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Friday, January 19, 2018

Caregiver and nascent care recipient

This button was on my press pass to the Fall 2017 Health 2.0 Conference. I thought at the time, 'yeah, nice, that's pretty cool' given my ailing daughter's situation after her March 29th dx of Stage IV pancreatic cancer. She just had her second chemo round of a new 2-drug chemo regimen after 9 months of her first Folfirinox chemo cocktail. Folfirinox works until it no longer does -- roughly 9-12 months. We are now there.
Danielle also had to go in for an interventional radiology ovarian cyst drainage px this week, as if there wasn't enough to deal with. It was a "success," albeit another long day.
Below, the entrance to our weekly Kaiser-Permanente schlep.

Luckily for us, this K-P facility is merely 7-8 minutes from our house.

I lost my first-born (Danielle's elder half-sister) to cancer 20 years ago this July 1st. I thought nothing would ever be more difficult than that.

I was wrong. On so many levels.

Not the least of which being that a year of unremitting stress (commencing with the election of the brutish Donald Trump) has caught up with me.


My late Dad had his aortic valve replaced (along w/ a bypass px) in 1996 at age 80. My late Mother had chronic CAD as well, eventually having to have a pacemaker implant.

So, cardiovascular disease is in my bloodline genetics. I've been on relatively low-dose statins and BP meds for years. I do what I can: sparse with the red meat and fats and junk foods, gym rat devotee, not obese (5'10", 174 lbs at age 71). I did a cardiac treadmill about a dozen years ago, and never did get up to "heart rate." Barely broke a sweat (those were my heavy full-court hoops days).

Continuing delusions of grandeur, 2016

I ended up in the hospital with sepsis in early April 2015 in the wake of my prostate cancer biopsy. Wrote about that lovely entire experience here. While admitted, I had a cardiac echo px. Nothing ever came of it until my new Primary noticed a "heart murmur" during a subsequent exam quite some time later. He looked in my chart (Epic) and quickly found the earlier Muir Medical Center cardiac echo report. It had been deemed of "non-clinical" import. Which is probably why no one brought it up, and, admittedly, I'd not looked via the patient portal. I had other things to deal with at the time.

After Danielle fell ill, I saw my Primary again, and asked for several referrals, worried about my persistent daily stress levels, and the potential impact on my renewed "caregiver" duties.

Among the docs I subsequently saw was a cardiologist (whom I really like). I had a full workup, including bloodwork, static EKG, treadmill EKG, and another cardiac echo.

My EKGs were fine. My bloodwork panel assays were all in the normal range, my BP is "normal," my BMI is normal.

My new cardiac echo, however, indicated a worrisome decline in my aortic valve viability ("stenosis"), and, while my "ejection fraction" was normal, prudence would dictate "active surveillance" follow-ups.

In December I had yet another cardiac echo px.

Further worsening of stenosis, and a drop in ejection fraction (the latter getting closer to the line). Time to discuss action.


Transcatheter Aortic Valve Replacement. A "non-invasive" alternative to "SAVR," (the onerous traditional open-heart surgery). Sedation and a Local, and you go home a day later with a sore groin.

Dr. Chang (my cardio doc) had mentioned it, saying that it's becoming the "standard of care" outside the U.S. But, while the TAVR px is done in the states, it's only approved here for "high" or "prohibitive surgical risk" patients (i.e., older and sicker patients).

And, that cohort restriction problematically biases the relative TAVR vs SAVR outcomes stats, making it difficult to make a fully-informed choice under the pressure of time.

Given that the TAVR option appears to not be an unalloyed outcomes blessing in any event (to the extent we can truly know, via the relative paucity of current data), I am likely to opt for the SAVR px, and will soon meet with a recommended cardiac surgeon to discuss it. I suppose I could go all "Medical Tourist," fly to Germany or Switzerland, pay cash (~$100k), and do a TAVR.

Probably not. I could pay for it (ugh), but, probably not, all things considered.

