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Monday, January 16, 2017

Health 2.0 #WinterTech 2017

Following up on my prior post. Above, Julia Morgan Ballroom, 465 California Street, downtown San Francisco, 7 a.m., the calm before the storm.


Above, the emblematic WinterTech 2017 slide of the day. The recurrent major topic was that of speculations as to the future of "Obama Care" (and specifically what it portends for #SiliconValley and venture capital investments in Health IT) under the incoming Trump administration. Below, the signature of Tea Party Republican Dr. Tom Price (orthopedic surgeon) of Georgia, Trump's nominee for the next Secretary of HHS." The Price is Right?"


Above, an audience phone-text poll on the likely alternative futures of Obama Care under Trump. "Obama Care Lite with Slowed Value" was the winner with about 2/3rds of the vote. ("Obama Care Lite" meaning that "repeal" measures will be in large measure "cosmetic" --  meant to be political pacifiers, while core coverage elements of the ACA will remain quietly in place, with some decrements in "value" QI initiatives).

Anybody's guess at this point. As I write, it's Monday Jan. 16th. This headline blares forth online at HuffPo:

President-elect Donald Trump says he’s putting the finishing touches on his plan to replace Obamacare.

It sounds absolutely terrific, like the best health plan ever!

It also sounds wildly out of step with what Republicans in Congress, or even some of Trump’s own advisers, have said they would like to do.

Trump’s comments, which he made in an interview with The Washington Post that appeared Sunday, could mean he’s gone rogue and decided that, at least on health care policy, he has more in common with Sen. Bernie Sanders (I-Vt.) than House Speaker Paul Ryan (R-Wis.).

Or they could mean that, in reaction to public anxiety and recent protests over the possibility of more than 20 million people losing insurance, Trump is already misleading people about what he and his Republicans are planning to do.

Or Trump’s statements could mean that he has no idea what he’s talking about...
You're gonna get cognitive whiplash trying to stay abreast of this stuff.

Succinct summary update of the day's highlights in my inbox:


Co-host Indu laid out the day's WinterTech themes at the outset, based on emergent trends stemming from 2016:
  • New care delivery models;
  • New insurance models;
  • Technology advances;
  • Analytics;
  • Emerging (non-U.S.) markets.
If there was any consensus coming off the stage as to where things are headed, it was a prediction of inexorably increasing patient "OoP" (Out of Pocket) participation in health care expenditures, and whatever that may imply for "innovative care delivery" and other "consumer-facing apps" models.

BTW: The policy debate has been fairly raging over at THCB these days. I mostly stay out of the comments of late. Let these (mostly untraceable screen name) know-it-alls have their respective contending says.

To me, health care policy arguments ignore a couple of fundamental things. First, there's the "Ich/Du/Sie" PoV problem:
  • I deserve full, affordable first-dollar indemnity coverage for my medical misfortunes;
  • You need to have significant "skin the the game" to inhibit you from overutilization, which drives up my costs;
  • He is a mooching parasite, a free-rider driving up my costs.
Then there's the ideologically glossed-over actuarial reality:
Health care UTIL risk is roughly, speaking of only adults in E-Z round numbers, a 60-year proposition tightly coupled in the aggregate with age (in sort of "hockey stick" fashion). We have long known this. Yet we continue to insist on selling "coverage" (much of which is 3rd party-intermediated "pre-payment," not "insurance") in one-year chunks (wherein everyone thinks they're getting screwed on both the insuree and insuror sides). None of the ensuing administrative paper-shuffling going to deductibles, co-pays, coinsurance, and other fine-print policy babble adds any value to actual care delivery (notwithstanding its profitability to the intermediaries).
Of course, the alternative would be the "social insurance" model now decidely out of favor with the GOP.
Agggh...
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Some random photos from WinterTech...


All told, an interesting day, notwithstanding the intractable equivocality of the myriad learned opinions set forth.

Met some cool people.
  • Aristotle Mannon, Founder and CEO of bosWell. "Client data collection, made simple.
    bosWell provides free web-based record keeping and reporting tools for community based organizations."
  • Ursula Hessenflow, CEO and Co-Founder, myLAB Box. "myLAB Box is a first-of-its-kind service that delivers STD screening solutions to your doorstep allowing you to keep private things private."
I spoke with a young woman with the company DesignMap, one of the WinterTech booth vendors.
"User experience design to improve the workplace."
"DesignMap brings years of experience from internal teams, startups and enterprise tech firms to deliver smart 
solutions to make enterprise software great."
I asked her a number of questions going to EHR "usability" (UX). I don't think she understood the drift. I got nothing but generalities. I expect to have better luck when I do a follow-up with ElationHealth.

 BTW, in the context of "Venture Capital," it's worth revisiting my recent citing of Steve Tobak's fine book. I still think Steve would be a great WinterTech panelist.

ERRATUM

My latest book.


From the Conclusion:
Public ignorance means power for institutions, because it lowers the probability of accountability. Institutions are built on delegation of decision-making, which allows a division of labor and the development of expertise. Yet delegating choice also creates the opportunity for abuse, for an agent to take hidden actions against the principles interest or to use limited knowledge about options to pursue an agenda the principal would not favor if fully informed. Information costs involving uncertainty about quality or trust often drive choices away from markets and into the hierarchical structure of firms. Information costs contribute to him perfectly functioning markets when there are negative spillovers like pollution, anti-competitive acts and cartels, or asymmetries in knowledge about goods and services such as with credit, insurance, and healthcare industries...
 Theranos, anyone? apropos, see my recent post "2017: Disruption ahead on all fronts, for good and ill."
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More to come...

