professional practices with a various mix of primary health care professionals (including GPs or family physicians, registered and advanced nurses, community pharmacists, psychologists, nutritionists, health counsellors, and non-clinical support staff), different models of teamwork, and different target populations (for example as seen in Australia, Canada, the United Kingdom and the United States) (Socha-Dietrich, 2019[101]).
 Comprehensive health services in the community, (for example in Costa Rica), including disease prevention and health promotion, curative services, rehabilitation and management of chronic diseases. Care co-ordination between health professionals is key to enabling the early detection of disease, reducing the exacerbation of diseases, avoiding duplication of services, and increasing provider and patient satisfaction.
 Population health management, generally based on risk stratification using sophisticated IT systems (for example in Canada and Spain), is implemented to better understand the health and risk profiles of the community and to undertake proactive management of patients’ needs. Patients are stratified to identify opportunities for intervention before the occurrence of any adverse outcomes for individual health status.
 Engagement of patients in shared decision making,

Hopper

Opioid epidemic and the need for urgent measures

Addressing Problematic Opioid Use in OECD Countries

Some months ago I explained my concerns about opioid epidemic. I said that the problem is closer than most people think. In the last five years, there has been a 45% growth in publicly funded opioid prescription  in our country. Now OCDE presents the current situation in a report that highlights where we are and what can be done. The key messages are these ones:

• Better Prescribing: Doctors can improve their prescribing practices, for instance, through evidence-based clinical guidelines (e.g. for opioid prescription, for adequate medication-assisted therapy for OUD patients), prescribers training, surveillance of opioid prescriptions, and regulation of marketing and financial relationships with opioid manufacturers. In addition, patients and the general public can also benefit from clear educational materials and awareness interventions to enhance their opioid-related literacy and reduce stigma.
• Better care: Including the expansion of coverage for long-term medication-assisted therapy (e.g. methadone, buprenorphine, naltrexone) coupled with specialised services for infectious diseases management (e.g. HIV, hepatitis) and psychosocial interventions. Some countries have implemented interventions such as the availability of overdose reversal medications for all first responders, needle and syringe programmes, and medically supervised consumption centres.Quality of care must be improved and measured. 
• Better approach: There can be better coordination across the health, social and criminal justice systems. Governments can consider setting up of coordinated networks among the three sectors aiming to facilitate access to integrated services for people with OUD. In addition to health services, social interventions around housing and employment support, and law enforcement uptake of a public health approach are central.
• Better knowledge and research: Including the use of big data and impact evaluations to generate new information from different sources along with the application of advanced analytics. In addition, quality of care measurement should be enhanced in areas such as opioid prescription, OUD health care services, and patient reported indicators (e.g. PROMs, PREMs). Research and development is needed in key areas such as new pain management modalities and OUD treatments.

Population-based genomic medicine in an integrated learning health care system

Patient-Centered Precision Health In A Learning Health Care System:Geisinger’s Genomic Medicine Experience
The Path to Routine Genomic Screening in Health Care
Medicine's future

If you want to know a latest development on the implementation of precision health, then Geisinger Health System is the place you have to go. And the Health Affairs article explains the details about the initiative and MyCode biorepository.

In 2014 the MyCode initiative began to conduct whole exome sequencing and  genotyping on collected samples, as part of a collaboration with Regeneron Pharmaceuticals and the Regeneron Genetics Center.12 Whole exome sequencing analyzes genes that code for proteins and associated gene regulatory areas—about 1–2 percent of the whole genome containing the most clinically relevant information. To date, nearly 93,000 exome sequences have been completed.

 The rapidly changing knowledge about gene-disease associations requires a process to reanalyze previously analyzed sequences and incorporate new knowledge about variants’ pathogenicity. Approximately 3.5 percent of participants have a reportable variant. As of January 2018, results had been reported to over 500 MyCode patient participants.