Beyond the well-known patient post-op adversities of the SAVR px per se, my daughter's relentlessly worsening condition dictates that I address this sooner rather than later.

So if this blog goes increasingly dark for a while, you'll know why.

If this blog goes away, I guess you'll know why as well.


Next up, HIMSS 2018. Given all of the foregoing, I rather doubt I'll be there, notwithstanding that it's again being held in my old Las Vegas stomping grounds.
In 2012, just on a lark, I applied for a HIMSS Conference press pass. To my utter surprise, they approved it!


Planning to have open heart surgery anytime soon? You might want to ask your cardiologist to book an afternoon slot in the OR.

New research shows that heart operations performed in the afternoon produced better outcomes than those done in the morning.

Because afternoon heart surgery syncs with the body's circadian clock (the internal body clock that controls when people sleep, eat and wake up), it reduces the risk of heart damage, the French researchers said.

"Currently, there are few other surgical options to reduce the risk of post-surgery heart damage, meaning new techniques to protect patients are needed," said study author Dr. David Montaigne, a professor at the University of Lille.

In one part of the study, his team tracked the medical records of nearly 600 people who had heart valve replacement surgery for 500 days, to identify any major cardiac events such as a heart attack, heart failure or death from heart disease. Half had surgery in the morning while the other half had it in the afternoon.

The risk of a major cardiac event was 50 percent lower among patients who had surgery in the afternoon than in those who had surgery in the morning. That would work out to one less major cardiac event per 11 patients who have afternoon surgery, the researchers said…
Link here.


My friend the Health Care Futurist Joe Flower and his wife Jennifer are selling their Sausalito live-aboard tug.

I've been on it, it's magnificent. I'd buy it in a heartbeat had I the money. I've had my eye on this one up on Vancouver Island, BC. Seriously.

More to come...

Thursday, January 11, 2018

WinterTech 2018 in San Francisco

Conference recap coming shortly. I have about 100 photos to triage. Had a surgical consult this morning, and my daughter started a new chemo regimen as well. Plus, our son Nick rescued a chocolate lab mix dog who was out running loose on the road somewhere west of Sacramento. He seriously needed (and got) a bath. We're gonna go to the shelter and get him scanned for a chip.

 Busy day.

This marks my 4th year of being invited to participate in coverage of WinterTech, following 2015, 2016, and 2017. Definitely an honor to be included.


Between adverse developments on our daughter's dire medical situation, my doc visits for my own upcoming major px, and our newly "fostered"rescue dog (no chip, no online "lost dog" notices), I've just now gotten to triaging my WinterTech photos.

Let me begin with morning Keynoter Mark Ganz, President and CEO of Cambia Health.

You coulda heard a pin drop. Mark had to pause a couple of times, fighting back tears as he recounted his Georgetown U Law School interactions with the late Father Tim Healy. About to have to withdraw from law school over finances, Mark was told by Father Healy "don't worry, we'll cover it," and went on to clarify that he meant that it was not a "loan" to be repaid, but that Mark's subsequent obligation would be to "pay it forward" by doing good works in the world.

Mark asked of the audience: "Why do you do what you do? Is it born of hope? To make the world a more just place? Or is it just to make money, to bring in hefty 'exit' returns?" He went on to exhort "Challenge your VCs," and admonished attendees to "ask yourselves three questions every day" -- 
  1. Do I have hope?
  2. Do I believe I can be the catalyst for real change?
  3. Am I willing to risk it all?
Absent affirmative responses to all three, Mark advised "you need to reconsider."

It was compelling. He offered us a slide:
“The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern. Beautiful people do not just happen.” - Elisabeth K├╝bler-Ross
Stay tuned. Gotta take the stray rescue to the vet. More later.

OK, looks like he's only 2-3 years old. He weighed in at 73 lbs. Given the size of those paws, he may have another 10-20 lbs to go. Lordy.

$280.17 later he's had a full workup and now has a rabies tag.


"Software as a Medical Device?" A new area for FDA oversight and certification. Interesting.
"Software intended to be used for one of more medical purposes that perform [sic] these purposes without being part of a hardware medical device."