Tuesday, January 10, 2017

On the Eve of WinterTech

It's "J.P. Morgan Week" in San Francisco (hashtag #JPM17), amid which I will be covering the Health 2.0 WinterTech Conference (hashtag #WinterTech. Register here).


Where did that year go? My WinterTech 2016 experience.

Interesting article up over at THCB:
JP Morgan Week: Lessons For Investors From the Theranos Story
Jan 10, 2017


Theranos raised $900 million from investors and achieved a market capitalization of nearly $9 billion. Today, its investors may have lost most of their money and the company is pursuing a new strategy. It’s a familiar story to lenders and investors and likely to be hallway chatter today as the 35th Annual J. P. Morgan Healthcare Conference convenes in San Francisco.

Theranos targeted the lucrative blood testing market offering a new technology that allowed labs to do 30 blood tests almost instantly with a single drop of blood. The company began its operations in 2003 with a $5.8 million investment from Draper, Fisher, Jurvetson and other venture funds. By 2010, it had raised $83.4 million more in three follow-on rounds and then scored a reported $633 million investment in 2014 increasing its market value to $9 billion. In those 11 years, the company operated in relative secrecy: its 60-plus patent filings gave clues about its activities while its CEO, Stanford drop-out Elizabeth Holmes, shunned the spotlight...


Stories like Theranos are familiar to every investor and lender gathered in San Francisco this week. All of them have had disappointing results because an organization where they’ve parked capital as debt or equity has failed to meet expectations due to poor execution, or changing market conditions derailed their plan. And some have faced the enormity of challenges like those facing Theranos today in the companies/organizations they’ve funded...

Looming prominently at JPM this week is speculation about the Trump administration’s replacement for the Affordable Care Act...
Yeah. Theranos, ugh. I'll have more to say on them once I've finished reviewing the CMS lab QA assessment.
"Looming prominently at JPM this week is speculation about the Trump administration’s replacement for the Affordable Care Act."
In that regard, everyone might want to read medical economist J.D. Kleinke's recent "out-of-retirement" piece. As he noted on Facebook: "No, I haven't come out of retirement . . . but after all the dangerous and annoying nonsense we heard this week about the ACA, I really had to write this . . . or my head would explode."
Why There Is No Obamacare Replacement — In One Picture

There is no conservative replacement health reform plan for Obamacare — because Obamacare is a conservative health reform plan.

After six years of promising to repeal ‘n’ replace the President’s signature domestic achievement, Republican lawmakers have no coherent alternative to the Affordable Care Act for one good reason: because the Affordable Care Act was once the market-based alternative to a real, not imagined, “government takeover” of health care.

What has always made the ACA a political pariah to Republicans, typified by the bizarre claim by House Speaker Paul Ryan (R-WI) on Wednesday that “Obamacare” has “ruined” and “dismantled” our health care system, is the plan’s namesake — far more than its necessarily complex architecture or any of its actual details, unless you count the details they made up.

And so, if only for kicks, how about some actual historic facts and context about a health reform plan that was actually decades in the making, only three years into full implementation, and on the eve of blind destruction by demagogues who have no idea what they’re taking about.

The chart below illustrates where the ACA sits, ideologically, relative to all other health reform plan models.
This chart places the ACA along a continuum of all serious reform options developed, debated, and discarded or ignored since the 1980s. They are all here: from the single-payer, centrally controlled models popular with those who detest corporations and the corrupting influence of money in medicine — two actual, not imagined “government takeovers of health care” — to a fully free-market, laissez faire model favored by those who detest regulation and the heavy hand of government in medicine...
J.D. rocks. Read the entire post. I first cited him on this blog in 2011 in my post "Use Case."
HIT market failure ... If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone, fax, and Post-It note.

Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix.

This is the textbook definition of a market failure. All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning. The most obvious examples of such failures (such as public transit and the arts) are subsidized by society at large because such subsidies yield benefits to the public that outweigh their costs. Economists refer to these net benefits as “positive externalities,” defined as effects that cannot be captured through the economic equation of direct cost and benefit...
This year, the health space policy focus -- early on, anyway -- will be on the "Repeal and (not) Replace ObamaCare" battle on the Hill (and on K-Street), along with related fights over Medicare and Social Security. Not that MedTech and Health InfoTech will be exempt from the upshots, (e.g., we see calls for #TrumpleThinSkin to summarily rescind Meaningful Use Stage 3 -- as if that were within his Presidential purview), just that Health IT is relative chump change in the context of the huge pending ACA fight.

JUST UP AT THE INCIDENTAL ECONOMIST
Screwing Congress
January 10, 2017, Nicholas Bagley

There’s been a lot of talk about the executive actions that President Trump might take to reshape the Affordable Care Act. Here’s one I haven’t heard discussed: undoing the Hill fix.

Prior to the ACA, members of Congress and their staffers got health coverage through their jobs, just like most Americans. But Congress wanted to signal that it believed in the new exchanges that the ACA created. The ACA therefore sent members and their staffers onto the exchanges. Specifically, the ACA says that “the only health plans that the Federal Government may make available to Members of Congress and congressional staff … shall be health plans that are … offered through an Exchange.”

That left an open question. Could the federal government continue to pay for members’ and staffers’ health plans? Or would they have to pay for their plans out of their wages?

The statute wasn’t entirely clear, so the Office of Personnel Management weighed in. It concluded that the ACA allowed the federal government, as an employer, to purchase exchange plans for members and staffers. That was good news for people who work on the Hill: zeroing out their health coverage would have amounted to an enormous pay cut...


...Mr. Trump, the Hill fix was never illegal. But the ACA gives you the flexibility to undo it. You’ll be president in ten days. Your move.
Interesting.

UPDATE: CONGRESS "REINS" IN TRUMP?