Interesting article, a private initiative of public interest. More info in: Science and Annals

 Josep Esquirol in Palafrugell 

Health in all policies narrative

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

A good review on the topic is welcome. You'll find this article in Annual Reviews of Public Health. If health is created largely outside the health sector, engagement in health governance, policy, and intervention development and implementation by sectors other than health, is therefore important. I have reviewed this topic earlier, but I suggest a close look at it and its assumptions:

(a) Health is created largely outside the health care (or disease) sector; (b) the health care (or disease) sector, however, often carries social ownership of all health issues, even when they are beyond its control; (c) the health sector itself is a reproduction of (power) divisions in the public and private sectors and, while calling for integration, is itself fragmented; and (d) calls for broad social engagement with integrated research, policy, action, and governance for health may not align well with assumptions a–c.

The purpose of the article is to provide an evidence-based overview of how broad social engagement in health policy, action, and governance can be initiated, developed, and sustained.

 In Barcelona Caixaforum, right now.

An article that surpasses publication bias

Evaluación de la efectividad de un programa de atención integrada y proactiva a pacientes crónicos complejos

Publication bias (Wikipedia dixit): Publication bias is a type of bias that occurs in published academic research. It occurs when the outcome of an experiment or research study influences the decision whether to publish or otherwise distribute it. Publication bias matters because literature reviews regarding support for a hypothesis can be biased if the original literature is contaminated by publication bias. Publishing only results that show a significant finding disturbs the balance of findings

We've just surpassed such conventional view and have published a new article on integrated care and I've prepared a short post in the blog of Gaceta Sanitaria (in castillian):

La integración asistencial a examen

Todo estudio experimental tiene un contexto, y antes de entrar en el detalle resulta crucial comprenderlo para evaluar sus resultados. Hay dos términos usuales en la política sanitaria de nuestros días: integración asistencial y cronicidad. En Gaceta Sanitaria encontrareis el artículo: “Evaluación de la efectividad de un programa de atención integrada y proactiva a pacientes crónicos complejos”. El programa tiene lugar en el Baix Empordà, en una organización sanitaria integrada y si comparamos indicadores de utilización y calidad seleccionados (Tabla 4) observaremos que superan sustancialmente la media del sistema sanitario público catalán. Este ya es un primer reto en sí mismo, mejorar cuando se parte de una posición de ventaja relativa.

Los profesionales están acostumbrados a dos décadas de práctica asistencial integrada. Esto significa que cualquier aproximación organizativa alternativa se internaliza y se difunde, lo que dificulta aislar el impacto.

Se aplicó un modelo predictivo que resultó ser el punto de partida para la selección de pacientes. Es previsible que en un futuro próximo sea posible la estimación probabilística de trayectorias y episodios para los enfermos crónicos complejos. Esto nos aportaría mayor precisión a la estratificación dinámica de pacientes.

Las conclusiones del estudio muestran ligeras reducciones en la utilización hospitalaria fruto del programa. Pero mantienen patrones similares entre los distintos grupos sujetos a intervención. Es por ello que destacaría dos afirmaciones del artículo: “una situación general de alta calidad asistencial previa y mantenida en el ámbito de la intervención, y una inevitable contaminación entre grupos,  dificultaron la demostración de una efectividad marginal del programa” y “la estratificación de la población con una identificación explícita de los pacientes crónicos complejos puede ayudar a avanzar los resultados, y el criterio clínico los hace  extensivos a todos los pacientes de características similares”.

Esto nos lleva a confirmar las dificultades de los estudios experimentales en los que deseamos probar el impacto de un cambio organizativo. Este estudio sería candidato a no ser publicado, porque su resultado mantiene una ambivalencia y no permite pronunciarse con claridad sobre la opción defendida con carácter general en nuestros días: la superioridad de la atención integrada y proactiva de los pacientes crónicos complejos frente a otras alternativas. Sin embargo, su publicación además de alertar sobre la dificultad de este tipo de estudios, nos señala nuevas pistas.  Más allá de los cambios en la utilización y coste que representa la integración asistencial, necesitamos medir los resultados en salud y la calidad en los episodios asistenciales, comprender el impacto en salud de estas estrategias organizativas. Esta es la tarea más relevante y sobre la que se deberían enfocar nuevos estudios. Es por ello que las investigaciones las estamos centrando en la medida de los cambios en la esperanza de vida de buena salud a lo largo del tiempo y en la medida de los episodios. Este tipo de medidas agregadas, junto con otras de carácter fisiológico y de percepción de salud y bienestar tienen que permitir alcanzar una visión más completa de lo que aporta la integración asistencial.

