• Future Directions for Microsoft


    The five most significant initiatives that Microsoft has invested in are the Internet the Things (IoT), Big Data, corporate social responsibility (CSR), mobile telecommunications, and healthcare IT (HIT). We will review why each initiative is among the most important, why Microsoft became involved in each, and how the initiative has or will affect the company in the future.

    Internet of Things

    IoT refers to devices being connected to the Internet. These devices contain embedded sensors and software that allow them to talk to other machines, providing data that can lead to better decision-making. In recent years, Microsoft has entered into many strategic partnerships with companies like Toshiba, Fujitsu, and Texas Instruments to target this market (Singh, 2015). Their most recent release in IoT is the Azure IoT Suite, which will integrate IoT technology into their cloud service (McLaughlin, 2015).

    The market potential here is so large that any telecommunications company stands to gain from capturing even a segment. It is estimated that IoT will contribute $US 10 - $15 US billion to global GDP in the next two decades (Press, 2014). This is due to the convergence of several factors, including the drop in sensor prices, increased adoption of broadband, memory becoming affordable (thereby allowing for greater data storage and analysis), and the adoption of IPv6. This last factor will allow for an essentially limitless number of Internet connected devices. Only about 10% of the IoT financial impact will be the result of the devices themselves. Most of the impact will be from how those devices are connected (Bauer, Patel, & Veira, 2014). It is likely that Microsoft became involved in IoT at this time because of the size of the potential market, and they stand to make a significant financial gain if even the less optimistic predictions are correct.

    Big Data

    Equally important to IoT will be the collection, storage, and processing of the large data sets IoT will generate. These initiatives fall under a variety of names, including business analytics, business intelligence, and data science. However, the umbrella term “Big Data” is generally used because with the cost reduction in storage, almost all data is becoming “Big.”

    Microsoft has made significant progress in this space. They have developed a variant of SQL (called U-SQL) to run with Azure Data Lake Store, that has been specifically designed for large data sets (Patrizio, 2015). Products such as Business Analytics Accelerator are targeting the telecommunications sector, while their acquisition of Revolution Analytics targeted the R programming language that is primarily used for data analytics (Brust, 2015). Furthermore, the company is slowly developing a reputation for making accurate predictions using Bing Predicts (Stenovec, 2015).

    The integration of technologies such low cost storage, affordable bandwidth, ubiquitous sensors, and sophisticated machine learning are likely to change how a great deal of decisions are made. Up until now, decision-making relied on data models where the data was limited and the statistical techniques conformed to those limitations. However, as sensors collect data constantly and in real-time, the available data sets will come closer to reflecting a truly comprehensive and accurate picture of conditions as they unfold (Mayer-Schönberger & Cukier, 2013). It is likely that Microsoft is investing in Big Data because it promises to be a revolutionary technology; one which will allow them to gain market share in a lucrative industry segment while improving their own forecasting and decision-making.

    Corporate Social Responsibility

    Microsoft’s CSR initiatives are wide-ranging. They include such diverse projects as bringing solar-powered wireless Internet access to rural Kenya and providing computer science training through YouthSpark for students who would not normally have access to technology (OPIC, 2015).

    Research indicates that the public’s desire to interact with a company, whether making purchases or seeking employment, is more heavily weighted toward their perception of the company than their perception of the products and services provided by that company. 42% of how people feel about a company relates to their corporate social responsibility (Smith, 2012).

    A corporation’s reasons for engaging in CSR are usually a mix between how they believe it will affect their earnings, and what they believe their responsibility is to the greater community in which they operate. One school of thought claims that a company’s only responsibility is to their shareholders. In the strictest sense, this means increasing the value of the stock. However, most companies today choose to take a more holistic view, whether within their local communities or on the broader stage that Microsoft inhabits.

