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Wednesday, February 10, 2016

Here you go, steal my private medical data, let me help out

So, I saw an article of interest today in my email inbox (from one of my many daily feeds, MedPageToday.com), one having to do with a writer's experience with prostate cancer. Recall my recounting of my own dx and tx last year.
Prostate Cancer: Driving the Personalized Medicine Highway
Howard Wolinsky decides it may all be in the genes


by Howard Wolinsky
Contributing Writer, MedPage Today

Howard Wolinsky a journalist based in the Chicago area, was diagnosed with early prostate cancer in 2010. In part one of this series he described his diagnosis and his decision to chose active surveillance. In the second part, he shared his experience during 5 years of active surveillance and in this part he tells his continuing quest to make the best -- and most informed -- decision about his care...
Nice, thoughtful piece. I could relate, given what I've recently been through. Going public has its net virtues, a decision I made last year as well.

I posted a comment.
Interesting article. Very nice. I was treated for Gleason 6 prostate cancer (3+3, 6 of 12 cores positive, PSA elevating over 18 months to more than 9) last year. My urologist had an OncoType dx assay run, which indicated a mid-level "indeterminate" level of aggressiveness. I opted to zap that puppy with 2 months of daily Calypso IMRT (I called it "Nuke the Donald") after many tests (post-biopsy, including endo-rectal coil MRI and a bone scan) and much consideration -- which comprised both a 2nd opinion consult at Stanford RadOnco and listening to the many stories in my cancer support group. I'm pleased with my outcome this far.

Been writing about the (clinically anxious and bureaucratically frustrating) experience here: regionalextensioncenter.blogspot.com/2015/06/the-us-healthcare-system-in-one-word.html

I too have concerns about hype over "Omics-based" "personalized medicine" and will continue to follow developments.
I then tee'd it up on Twitter. I have my tweets set up to post through to my Facebook page. Below, this is what showed up in my FB feed.

Whoa... OK,
"Patient:  Wolinsky, Howard N," 
"JHT MR# T1604312"
"Birthdate:  09/29/1947"
"Gender:  M"
Seriously? Full name, DoB, Gender, MedRec#?

I immediatel
y channeled my Inner Latanya Sweeney. Dr. Sweeney, you may recall, is the noted privacy investigator and policymaker who once backed her way into former MA Governor William Weld's medical record starting out with merely Name, Gender, and ZIP Code.
The Massachusetts Group Insurance Commission had a bright idea back in the mid-1990s—it decided to release "anonymized" data on state employees that showed every single hospital visit. The goal was to help researchers, and the state spent time removing all obvious identifiers such as name, address, and Social Security number. But a graduate student in computer science saw a chance to make a point about the limits of anonymization.

Latanya Sweeney requested a copy of the data and went to work on her "reidentification" quest. It didn't prove difficult. Law professor Paul Ohm describes Sweeney's work:

At the time GIC released the data, William Weld, then Governor of Massachusetts, assured the public that GIC had protected patient privacy by deleting identifiers. In response, then-graduate student Sweeney started hunting for the Governor’s hospital records in the GIC data. She knew that Governor Weld resided in Cambridge, Massachusetts, a city of 54,000 residents and seven ZIP codes. For twenty dollars, she purchased the complete voter rolls from the city of Cambridge, a database containing, among other things, the name, address, ZIP code, birth date, and sex of every voter. By combining this data with the GIC records, Sweeney found Governor Weld with ease. Only six people in Cambridge shared his birth date, only three of them men, and of them, only he lived in his ZIP code. In a theatrical flourish, Dr. Sweeney sent the Governor’s health records (which included diagnoses and prescriptions) to his office.
Lordy. (Note: I first cited Dr. Sweeney in 2011 in reporting on my HealthInsight HIE rollout.)

Let's assume, for the sake of illustration here, that the foregoing Wolinksi PHI data are for real -- "live/hot data" innocently, if naively, scanned for MedPage article art.

Need I elaborate?

OK, I will. First thing I would do as an adroit "social engineer" would be to Google every public fact I could find regarding writer Wolinsky. This would be preparatory to calling John Hopkins with some slick talking points script I'd use to extract everything I could glean (the big prize obviously being private financial/payment data).

Need I elaborate further? Use your imagination.
Tangential erratum: from 2000 to mid 2005 I worked in risk management in a credit card bank. Part of my work involved fraud detection and mitigation/countermeasures. I had routine cross-departmental interactions with a number of bank units: e.g., Compliance, Operations, Collections, and Marketing. I also had unfettered access to the breadth of the bank's internal IT network.
Once, our Marketing luminaries produced and mailed out one of their iterative slick 4-color pitch brochures for national mail campaigns.

It had a pic with live Visa Card number on the cover art.

Need I elaborate on what happened forthwith?
Yeah, we got hit for a bundle prior to tying off that self-inflicted wound.
We also had an "Apply for a Visa Card" feature on our homepage. Curious, I looked at the under-the-hood HTML code.

OK, I entered my son's info (he was in high school at the time, no job no credit history). The data simply went to an unencrypted .txt file visible to and accessible by anyone knowing what "View Source" means.

A week later we got credit card mail pitches at home in Nick's name, all from our competitors. Jeez...
The Sweeney Data Map

Click to enlarge. Where do your medical data go? Source link here.

DEBORAH PEEL'S LATEST ON THCB

The National Self-Appointed Privacy Scold.
Give up Your Data to Cure Disease? Not so Fast!
Deborah Peel, MD

This weekend the NYTimes published an editorial titled Give Up Your Data to Cure Disease. When we will stop seeing mindless memes and tropes that cures and innovation require the destruction of the most important human and civil right in Democracies, the right to privacy? In practical terms privacy means the right of control over personal information, with rare exceptions like saving a life.

Why aren’t government and industry interested in win-win solutions?  Privacy and research for cures are not mutually exclusive.