A tribute to the great Jim Croce (1942-1973)

A prescription for “high-need, high-cost” patients

David Blumenthal presented at the recent  OECD health conference the Commonwealth Fund report: Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers
These are the recommendations:

1. Make care coordination a high priority for patients with complex needs
2. Identify patients at greatest need of proactive, coordinated care
3. Train more primary care physicians and geriatricians
4. Improve communication between providers, e.g. integrated clinical records
5. Engage patients in decisions about their care
6. Provide better support for carers
7. Redesign funding mechanisms for patients with complex needs
8. Integrate health and social care, and physical and mental healthcare
9. Engage clinicians in change, train and support clinical leaders
10.Learn from experience; scale up successful projects

Once again, the issue is not about what, but about how, according to the specific setting. This is the reason why change implies modify incentives and coordination mechanisms. This is the hardest part, with cost and benefits uneven distributed over time and people. And this is the reason why recommendations fail so often in its implementation.

At Tate Britain, righ now, David Hockney

Predictive modeling in health care (2)

Analysing the Costs of Integrated Care: A Case on Model Selection for Chronic Care Purposes

How do you want to manage, with a rearview mirror or just looking forward? Big data allows to look forward with better precision. The uncertainty about the disease and about the cost of care is large when you enter in hospital from an emergency department. But, after the diagnosis (morbidity), could we estimate how much could cost an episode?. If so, then we could compare the expected cost and the observed cost on a continous process.
Right now this is possible. Check this article that we have just published and you'll understand that costs of different services according to morbidity can be reckoned and introduced in health management. This analysis goes beyong our former article, much more general. So, what are we waiting for? Big data is knocking at the door of health care management, predictive modeling is the tool.

Amazing concert by Caravan Palace in Sant Feliu de Guixols three weeks ago.

Efficient health systems

The five principles behind the world’s most efficient health systems

I was reading The Guardian this morning and I found this article. Forget for a while if there are five principles or more, its an op-ed. These are the key principles:

1. Integrated care
2. Hospitals as Health Systems
3. Standardise and  simplify
4. Take social care seriously
5. Payer power

You may agree or not, but it is worth checking it out.

PS. If you want to know our research contributions on integrated care, I suggest you attend this workshop.

Physicians' quality: incentives and information

In the USA, the Affordable Care Act requires the federal government to post information about physician performance and quality of care on a public website. The recent experience of public and private initiatives has been reviewed in a Health Affairs Brief. If you want to know the implications and details on how to make information accessible for citizens, this is a key document to read.

• By 2019 doctors who treat Medicare beneficiaries must choose between two options—enroll in a program called the merit-based incentive payment system or sign up to be part of an alternative payment model.
• The merit-based incentive payment system will adapt and combine multiple programs —PQRS, the EHR meaningful-use program, and the value-based payment modifier initiative—into one.
• Doctors opting for the merit-based incentive payment system must report quality-of-care measures to CMS. How is to be determined, but CMS likely will use an upgraded PQRS reporting system.
• Physicians will be scored on four components of care: quality (30 percent); resource
use (30 percent); meaningful use of EHRs (25 percent); and practice improvement  activities (15 percent).
• Physicians choosing the alternative payment model path would have to be part of an integrated health system, join an ACO.

Sounds interesting. Incentives and information altogether, a hint for other health insurance markets on what to do about it.

Beware of healthcare providers consolidation

The Potential Hazards of Hospital Consolidation Implications for Quality, Access, and Price

The key message:

  With the current most substantial consolidation of health care in US history, the concerning implications of the trend of hospital consolidation on quality, access, and price must be carefully considered. However, unlike banks that became too big to fail, 85% of US hospitals pay no taxes because they are designated as nonprofit organizations serving a public good. Hospitals can set prices that are ultimately passed on to others in the form of escalating insurance deductibles and taxes.

The alternative:

 The good work of integrated hospitals should continue to create networks of coordinated care, while at the same time, physicians and patients should insist that hospitals compete on transparent prices and quality outcomes. Achieving this goal is an important prerequisite to a functional health care system.

