Search the KHIT Blog

Saturday, November 30, 2013

A Thanksgiving weekend blogging respite

Well, our wedding anniversary fell on Thanksgiving Day this year (our 33rd), and, as a bonus, our son flew in to visit for the weekend. Above, we all went to Scott's in Jack London Square in Oakland for Thanksgiving Day dinner.

Below, the dusk view from The Cliff House in San Francisco.

Hope everyone is having a safe and happy holiday weekend. I'll pick back up on topical blogging Monday. Maybe even tomorrow evening should the news warrant it.

Tuesday, November 26, 2013

Buckshot: the continuing randomness of U.S. healthcare "value"

I've been doing summary reporting on selected annual HEDIS outcomes across the life of this blog. See my 20102011, and 2012 posts (scroll down in any of them). A salient example from 2010:

HEDIS deploys two proxies which combine to connote value: "quality" (y axis) and "RRUs" (Relative Resource Units, the "cost" analog). As I observed in 2010,
Zero apparent linear "Pearson-R" relationship between cost and quality of outcomes (albeit via their summary "quality vs. cost" proxy scales). The foregoing plot addresses cardiovascular disease, but the scattergrams in the report illustrating other major chronic conditions (hypertension, diabetes, COPD) evince the very same random buckshot patterns. My red rectangle upper left quadrant annotation above is meant to focus on the question this begs of me: are we, consequently, paying too much? What is it about the "above average quality/below average cost" segment that we might discern were we able to "peel the onion back" in search of relevant causal correlates? Is use of HIT a factor? And/or other organizational factors? ( The NCQA report is silent on such implications).
Nothing has changed materially. Below, some selected scatterplots from the 2013 HEDIS Annual Report (pdf).

Groundhog Day. Payor doesn't matter. Major chronic dx doesn't matter. Buckshot.

Below, a graphic of a different (albeit related) sort. from the OECD 2013 report "Health at a Glance 2013."

The outlier U.S. Pay double, get less.

NYeC 2013 Wrap-up

On November 14-15, NYeC held its third annual Digital Health Conference. This year’s conference was the biggest yet with more than 1100 attendees, 70 speakers, and 15 break-out sessions. Top level health IT professionals, CIOs, CMIOs, venture capitalists, entrepreneurs, academics, and a multitude of vendors gathered to discuss and learn about the latest thinking and innovation in the Health IT ecosystem. Two nationally-known experts on the power of data and analytics gave keynote addresses: George Halvorson, Chairman of Kaiser Permanente and Jim Messina, National Director of Organizing for Action and Campaign Manager for President Obama's re-election campaign. Both provided provocative and unique insights on the power of data analytics to significantly improve patient care and transform care delivery.
Hot discussion topics at the conference included HIE trends, the importance of interoperability standards on driving Health IT innovation, and the value of empowering consumers with their own health information as a tool to advance healthcare.
Thanks to all of our sponsors, partners, and speakers who helped to make this year's Digital Health Conference a resounding success.

LOL. There I am, front row in the Grand Ballroom at 1:52, blogging away into my Mac Air.



More to come...

Monday, November 25, 2013

"He never met a vegetable he didn't hate"

And now he's dead. Not quite 50 years old. An accomplished nuclear QA professional. Leaving behind two young daughters and a wife beset by MS.

My wife's now-late former colleague and friend of more than twenty years. Cheryl told me she'd seen a missed call from him logged in her iPhone. She was very happy; they'd not spoken in a while. She was eager to catch up.

She tried calling back, unsuccessfully. Left a message.

Last night I came downstairs into the kitchen. She was standing at the stove, preparing supper. We'd had such a great day together.

Her burning red eyes were overflowing with painful tears.

She'd just gotten a call back. It wasn't her friend, it was his wife (also a long-time friend), now his widow.

He died of a heart attack without warning on Saturday.

Cheryl said they'd all long fussed at him over his crappy diet. The Triple Meat Pizza Man.