How is it that government and the healthcare industry have zero comprehension that the right to determine uses of personal information is fundamental to the practice of Medicine, and an absolute requirement for trust between two people?

Why do the data broker and healthcare industries have so little interest in computer science and great technologies that enable research without compromising privacy?

Today healthcare “innovation” means using technology for spying, collecting, and selling intimate data about our minds and bodies.

This global business model exploits and harms the population of every nation.  Today no nation has a map that tracks the millions of hidden data bases where health information is collected and used, inaccessible and unaccountable to us.  How can we weigh risks when we don’t know where our data are held or how data are used?...
Worth reading and considering. Notwithstanding that I'm not a Peel fan. (See also here.) I'm still trying to ferret out aggregate coherence in her latest THCB post.

apropos of the privacy thing...
Insurors want to nudge you to better health. So they're data mining your shopping lists.
Rebecca Robbins, STATnews

Health insurers are scooping up huge quantities of personal information in a bid to figure out when you’re likely to get sick — and to design interventions to keep you healthy.

Insurance companies have always had access to your medical records, and in some cases your genetic data, too. Now, they’re paying data miners to sift through information on everything from what model car you drive to how many hours you sleep, from which magazines you read to where you shop and what you buy.

The goal: To decipher patterns that will allow them to steer you away from health emergencies. And to save themselves a whole lot of money in the process.

“I think I could better predict someone’s risk of a heart attack based upon their Visa bill than their genome,” said Dr. Harry Greenspun, a director at Deloitte who leads a team that mines data for health insurers and other clients...
The Digital Panopticon. See also Morozov's "Your Social Networking Credit Score." Recall my coverage of WinterTech 2016? "Digital exhaust"?
One presenter demo'ed an app purporting to generate a general personal "health score" once seeded with some basic info, after which the score would get "refined" by the addition of various social media metrics (the creepy phrase "digital exhaust" comes into play in this regard). Someone used the "FICO score for health" analogy in response.
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More to come...

Monday, February 8, 2016

When Bill Gates speaks, I tend to listen

OK, here's so applied "public health data analytics" for you.


See Ezra Klein's companion article "The most predictable disaster in the history of the human race."

Recall the movie "Contagion"?


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More to come...

Thursday, February 4, 2016

"Chronomodulated therapy" - yet ANOTHER Health IT vector to track?


Interesting article from The Atlantic:
Medicine in the Fourth Dimension
In light of circadian research, prescriptions like “Take Once Daily” are terrifyingly vague.


...Set to rival the personalized medicine “revolution” in the breadth of its implications, the incorporation of circadian rhythms into our health care systems will require re-orientation on a paradigmatic scale.

The idea is that biological rhythms, daily oscillations in physiological processes, make the morning body a functionally different creature from the same body at night. There are peak times of day for each organ’s cell division and metabolism, as well as core temperature and gene expression. Moreover, our illnesses are rhythmic, and our pathogens have body clocks. It makes for a major strategic advantage over disease, and the current resistance in the medical field—a misconception that timing effects are somehow minor—is no longer tenable.

Oncology is forever chasing ways to separate the enemy within from its surrounding tissue and reduce ghastly treatment side effects. Just as each of our cells has a circadian cycle, tumor growth is rhythmic. Some lymphomas see a peak in cell division late in the evening, whereas gut lining divides 23 times as much in the early morning as it does at night. In this case, chemotherapy in the evening targets the tumor while doing away with excruciating effects on healthy tissue. The point is that distance between healthy and diseased tissue does not have to be spatial if you can separate them in time...
Yeah. But, imagine the difficulties in sorting out temporal efficacy for Rx's administered outside of controlled clinical trials or inpatient settings.
Messaging is going to be every bit as important as evidence in coming days. Because it’s not just cancer treatment that would have to be adjusted to get out of our static, 3-D mentality. The dosage of any drug is wildly approximate without a prescribed hour of administration, because all drugs undergo absorption, metabolism and elimination. And all of these processes are controlled by the circadian system—at the cellular level, the organ level, and in the body as a whole.

Even Paracetomol (Tylenol) is profoundly rhythmic in its bioactivity, and its liver toxicity. The practical limitation comes in identifying the optimal time for each patient, which may not be feasible for acute treatment but becomes critical in chronic diseases. In this light, the common prescription “Take Once Daily” becomes terrifyingly vague...
 OK, "is there an App for that?"
Text messaging helps people to remember their medication. So why don’t we do it?
Aaron Carroll, MD
...Researchers looked at all RCTs examining a mobile text messaging system to improve medication adherence in adults with chronic disorders. The main outcomes of interest were odds ratios of adherence.

They identified 16 RCTs. Five of them involved personalized messages. Half of them used two-way communication, and half sent a text message every day. Half of the interventions were 12 weeks of more.

The pooled analysis found that text messaging significantly improved medication adherence (aOR 2.1). The effect wasn’t different based on study characteristics or text messaging characteristics. Even after an adjustment for potential publication bias, the results were still statistically significant (aOR 1.7).

These are relative improvements, of course. But the authors cite literature that finds that baseline adherence rates in developing countries of people with chronic disease are about 50%. Using the odds ratio found in this study means that text messaging could be expected to increase this adherence rate to about 67.8%, or an absolute rate increase of 17.8%. That’s stunning.

There are still “short term” results. Many of them rely on self-reported adherence measures. But still… this is pretty impressive.

In the 11 studies that reported on text message acceptability, most showed moderate to high levels of satisfaction with programs. The study that used twice-daily text messaging found that only 6% of participants said the messages were intrusive and inconvenient.

This stuff works. It’s not expensive. People like it. Why aren’t we trying this more often in systems-level studies?
See also Dr. Carroll's post
Texting people actually gets them to improve their modifiable risk factors

...Researchers looked at patients with coronary heart disease being treated at a tertiary care center in Australia. They had to be older than 18 years and have one of the following: a prior myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, or at least 50% stenosis in at least 1 major epicardial vessel. They were randomized to two groups. The first got “usual care” The second got usual care, but also received semi-personalized test messages which were tailored to provide advice, motivation, and information that aimed to help them change their diet, be more active, or stop smoking (if they were)...