Integrated care and population health

Population health Systems: Going beyond integrated care

In this blog I have mentioned several times the works by Kindig on population health. If integrated care makes sense, it is because it improves population health. Otherwise we should talk about diferent things.
A new report by the King's Fund sheds some light on several experiences of integrated care. It's worth reading, because you'll see that there is not only one way to achieve the final goal, and the tool -better coordination- has to be suited to the specific setting.

The "recipe":

At a practical level, developing a population health systems perspective requires the following elements as a minimum:
• pooling of data about the population served to identify challenges and needs
• segmentation of the population to enable interventions and support to be targeted appropriately
• pooling of budgets to enable resources to be used flexibly to meet population health needs, at least between health and social care but potentially going much further
• place-based leadership, drawing on skills from different agencies and sectors based on a common vision and strategy
• shared goals for improving health and tackling inequalities based on an analysis of needs and linked to evidence-based interventions
• effective engagement of communities and their assets through third sector organisations and civil society in its different manifestations
• paying for outcomes that require collaboration between different agencies in order to incentivise joint working on population health.

FT on cancer drugs pricing

A bit worse before it gets better

Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease

A new mental frame was created some weeks ago when President Obama gave a speach on the creation of the initiative on Precision Medicine. To be honest, the term was in the title of a 2011 report by IOM.
In my opinion, it is a bundle: stratified medicine+big data+regulatory science+... This is the bundle of the new buzzword, and unless new details arise, nothing specially new.
Now the New Yorker speaks abouts the problems of precision medicine, and focuses on the risks. The final paragraph illustrates the issue:

For Solomon, genetics is simply a new tool with a learning curve, the same as any other. “When the electrocardiogram was first developed, about a hundred years ago, most physicians thought it was voodoo,” Solomon said. “Now, if you don’t understand it, then you shouldn’t be practicing medicine.” But Mary Norton sees that analogy as too simplistic. The pace of genetics research, the variability of test methods and results, and the aura of infallibility with which the tests are marketed, she told me, make this advance a more complicated one than the EKG. Norton believes that, as genetics becomes increasingly integrated into medical care, “over time everyone will come to have a better understanding of genetics.” But, as the demand for DNA testing increases, she says, “it will probably be a bit worse before it gets better.”

Could we avoid the initial bit worse of  "imprecision of stratified medicine"? . I'm full convinced that appropriate regulatory efforts could mitigate such impact. Unfortunately, governments are on vacation.

The massive information leak ever known

No Place to Hide: Edward Snowden, the NSA, and the U.S. Surveillance State

 If someone says to you that a governmental agency has been collecting  data on more than 97 billion emails and 124 billion phone calls in just 30 days, you'd probably think that it is not possible. Imagine a system that has the capacity to reach up to 75% of US emails (!). This is impressive.
Unfortunately, this is absolutely true. Nobody has  rejected it at NSA.One year after the Snowden disclosure of surveillance activities, the US Congress has had to change existing laws and Courts  that allowed such practices.

The international data collected in a single thirty-day period from Germany (500 million), Brazil (2.3 billion), and India (13.5 billion). And yet other files showed collection of metadata in cooperation with the governments of France (70 million), Spain (60 million), Italy (47 million), the Netherlands (1.8 million), Norway (33 million), and Denmark (23 million).

As you may imagine this is not a US issue, but unfortunately the impact and public pressure for change over politicians is different across countries.

I've finished reading the Greenwald book and The Snowden files. I suggest you to start with Greenwald one, the original source better than the remake. I think that one of the most interesting parts is when he explains the rationale for his information disclosure, in Chapter 2:

“The true measurement of a person’s worth isn’t what they say they believe in, but what they do in defense of those beliefs,” he said. “If you’re not acting on your beliefs, then they probably aren’t real.”

  “I do not want to live in a world where we have no privacy and no freedom, where the unique value of the Internet is snuffed out,” Snowden told me. He felt compelled to do what he could to stop that from happening or, more accurately, to enable others to make the choice whether to act or not in defense of those values.

 The book is a milestone over the conflict between freedom and surveillance, over the value of privacy in our current times. It explains many details and raises a lot of uncertainty when using internet for any reason.

PS. By the way, I haven't seen any request to our politicians about how many emails have been suplied to US authorities, how they can justify such leakage and how they have selected them. Somebody must responsible for that.


PS. New report on integrated care, by Antares.

Parov Stelar, All night