    Microsoft specifically uses the word “responsibility,” saying that they must fulfill their responsibilities to the public through social initiatives (Smith, 2012). Microsoft’s significant resource commitments to public sector issues, both through their company and through the Gates Foundation, suggest that the reason they are involved in these initiatives does support their rhetoric. Judging from how well they do in CSR rankings, it is likely that these efforts will continue to have a positive affect on attracting and retaining their customer base.

    Mobile Telecommunications

    Microsoft’s major initiative in mobile technology was the acquisition of Nokia in 2014. While they have a small segment of the mobile devices market, the prevalence of Microsoft software means that most of their services are available for use on tablets and smartphones. Satya Nadella, Microsoft’s CEO, has stated part of the company’s strategy under his tenure will focus on mobile and cloud services (Blattberg, 2014).

    Smartphone penetration rates have surpassed personal computer rates (Basenese, 2013). Mobile device such as the smartphones and tablets have replaced the large collection of consumer electronics that used to be required for the same set of activities. A smartphone now acts as a camera, phone, answering service, GPS, video camera, music player, radio, calculator, and the list goes on. Because cellular phones are generally cheaper than personal computers, they are capable of accessing a wider variety of untapped markets, such as the developing world and low income households in the developed world.

    This is one initiative where CSR is most likely to overlap with market growth, expanding on the ideal of “doing well by doing good” (Brainerd, Campbell, & Davis, 2013). Large portions of the globe still do not use technology products, and mobile devices are the most likely foothold into that market. Often the gains made by access to technology in the developing world allow for great improvements in social conditions, such as the examples of farmers being able to access weather and crop price data, or rural communities being alerted of impending natural disasters (Schneider, 2015). Continuing to invest here should allow Microsoft to focus on a largely untapped market that shows remarkable growth potential, while also reaping the benefits of an effective CSR strategy.

    Healthcare IT

    Microsoft has been integrating features into their software platforms that target the healthcare industry. They have been working to enhance Skype as an alternative to dedicated telehealth products (mHealth, 2015). Windows 10 includes security standards that meet healthcare standards and collaboration features that allow healthcare providers to share patient documentation (Kern, 2015). In this way they are offering their software platforms as an alternative to costly electronic health records (EHR), whose deployments have generally been problematic. This allows them to target medical centers that are not ready to commit to EHR, but would still like to utilize technology to decrease costs and improve efficiency (Healthcare Innovation Editors, 2015).

    Healthcare is one of the few industries that has maintained robust growth even in the face of the global economic crisis. Much of this is due to the fact that the worldwide population is aging. The elderly population (those 65 and over) is projected to triple by 2050, going from 531 million in 2010 to 1.5 billion in 2050 (Kochhar, 2014). This will mean more long-term management of chronic health conditions and more in-home care opportunities, such as telemedicine and home testing devices. This is another large market that is relatively recession proof, and increasing investment should lead to steady growth, if only due to demographic factors.


    These are the five initiatives that Microsoft should put the most focus on. All five have the potential for increased or sustained growth, with some promising significant growth, while allowing the company to enhance its corporate image and engage with the worldwide community in meaningful ways.




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  • Crew Resource Management

    Using crew resource management in medicine is a fascinating idea, particularly for an aviation junkie. Aviation is one of the great safety success stories. We haven’t been flying that long. “Commercial” aviation started in 1908 when Wilbur Wright took an employee flying. In 106 years we’ve gone from flying being one of the more dangerous activities you could participate in, to it now being among the safest. Depending on who you talk to, upwards of 98,000 people die each year from medical error in the U.S. The deadliest year in aviation was in 1972, and only 2,429 people lost their lives worldwide.

    Of course, you can argue that there are far more moving parts in medicine, but aviation is a highly complicated business. There may be only one pilot and one co-pilot, but each machine has millions of moving parts that all have to be sourced and quality controlled, and maintained. At peak flying time (around 3 pm), there are approximately 19,000 airplanes in the air. Some in good weather, and some in terrifying conditions. Yet in 2013 only 265 people died.