"Chronomodulated tx," 'eh?

The other aspect, which goes more to the Omics-based "personalized medicine" idea, goes to dosage.


I lot of our quantification of things is simply rooted in the convenience arising from our arbitrary decimal number base system. Given that humans normally have two hands comprised of five digits each, we tend to round a lot of things off into 5's and 10's. (As I write, major hoopla is in the air in my Bay Area over the ostensible milepost "Superbowl 50!")

Like a lot of people in my age cohort, I'm on Lisinopril 10 mg. and Simvastatin 40 mg. Why not, e.g., "11.23 mg." and "37.68 mg." respectively? Clinically correlated ("personalized") to a raft of my vitals and bioassay metrics? (I take the recommended baby aspirin -- 81 mg. Why 81 and not "80" or "82"? And so on...)

Anyone (beyond mathematicians per se) with a programming background, who has necessarily spent any time mucking around in binary, octal, and hexadecimal, knows that number bases  -- and their associated rounded "mileposts" -- are arbitrary (you could use a numbering system of any "base"). We all sort of know this on the briefest intuitive reflection. Time? We track it down to base-10 "microseconds" and less (see, e.g., the Michael Lewis book "Flash Boys"), but then there are 60 seconds to the minute, 60 minutes to the hour, 24 hours to the day, and 365.25 days per year (adjusting for the quadrennial leap year).

"Personalized Rx dosage" factors in addition to "Chronomodulation"?

Yeah, the docs really want to have to keep up with all of that in their EHRs.

BUILD AN APP FOR THAT? SWIFTLY NOW...


Interesting piece on the Apple "Swift Programming Language."
100 Days of Swift
Learning Apple’s new programming language
Since Apple announced Swift as the new modern language for their products, I’ve been wanting to learn it. Even though my background isn’t programming, I decided to give it a shot. A little more than a month ago, I finished my 100 Days of Swift Project...
What are some good resources to learn Swift?

I studied and read everything I could find on Swift. I also read plenty of material on programming concepts like Object-Oriented Programming and MVC Architecture. I think it’s more important to learn programming than it is to learn Swift syntax. I’ll speak more about that in the next section. In no particular order, here are some good places to start learning Swift:

  1. The Swift Programming Language by Apple: This book covers the Swift syntax. It’s also available online for people who prefer using their Web Browser. (Free)
  2. Developing iOS 8 Apps with Swift by Stanford: This is an iTunes U course taught by Paul Hegarty, he worked at NeXT with Steve Jobs. He teaches you how to build a few apps with Swift. (Free)
  3. Ray Wenderlich: This site has a huge team of talented people who make tutorials for a range of programmer levels. The free tutorials are more than enough to get started with. There’s also books and subscription only tutorials. (Free / Paid / Subscription)
  4. Design+Code by Meng To: He packs a considerable amount of material in his book. Meng teaches how to build an app from scratch using Xcode, Sketch, Swift, Spring Animation Library and more. He regularly updates the book with new material without charging previous purchasers. (Paid)
  5. Swift By Example by Brett Bukowski: This site helps you learn Swift Syntax by providing explanations for code in a simple side by side view. (Free)...
My Health IT BFF Jerome Carter, MD is now using Swift.
You Had Me at “Swift”
by JEROME CARTER on AUGUST 18, 2014


Some things are simply destined to happen.   I have written a few times about my multi-year journey in modern software development.   Over the last few years, I have studied software architecture, object-oriented analysis and design, discrete mathematics and workflow analysis and had a lot of fun.  Netbeans and Xcode are on my MacBook Pro, and I have discovered that I like PHP, Python, and C#.  I am also happy to report that the web application I have been working on for what seems like forever is still on schedule.

When first announced, Apple’s Swift programming language struck me as interesting, but I did not give any serious thought to using it for anything, being already occupied with the web application.  I played with it, but only in a summer romance kind of way.   Well…things change.

Swift has a few things that make it really attractive for me.  It is compiled, but acts like a scripting language.   Syntax-wise it seems very familiar, and thinking in Swift is coming easier than expected.  Going from Python and PHP to Swift is not the least bit jarring.  Even better, all of the OOP that I learned–patterns, interfaces, closures—is readily usable with Swift...
Go to EHRscience.com, keyword search on "Swift." Bring a Snickers, you're gonna be a while.

From the Apple iBook:
About Swift
Swift is a new programming language for iOS, OS X, watchOS, and tvOS apps that builds on the best of C and Objective-C, without the constraints of C compatibility. Swift adopts safe programming patterns and adds modern features to make programming easier, more flexible, and more fun. Swift’s clean slate, backed by the mature and much-loved Cocoa and Cocoa Touch frameworks, is an opportunity to reimagine how software development works.

Swift has been years in the making. Apple laid the foundation for Swift by advancing our existing compiler, debugger, and framework infrastructure. We simplified memory management with Automatic Reference Counting (ARC). Our framework stack, built on the solid base of Foundation and Cocoa, has been modernized and standardized throughout. Objective-C itself has evolved to support blocks, collection literals, and modules, enabling framework adoption of modern language technologies without disruption. Thanks to this groundwork, we can now introduce a new language for the future of Apple software development...
Swift is friendly to new programmers. It is the first industrial-quality systems programming language that is as expressive and enjoyable as a scripting language. It supports playgrounds, an innovative feature that allows programmers to experiment with Swift code and see the results immediately, without the overhead of building and running an app...
Note that it supports OS X, the Apple desktop/laptop OS (which is my platform), so it wouldn't be just limited to "mHealth" apps.

ALSO OF Rx  INTEREST

FROM STATnews.com:
Big Pharma’s big push to get patients to take their meds

Drug companies around the globe are spending big to push patients to take their pills.

