In a tech nation podcast Dr. Moira Gunn interviewed Tom Hayes about network culture. While the conversation was generally interesting the notion of being attention rich or poor really caught my attention. By this he meant that for those of us in what might be termed the connected world we suffer from an abundance of information to which we have to little time to attend. That is we are attention poor. While less connected individuals have a lot of attention that they are not using and are thus attention rich. This all relates to the attention economy first described in the 70's. As often described the attention economy means that producers of content will succeed to the extent that they can provide more information and less fill.

What peaked my interest in this was an experience I had a few months ago. We had developed a web site for providing information on a particular mental health related project to both family/consumers and professionals. The professionals to whom the site were shown were quite positive and interested in testing some of its features. However, none of them actually went on line later to do this testing. The family/consumers, on the other hand, were very enthusiastic sharing the site and information with others and wanting to push for its expansion.

From the processional's perspective - Since they were attention poor, having lots of content to which they needed to attend, this site did not really provide enough new information to warrant spending very much of their limited attention.

From the family/consumer's perspective - They were willing to invest their attention in it. Whether this was because they were attention rich and the cost minimal OR because we provided enough new information to overcome the attention cost of those who are attention poor, we do not now know. However, this would be an interesting test. Do we get higher utilization among those who are attention rich?

Another, perhaps more interesting, question would look at the digital divide through the lens of the attention economy. The poor are less likely to have access to the Internet.  Does this mean that they would be attention rich and more accessible to sites that would meet their information needs? Is there a relationship between attention and poverty? Or do the day-to-day difficulties of living with poverty not allow someone the luxury to have any attention to spend even if they did have access?

I got enthused about an new security device, Yubico's YubiKey, after listening to Steve Gibson's Security Now podcast episode 141 (with a brief description) and episode 143 (with an interview and full description). Basically, this slim USB device emulates a keyboard and emits a unique password each time it is touched. Using a web service, as well as other methods, you can test to make sure the string is a valid password. Various software examples for doing so is available from their web site.

Since I deal with securing protected HIPAA data I am constantly on the lookout for solutions to further protect access to that information. Combined with a user ID and password this device seemed to offer a simple, cost effective, two factor authentication approach.

Yubico provides a variety of sample code for Java, C, and a C# .NET. However, I needed a VB implementation that I could use in DotNetNuke. To this end I created a new DNN module, rewrote the code from the C# example, and implemented a basic system for validating the YubiKey against the Yubico's web service.

The basic code for the validations is below

Function verify(ByVal strAuthorizationId As String, ByVal strOdp As String) As Boolean
Dim _result As Boolean = False
Dim _response As String = ""
Dim request As HttpWebRequest
Dim response As HttpWebResponse
Dim strYUBICO_AUTH_SRV_URL As String = "http://api.yubico.com/wsapi/verify?id="

Try

request = HttpWebRequest.Create(strYUBICO_AUTH_SRV_URL + strAuthorizationId + "&otp=" + strOdp)
response = request.GetResponse

Dim ver As String = response.ProtocolVersion.ToString
Dim reader As StreamReader = New StreamReader(response.GetResponseStream)

' Review the response and proceed accordingly
Dim str As String = reader.ReadLine

Do While str <> ""
str = reader.ReadLine
_response += str + "-"
If str.StartsWith("status=") Then
If str.StartsWith("status=OK") Then
_result = True
End If
Exit Do
End If
Loop

If Not _result Then
' Write failed attempt to log
Dim objEventLog As New DotNetNuke.Services.Log.EventLog.EventLogController
objEventLog.AddLog( _
"Yubikey Authenticaion Failure", _
"ID: " & Left(strOdp, 12) & " Returned: " & _response, _
PortalSettings, _
-1, _
DotNetNuke.Services.Log.EventLog.EventLogController.EventLogType.ADMIN_ALERT)
End If

Return _result

Catch exc As Exception

ProcessModuleLoadException(Me, exc)

End Try

End Function

I have also zipped the source code and the installation file if you would like to explore and play with this function. NOTE: To use this code you will need to replace

Dim _authId As String = "-1" '

with your code that can be obtained for free from http://yubico.com/developers/api/

I have listened, three times so far, to a wonderful podcast of Eben Molegan a Professor at the Columbia Law School and the Founding Director of the Software Freedom Law Center. In a "discussion" with the famous publisher and proponent of open source software Tim O'Reilly,  Eban offers Tim the "opportunity to engage in a dialogue" or rakes him over the coals (it is sometimes not clear which) about the relative lack of importance of the concept of open software and the increasingly important conflict between the rights to keep things private and the rights to keep things open. While we don't get very far in this discussion it is lively and fascinating and makes me want to learn more about Modlen's thinking.