Now he's dead, leaving behind a shockwave of anguished cell phone calls pulsing out all around the world by a huge network of inconsolable friends.

Services will be Wednesday in Chicago. The day before Thanksgiving Day, amid acutely crappy holiday travel weather. A lot of people will not be able to make it.

Our 33rd wedding anniversary falls this year on Thanksgiving Day. There will be a damper on our celebration.

Maybe Stage 3 Certified EHRs should have a sub-template for "nutrition" under the Social Hx panel, with checkboxes for Triple Meat Pizza and Routine Consumption of Nuts.

(I know it's way more complicated than that. Still, "The Social / Behavioral / Nutritional Components of Health..." )

Dunno. It's a sad day in my house.


Stop selling those DNA tests, FDA tells 23andMe
Maggie Fox NBC News, Nov, 25th, 2013

The Food and Drug Administration has ordered DNA testing company 23andMe to stop marketing its over-the-counter genetic test, saying it’s being sold illegally to diagnose diseases, and with no proof it actually works.

The heavily marketed test includes a kit for sampling saliva, and the company promises to offer specific health advice. “Based on your DNA, we’ll provide specific health recommendations for you,” the company says on its website. "Get personalized recommendations."

In an unusually scathing letter dated Friday, the FDA says it’s been trying to work with the company to get some sort of evidence that the test can do that with any accuracy.

“The Food and Drug Administration (FDA) is sending you this letter because you are marketing the 23andMe Saliva Collection Kit and Personal Genome Service (PGS) without marketing clearance or approval in violation of the Federal Food, Drug and Cosmetic Act,” the agency says in a letter addressed to Ann Wojcicki, CEO of 23andMe.

“Therefore, 23andMe must immediately discontinue marketing the PGS until such time as it receives FDA marketing authorization for the device.”...


Next Monday, Dec. 2nd actually -- 1st business day of the new month, all the DC pundit talk will be about the status of the troubled The Obama Administration has already started moving the goalposts. I rather doubt that Sebelius will be fired or forced to resign right away, but if credible reports (and grudging admission) show a lack of substantive progress, the chorus of calls for her head will grow increasingly loud.

We'll see.
“No matter how we reform health care, we will keep this promise: If you like your doctor, you will keep your doctor. Period. If you like your health care plan, your will keep your health plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.” - President Obama, verbatim, speaking to the AMA in July 2009
UPDATE contractor had high confidence but low success

...The Obama administration has set a Nov. 30 deadline — next Saturday — by which officials have promised that will work smoothly for about four out of five consumers who attempt to use it to sign up for health plans. Even now, the official familiar with the project said, CGI’s work on the repairs is not always going well; roughly one-third to half the new computer code the company is writing cannot be used because it is revealing flaws when it is fully examined by a group of outside testers, including some insurance companies....
Stay tuned.


More to come...

Friday, November 22, 2013

Let's Go Nuts!

This has been the buzz of the health-related mainstream media this week.
Increased nut consumption has been associated with a reduced risk of major chronic diseases, including cardiovascular disease and type2 diabetes mellitus. However, the association between nut consumption and mortality remains unclear.

We examined the association between nut consumption and subsequent total and cause-specific mortality among 76,464 women in the Nurses’ Health Study (1980–2010) and 42,498 men in the Health Professionals Follow-up Study (1986–2010). Participants with a history of cancer, heart disease, or stroke were excluded. Nut consumption was assessed at baseline and updated every 2 to 4 years.