The pharma industry loses tens of billions in worldwide sales each year when patients don’t fill, or refill, their prescriptions.

So drug makers from London to Tokyo to Cambridge, Mass., are pouring money into programs aimed at cajoling — or nagging — patients to take every last pill their doctors prescribe. The companies are investing in smart pills that will send alerts when they haven’t been swallowed at the prescribed time. They’re subsidizing gift cards to thank patients who remember to refill. They’re paying patients to go on talk circuits to tout the virtues of taking medication properly.

They’re even lobbying the federal government for permission to pay third parties, such as pharmacists, to encourage patients to take their pills.


Drug companies say these investments are focused on improving patients’ health. “We’re not pushing pills here, we’re pushing adherence,” said Joel White, president of the Council for Affordable Health Coverage, an advocacy group that works with the industry.

But Matt Lamkin, an assistant professor at the University of Tulsa College of Law who’s studied the issue, sees another motive.

Pharma companies have the sense “that they are leaving billions on the table” when medicine isn’t taken and prescriptions aren’t filled, Lamkin said. The push to improve adherence, he said, “reframes the goal of boosting sales as a goal of public service”...
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More to come...

Monday, February 1, 2016

statim!


I heard an NPR segment while driving last week, featuring someone from this organization. I forget the topic, but I did shout a note in my iPhone while stopped at a red light to look them up. Check them out. their tagline -- "reporting from the frontiers of health and medicine" -- seems rather spot on. I've been reading through various articles and watching some of their videos. A lot of nice content, pretty much spanning the gamut.

Topically, first, "The Regulars."
  • Morning Rounds: Your daily dose of news in health and medicine 
  • Pharmalot: Taking stock of the drug industry, from the lab to the medicine chest 
  • Gut Check: Going beyond the headlines to make sense of scientific claims
  • Science Happens! A video series that takes you inside labs to see discoveries in action
  • The Watchdogs: Keeping an eye on misconduct, fraud, and scientific integrity
  • Signal Podcast: A biweekly podcast that explores how your medicines get made
  • Kendall Squared: Dispatches from the world’s epicenter for biotechnology and drug discovery
  • Pulse of Longwood: Inside one of the nation’s largest hubs of hospitals and biomedical research
  • Endnotes: Stories about people living with limited time, their caregivers, and issues they face
  • So Tell Me: A weekly conversation with people driving today’s insights and advances
Then, other topical headings.
  • In the Lab: Putting the latest scientific research under the microscope
  • Money: The business behind science, medicine, and the drug industry
  • Politics: Tracking how politics and policy intersect with science and health care
  • Health: The latest developments affecting patients and practitioners
  • First Opinion: Perspective and commentary from experts around the world
I also signed up here for their daily notices:


One more routine stop for me, in addition to my daily inbox feeds, ad hoc keyword searches, and routine first-cup-of-coffee health-related destinations such as Science Based Medicine, The Incidental Economist, The Neurologica Blog, THCB, and EHR Science, to cite just a few.

Recall my reporting in my recent WinterTech post on the startup now underway in Michigan by my Niece and her husband Jeff ("Neuro Trainer™"). Interesting STATnews video, "Could playing a dolpin in a video game help stroke patients recover?"


Not sure why this embedded so small. No adjustable H/W parameters in the iFrame code. Watch it here at the source if you wish.

Below: This was interesting in particular as well:
Updated: Experts argue the benefits, pitfalls of a unique patient identifier

Your medical records probably bear different numbers — one for your primary care physician and his or her medical group, one for each hospital you’ve been treated in, different ones for different specialists. This can make it difficult to retrieve your medical information.A common way to match and collect health records is by using a person’s name and birthdate. But consider this: In a health database of 3.5 million Houston-area residents, about 70,000 share the same first name, last name, and birthdate.

When the Health Insurance Portability and Accountability Act was signed into law in 1996, it called for creating “a standard unique health identifier for each individual” to make it easier to link a person with all of his or her health information, no matter where it was stored. In 1998, Congress eliminated that requirement and even prohibited the use of federal funds to develop a unique identifier.Twenty years later, the issue is still very much alive. STAT asked experts to offer their perspectives on why the United States should, or should not, create a unique health identifier for each of us.Tommy G. Thompson: Test identifier to fight medical fraud

Michael D. Greenberg: Unique identifier could protect privacy
Adrian Gropper: Identifier adds nothing beyond “coercive surveillance”
Douglas Fridsma: Make the conversation about patient benefits
Twila Brase: Block the identifier, block national health care
Stephen Smith: Unique identifiers work in the UK...
I follow Dr. Gropper a lot, and have seen him at various conferences I cover.
By Adrian Gropper: Implementing a unique patient identifier would add nothing to our health care system beyond coercive surveillance. It would collect information about us without our consent or even our knowledge, much as the National Security Agency has been doing with telephone records.

Patients are just people. Why bother with a number when scanning the iris of the eye is arguably a perfect way to identify each of us. The technology for doing this is becoming almost as inexpensive as that needed to read a credit card. It’s not a stretch to imagine iris scanners appearing in doctors’ offices, hospitals, ambulances, and the like to match individuals with their health records.

That might be efficient, but it isn’t voluntary and offers us no say about what information is matched and who has access to it, nor does it offer any transparency into the process.

There are other ways to accurately match individuals with information about them. The Internal Revenue Service, for example, is quite good at matching people with their financial information by asking for their name, date of birth, and Social Security number the first time they register at a bank or employer. For health, we could ask individuals to supply their name and an email address, cellphone number, or other familiar unique identifier. Then, whenever an entity wants to access an individual’s data, be it a physician, lab, pharmacy, insurer, or someone else, a notification would automatically be sent to the person by email or text asking if that’s what they intended. This kind of familiar opt-in system gives the individual control over his or her data and the ability to see who is looking at it.