Yeah, that should be fun. From The New Yorker,
SUSPENDING THE RULES: HOW CONGRESS PLANS TO UNDERMINE PUBLIC SAFETY
Elizabeth Kolbert

A handy rule of thumb in Washington is that the more pernicious the act, the more high-minded the title. Thus, last week, the House of Representatives approved the Regulations from the Executive in Need of Scrutiny Act of 2017, also known as the REINS Act. The bill would strip the executive branch of the power to issue significant new rules on topics ranging from air quality to food safety. In normal times, such a power grab by Congress would surely face a veto threat from the President, but, of course, these are not normal times.

Under the latest version of the REINS Act, a regulation with “an annual effect on the economy of $100,000,000 or more” could not take effect without congressional approval. In this way, either the House or the Senate could easily scuttle a major new regulation—one that requires food producers to sanitize their tools, for example—simply by doing nothing. “Given partisan gridlock in Congress, this could result in a de facto ban on new public interest safeguards,” Alison Cassady, the director of domestic energy policy at the Center for American Progress, noted in a recent post on the bill.

The ostensible justification for the REINS Act is a fear of executive overreach. However, it’s easy to discern the real—and darker—motive. No agency imposes a regulation with “an annual effect on the economy of $100,000,000 or more” lightly. Such regulations take years to draft and finalize. They’re subject to multiple levels of review, not to mention months of public comment. These regulations also tend to be the sort that have an impact on big corporations, in areas such as energy production, workers’ safety, and lending practices, and, not surprisingly, big corporations often don’t like them...
Interesting. This, though, differs materially from "the Secretary shall" kind of statutory regulations that are a staple of federal legislation. See, e.g., my December post "The Price is Right..."

One more thing to watch.

BOOKSHELF UPDATE

Almost finished with this book. A very long read, a comprehensive and important look into the critical issues we face at the intersection of science and policy.


Stay tuned. Maybe I'll finish it today. Also have just started this one:


The foregoing will be contextually connected with the three below (as well as a number of others).


I refer to the latter three as "The arc of existence from the Big Bang to the Anthropocene." I may take this rumination over to one of my other blog platforms, maybe Medium.
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More to come...

Tuesday, January 3, 2017

"Elation" and "EHR" -- a word and an acronym not typically found together


First, some setup context, excerpted from a September 2016 Wall Street Journal Op-Ed.
Turn Off the Computer and Listen to the Patient
The practice of medicine is a subtle art. Doctors need to give patients their undivided attention.

By CALEB GARDNER and  JOHN LEVINSON
Sept. 21, 2016
 

Of the many problems facing modern medicine, the deterioration of the patient-doctor relationship is one of the most pernicious. Today our health-care system is losing its humanity amid increasingly automated and computer-driven interactions between doctors and patients.

The signs and symptoms of this pathology are everywhere ... Primary-care appointments are now as short as five minutes, and the physician must spend much of that time typing instead of attending to the patient and performing a physical examination. Medical students and residents are spending more time with screens than with patients ... Meanwhile, fewer doctors would like to see their children enter a career in medicine, and escalating health-care costs are crippling families and the economy without improving public health.

The electronic health record (EHR), once a promising new medical technology, is a major cause of this disconnect. Not long ago, doctors dreamed of a time when unwieldy paper charts would be replaced by streamlined computer systems, freeing them up for more direct patient care. But now these computer systems are distracting and burdensome. Senior physicians are retiring early because of the EHR, while young doctors feel the humanity draining from a profession to which many were drawn because of a desire to interact and connect with people.

How did we get here? One cause is the development of third-party health-care financing, which grew out of the Great Depression and eventually led to the ascendance of insurance corporations with the ability to influence the clinical practice of hospitals. Similar economic forces have decimated private medical practice, as physicians become employees of hospitals and larger hospital systems. Medicine has become corporatized.

In 2009, with this stage set, Congress passed the Health Information Technology for Economic and Clinical Health (Hitech) Act. The act was designed to improve the U.S. health-care system by promoting and standardizing the use of computer technology by physicians. It prescribed, in great detail, a set of federal standardized instructions for how doctors must use computers in medical practice, such as what data to collect from patients. It also provides a mechanism by which hospital systems can prompt doctors to make decisions that are more in line with the hospital goals and practices. These instructions, enforced by financial incentives, are collectively called “meaningful use.”

Computer programs and one-size-fits-all rules for medical practice have thus become central to the care process...


...Computer algorithms don’t result in higher quality care because the practice of medicine remains a subtle art. Careful listening and undivided attention are important, and the incessant electronic reminders and check-boxes that divert a doctor’s attention while the patient sits on the examination table are a distraction equivalent to texting while driving, and will end up hurting patients.

The patient also suffers because medical records are now used primarily as management tools for billing compliance and population-data collection ... Meanwhile, growing medical specialization and restrictions on resident work hours have led to more shift changes and transitions of patient care from one doctor to another, moments when clear and efficient communication is most vital...


...Medicine is both losing its humanity ... and buckling under the weight of massive, ill-designed electronic information systems.

The answer isn’t to resist technology. Information systems are central to the future of good doctoring, and industry professionals should continue designing electronic systems to enhance medical care and facilitate the connection between patients and physicians. Meanwhile, however, medical practices should be allowed to turn off the “meaningful use” software prompts and return to the job of taking care of real people. Doctors have an obligation to act as stewards of the medical profession and with humanity toward patients and should insist upon the undivided attention necessary to do so.


Dr. Gardner is a physician and resident at Cambridge Hospital in Massachusetts. Dr. Levinson is a cardiologist at Massachusetts General Hospital and Harvard Medical School.
You don't have to search far at all to find voluminous evidence of clinician dissatisfaction with digital health IT, particularly in conjunction with the now-waning, widely hated federal Meaningful Use initiative (which, recall, was the topic that started this blog in 2010 at the outset of my tenure with the Nevada-Utah REC run by HealthInsight, my now thrice-former employer).