    If nothing else, the medical establishment could use the kind of transparency that the aviation industry enjoys. Perhaps medical mishaps would decrease quickly if every time there was a questionable hospital death, an NTSB-equivalent team showed up to run an investigation. While teamwork, problem solving, and standardized operations are among the factors that both groups can use in common, not letting hospitals oversee themselves might be a good start. No one suggests that Delta run its own investigation when one of its planes go down.

  • Courage

    I got a text from my doctor today.  It gave me the date and time for my next appointment, and all I had to do was type “confirm.” I was so pleased.  I hate the old confirmation process.  The doctor’s receptionist calls me and listens to my voice mail.  She (and it’s always a she) leaves a message with the date, time, doctor’s name, her name, and a call-back number.  Then I call the number, get a phone tree, have to listen to the entire phone tree, hopefully press the right number, hopefully the machine doesn’t disconnect me, and maybe I actually get to talk to a live person.  Who may transfer me to someone else. Who might be at lunch. Or only works on Tuesday mornings and Saturday night after midnight. 

    This time I only had to type C-O-N-F-I-R-M.  Sheer heaven.

    When you study health informatics, everyone starts to look like a patient and you notice details that you missed before.  Whether it’s a texting confirmation, or something more weighty.  My heat broke on a particularly cold night last week, and the man who came to fix it had a scar wrapping all the way around the front of his hairline.  So being the naturally curious type (or nosy, depending on what region of the country you are in), I asked him about it.  Luckily, he seemed happy to share.  Turns out he had, had some awful ATV accident when he was 12. It was bad enough that he woke up a week later in the hospital and didn’t remember a thing.  His face was so badly smashed in that his damaged nasal cavity was leaking fluid into his spine, which somehow led him to contract meningitis, and they had to reconstruct his facial structure.  Not surprisingly, he had to quit football, and when he went to play baseball, he had to wear protective headgear. All this at the age of 12.

    Now he is fairly handsome young man, and looks healthy and full of energy.  Studying health informatics has resulted in me hearing lots of stories just like that one.  And whenever I hear these stories, I imagine how technology will help people who find themselves hurt, scared, and in pain.  It reminds me of how brave people are, and I don’t think there is anything that improves life more than witnessing courage.

  • SAP versus Oracle

    Deciding between SAP and Oracle is essentially a decision between two different cultures. These are large investments that tie the customer into one of two separate and distinct cultures. And since buyer’s remorse would be prohibitively costly, making the right decision before committing is crucial. Technically speaking, these are global corporations. But SAP is primarily a German company, while Oracle is immersed in San Francisco’s tech culture.

    SAP is the world enterprise resource planning (ERP) leader, with 24% of the market. This is its core competency, and has been since the company started in 1972. It is headquartered an hour outside of Frankfurt, Germany’s fifth largest city, in the town of Waldorf. With US$ 21 billion in revenue (2013) and 66,000 employees, it is the third largest software company in the world.

    With US$ 38 billion in revenue and 122,000 employees, Oracle is the second largest software company in the world, but only holds second place in ERP with an 18% market share. The company started in 1977, but didn’t make tentative steps into ERP until the 1990’s, only getting serious after 2004, through a series of acquisitions. Though it has tried to position itself as the more nimble choice to German stodgy tradition, both organizations are behemoths.

    These two companies have been playing out the greater debate on which direction capitalism should take by being flagship examples of the difference between German and U.S. economic systems, with America standing for competitive and destructive creation, while Germany holds the line on planning, prudence, and stability. This contrast is reflected in their ERP systems, with SAP taking a more centralized approach, and Oracle providing various, less integrated options. So what are the practical differences for someone weighing the pros and cons?

    SAP has more customers claiming implementation failures and significant operational disruption. Their total cost of ownership (TCO) runs 4%, being the more expensive choice to Oracle’s 1.7% TCO. But their time to implementation runs 4 months, against Oracle’s unimpressive 22.5 month showing.