Access to our health information is a first-order privacy issue. Most of the matching and access is done for purposes that don’t benefit the patient. Some access is done for risk adjustment, some for marketing services, and some for setting prices while effectively keeping cost and quality in medicine a secret. Take a look at TheDataMap, developed by Latanya Sweeney of Harvard University’s Data Privacy Lab, to see the types of organizations that routinely tap into our health information.

Americans need a health care system that encourages trust in our doctors, labs, pharmacies, hospitals, and more. You don’t build trust in a system by introducing involuntary and coercive practices like a unique patient identifier just because they are efficient.

Adrian Gropper, MD, is chief technology officer for Patient Privacy Rights.
I've been hip to Dr. Latanya Sweeney for years, I cited her on this blog back in 2011.

So, given that my interests on this blog extend out from its onset core of Health IT per se to overlapping and interweaving topics such as HIT "UX," informatics/"data" issues more broadly (including the misnomer "interoperability"), process QI, applied clinical science (inclusive of "the Omics"), medical pedagogy and clinical cognition (and the so-called "Art of Medicine"), HIT privacy, health care economics (including IP, VC investing, and the impacts of AI) and public policy, and organizational dynamics, etc., -- and, of course, the "caregiver" and "patient experience," --  STATnews.com will surely keep me even busier.

statim!

OTHER NEWS

My friend Joe Flower has a new post up on LinkedIn:

Who Is The Real Customer In Healthcare?

Almost none of the buy or pricing decisions involve people "playing" with their own money and their own health. The buying decisions are mostly made by the medical practitioners themselves, and the pricing decisions are mostly made in negotiations between each medical organization and the insurance companies, or between the whole industry and the government, for Medicare and Medicaid.

A real customer is the person who gets the benefit of the product, who can choose it, who pays enough of the cost for it to make a difference in their choice—and who can walk away from the deal, shop elsewhere, buy an alternative way to solve the problem, or even buy nothing. None of that is true of the patient in the traditional healthcare setup...
Tell me about it.

Below, more shots at MU:
How has meaningful use really affected healthcare providers?

We praised the inclusion of HITECH in the American Recovery and Reinvestment Act of 2009 as a stimulus to expand EHR adoption and improve the quality and effectiveness of patient care for all time. Today, many respected healthcare leaders argue that it is time to declare victory and move on.

Those leaders were recently encouraged by CMS leader Andy Slavitt’s announcement that Meaningful Use would end soon and be replaced by something better. Unfortunately, “April Fools” was declared only two days later, when CMS administrators, including Karen DeSalvo, MD, National Coordinator for Health Information Technology, said the program was going to be with us for the foreseeable future. Now, we can look forward to more good ideas from our government.

It is time to consider the impact of Meaningful Use. How has it affected the provider community? How has it accelerated, or retarded, the innovation of healthcare practice? How has it influenced the economics of healthcare? What has it done for the most important stakeholder, the patient? If it has not achieved the full potential ascribed to HITECH, what are the causes and what are the best next steps?...
Well, HITECH was the source of my REC job. Not that I didn't take my own shots at it. Now, with the bulk of the MU money all essentially out the door (~$32 billion), it should be a relatively easy kill -- though, with this being an election year, we may not see a lot done on The Hill across a breadth of legislative areas (with the likely exception of several more Quixotic bills declaring ObamaCare repealed for the umptie-dozenth time).
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THERANOS UPDATE

I've had my recent observations regarding the travails of Theranos, here, here, and here. STATnews is on it today.

Is Theranos done?

The Silicon Valley upstart wowed the medical world with a whopping $9 billion valuation, a supremely media-savvy CEO and the promise that it could revolutionize health care by using just a few drops of blood to run scores of lab tests at a fraction of the current cost.

But these days, Theranos is sinking deeper and deeper into a quagmire. Regulators keep issuing sharp warnings about its lab practices. Pharmacies keep pulling back from its partnerships. The Wall Street Journal keeps raising questions about its technology.

Does Theranos have a chance to regain the confidence of potential investors, partners, and patients — or is it on an irreversible decline? For clues, keep an eye in the coming months on these five bellwethers...
Good piece. Read all of it.

ANOTHER UPDATE

Looks like Theranos is back actively and adversely in the news. Daily Beast:
Theranos Sounded Too Good to Be True—and It Is

...“Is Theranos Finished?” asked health and medicine outlet STAT, which noted that the company “didn’t respond to questions about how it’s doing financially.” Between the government regulation and the rocky business deals, those are reasonable questions to ponder....
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More to come...

Monday, January 25, 2016

More on the "Upstream." Lead in the water supply.


ScienceBasedMedicine.org has a compelling analytical commentary up on the Flint, Michigan water contamination travesty.
...For those of you who haven’t heard of it yet, the Flint water crisis refers to the ongoing contamination of the tap water in Flint, MI with unacceptably high levels of lead that resulted from change in its water supply nearly two years ago to Flint River water. Because river water is more corrosive than the previous supply that came from Lake Huron (why I’ll explain later) and Flint river water was not properly treated to decrease that corrosiveness, the new water leached lead from old pipes. This resulted in the contamination of the drinking water with dangerous levels of lead in many homes in the city. In addition, there has been a marked increase in the number of cases of Legionnaires’ disease thought to be linked to the new water supply...
A lengthy, thorough piece on an egregious episode of criminal negligence and utter moral indifference perpetrated by Michigan government officials -- starting with Michigan Governor Rick Snyder.

My Photoshop reaction.


Health impacts of the "Upstream," anyone? More on the "Upstream" here as well.


THE HITS JUST KEEP ON COMIN'
Flint children never had a fair shot, even before lead poisoning

On one level, the Flint lead poisoning scandal is about a state mismanaging a city under financial duress and moving the city to a water supply that turned out to be unsafe.

But on another level, it's also about something deeper: the vulnerabilities kids face when they grow up in poverty. They are more likely to have lower test scores, become teen mothers, and experience violent crime. And it's not just a lack of opportunity: A recent study found that the stresses of poverty actually stunt brain development.