Beyond MU grouchiness specifically and complaints regarding health IT UX shortcomings more broadly, some critics even go so far as to question our fixation on digital health "structured data" per se. See, e.g., my December 2015 post "Are structured data the enemy of health care quality?"

Tangentially, see also my recent post "Clinical workflow, clinical cognition, and The Distracted Mind."

I think the full-featured EHR is here to stay for quite some time yet to come, notwithstanding all the chatter about our "post-EHR/mHealth world." Given the continuing "productivity treadmill" time constraints in the irreducibly high cognitive burden, high stakes, chronically fragmented enterprise that is clinical care delivery, the more workflow-efficient the UX the better.

"Elation EHR"

OK, then.

Saw a THCB post by Health 2.0's Matthew Holt. It spurred this post.
Elation’s Kyna Fong on a new type of EMR company
Jan 3, 2017, by Matthew Holt


There’s so much happening in the Health 2.0 world of new technology in health that it’s hard to keep up. AI, VR, AR, Blockchain–and they’re just the buzzwords keeping the VCs happy. So this year I’ve decided to try to interview more interesting new companies to keep you in the know. We’ll see how long that resolution lasts but first up is Kyna Fong, CEO of ElationHealth. Yes, she left a Stanford tenure-track professorship to start an EMR...



I have yet to personally meet any "elated" EHR users, notwithstanding my more than a decade of work spanning DOQ-IT and then Meaningful Use. But, maybe the bold naming here is appropriate. Dunno. Bears further study.

Cloud-based subscription model per provider (support staff logins included), monthly ($349) w/no contract, or annual prepayment at an 8% discount ($321 x 12 = $3,852). Reduced fee ($175/mo) for non-Rx Mids. What about full panel data migration from a prior EHR?
"If you are interested in having us move all your patient care data from your old system, we offer a Custom Data Import from almost every EHR, including Practice Fusion, Allscripts, Amazing Charts, Spring Charts, NextGen and Care 360 for example. It is a one time, additional fee of $9,995."
That all sounds pretty reasonable. Say you're a busy solo doc who averages 20 pts/day, 48 weeks/yr. That works out to 80 cents per pt encounter -- perhaps ~1% of average reimbursement? (way cheaper than schlepping paper, and probably cheaper than most EHR competition).

Also, say you have an active panel of 2,000 pts. The full migration fee would be around 5 bucks per chart. My former Primary in Las Vegas (also a MU client) spent a year populating his new EncounterPRO EHR with the next day's patient visits every night after office hours (he didn't trust his staff to do it accurately; I still can't believe he did that). Another MU client doc of mine in Reno hired a med student to slowly do his MicroMD chart pre-population transcription.

You simply couldn't do all of that for $5/chart. apropos, see one of my 2014 posts "ROI - Health IT Return On Investment 101."
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Matthew's YouTube interview with the CEO:


From Forbes:
Can Kyna Fong's Elation Health Help Save $240 Billion In Healthcare Costs And Improve Patient Care?

A Series of Forbes Insights Profiles of Thought Leaders Changing the Business Landscape:  Kyna Fong, Co-founder and CEO, Elation Health
The Institute of Medicine (IOM) published a report in 2014 estimating that the country loses some $750 billion annually to medical fraud, inefficiencies, and other siphons in the health-care system. That’s about 8% of our $3 trillion annual healthcare spend. Over half of the loses are accounted for by unnecessary services, inefficient care, or the failure to prevent problems that require expensive intervention. Elation Healthundefined, co-founded by its CEO, Kyna Fong, along with her co-founder brother Conan Fong, is out to change that dynamic through its cloud-based patient-physician platform. But that’s only part of the story.

“I started the company with my brother, and our mission is to strengthen the relationship between patients and physicians and really enable phenomenal care for everyone. We do this today through a cloud-based, patient-focused care platform that physicians use in all aspects of patient care. It’s a lightweight tool that not only enables the physician to understand the longitudinal story of the patient’s health, but also allows the physician to collaborate with the broader team of providers in different organizations that also care for the patients,” says Fong.

The typical physician shares patients with over 200 other doctors and patients see a multitude of doctors over their lifetime.  Allowing doctors and patients to collaborate across organizational boundaries and share information is a critical challenge that ends up with billion dollars of wasted health expenditures. This lack of interoperability leads to waste and often poor patient care.

“Our focus from the get go has been to build products that put clinical needs first and bring patients and physicians closer together. We call this our clinical first approach and we think that this is the foundation upon which we need technology to be built in order to actually improve outcomes,” says Fong...
See the 90 second animated Vimeo pitch video from their website ("privacy settings" restricted from iFrame embedding). None of the laments set forth in the short video and audio V/O are exactly news. To the extent that Elation EHR can significantly and cost-effectively mitigate them, it should find a ready market. A couple of scary smart people, these sibling co-founders.
Kyna holds a Bachelor of Arts in Applied Math, summa cum laude, and a Masters of Science in Computer Science, both from Harvard University, as well as a PhD in Economics from Stanford University's Graduate School of Business. Previously, she was a professor at Stanford University's Department of Economics.

Conan holds a Bachelor of Science with distinction in Microbiology & Immunology with double minors in Management and Economics from McGill University, as well as a Masters of Health Sciences in Health Finance & Management from Johns Hopkins University's Bloomberg School of Public Health.
All very interesting. I have a number of questions for them. I've also apprised Dr. Carter of EHRscience.com about this company. Stay tuned.