In the course of the talk he dropped a few wonderfully contrarian ideas.

• We are not headed toward a centralized (in the clouds) system but rather have a wildly decentralized one with massive storage and computing power available to us outside of the cloud.
• Soon people will wake up to the serious security problems of AJAX and people will run from those applications as they do from ActiveX applications today. (This view point is also shared by Security Now's Steve Gibson.)
• Soon people will realize that the all knowing security and spy organization (aka Google) whose major item for sale is advertisement is really worth very little and is only a tiny part of that which is important.

If you have interest in software and freedom and in the clash between competing legitimate freedoms give this fascinating and entertaining discussion a listen.

At the Missouri's state mental health Transformation Implementation Kick-off in Jefferson City Joel Slack President of Respect International described his own psychotic break during college and his life history following that event. It is a remarkable story. Through his experiences he realized that respect for yourself, which is realized by treating others with respect and being treated with respect by others, is the basis of mental health.

Joel now leads "Respect" seminars world wide and the respect seminar will be available to the citizens of Missouri as part of our new transformation.

As I listened to his stories I reflected on some of those in the past who have made exactly this same point.

"We are all much more simply human than otherwise."
Harry Stack Sullivan

"Act to bring out the best in others so that you can bring out the best in yourself."
Felix Adler

---- update ----

Joel will be presenting a free workshop in Jefferson City 1-5 p.m. Tuesday, May 13 at First Assembly of God Church, 1900 Highway C, Jefferson City, MO 65109. Located at the intersection of Southwest Blvd and Hwy C, approximately one block west of the Hwy 54/Ellis Blvd Exit. "Advanced registration is suggested. To register, please provide your name, agency or affiliation (if any), e-mail (for confirmation) and if you are interested in obtaining CEUs. Phone: 573.526.3702, Toll Free: 800.364.9687, transformation@dmh.mo.gov"

As I was using Gmail this morning I noticed the new feature notification for "Custom Time." Opening the link I found that Gmail had added the ability to alter the sent time header on an email message.

-

This seemed a bit strange (e.g., using an e-flux capacitor - but geeks are fond of borrowing terms from SI-FI for their new inventions). Besides, the Google folks are always ones for creating things outside of the box. Finally, after reading and closing the page I realized what this was all about - 1-Apr! Perhaps I would have been faster if they had not used the calendar image for 31-Mar.

Great job guys. You brought a smile to my lips this morning.

According to this NY Times article bad guys can get encrypted data out your computer by reading keys from the DRAM chips. This original report demonstrated that decryption data does remain in these dynamic chips for some time after the computer has been turned off and that chilling those chips will extend that period of time.

So what does this mean practically? Perhaps there are other ways, but off hand what I can envision is:

You are rushed by bad guys (take for example Jack Bauer) while you are using the computer and reading your encrypted data. You quickly unplug it but your assailants are able to open the computer and chill the chips before they loose their stored information.

It seems to me that in this case you are in trouble no matter what. So, unless there is some other way this might work I am not going to worry about it.

I am back from attending the National Association of State Mental Health Program Directors NASMHPD Research Institute's18th annual conference of State Mental Health Agency Services Research, Program Evaluation and Policy in Arlington VA. I posted notes on all of the presentations that I attended so you can read about those as you like. They also promised to have slides available on their web site so you can get more detail as well (the abstracts are already available from the link above).

NRI was interested in getting more participation from research institutes like MIMH and offered us an all expenses paid trip to the meeting (as well as individuals from two other Institutes). As the newest Division Director at the Institute I got asked to attend. While NRI paid my way they did not ask me to write about the experience and they may have never even considered that someone would blog their conference. So the comments (and errors in those comments) in this and the other posts from the meeting are my own.