Add to that lead poisoning — which also stunts growing brains — and that's what you have in Flint, Michigan...
Could What Happened in Flint Happen Anywhere?
Other U.S. cities, particularly in the Northeast and Midwest, could face the same water crisis because millions of utility lines contain lead, a potent poison.


Flint’s crisis with drinking water contamination has been cast as a unique series of fumbles and cover-ups. But the Michigan city’s plight also illustrates a much wider concern: Millions of Americans drink water that flows through lead pipes, fittings, and solder, most installed before the 1970s.

Lead pipes can be found in much of the U.S., but surveys show they are concentrated in the Northeast and Midwest. Nobody really knows how extensive they are today: A 1990 study estimated that 3.3 million utility service lines contain lead—plus twice as many connecting pipes, and countless amounts of lead solder. In addition, many homes have plumbing that contains the hazardous metal.

If utilities don’t carefully balance water chemistry and treatment methods, and if regulators don’t enforce the rules, lead can leach from utility pipes and household plumbing systems and wind up in people’s water. That’s what happened in Flint. A decade ago, it happened in Washington, D.C., too. About 640,000 District of Columbia residents were exposed to lead when changes in disinfection chemicals allowed lead to leach from pipelines.

And health experts warn that the same crisis could happen again elsewhere, especially as local and state public health budgets shrink...
Does The EPA Bear Responsibility For Flint?

A blame game has erupted over the lead-ridden drinking water in Flint, Michigan. For weeks, residents, politicians, and observers across the country have been asking: Who is responsible for this public health catastrophe?

Politically, blame is polarized. Progressives have taken aim at Michigan’s Republican governor, Rick Snyder, who they say failed to recognize through his state environmental agency that Flint’s water was unsafe. Meanwhile, some conservatives have targeted the Democratic emergency manager of Flint, who they say was ultimately responsible for switching the city’s water supply to the highly suspect Flint River.


The most controversial culprit, however, is the federal Environmental Protection Agency. Long before the crisis erupted, an EPA employee sounded the alarm about a serious lead problem in Flint’s drinking water system. But his higher-ups declined to make that information public, and instead tried behind the scenes to get the Michigan Department of Environmental Quality to take action to solve the problem.

Now, many insist the the EPA should have gone public with what it knew. “With a clear mission to protect human health and the environment, the EPA must be held to the same standard of accountability as state agencies,” the Detroit News wrote in a scathing editorial last week. Indeed, it seemed perplexing that the EPA would sit on troubling information about a potentially poisoned water system in a city of nearly 100,000 people. Why on earth would the EPA do that?...
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[T]he nightmare in Flint reflects the resurgence in American politics of exactly the same attitudes that led to London’s Great Stink more than a century and a half ago. - Paul Krugman, Michigan's Great Stink
Flint, Michigan's water crisis: what the national media got wrong

...Who's really responsible for the Flint water crisis

Many national media reports would have you believe that the crisis began in April 2014, when the city started drawing its water from the Flint River. They'd also have you believe that the crisis was the fault of the locally elected officials who made a catastrophic decision, not to mention city residents who did not hold their leaders accountable.

The stage was set on March 16, 2011, when Michigan Gov. Rick Snyder signed Public Act 4. This measure broadened an earlier law that provided an "emergency financial manager" for financially distressed cities and school districts. Under the new law, "emergency financial managers" became "emergency managers" with the power to cancel or renegotiate city contracts, liquidate assets, suspend local government, unilaterally draft policy, and even disincorporate. (It is worth noting that Michigan emergency managers have done all of these things except disincorporate, which was entertained by a manager in the city of Pontiac.)

The need for an emergency manager was determined by a series of highly subjective criteria. Almost every city that got one was a poor, African-American-majority city devastated by a shrinking industrial sector: Flint, Pontiac, Detroit, Highland Park, Benton Harbor, and so on.

Flint was one of the first cities to be assigned an emergency manager in 2011, and over the course of four years had four such managers.  One of the first manager's first acts was to suspend local government, and this remained essentially in force until the departure of the last emergency manager in 2015. Even today, Flint is under the scrutiny of a "transition advisory board" that has veto power over any local decision, and that has frequently overstepped its professed limited mandate to assure fiscal restraint.

Many Michiganders found Public Act 4 to be a violation of a strong state tradition of "home rule," and so overturned it by referendum in the 2012 election. But that didn't last long: the Republican-dominated state legislature immediately passed Public Act 436, which was almost identical, although it included a provision to pay the emergency managers from state coffers rather than local. Under Michigan law, a bill that includes an appropriation like this cannot be voided through referendum.

Some emergency managers, true, delegated limited responsibilities to the mayor or to members of the city council, but they always retained (and used) their powers to void any decision with which they disagreed. This is the key point that early coverage by flagship newspapers like the New York Times and the Washington Post neglected to mention: From 2011 to 2015, Flint officials had no real control over municipal policy...
THURSDAY UPDATE

The Next Flint
The communities most susceptible to calamitous infrastructure failures are marginalized places inhabited by marginalized people. And many of them are suburbs.

hen Rohan Hepkins, the mayor of Yeadon, Pennsylvania, heard about the water crisis in Flint, Michigan, he sensed a pang he’s known for a while. “I just felt like, here we go again. That’s what happens to the disenfranchised.”

It’s also what could happen to older communities with aging infrastructure and declining tax revenues. No community can avoid the fact that America’s water infrastructure could require an investment of $1 trillion or more over the next 25 years. Some places, however, are more susceptible to crisis than others. An unholy brew of circumstances created the tragedy in Michigan—in which a money-saving decision to switch water supplies corroded the coating in Flint’s aging pipes, contaminating the supply with lead—yet similar circumstances afflict marginalized municipalities populated by marginalized people across the nation. Some of the most vulnerable communities are small post-industrial cities, like Flint. But the next infrastructure crisis is just as likely to occur in an aging, inner-ring, mostly black or Latino suburb.