    The main differences here revolve around functionality. SAP’s service provides a more integrated, comprehensive platform, whereas Oracle is piecing together different platforms to offer a more tailored experience. SAP rates better on delivering the expected functionality, whereas Oracle wins the contest when it comes to a faster payback, with less training required for a less all-inclusive product. Furthermore, there are some differences in direction for future technologies. For example, SAP in-memory technology is being focused as highly functional and integrated while Oracle is selling itself as being easier to integrate with existing systems. And it has been more successful at transitioning into the cloud.

    Overall, Oracle is the cheaper alternative, but not as convenient and useful as a more comprehensive, centralized system. If more customization is required, Oracle may be the better selection. But if a company wants to be up and running quickly with a minimum of hassle, than SAP could be the better course of action. Finally, SAP may have an advantage in the future being the European market leader. ERP is projected to grow 22% in Western Europe in the next several years, while ERP worldwide has only been hitting 2.2%. For companies that have a significant European presence, or want to expand into this market, SAP would come out on top.

  • Clinical Decision Support

    In reading about clinical decision support (CDS) and evidence-based medicine, I am inclined to think as much change needs to happen in the social system as in any information system.  We seem to be at a stage in medical research where there is too much information to process, not enough people to process it, and not enough time. Furthermore, it’s not clear that more funding would improve the system at a foundational level. This last is almost a moot point, since greater funding than we already have is unlikely to be forthcoming.

    No matter how well-designed your system, information overload is information overload.  The requirements of medical specialization are so great, that each provider can only be expected to master a tiny portion of the field.  This leaves a huge gap between the primary care provider (PCP) and the specialist, so much so that it may be difficult for a PCP to know where to send a patient.  And since most illness and disease crosses these knowledge boundaries, the type of integrated approach necessary for true healing is usually not happening. It seems like we are doing more harm than good by trying to do more than we can.

    Until we develop effective AI, HI is simply a tool.  It can’t give you greater brain capability.  There is so much new information being put into the system, that sorting through evidence-based guidelines is a job in itself.  Improving the information system certainly helps.  But at the same time, doctors should be seeing fewer patients, taking more time for an accurate assessment and diagnosis, and having someone whose job it is to assist them in consolidating the knowledge that the information system provides.

    In law, attorneys have paralegals. In politics, politicians have aides.  Both these jobs essentially require contextualizing vast amounts of data for the person who has to make the ultimate decision.  While some medical practices may have physician assistants (PA) who fulfill this function, often a PA is discharging an entirely different type of responsibility by simply seeing less complex cases. In an ideal world, each physician should have a clinical medical librarian to research and digest the evidence-based research.

    The problems of this information overload are illustrated by the example of pharmacists overriding medication warnings.  Apparently the fix in this case was to reduce the number of warnings.  But assuming the warnings were valid, this opens the door for liability.  If you know there is a risk in a medication (no matter how low), and you choose not to share it because your providers can’t process that amount of information, you are essentially withholding information from the patient.

    At the end of the day, there is too much information in the system for providers to process. IT systems organize, disseminate, recombine, reshuffle, and perform a whole host of services.  But they can’t think for us, and more thinking, with more time to think, is what’s required here.

  • Future Trends

    If personal health records (PHRs) are adopted more readily by the elderly, perhaps this greying of the U.S. population will have a domino effect in other areas of health IT and on the internet itself. Older people have a reputation for being less tech savvy, but if they are drawn to the use of PHRs, how can this be capitalized on in other realms?

    The observation that most medical practices in the U.S. are small, without the budget to deeply invest in electronic health records (EHRs), may also have interesting implication for the future. Does this point towards the adoption of more cloud offerings with perhaps a basic level for most practices, and a more robust level for the larger medical centers? This price structure looks more like the one for mobile apps, where those who invest in the “expensive” apps are supporting those who think they can function with the free version.

  • OS Landscapes

    Some people believe that Unix will shortly be phased out. They cite its greater cost as the primary driving actor in this prediction. However, Unix has some advantages that may mitigate its high price tag.