It was interesting that while NRI paid for our attendance, they made no efforts during the meetings to meet me (or I presume the other research institute attendees) or to have us meet together to explore their goals for our participation. While I was exhausted from the rounds of presentations this seems like a missed opportunity that I suggest they address if they do this again.

When I first looked at the two and a half day program there was lots of stuff that seemed of interest. After all, I have been working in public mental health for over 25 years so how could presentations for the NRI be uninteresting. The night before I read the abstracts and plotted out my selections. However, I was beginning to get cool feet and felt that I might be in for the usual sort of conference "fluff" that was long on flash and short on substance. One of the reasons for this is that a couple of the presentations were reporting anew the same sort of work I had read 25 years ago.

Well I was wrong. The presentations were anything but fluff. They were solid, data supported, presentations that showed states effectively using information to make changes to improve the lives of their citizens. Outstanding!

I have always been an "L" and believe that government could (and should) be a source of help for those in need. As a single individual I cannot have much impact of the mental health needs of my fellows. But as a member of a community, which is what a state represents, our united efforts and dollars can have a positive impact. Those attitudes have taken a beating in recent years, but the programs presented at this conference and the states hosting them have shown this can be true. They have helped excite me and restore my belief in the power of the community, as represented  by our governments, to be a positive force in the lives of those in need.

To me, this is great outcome and well worth my time and effort. Thanks for the invitation, I'll be back!

To make it easier to find them, here are the available posts:

• NRI - Better but not well
• NRI - Learning Collaboratives in New York
• NRI - Chronic Medial Disorders with SMI
• NRI - Behavioral health assessment system
• NRI - Collaborative Research
• NRI - Improving data
• NRI - PTSD
• NRI - NOMs and TRAC data systems
• NRI - Enhancing mental health treatment effectiveness
• NRI - Grading the states
• NRI - Describing state mental health agencies
• NRI - Evidence based practice in practice

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC, PTSD Then and Now, There and Here, Robert J. Ursano, MD, Director, Center for the Study of Traumatic Stress www.usuhs.mil/csts.

Robert Glover (Ex Dir., NASMHPD) introduction. NASMHPD has been focusing on this at a high level and considers it a serious problem. Concerned about suicide prevention particularly with returning National Guard and reservists. 1-800-273-talk (www.shicidepreventionlifeline.org) suicide prevention lifeline which has access to military. On last Saturday 238 vets called the line for help!

"Trauma is bad for your health" and "War is a trauma."

Hospitalizations in the DoD for trauma are second only to those for pregnancy.

Trauma associated with death is important for some individuals but trauma associated with separation and return is the common event for all service personnel.

War is an intentional and human made traumatic event the combination of which create the most trauma. 1.5 million Americans have returned from Iraq or Afghanistan (300,000/state; 1,500-6,000 cases of PTSD/Depression per state). Because combat is an ongoing traumatic event it is harder to treat and does not respond as readily to medications.

Of the vets who have problems only 20% actually get specialized MH treatment. If you have PTSD you are likely to fear admitting the problem or getting service because it would negatively impact your career. This is no different from the risks people in the general population feel.

PTSD treatment (for all individuals) often does not begin for 12 years after the events. Even then only 65% actually get treatment. PTSD seems to increase over the course of time with injured solders having 12% PTSD and 9% depression after 7 months.

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC two presentations on the implementation of evidence based practices.

Linking Outcomes to Services: Using Montana's Recovery Markers for Program Development and System Change, Alison Hwong & Bobbi Renner.

Fourth largest state but a rural frontier population with 12 Native American tribes and seven reservations. They have developed a web based system to measure their outcomes.

Four recovery markers are used

1. Employment status,
2. housing,
3. level of symptom interference, and
4. substance use.

which are collected every 3 months. The Information system also links to pharmacy data, demographic, diagnosis, functioning, living status, and service provides. Will be able to link to the medicare/medicaid data.

[The nice thing about the markers is that they are typically single items with a few categories. This will be simple for users to enter and conceptualize, though psychometrically weak. Their simplicity may also lead to system gaming.]