During 3,038,853 person-years of follow-up, 16,200 women and 11,229 men died. Nut consumption was inversely associated with total mortality among both women and men, after adjustment for other known or suspected risk factors. The pooled multivariate hazard ratios for death among participants who ate nuts, as compared with those who did not, were 0.93 (95% confidence interval [CI], 0.90 to 0.96) for the consumption of nuts less than once per week, 0.89 (95% CI, 0.86 to 0.93) for once per week, 0.87 (95% CI, 0.83 to 0.90) for two to four times per week, 0.85 (95% CI, 0.79 to 0.91) for five or six times per week, and 0.80 (95% CI, 0.73 to 0.86) for seven or more times per week (P< LT 0.001 for trend). Significant inverse associations were also observed between nut consumption and deaths due to cancer, heart disease, and respiratory disease.
In two large, independent cohorts of nurses and other health professionals, the frequency of nut consumption was inversely associated with total and cause-specific mortality, independently of other predictors of death. (Funded by the National Institutes of Health and the International Tree Nut Council Nutrition Research and Education Foundation.)
Full paper PDF here. The paper closes with this:
In conclusion, our analysis of samples from these two prospective cohort studies showed significant inverse associations of nut consumption with total and cause-specific mortality. Nonetheless, epidemiologic observations establish associations, not causality, and not all findings from observational studies have been confirmed in controlled, randomized clinical trials.
Pretty interesting. I love nuts. Routinely sprinkle chopped-up nuts in my salads, and eat them as snack foods. But, re "association vs causation," are healthier people per se more likely to have a habitual taste for nuts (or myriad other foods thought to be beneficent)?

Just checked over at They've not chimed in on this yet. Their current post is "Do vitamins prevent cancer and heart disease?"


From THCB today

This guy is a lawyer.
Another Law Raising the Cost of Health Care

While there has been much focus lately on the ways in which ObamaCare is chilling the growth of private business, we should not overlook the continuing deleterious effects of the one surviving relic of HillaryCare, the Health Insurance Portability and Accountability Act (HIPAA). Quietly, September 23 came and went as the compliance effective date for a new rule, expanding the reach of HIPAA, and likely driving many smaller players out of the health care industry...
My response in the comments:
“Spearheaded by then First Lady Clinton, HIPAA was established in 1996 to improve privacy of personal health information”

HIPAA 1996 was an INSURANCE REFORM bill and law, not a “privacy” law. The “Kennedy-Kassebaum” bill. You could call it “ObamaCare Precursor, v1.0″
According to respected medical economist (and former Hill policy operative) J.D. Kleinke, “PHI privacy” was an 11th hour tossed-in faceless bargaining chip. Only 13 of the 167 pages of the law refer to it. I have my yellow-highlighted, sticky-noted, red-penned copy.
(See Subtitle F “Administrative Simplification”).

Washington Post, James K. Glassman, Tuesday, April 23, 1996

“…New, stricter laws will be needed to correct the deficiencies, and probably more after that. Inevitably, Americans will arrive at the destination they rejected when Bill and Hillary Clinton proposed it: government-controlled health care.

“…At its heart, the bill does two things that seem worth doing. First, it makes insurance policies more “portable” by requiring insurers to issue you a policy if you lose or leave your job. Second, it prevents insurers from denying you a policy if you have a pre-existing medical condition…”

“Both of these measures seem humane and sensible. Unfortunately, they are also expensive. For example, if an insurer does not have the right to reject — or delay for a long time — coverage of someone who has a disease that’s costly to treat, then the insurer will have to raise premiums.

The bill sponsored by Sen. Ted Kennedy (D-Mass.) and Sen. Nancy Kassebaum (R-Kan.) does not cap premiums — which is why so many Republicans support it. But caps will come because the outcry over higher rates will be deafening, and politicians will be forced to respond. That’s what makes this bill so insidious and its “modesty” so illusory.

Just take a look at what’s happened in the state of Washington. The state’s program, says an article on the front page of the Wall Street Journal, “contains many provisions — broader public access to insurance rolls, portability and short waiting period for people with pre-existing heath problems — that mark the health-care bills that congressional reformers are pushing.”
The article continues: “But three years into Washington state’s program, rates for its 400,000 individual policyholders are soaring, in some cases to triple their former level. . . . More than 30 insurers have notified the state they no longer want to do business here.”
The Washington state program is broader than Kennedy-Kassebaum, but the effects are likely to be similar. What Congress wants to do is to force insurers to insure sick people. When that happens, everyone else will have to pay more in premiums. And when that happens, the healthiest people (mainly the young) will decide they don’t need insurance at these prices, so they’ll drop out of the system. And when that happens, premiums will increase even more sharply for those who are left, because the healthy people who subsidized the sick people will be gone…”

Sound familiar? Groundhog Day, anyone?