Kyna Fong reported on at Health System Management:
Kyna Fong, PhD, co-founder and CEO of Elation Health ... in a keynote address at the 3M Value-based Care Conference in Chicago ... noted that most value-based initiatives focus on plan and incentive design, data analytics and predictive modeling. These things need to strengthen the patient-physician relationship, not undermine it.

She shared five guiding design principles to develop “thoughtful technology that is clinical first, patient-centric and embedded in the physician workflow”:

  1. Engage the physician in their workflow with timely feedback. Physicians have very little time to interact with the technology and it is more important for them to focus on clinical needs and patient relationships. The information must be available at the physician’s fingertips in less than 30 seconds to achieve what Dr. Fong calls “high consistent use.”
  2. Meet reporting needs without adding a burden to PCPs. Technology that automates quality reports makes the PCPs job easier. “It is unsustainable to expect PCPs to spend more time with technology. We should minimize the diligence and effort required to get paid.”
  3. Elevate the patient to an active, engaged member of the care team. “The patient is a powerful potential actor in the value-based care movement, if motivated.” Any solution needs to engage patients and make care quality clear to them. They should be encouraged to track and improve it. Every visit summary should be shared with the patient, as well as their clinical profile and health maintenance schedule. Finally, the data should be portable to other providers. It would save massive amounts of time for physicians and result in better patient awareness and education about their own health.
  4. Accommodate delivery of care by teams across settings. The team needs to be connected by a common patient record. Patient loyalty is to the best care, regardless of the IT system. Patient data needs to be able to follow them through the care system and travel faster.
  5. Make the technology affordable, whether for a multi-million dollar health system or a small physician practice. “Servers are cheaper and upgrade cycles are more frequent. We are past the point that the delivery of care needs to be constrained by technology. We don’t need to put all physicians under the same roof just for the sake of technology.”
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UPDATE: AN EMAIL FROM MATTHEW HOLT
Impact on Health Tech Investing in 2017
 
There's one overriding topic about American health care starting this week, going to January 20 and maybe even beyond--Just how do Trump and the Republican Congress "repeal and replace" the ACA? And of course what does that mean for health technology investment environment? Especially given that 2016 was a record year with Health 2.0 counting more than $5bn raised.

Our sense is that "repeal & replace" becomes "amend & defund." So what will that mean for health tech, for insurance companies, and hospitals? And will emerging markets like China or India start to lead digital health investing?

Want to sort out this muddle for your investing or business strategy in 2017? Health 2.0's Wintertech Conference in San Francisco next Wednesday is the place where all these issues are put into context.
 
Register today for WinterTech before tickets sell out.
OFF-TOPIC ERRATUM

From my Facebook page.

Shit.
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More to come...

Sunday, January 1, 2017

2017: Disruption ahead on all fronts, for good and ill

"More Disruption Please" - athenahealth CEO Jonathan Bush



Happy New Year. I guess. 

In 2016 we certainly had domestic political disruption the likes of which I've never before seen across my 70 years. I remain mentally enervated in the wake of the fractious, garishly low-road 2016 political campaign, and rather aghast (though hardly surprised) at the outcome. Newly-empowered hard-right Republicans, under the Presidency of the garrulous, shamelessly contradictory Donald J. Trump (and his even more radical, nihilist "alt-right" supporters), are positively chomping at the bit to begin breaking things -- uh, disrupting the status quo across the breadth of domestic and international policy fronts. From "repealing ObamaCare" to more zealous (and collateral damage indifferent) prosecution of the "war on terror" (and ramped-up aggressive militarization more broadly) to mass deportations to blunt-axe, broad-brush regulatory and civil rights rollbacks to drug policy to trade policy to privatization attempts spanning a gamut of arenas inclusive of Medicare, Medicaid, the VA, Social Security, and education, to say "everything's on the table" is to put it mildly. We're gonna need a bigger table.

Then again, maybe most of these concerns will prove largely unfounded, given the formidable inertial weight of incumbent politics -- i.e., "the Swamp" that is unlikely to be drained notwithstanding the Trump campaign rhetoric.

My wife and I will be paying particular attention to GOP attempts to eviscerate Medicare and Social Security. She retires in June, and we will thereafter be dependent on Medicare (plus our remaining HSA stash) for our health coverage and our Social Security pension benefits and our IRAs. Feeling just a bit of anxiety over being at the mercy of the disruptive political winds going forward.

BOBBYG'S NEVER-ENDING BOOK REVIEWS

My latest read, on -- well -- "disruption." Read this Friday on BART and between loads of doggie laundry amid my weekly Muttville.org volunteer shift.


This book examines the increasingly rapidly changing nexus between digitally-empowered citizens and their governments, both here in U.S. and around the planet.
Disruption has become one of Silicon Valley’s most popular, if cloying, buzzwords. One is hard pressed to find a startup that does not describe itself as a disruptive technology, or a company founder who is reluctant to take on the establishment. The concept has also come to stand for a form of libertarianism deeply rooted in the technology sector, a sweeping ideology that goes well beyond the precept that technology can engage social problems to the belief that free market technology-entrepreneurialism should be left unhindered by the state...
 ...[W]ell-established companies are ahead in developing new technologies that meet the needs of established customers, but they cannot see beyond the worldview that made them successful. This blind spot allows new companies to innovate on the margins. Disruptive technologies first find a niche audience, and once their value is proven, they widen their market, taking down the establishment. In short, hierarchical institutions with entrenched practices, interests, and consumers are bad at anticipating and catering to new markets and are therefore vulnerable to nimble innovators...