Click to enlarge. Difficult to read.

Part of FDA's "Pre-Cert Pilot Program." This is good, given that the future of digitech will be increasingly comprised of software applications that are independent of fixed, dedicated hardware.

Bakul Patel here on YouTube.


"Digitization Across the Health Care Continuum." Yeah, this has been a major theme across the past couple of years. Progress seems still to be spotty, but, perhaps we're getting close to a "tipping point." Click to enlarge, also difficult to read.
It's interesting to me, I should honestly say at this point that my schtick may be getting somewhat dated (DSLR photo-heavy visual reporting necessarily uploaded post-conference). All you really need to do any more is follow the Twitter event hashtag "#WinterTech" and click "Latest" for near-real time participant documentation of the proceedings. While smartphone photos are not as sharp as mine (and there are character-count limitations), the immediacy trade-off is, well, in a word, one of "satisficing," 'eh?

I've told Lisa Suennen repeatedly that she could be a star at stand-up.
What a combination of smarts and humor!

Again, I can't caption ID all of the people I shot. Stuff goes by too fast. You can see the WinterTech page to link a lot of faces and names ("Our Speakers").

Of particular personal interest to me was the panel segment "Four CEOs and their VCs," in light of developments for my niece's husband Dr. Jeff Nyquist and his recently funded startup "NeuroTrainer."

Also on the agenda, the "FICO Score for Health" was back.
Dacadoo is the "Health Score" company - providing a mobile-first digital health platform that helps people live healthier, more active lives. The dacadoo platform allows organizations to offer a fun, engaging experience that measures, coaches and improves people's health across three key dimensions: lifestyle, biometric and emotional wellbeing. Dacadoo takes inputs from a variety of tracking devices, as well as its own app and applies a research-backed, patented process to calculate a single, composite health score for each individual. Dacadoo's customers include large and mid-sized companies, health and life insurance companies, and health & wellbeing service organizations.
I used to work in credit risk modeling and management (large pdf). Would love to see this algorithm.


FYI, over at Medium, there's a recently updated six-part series:

Understanding Venture Capital
Our new series takes a hard look at how venture capital works, and finds positives — and plenty of negatives.
There's now audio transcription. Nice.

Member paywalled. I finally joined a while back. Only $50 a year. Lots of good stuff there. I use Medium every now and then, but I find the authoring platform rather stiff and weak. Limited functionality.

One prediction from the WinterTech stage was that of a record year in 2018 for VC investing in the digital health space. I hope so. I guess we'll see.

I have more stuff in my notes, but I'm gonna pop the clutch and upload the foregoing for now.

Stay tuned.


"Science Fiction Coming to Life," by Dr. David Shaywitz over at THCB.

And, at the take-no-prisoners Naked Capitalism:
CES Shows That the Future Will Not Work
Posted on January 15, 2018 by Yves Smith

A new article by Taylor Lorenz in the Daily Beast, CES Was Full of Useless Robots and Machines That Don’t Work, by virtue of doing what tech writers are never supposed to do, namely report as opposed to cheerlead, is being buried despite its importance.

Lorenz went to the what is the biggest, most important consumer tech trade show in the US, and arguably the world, and found that tons of the great new gotta-have-them wares in the pipeline don’t work. As in unabashedly, obviously don’t work or are so ludicrously not fit for purpose as to be the functional equivalent of not work…
"Silicon Valley is no longer about products. It’s about VC hype and pump and dump..."
Excessively broad-brush and harsh?


I would personally try this product.

Very interesting. I may have to give this a spin.


Health 2.0 has posted its own recap of #WinterTech 2018.

Video of the Conference Kickoff here. Mark Ganz opening Keynote video here.

More to come...

Tuesday, January 9, 2018

Blockchain and health care?