Search the article for the word “privacy.” You won’t find it.


Oh, 2014 CEHRT, Where Art Thou? 

39 days to the onset of calendar year Stage 2, Year one of the Meaningful Use program. Below, inpatient setting complete certified products to date.

Nine vendors, nominally 15 products (and, looks like perhaps one overcount -- MEDITECH v5.66; I simply scraped the data off the CHPL and dropped 'em into Excel).

There are 240 "modular" certs on the inpatient side. And, 194 modules and 57 complete products on the ambulatory side (comprising 26 vendors).

2011 certs to date, by way of partial contrast, total 1,831 outpatient and 72 inpatient "complete" products.

A little late in the day, are we not?

More to come...

Tuesday, November 19, 2013

Healthcare "Big Data" will not be a panacea

Risk Calculator for Cholesterol Appears Flawed
By GINA KOLATA, New York Times, November 17, 2013

Last week, the nation’s leading heart organizations released a sweeping new set of guidelines for lowering cholesterol, along with an online calculator meant to help doctors assess risks and treatment options. But, in a major embarrassment to the health groups, the calculator appears to greatly overestimate risk, so much so that it could mistakenly suggest that millions more people are candidates for statin drugs.

The apparent problem prompted one leading cardiologist, a past president of the American College of Cardiology, to call on Sunday for a halt to the implementation of the new guidelines.

“It’s stunning,” said the cardiologist, Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic. “We need a pause to further evaluate this approach before it is implemented on a widespread basis.”...

Making sure we come to scientifically accurate and effective conclusions across the vast expanse of health care conditions are treatments will not be easy. Given increasingly easy access to "big data," there will be much naive quantitative enthusiasm, some of it merely wasteful, some of it dangerous to deadly.


apropos of data, I joined this Meetup group. Our first meeting is tonight.

First Meeting- discuss format of meetings, network
Wednesday, November 20, 2013
7:00 PM to 9:00 PM

Hacker Dojo
599 Fairchild Drive, Mountain View, CA

Hi everyone,

With the help of a meetup member Steve Banville, we have a conference room reserved at Hacker Dojo for Nov 20th.  Thanks Steve for your help.  I have also been speaking to a few of the members offline and it seems that it would be best if we start off with a meeting to discuss the agenda, the objectives, the format, frequency of meetings, etc of the Meetups.  I want this Meetup to be a real learning experience rather than a gloss over of methodologies.  It would be very useful to discuss how we think we can make this relevant for us.  I will send out a more detailed set of topics that I'd like to discuss in the 1st meeting. 

In the meantime please rsvp to let me know whether you can make it.  We may need to adjust the conference room reservation based on the number of people that rsvp.

Thank you, Seema.
Should be interesting.
This group is for anybody who practices Statistics, loves data and wants to grow their skills. Objectives of the meetups would be hearing from guest speakers and some deep discussions on statistical methods and statistical and programming techniques. All statisticians are welcome, from Big Data Scientists to Survey Statisticians and analysts.
A couple dozen stats people have signed up to attend. Link to the group is here.

Whose data is it [sic] anyway?

A common and somewhat unique aspect to EHR vendor contracts is that the EHR vendor lays claim to the data entered into their system. Rob and I, who co-authored this post, have worked in many industries as analysts. Nowhere, in our collective experience, have we seen such a thing. Manufacturers, retailers, financial institutions, etc. would never think of relinquishing their data to their enterprise software vendor of choice.