    Unix was created in the 1960’s by AT&T’s Bell Labs, and became commercial in the mid-1970’s. Although it has a variety of customers, Unix has been primarily used by large corporations due to its cost. This high cost is the result of each Unix system being custom written for each separate client. There are estimated to be approximately 5.5 million installations. It even has bragging rights for being the system used by the popular Apple OS X.

    Linux was released in the early 1990’s, after being developed from a Minix (mini-Unix) framework. It is an open source product that began being used by small-to-medium companies, but now more companies are migrating from Unix to Linux. Google uses it to process their search algorithms and their Android mobile OS. Proponents claim that it is somewhat more secure because it is open source, which leads to constant innovation. It is free to use and modify, but vendor assistance can be purchased separately.

    With the Unix system, vendor assistance is included in the cost. Servers start at US$ 25,000 – US$ 250,000 for a mid-range system, and can run up to US$ 500,000 for a high-end system. Since Linux is free, and clearly the market leader with approximately 25 million installations (not including Android), why would people continue to use Unix? Or is it the Blackberry of operating systems?

    The obvious downside to Linux is that open source means inconsistencies and constant change. So while customers may have to wait for a patch when a problem is discovered, they also know that Unix provides published standards that can be relied upon. This makes it simpler to operate for both users and vendors. Unix is targeted only toward a particular hardware architecture, so it can be utilized to use every feature.

    Unix is still the platform of choice for the financial infrastructure, and large operations requiring 24/365 coverage. Instead of being phased out, it is likely to continue to be the “luxury” model of operating systems, particularly given how risk averse financial institutions are.

    When people begin to argue about the pros and cons of Apple’s iOS mobile operating system versus Google’s Android, they will probably start with the tiny details that impact their daily lives. iOS devotees claim that the pop-up window notification trumps the Android notification bar, or that they can’t live without the message counter. They swear FaceTime beats Skype mobile. But how else does iOS stack up against Android?

    iOS is Unix based, whereas Android uses the open source Linux. In some ways, the debate here mimics the Unix/Linux debate for larger platforms. Because Linux is open source, Android offers a wide variety of different features and price points. With iOS, there isn’t much choice. However, that lack of choice provides some benefits. When upgrades become available for iOS, they are generally available for all devices. This happens in a more piecemeal fashion in the Android ecosystem. Apps made for the iPad are generally made specifically for that platform. Apps made for Android tablets tend to simply be scaled-up versions of their mobile phone cousins.

    Android’s variety may continue to be a strong selling point as Google moves further into the ubiquitous computing space. With Andriod@Home (home automation), ingestible diagnosis sensors, internet blimps, self-driving cars, Google glass, and Android watches, the company is aggressively investing in segments that computerize previously unconnected parts of our life.

    The fact that their phones connect seamlessly with the present array of Google offerings (Google calendar, contacts, docs, drive, etc.) also makes them more than competitive with Apple’s iCloud service. These selling points seem more important than the iPhone’s mute switch or its generally longer battery life. These are features that will eventually be improved in the Android choices.

    iOs is less likely to be the victim of malware, because Apple verifies the IDs of their app developers. On the other hand, the Android applications are isolated from its main system, making it less vulnerable to bugs. Google Now is generally considered faster and more useful than Siri, but that may change with the iPhone 6. Android is rated as being more stable with fewer crashes. The list goes on.

    Finally, there is the cost. While there are luxury phones using Android that run several thousand dollars, the iPhone is generally more expensive than Android devices. Apple used to be able to justify their higher cost on the basis of superior quality, but companies like Samsung now seem to be meeting those same quality standards.


  • Misplaced priorities

    Mobile health apps are colorful, fun, often useful, cheap, and obtainable by anyone with a smartphone. For people with some disposable income, wearable technologies like the fitbit and Jawbone Up provide motivation and enjoyment. Tablets operate almost like portable desks, where professionals of all types can essentially take their office with them. And people do have personal attachments to their devices, which probably now rival the affection they feel for their cars. This bodes well for people using and learning from the seemingly endless mobile options available.