Government has all the burdens of established corporations: institutionalized structures and norms that lead to lethargy, waste, inefficiency, and a lack of innovation. But their purpose is different from that of corporations, which have a mission to maximize value for their shareholders. In the capitalist model, we hope that the collective impact of the private sector benefits everyone to some extent. In the public sector, however, the very mandate is to serve everyone. Disruption theory explains the failure of institutions to innovate and their risks of collapse, not the social consequence of that failure. The Kodak workers who lost jobs, or towns where the steel mills closed, are not the core focus of business theory. And herein lies the problem for the state. 


Disruptive innovation—from Anonymous, to cryptocurrencies like Bitcoin, to grassroots mapping of natural disasters—is challenging many core functions of the international system, functions once controlled by states and international institutions.

For now, the challenge posed by disruptive innovation does not mean the end of the state, but it does suggest that the state is in decline, exposing laws, ethics, norms of behavior, and hierarchical structures that emerged amid an older set of technologies as constraints. Put another way, the state is losing its status as the pre-eminent mechanism for collective action. Where it used to be that the state had a virtual monopoly on the ability to shape the behavior of large numbers of people, this is no longer the case. Enabled by digital technology, disruptive innovators are now able to influence the behavior of large numbers of people without many of the societal constraints that have developed around state action. These constraints, which disruption theory treats as weaknesses, have historically been strengths of democratic societies: They hold government accountable and ensure that it operates within the rule of law and within the bounds of prevailing moral and ethical norms. There are of course varying degrees of success within this framework, but the idea of collective representation via institutional governance is what has separated modern democratic societies from anarchy...

Owen, Taylor (2015-03-02). Disruptive Power: The Crisis of the State in the Digital Age (Oxford Studies in Digital Politics) (pp. 6-10). Oxford University Press. Kindle Edition.
"One is hard pressed to find a startup that does not describe itself as a disruptive technology, or a company founder who is reluctant to take on the establishment."

The hapless Theranos, anyone?

I found Disruptive Power a compelling read. Finished it in one day. Chapter 8 is particularly interesting. Recall that controversial "libertarian" digital investor and Donald Trump billionaire supporter Peter Thiel (co-founder of the "big data" company Palantir) is now a close advisor to the incoming President (he was present at the recent Trump Tower "digital summit" attended by most of the top Silicon Valley CEOs).
The Violence of Algorithms 
In December 2010, I attended a training session in Tysons Corner, Virginia, just outside Washington, DC, for an intelligence analytics software program called Palantir. Co-founded by Peter Thiel, a libertarian Silicon Valley billionaire from PayPal and Facebook, Palantir is a slick tool kit of data visualization and analytics used by the NSA, FBI, CIA, and other US national security and policing institutions. As far as I could tell, I was the only civilian in the course, which I took to explore Palantir’s potential for use in academic research. 

Palantir is designed to pull together as much data as possible, then tag it and try to make sense of it. For example, all of the data about a military area of operation, including base maps, daily intelligence reports, mission reports, and the massive amounts of surveillance data now being collected could be viewed and analyzed for patterns in one platform. The vision being sold is one of total comprehension, of making sense of a messy operating environment flooded with data. The company has a Silicon Valley mentality: War is hell. Palantir can cut through the fog. 

The Palantir trainer took us through a demonstration “investigation.” Each trainee got a workstation with two screens and various datasets: a list of known insurgents, daily intelligence reports, satellite surveillance data, and detailed city maps. We uploaded these into Palantir, one by one, and each new dataset showed us a new analytic capability of the program. With more data came greater clarity— which is not what usually happens when an analyst is presented with vast streams of data. 

In our final exercise, we added information about the itinerary of a suspected insurgent, and Palantir correlated the location and time of one meeting with information it had about the movements of a known bombmaker. In “real life,” the next step would be a military operation: the launch of a drone strike, the deployment of a Special Forces team. Palantir had shown us how an analyst could process disparate data sources efficiently to target the use of violence. It was an impressive demonstration, and probably an easy sell for the government analysts taking the course. 

But I left Tysons Corner with plenty of questions. The data we input and tagged included typos and other mistakes, as well as our unconscious biases. When we marked an individual as a suspect, that data was pulled into the Palantir database as a discrete piece of information, to be viewed and analyzed by anyone with access to the system, decontextualized from the rationale behind our assessment. Palantir’s algorithms—the conclusions and recommendations that make its system “useful”—“useful”— carry the biases and errors of the people who wrote them. For example, the suspected insurgent might have turned up in multiple intelligence reports, one calling him a possible threat and another that provided a more nuanced assessment of him. When the suspected insurgent is then cross-referenced with a known bombmaker, you can bet which analysis was prioritized. Such questions have not slowed down Palantir, which developed a billion-dollar valuation faster than any other American company before it, largely due to its government security contracts. In 2014 Palantir’s value was between $ 5 billion and $ 8 billion dollars. 

And analysts who use it have no shortage of data to feed into the system. All around us sensors are collecting data at a scale and with a precision that in many cases is nearing real-time total surveillance... [ibid, pp. 168-170].
Chapter 8 continues on to list myriad activities of private corporate digital initiatives where companies are essentially "working both sides of the street," at once enabling innovative "digital democracy" efforts and concomitantly and quietly lending their cutting-edge technical capabilities to numerous states -- many of them hostile to U.S. (and private citizens') interests.

Given that AI/Machine Learning advances are at the forefront of DigiTech these days, (e.g., see my posts "The Great A.I. Awakening? Health care implications?" and "What might Artificial Intelligence bring to humanity?") I find Taylor Owens book quite instructive as we think about where things may head this year. Well worth your time.