“The post–World War II suburbs are starting to sag, because they were not meant to last this long,” says Myron Orfield, director of the Institute on Metropolitan Opportunity at the University of Minnesota Law School. “The housing is rotten, the infrastructure is rotten. But it is the nonwhite suburbs that are the poorest places in metro America, with the smallest tax bases. There are thousands of them, and they are all going to have Flint problems all over the country”...
What a mess.
There are roughly 7.3 million lead service lines in the U.S., according to an estimate by the Environmental Protection Agency, down from 10.5 million in 1988. Service lines are the pipes connecting water mains to people's houses. They're mostly found in the Midwest and Northeast.

Despite the life-altering consequences of lead poisoning, there is no national plan to get rid of those pipes. A top reason for continuing to use lead service lines instead of immediately digging them up is that utilities can treat water so it forms a coating on the interior of the pipes -- a corrosion barrier that helps prevent lead particles from dislodging and traveling to your faucet. But if the water chemistry changes, the corrosion controls can fail.
Link.

Documentary filmmaker and Flint MI native Michael Moore is not amused.


MORE...
Amid denials, state workers in Flint got clean water

LANSING -- In January of 2015, when state officials were telling worried Flint residents their water was safe to drink, they also were arranging for coolers of purified water in Flint's State Office Building so employees wouldn't have to drink from the taps, according to state government e-mails released Thursday by the liberal group Progress Michigan.

A Jan. 7, 2015, notice from the state Department of Technology, Management and Budget, which oversees state office buildings, references a notice about a violation of drinking water standards that had recently been sent out by the City of Flint...


State officials could not immediately answer e-mailed questions about the water purchases, including how long the state continued to buy bottled water for state employees in Flint while telling Flint residents the water was safe to drink. An official said the administration was "looking into these issues."

Lonnie Scott, executive director of Progress Michigan, said it appears the state was not as slow as initially thought in responding to the Flint drinking water crisis.

“Sadly, the only response was to protect the Snyder administration from future liability and not to protect the children of Flint,” Scott said. “While residents were being told to relax and not worry about the water, the Snyder administration was taking steps to limit exposure in its own building”...
 Oops.
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More to come...

Thursday, January 21, 2016

Coming soon, HIMSS 2016 Conference in Las Vegas


OK. A couple of years ago HIMSS made a distinction between "press pass" issuance for their annual conferences and what they called "social media ambassadors," the latter, I guess, being thought of as "media lite" -- not really the Serious "press," but valuable enough in terms of PR outreach to warrant the comp badges (and, I'm a mere independent "blogger" not on deadline for some traditional media company). I last attended in 2014 in Orlando as a "social media ambassador." (I didn't attend HIMSS 2015 in Chicago last year, as I was being biopsied at the time for what turned out to be the prostate cancer whose tx consumed much of my time and attention in 2015, mucking up my coverage of the annual Health 2.0 conference in Santa Clara.)

Well, seems that this year I'm back to simply being "press." HIMSS is back in Vegas, and I will attend, as I first did in 2012, the last time the HIMSS Conference was held in the town where I lived from 1992 through 2013.

2016 seems to me a pivotal year for Health IT and healthcare more broadly (though, yeah, I know, we say that every year), so I will be all eyes and ears. This time I'm going to plot out a detailed sessions plan well in advance and reach out to key attendees.

When you go to the HIMSS16 full sessions schedule search page, you find a set of filtration drop-down panels.


Filtration by topic:


The only limitation is that the subtopic choices within any one drop-down filter panel are mutually exclusive; there's no "select all that apply" functionality (which, net, is probably a good thing).

apropos of WinterTech 2016,


You find one session devoted to Health IT venture capital.
Health IT Entrepreneur’s Guide to the Universe

March 1, 2016 — 11:30AM - 12:30PM, PT Sands Expo Convention Center, Delfino 4001, Session ID: 35

Description
New ideas in healthcare are driving novel technologies and improving focus, quality, efficiency and effectiveness of care delivery.  Innovators require the support of an entrepreneurial structure and capital to move from design to prototype, alpha to beta test, and pilot to commercialization. We will provide an overview of healthcare innovation process, and strategies for identifying collaborators, strategic partners, customers and capital.  


Speaker(s):
Howard Burde, JD, FHIMSS
Eric Toone, PhD


Level:
Intermediate


Learning Objectives:

  • Outline and illustrate the process of developing a health IT idea into entrepreneurial reality
  • Discuss considerations for collaborators, advisors and strategic partners, as well as allied solutions
  • Evaluate appropriate methods of protecting intellectual property, assessing markets and determining how to reach customers
  • Identify sources of capital and what each type of investor offers to, and demands from the innovator
Filter: Entrepreneurship and Venture Investment
And so on. You can rather easily register/login and fill out "your dance card."

In addition to the foregoing, some of my priority topics -- given the historical thrusts of this blog -- will likely run to "Business of Healthcare and New Payment Models," "Career/Workforce Development and Diversity," "Clinical Informatics and Clinician Engagement," "EHRs/Meaningful Use," "Health Information Exchange and Interoperability," "Human Factors, Usability and Design," "Innovative Processes, Solutions and Emerging Tech," "Leadership, Governance, Strategic Planning," 'Process Improvement, Workflow, Change Management," and "Quality and Outcomes."

Good luck trying to fit all of that in. I will no doubt be subselecting session priorities within those categories.

UPDATE ON THE VENTURE CAPITAL THING

Another interesting read, apropos of my prior post on WinterTech 2016.


I've yet to buy this one. Based on the Amazon ratings/comments and the "Look Inside" excerpt," it looks perhaps worthy. I used Dragon to read in the following:
Introduction

For years, this question has played in our minds: why do some startups defy all odds and become multibillion-dollar successes while many others fail? Is this purely a stroke of luck or is there a science behind the success? If so, what are the common characteristics among successful startups and entrepreneurs? To find answers to these questions, we went straight to the source and asked the venture capital investors who are part of some of the most notable successes of our time.