    However, we’ve been through this love affair with technology in the field of education, and the results have been disappointing. For several years, every school budgeted (often significant amounts) to get the latest technology, or the latest technology they could afford. Yet all those resources have not improved test scores or literacy rates, while quite a lot of research points to the damage that is being done to developing brains by the peripatetic nature of screen immersion. Countries still employing traditional teaching methods without technological enhancements are surpassing us.

    Without a doubt, technology is going to continue to proliferate in both education and healthcare. And it will help a lot of people. But what groups will it actually help? What percentage of the population will it actually help? And at what price? We should pay attention to the lessons learned in educational technology to increase our chances of successfully utilizing technology in healthcare. The fact that 90 million people in America read at or below the level of a 6th grader may have a greater impact on health outcomes than any mobile technology intervention can counterbalance.

  • Executive Support Systems: From Bullets to Hospital Beds

    Marilyn Hewson was made CEO of Lockheed Martin (Lockheed) in January 2013. Lockheed is the third largest aerospace and defense contractor in the world, and the largest provider of information technology services to the U.S. government. She has been with the company for 31 years, and the company celebrated their 102nd anniversary with a fiscal year 2013 revenue of US$45.358 billion. Their core businesses are aerospace and defense, space exploration, and IT, and they have been diversifying into such fields as energy, data analytics, and healthcare, to address the shrinking defense budget.

    Mrs. Hewson was trained as an economist, receiving her master’s degree in the field from the University of Alabama. Additionally, she has attended executive business training programs at both Columbia and Harvard, building on her undergraduate business degree. She was appointed by President Barack Obama to the President’s Export Council, which is the nation’s most prestigious advisory board on international trade. She has sat on many additional boards, including Sandia National Laboratories and the Congressional Medal of Honor Foundation.

    As President and CEO, she holds the most senior position at the company, and has seven Vice Presidents (VP) who are her direct reports. They oversee approximately 116,000 employees at 17 subsidiaries. Her primary business function is overall strategy. In this capacity she must have a working knowledge of every business function in the organization, including research and development (R&D), production and quality control, sales, marketing, distribution and logistics, management accounting, public relations, and even recruitment of high-level executives.

    Mrs. Hewson must make an exhaustive array of decisions. To begin with, she must be an expert on governmental affairs. This includes not only political considerations at the national, state, and local levels, but knowledge with agencies with widely different cultures, from the Department of Defense (DOD) to the National Aeronautics and Space Administration (NASA).

    Additional, she routinely makes decisions in Lockheed’s dealings with foreign governments. Her position is closer to that of ambassador, given the economic clout the company holds. This entails an ongoing sensitivity to those foreign nation’s relationships with the United States.

    As a high technology company CEO, she oversees some of the most advanced platforms and systems ever created, such as the F-35 Joint Strike Fighter and the Orion Multi-Purpose Crew Vehicle. This requires a highly educated and skilled workforce, and a conversant knowledge of the science and engineering that make these complex projects run.

    Aerospace and defense have some of the longest development life cycles, often spanning decades. Because of this, she must make decisions about identifying our future adversaries and what kind of technology they will have developed. While ultimately Lockheed makes these decisions in tandem with the government, it is often company scientists and engineers who have the expertise to make the best predictions.

    Finally, she must make the same assortment of decisions that senior leadership in any capacity must address, such as the national and worldwide economic climate, legal and regulatory issues, judging who Lockheed’s largest competitors will be (such as Boeing and Northrop Grumman), and dealing with shareholder relations. This last is particularly important, given that her predecessor was removed for having an affair with a subordinate.

    To make these decisions requires information from countless sources. She must be up-to-date on world affairs, and breaking news that can impact the political scene and defense posture of the country. She needs upcoming changes in regulations, scientific papers that describe developing technology, legal advice on both national and international law, and an array of the latest economic forecasts, in addition to daily reports on the state of the market.