BTW: I came by the Owen book in the wake of searching the word "agnotology" ("the study of culturally induced ignorance or doubt, particularly the publication of inaccurate or misleading scientific data") after reading this article: "AN INTERVIEW WITH MICHAEL BETANCOURT, AUTHOR OF AGNOTOLOGY & CRISIS IN DIGITAL CAPITALISM."
...The issue with digital production is not really about hand labor or digital labor, it’s about how digital production generates an illusion of separation between effects and means—the disconnection between what you do with a computer system, such as download a file from an Internet server, and the resources and physical supports required to make that download possible. This idea appears as the belief that the digital ends “scarcity,” that it eliminates costs and makes everything equally available to everyone. While we as a society consciously know these things cannot be true, at the same time, the behaviors that the “aura of the digital” describes all proceed as if they were true: it is not simply an issue of consumption; it is also (perhaps even more so) a description of expectations for how economic and social policy should be formulated.
The element of labor in all this is only the smallest part of what’s happening with digital capitalism: this general rejection of anything built in the physical world, including all the laws, regulations, protections, and social conventions that make society function. Anything that impedes the expansion of digitally implemented capitalist protocols is conceived as either quaint or an irrelevant vestige that impedes economic “innovation and growth.” This conception is a fundamental element of how these transformations are justified by the defenders of this new economy, an issue that periodically receives acknowledgement in the news; journalist Paul Carr’s discussion from 2012 is typical:
The pro-Disruption argument goes like this: In a digitally connected age, there’s absolutely no need for public carriage laws (or hotel laws, or food safety laws, or… or…) because the market will quickly move to drive out bad actors...
Carr’s summary is to the point; the idea that digital technology negates the need for established protections ignores the harm that happens while waiting for these market-based “corrections.” It is a demonstration of how the aura of the digital eliminates physical impacts from consideration, but his description captures the nature of digital capitalism’s refusal of established social restraints: existing laws are simply an impediment to the expansion of digital technology. Belief in the transcendent aspects of this implementation means there is a blindness to the historical lessons and battles fought to gain the protections that are now simply being ignored. The superficial objectivity of the computer systems that are supposed to somehow replace established protections are simply machinic function—the uniform imposition of whatever ideology informs the design; machines are never impartial, they reify the beliefs they are built to enact. The rhetoric around Bitcoin, the sharing economy, social networks, digital distribution of media, etc. all reflect this process and the (usually implicit) demand that laws be replaced by unregulated, entirely new digital systems where the market will police itself without the need for oversight...
Consider how the so-called “sharing economy” operates: a few software companies introduce digital systems to facilitate some type of transaction. These middlemen connect customers with other providers while taking a large share of the transaction fees. But these software companies do not employ the providers—they are simply a medium, making the transaction possible. So the costs associated with whatever service is being provided—whether it’s a hotel room, taxi ride, or anything else—primarily fall on the provider. These are physical costs that are not the concern of the middleman software company, but they are costs for the people who actually do the work. The sharing economy is thus a parasitic exploitation where the physical costs associated with the business are not a part of the business model at all—nor does the business itself directly address them. This elision is typical of how the aura of the digital hides these concerns with physical resources and costs: CheapHotels, Uber, Airbnb, all of these companies reveal the same underlying process where the physical costs, legal restrictions, and social impacts all disappear from consideration.    

The agnotological element is implicit in this entire process: it is what makes these disappearances from consideration seem not only normal but appropriate. Agnotology is a general term for this type of artificially produced ignorance—it is the inability to recognize that the sharing economy or social networking or any of the various big data companies—makes factual statements become controversial, and invites counter arguments about basic information statements. With critiques of sharing economy, for example, companies such as Uber or Lyft, the answer is simply that the company allows people to make use of what they already own to turn a profit from their possessions, a claim that makes these companies sound like they are some type of global rummage sale when they are not...
Interesting interview.

As I observed earlier, the "disruptions" are likely to cut both ways. And, on the downside, the resultant social/civic wounds might well be very serious.

UPDATE

Looks like this book may have some topical relevance to the foregoing, as it goes to "public accountability."

Amazon blurb: "Investigative journalism holds democracies and individuals accountable to the public. But important stories are going untold as news outlets shy away from the expense of watchdog reporting. Computational journalism, using digital records and data-mining algorithms, promises to lower the cost and increase demand among readers, James Hamilton shows."
Looks interesting. Not sure I'll buy it. A bit pricey for the Kindle edition.

You might also recall my 2015 reporting on similar books such as "Spying on Democracy."

1/9 Update: I reached out to the author, Dr. Hamilton at Stanford. He's generously sending me a comp hardcopy edition of "Democracy's Detectives." I will be reviewing it soon (probably over at one of my other blogs), along with this one I'm nearly finished with.

Democratic governments the world over are increasingly paralyzed, unable to act on many key issues that threaten the economic and environmental stability of their countries and the world. They often enact policies that seem to run against their own interests, quashing or directly contradicting well-known evidence. Ideology and rhetoric guide policy discussions, often with a brazenly willful denial of facts. Even elected officials seem willing to defy laws, often paying negligible prices. And the civil society we once knew now seems divided and angry, defiantly embracing unreason. Everyone, we are told, has his or her own experience of reality, and history is written by the victors. What could be happening? 
At the same time, science and technology have come to affect every aspect of life on the planet...
Otto, Shawn Lawrence (2016-06-07). The War on Science: Who's Waging It, Why It Matters, What We Can Do About It (Kindle Locations 159-165). Milkweed Editions. Kindle Edition.
An excellent, bracing, albeit depressing read, particularly in light of stuff like this:
Is Anyone Actually a Scientist?
Forget the terrible “I’m not a scientist” schtick. Trump’s comments on climate change suggest no one is a scientist.
SPEAKING OF BOBBYG'S BOOK REVIEWS...

Recall my April 2016 look at Dan Lyon's hilarious book "Disrupted."