Ran across a post over on Medium, "Can Blockchain Help Us Improve Health?"
“There’s great excitement and huge investment around what blockchain technology can do to improve the delivery of health care...” BUT “...not everyone is equally optimistic that this technology is more than a passing fad”
I commented thereunder:

My concern goes to Gartner Hype Cycle conflation. Crypto financial transactions need, minimally, only four data elements, short and sweet:

  1. Payor_ID;
  2. Payee_ID;
  3. Amount;
  4. DateTimeStamp.
(And, of course, implicit in the foregoing are the (often pseudonymous) “Private Key” ID linkages to the transactors’ “Public Keys” that are used to validate the transaction, reflected via the DateTimeStamp. (Oh, and, gotta mention the “security hash” code linking the blocks.)

In contrast,
  1. The typical ambulatory EHR houses between 3,500 and 4,000 variables in its RDBMS schema (to say nothing of huge inpatient systems). A typical patient encounter may reflect hundreds of them (or more, comprising structured alphanumeric data, imaging, and open-ended text narratives). There were 60 vars in my most recent bloodwork alone. A typical “ROS” (Review of Systems data) houses 140 or so variables. And, all of these are typically “1 to n,” i.e. one-to-many longitudinal per patient (i.e., “progress note” stuff);
  2. Given that the ostensible “virtue” of the blockchaining architecture is its “immutability” (i.e., validated blocks cannot be modified once added), how do we handle the inevitable errors that plague all database systems? Find mistake(s)/omission(s), have to “append” execute a new block transaction (which is again “distributed” to everyone in the aggregate “ledger”/”wallet” population)?
  3. HIPAA 45.CFR.164.3,4,5 et seq data security, breach notification, and privacy requirements governing CE’s and their BA transactors (and also 42.CFR.2)?
  4. What of the continuing (lack of) “interoperability” problem (which I often irascibly refer to as “interoperababble”)? What of the clinical workflow implications? Clinicians are already drowning in data as they traverse the never-ending “productivity treadmill.”. How will the data variables in the validated new ‘blocks” be viewed by recipients? Will we need new, custom “download APIs?”
  5. Blockchain transactions are not “free,” they require payment of “transaction fees.” Crypto transaction fees have been on a steady, significant rise. Will they be reasonable (and stable) for health data transactions? Will such fees be bandwidth-consumption based?
Dunno. I have concerns. More inefficient IT Geek playground stuff w/respect to Health IT?


Currently, there are some 20 million crypto "wallets/accounts" (many of them anonymous duplicates), each a recipient of every accruing block addition transaction (the core peer-to-peer "distributed ledger" concept). I have to question the "bandwidth and data footprint efficiency" of this model -- beyond other reservations (some of them related).

Just some initial reactions.


More to come...

Monday, January 8, 2018

On Deck, Health 2.0's #WinterTech 2018, January 10th

Registration link
"WinterTech is up next, and we're extremely excited about the final agenda. The 2018 edition of WinterTech will be not only be focusing on the new investment treads in digital health, but will take a in-depth look into the revolution in choice within the consumer landscape and the rapid development of digital therapeutics.

Our jam-packed 1-day conference includes:

    •   Keynote presentation on how to create seamless health care experiences to meet the needs of consumers by Mark Ganz, CEO of Cambia Health.
    •   Panel discussion on the opportunities, roadblocks, and regulations within the field of digital therapeutics by Bakul Patel, Associate Director for Digital Health at the FDA.
    •   Investment Strategies Past and Present: a look into 2017 trends, surprises, and flops. plus predictions for 2018 by VC firms GE VenturesCanaan, Fifty Years, NEA, and B Capital Group.
    •   Fireside chat between 4 VCs and their CEOs on their relationship and investment models
    •   Access to the Investor Breakfast where start-ups and investors discuss business models and explore portfolios. Start-ups apply here.
    •   Live demos from some of the most innovative companies in the digital healthcare space.
Don't miss out the hottest digital healthcare event focusing on investment in the space. Register today."

See you there. I'm bringing with me Jeff Nyquist, PhD, founder and CEO of


Pretty cool graphic.

He's, like, a Very Smart Person.

More to come...