    Given how vast the scope of information is to develop strategies for Lockheed, her position requires a combination of information systems and human input to filter and assimilate. With her constant travel schedule and social obligations, the information system that supports her work should be focused on her direct reports. Each of these VPs must have access to sales figures, corporate intelligence, worldwide news, the latest technology journals, in-house legal counsel, professional accounting developments, and other sector specific information streams that would be included in an executive support system (ESS).

    Since it is their job to filter this endless stream of information, the interface between Mrs. Hewson and her VPs must be controlled but flexible, allowing them to access her immediately, while simultaneously providing structured, scheduled reporting times. She will need a light but powerful laptop that is durable enough to be carried everywhere, given that neither a tablet nor cellphone would provide enough functionality.

    Finally, her technology must be completely secure, utilizing the state-of-the-art, and constantly being updated and scanned for threats. As one of Lockheed’s core revenue streams is IT, the company essentially has an in-house testing lab and front row seat to what works and what has failed. This should give them a competitive advantage in developing a cutting edge ESS.

  • Altering Behavior

    There is no doubt eHealth can aid in patient self-management and creating effective education systems to aid in that management. However, we have a long way to go in figuring out where intervention is most cost effective and provides the best outcomes. If we are facing such skyrocketing costs in our lifetime, there should be some rational metric for allocating funding. And to create those metrics, we have to come to some basic agreement on what drives behavioral change.

     Thomas Goetz’s video (It's time to redesign medical data) has some weak conclusions. For example, he claims that fear is not a motivating factor in behavioral change, and then uses an example of speeding signs, which most likely are effective due to the fear of consequences. People don’t need a belief in their efficacy to stop speeding. Similarly, dental care comes with the fear of shaming.

    The role of efficacy can be equated with the ability to delay gratification, as in the oft-cited marshmallow experiments (See the amusing Ted Talk Don't eat the marshmallow!). This is a behavior that can often be traced to early childhood development, when individuals are exposed to conditions that either lead them to fear that their needs will not be met, or provide them with the assurance that their actions will provide rewards.

    If the development experts are to be believed, this is extremely difficult conditioning to overcome later in life. In a nutshell, fear (of legal consequences, of being shamed, of being outcast, etc.) is the dominant motivator in cultures of scarcity, where the likelihood of there being resources in the future is low. Efficacy is only realistically developed in people who are not subjected to constant scarcity. So at the least, we’re talking about trying to motivate two groups with entirely different motivations.

    A recent article describing attempts to impact texting while driving is one of the clearest examples of people’s inability to make healthy changes ("Trying to Hit the Brake on Texting While Driving"). The risk is of killing yourself or committing manslaughter. The benefit is to get a short message that in 99.99% of cases can wait until you stop your car. It must be the largest risk versus smallest reward in the history of risk and reward. Yet people still do it.

    Using drunk driving as an example, the article states, it was “education campaigns combined with tough, enforced laws” which led to the reduction of this deadly habit. And it’s only been a reduction. As Mother’s Against Drunk Driving (MADD) statistics report, “In 2012, 10,322 people died in drunk driving crashes - one every 51 minutes - and 290,000 were injured in drunk driving crashes…..At the cost of 199 billion dollars a year.” ( In some subcultures, there appears be more shame in bad breath, than in killing someone because getting high feels good. But if enforcement had an impact, fear is a motivating factor.

    Some researchers believe that eHealth may have immediate benefits, but that the data on long-term change is less hopeful. Perhaps those interventions that don’t show long-term progress should not be invested in. What about the interventions that cannot document either short or long-term change?

    While many initiatives may be cost effective, we will have to start rank ordering that effectiveness, if we hope to rationally allocate our resources. To do that requires consensus on how to alter behavior. We don’t simply want to be catching the low hanging fruit because it’s there.