Problems with implementation

• Lack of computer experienced (one user called reporting a strange moving line on their screen. After a bit of description it turned out to be the cursor.)
• Communication problems between users and computer professionals
• Art vs. science [practitioners think about treatment as a holistic interpersonal enterprise while computer folks are interested in the change in recovery markers]
• providers say they were required to enter to much information without additional compensation (advocacy groups wanted more information)
• maintenance level
• providers felt that the information collected "will never be useful to us"

[The implementation issues discussed in this presentation are exactly the same as those addressed during the early days of computer applications in mental health. Why is it we keep rediscovering the same facts over and over? Why have the folks who develop these systems not been taught the lessons we have learned?]

Ohio's Wellness Management and Recovery Program: Working Collaboratively to Develop, Implement and Evaluate a Statewide Recovery Initiative, Marion Becker, Airia Sasser, Timothy Boaz, Amber Gum, Wesley Bullock, Kelly Wesp, Deborah Wilcox, & Stephanie Rich. www.wmrohio,org 

Participants develop a wellness plan using a psycho educational (social learning model) curriculum with role plays, video, lots of interactive content. Trainers are pairs one consumer and one staff. Doing a rigorous evaluation because they want it to be an evidence based practice.

Session topics (10 2-hour sessions)

1. Mental Health recovery
2. Wellness
3. Understanding of Mental health
4. role of Medication in recovery and wellness
5. Learning to manage symptoms and side effects
6. Effective communication
7. communicating with your providers
8. Coordinating your care
9. Building social supports and involving others
10. Planning for wellness.

Lots of focus on learning new skills.

Have moved from systems data to individualized data. Asking each consumer what they want to achieve. Steve will provide these on request.

[This is a really nice idea and one that I have been advocating for a number of years. If an individual's services are being directed to areas A, D, and E why would we bother assessing changes in areas B, and F? While this makes sense to evaluators this does not seem to be clinically reasonable. With our advanced statistical and data management techniques we should be able to define specific outcomes for specific individuals rather than assuming everyone is the same.]

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC, Understanding State Mental Health Agencies, Ted Lutterman & Bernadette Phelan  (NRI).

State mental health agencies

Agencies provide services, public health, and public safety.

There has been a shifts in organization with reductions in the number of states with a separate department (19-13 1981-2007) and fewer linked directly to the governor. This is important because the closer to the governor the more resources are available.

Most states (26) have MH and ADA in the same agency. This has increased since the 80s. Most directly fund agencies (28) but many fund counties/cities (16) which adds another level of government to the provision of services.

In 1954 there wee 354 state hospitals with 550,000 residents. In 2007, 228 hospitals with 50,000 residents. The size of hospitals dropped in the 60s and 70s but hospitals themselves did not start closing in large numbers until the 90s.

In 1979 1 our of 3 hospital beds were psychiatric. In 2007 1 out of 7 is psychiatric. These decreases have lead to shortages of acute psychiatric inpatient capacity with increase ED treatment, long treatment waits, overcrowding, etc. States have been addressing this by trying to increase programs to keep folks in the community.

Many states are working to decrease service fragmentation by working with various other state agencies (housing, employment, juvenile and criminal justice, etc.

Most states have mental health courts or diversion programs (43).

Public mental health agencies treat 2% of the population with 96% of those being treated in the community. Almost half of these are not in the workforce and most live in private residence (76%). Most of those (75%) treated are seriously mentally ill.

Over time there has been no improvement in terms other the number who return to the hospital within 30 days (9%) or after 189 days (20%). [Interesting that with the increases in treatment effectiveness that this has not changes. Though it may be related to the fact the the number of individual served has decreased so that those in the hospital will likely have more difficulties.]

There has been a shift in funding from state funds to medicaid. with 45% currently coming from the latter.

Other state agencies

MH services are also provided by other state agencies. NRI is looking to see if they can get information from these other agencies so that they can better understand what states are doing for mental health. Sending letters from the state MH agencies and identifying where they can find the answers to the questions.

NRI has no data to report because they need to get the appropriate clearances (will report at the next year's conference).

While the states and agencies are interested in this there are challenges in getting the data. Agencies may not record data in an obvious way. For example states working with education counted all of the $s spent on special education as mental health services.

Note that all of the data they report is publicly available.