In this book you will hear leading startup investment practitioners discuss, in their own words, how they got identified promising ideas, markets, products and entrepreneurs, and how they helped build a game changing companies. We explored with them the lessons learned from not only the successes, but also their failures, to identify the factors that separate the two groups and also to draw the common patterns. Finally we asked them what advice they would give to entrepreneurs aspiring to build the next Google, Facebook, grew upon, or twitter.

To provide you with a 360° view of how to build successful startups, we have included interviews with several nominal entrepreneurs and exceptional startup operators. We explored with them the end to end journey from formation to exit and discuss the most common operating challenges along the way, and how they tackled them...

One of the most surprising revelations was that many successful companies arose out of non-consensus, unconventional, and in fact contrary and ideas. Most people didn't think those ideas was succeed at all, let alone become multibillion-dollar companies. In each of these cases, the entrepreneurs had very strong intuition and access to asymmetric information based on their predisposition toward, and early exposure to, potentially huge untapped or emerging market opportunity. Groupon, Twitter, and Facebook are great examples of that. Given the general market disbelief, these companies enjoyed very little competition until they broke off the chart. On the other hand, the riskiest startup ideas tend to be those most people can see are great ideas. Hence, there is so much competition that it negatively impacts everything from gross margin to valuation.

Surprisingly, most successful startups were not started with the goal to build a billion-dollar company. They rather started with a desire to solve a meaningful "pain point" — a VC term for a problem that causes people a lot of frustration. this is usually something that affects the entrepreneur personally and directly. Then the entrepreneur does a wonderful job of solving the problem for a small group of customers. Eventually the entrepreneur, with the help of venture investors, finds a way to expand the solution to a very large group of customers. This doesn't necessarily put management before market, but rather it emphasizes the fact that the best companies are created when great teams intersect with large market opportunities.

Whereas entrepreneurs focus on identifying and solving these burning pain points, venture investors trying to find those extraordinary entrepreneurs who are trying to solve potentially huge problems in a meaningful way. Venture investors tap into their tremendous network of contacts and "pattern recognition" — the art of leveraging lessons drawn from past successes and failures to identify a combination of factors and behaviors that may point to promising markets, entrepreneurs, products, business models, and so forth. Together, these build a "prepared mind" or "gut feel" about the emerging market opportunities created by the tectonic shifts in customer behavior and the enabling technologies that can be successfully applied to those shifts. Entrepreneurs are true visionaries, and venture investors are great pattern recognizers with an experienced toolkit of how to build companies — and how not to build them. Successful startups are created when a trusted relationship and line of communication is established between the visionary (entrepreneur) and the pattern recognizer (investor) for two way knowledge transfer.

In discussing the characteristics of the successful founders, the words are repeated most often are extraordinary passion, intelligence, authenticity, intellectual honesty, dogged persistence, risk taking, and integrity. Many of these entrepreneurs were scarred by past failures, or hungry to win big, or came from humble backgrounds. They also had this fact in common: they were hardly known to the world before starting companies that made them successful and famous. Most of these successful founders also paired with one or more cofounders rather than going solo. The cofounders they partnered with had not only complementary skills, but more importantly, a long history of working together. They had built a great chemistry with each other well before they became cofounders.

It's also clear from the interviews that most successful startups have an "A" team of 30 to 40 people stroking together in harmony towards a common mission. This gives them 10 times the productivity advantage over their competitors. These teams come together when the passion, intelligence, and charisma of the founders serve as a talent magnet to attract some of the best people in the industry to solve the toughest and most challenging problems for their customers. The first 10 to 12 hires in the startup team are extremely important, as they determine the DNA and culture of the company and, in turn, it's successful trajectory...

Successful startups also end up making drastic changes to their original plans in what's called a "pivot." Only a small percentage of such pivots — one in 10 — are successful, though. The successful pivot is a function of the "authenticity" and "intellectual honesty" of the entrepreneurs, where a deep knowledge of the market space and its fine nuances, combined with their ability to quickly adapt to new market realities, lazy key role in determining the effective degree and direction of the pivot. The journey to a successful pivot as a logical progression without any leaps from one strategy to the next, and the domain knowledge of the founders remains relevant in the new plan.

The interviews also reveal how important market timing is in determining startup success. It's probably the most overlooked concept by the entrepreneurs, and they usually end up being too early or too late to the market. Many companies fail not because they are too early or too late, but because they don't recognize or admit that, and change their plan’s cash burn accordingly…
That's enough for now. I get the general idea.

Also relevant to the topic, the work of the "Society for Effectual Action," from the perspective of the entrepreneurs' PoV:

www.effectuation.org
"Effectuation is a logic of entrepreneurial expertise. What makes great entrepreneurs isn't genetic or personality traits, risk-seeking behavior, money, or unique vision. Effectuation research has found that there is a science to entrepreneurship and that great entrepreneurs across industries, geographies, and time use a common logic, or thinking process, to solve entrepreneurial problems. Effectuation is a logic of entrepreneurial expertise that both novice and experienced entrepreneurs can use in the highly unpredictable start-up phase of a venture to reduce failure costs for the entrepreneur."
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BTW, this year's opening HIMSS Keynoter is Michael Dell.

Oh, and you can count on my going to Lindo Michoacan while I'm in town.


D.I. and Eastern, Javier's original property. When I lived in Vegas, we called it "headquarters."

Oh, and I will also have to hang with my old friends in the Santa Fe Band.

 

These guys are Vegas's top casino show musicians who have this band on the side. They're sprinkled throughout major shows such as Celine Dion, Jersey Boys, Donny and Marie, Legends in Concert, Carlos Santana, Vegas! The Show, etc.

I used to write a blog for them and do their photography.
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More to come...