UPDATE: ANOTHER LITTLE "DISRUPTION" THINGY
"[I]n Silicon Valley, you can’t merely make a better typewriter and sell that at a profit. No, you have to DISRUPT. You have to REINVENT. Well, at least you need the appearance of that, while you squeeze eyeballs until they pop out enough advertising dollars to give the VCs that 10x return."
From the post "Venture capital is going to murder Medium."

I've used the Medium platform episodically. I find it a relatively weak authoring tool. The "Theranos" of independent blogging/online "journalism"?

TECH ERRATA
A simple guide to CRISPR, one of the biggest science stories of 2016
Another biggie to watch this year.

Relatedly, STATnews chimes in on 2017 speculation.
10 stories that are key to understanding 2017
Below, a nice Silicon Valley rumination:
In 2016, the tech industry forgot about people
Oh, the humanity

by Lauren Goode @LaurenGoode


It’s been more than three years since I moved to Silicon Valley, and so far everything they say is true: it’s a place driven by optimism, hope, and high-priced electric vehicles. It’s a place where innovation thrives, and where failure is not only forgiven, but sometimes even lauded as part of a larger narrative. Those are the upsides.

The downsides can be less obvious, but 2016 brought them to light in cruel and unusual ways, as Fortune writer Erin Griffith points out in a recent article. The tech industry often operates under the belief that the world’s ails can be cured or at the very least sanitized with just the right kind of tech, from inconsequential things (can’t find a date? Just swipe) to matters of convenience (a drone will deliver that for you) to the literal difference between life and death (don’t worry, big data will help you live to 120). These are all human problems. And yet 2016 was the year tech seemed to forget about the humans: the way we work, what makes us tick, and that we’re all, actually, fragile and complex beings...
Yeah. Read her entire article. Well done.

REMINDER: DON'T FORGET


Register here. I will again be there.
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More to come...

Sunday, December 25, 2016

The Great A.I. Awakening? Health care implications?

From a very interesting long read at the NY Times:

...A machine can already detect tumors in medical scans better than human radiologists, but the machine can’t tell you what’s causing the cancer.
 
Then again, can the radiologist?

Medical diagnosis is one field most immediately, and perhaps unpredictably, threatened by machine learning. Radiologists are extensively trained and extremely well paid, and we think of their skill as one of professional insight — the highest register of thought. In the past year alone, researchers have shown not only that neural networks can find tumors in medical images much earlier than their human counterparts but also that machines can even make such diagnoses from the texts of pathology reports. What radiologists do turns out to be something much closer to predictive pattern-matching than logical analysis. They’re not telling you what caused the cancer; they’re just telling you it’s there.

Once you’ve built a robust pattern-matching apparatus for one purpose, it can be tweaked in the service of others. One Translate engineer took a network he put together to judge artwork and used it to drive an autonomous radio-controlled car. A network built to recognize a cat can be turned around and trained on CT scans — and on infinitely more examples than even the best doctor could ever review. A neural network built to translate could work through millions of pages of documents of legal discovery in the tiniest fraction of the time it would take the most expensively credentialed lawyer. The kinds of jobs taken by automatons will no longer be just repetitive tasks that were once — unfairly, it ought to be emphasized — associated with the supposed lower intelligence of the uneducated classes. We’re not only talking about three and a half million truck drivers who may soon lack careers. We’re talking about inventory managers, economists, financial advisers, real estate agents. What Brain did over nine months is just one example of how quickly a small group at a large company can automate a task nobody ever would have associated with machines.

The most important thing happening in Silicon Valley right now is not disruption. Rather, it’s institution-building — and the consolidation of power — on a scale and at a pace that are both probably unprecedented in human history...

But even enormous institutions like Google will be subject to this wave of automation; once machines can learn from human speech, even the comfortable job of the programmer is threatened...
I've had a good recurrent run here at "AI" issues. e.g., see "What might Artificial Intelligence bring to humanity?"

See also my 2013 NYeC Conference coverage "Smiling Almighty Jesus" riff going to "interoperability" issues. Gonna have to re-run that experiment now in light of the reported Google Translate improvement. Stay tuned. One has to wonder: might this level of cutting-edge intellectual and technical effort (Google Brain) bear actual transformative fruit in the health IT space (e.g., "interoperability"), relative to all of this incremental API ankle biting of recent years? Seeing the potential health data transparency and fluidity connection requires close study of the Lewis-Kraus article.

ERRATUM

From FoxBusiness "Predictions for 2017,"
Theranos will shut its doors. The lawsuits are piling up and that will drain the coffers of the embattled lab test technology startup. CEO Elizabeth Holmes will finally be forced to seek bankruptcy protection and fade into obscurity, at least until the movie Bad Blood comes out, starring Jennifer Lawrence as the troubled entrepreneur. 
How does one go from an estimated personal net worth of $4.5 billion to zero in the space of a year or two? Lordy. See "Theranos had an awful year, and it only has itself to blame."

IMPORTANT UPDATE

From The New Yorker.
REWRITING THE CODE OF LIFE
Through DNA editing, researchers hope to alter the genetic destiny of species and eliminate diseases.
By Michael Specter
A long read (may be paywalled; I'm a subscriber). Well worth your time. apropos of a trio of books I will soon be reviewing.


The arc of existence from the Big Bang to our worrisome Anthropocene. Advances in health IT functionality (including UX) may not mean diddley if we fail to attend to much larger existential issues.
"We have engineered the world around us since the beginning of humanity. The real question is not whether we will continue to alter nature for our purposes but how we will do so. Using a mixture of breeding techniques, we have transformed crops, created countless breeds of animals, and converted millions of wooded acres into farmland. Gene drives are different; one insect could affect the future of our species. But it is a difference of power, not of kind." - Michael Specter
 "Engineered traits fail in the wild. But what if we could change that?"
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More to come...