It confounds us as to why healthcare organizations let their vendors of choice get away with this and frankly, in this day of increasing concerns about patient privacy, why is this practice allowed in the first place?...

Prior to the internet-age the concept that any data input into software either on the desktop, on-premise or in the cloud (AKA hosted or time sharing) was [sic] not owned entirely by the users was unheard of. But with the emergence of search engines and social media, the rights to data have slowly eroded away from the user in favor of the software/service provider....

Of course this is not a good situation when we are talking about healthcare, a sector that collects the most personal data one may own. EHR purchasers need to take a hard detailed look at their software agreements to get a clear picture of what rights to data are being transferred to the software vendors and whether or not that is in the best interests of the HCO and the community it serves....

The second data ownership challenge to be very careful of is the increasing incorporation of patient generated health data into the healthcare delivery system. We project an explosion in the use of biometric devices, be it consumer purchased or HCO supplied, to monitor the health of patients outside of the exam room. Much of this data will find its way into the EHR. Exactly who owns this [sic] data and what rights each party has is still debatable. It is critical that before HCOs accept user data they work out user data ownership processes, procedures, and rights....
Yeah. We've been arguing about this all the way back to DOQ-IT and beyond. ePHI data ownership; a hopeless perplex of IP case law, muddled federal regulation, and widly varying state statutes. Who can "own" facts about me? It's not at all clear.

"Whose data are they anyway."

Well, that's ugly, I have to admit, my pedantic defense of "data are" notwithstanding.

Nevada Health Information Exchange Taps Orion Health HIE to Enhance Care Coordination Across the State
November 18, 2013,

Orion Health, a company focusing on eHealth technology, the Nevada Health Information Exchange (NV-HIE) and Nevada'sDepartment of Health and Human Services (DHHS), announced that the NV-HIE Board of Directors selected the Orion Health HIE to power and enable a statewide electronic health information exchange.

According to a release, Orion Health HIE was selected to provide the technology that will support NV-HIE services and programs that advance trusted information exchange for the coordination and continuity of health care for all Nevadans - anywhere, anytime...
DHHS is responsible for the State HIE Cooperative Agreement grant* awarded to Nevada as part of the 2009 federal stimulus bill. Under a grant sub-award from DHHS, the NV-HIE is utilizing state HIE grant funds to establish core HIE services that facilitate the trusted electronic exchange of personal health information, support the adoption of electronic health records (EHRs), and enable intra- state, interstate, and nationwide HIE.

DHHS is already offering Orion Health Direct Secure Messaging, as Nevada DIRECT (NV DIRECT), which enables standards-compliant communications between various health care providers and organizations. NV DIRECT will transition to NV-HIE and become part of its core HIE service offerings by the end of 2013.
I'm having trouble understanding how Nevada will be able to support two HIE's. The state, while geographically huge, has a relatively small population, more than 90% of which is clustered in two population centers: the 2 million-plus Las Vegas area, and the smaller Reno-Tahoe area.

HealtHIE Nevada (which yours truly named, btw -- shot these pics also) has had boots on the ground for more than a year. DHHS has had this grant money for nearly four years. Just now getting around to deploying?

Interestingly, DHHS does have the statutory authority to "regulate" HealtHIE Nevada out of business (SB43, now part of the Nevada Revised Statutes).
Sec. 6.1. The Director shall establish or contract with not more than one nonprofit entity to govern the statewide health information exchange system. The Director shall by regulation prescribe the requirements for that governing entity...

4. The Director shall by regulation establish the manner in which a health information exchange may apply for certification and the requirements for granting such certification, which must include, without limitation, that the health information exchange demonstrate its financial and operational sustainability.
Should be interesting to see how all of this plays out. Orion versus Optum. The bare-knuckle barroom brawl that is Nevada politics.

Below, my former colleague Rachel in a Vimeo promo video.

Nv-HIE website banner:

Maybe they should have contracted with Mana Health for website design.

"© 2013 Nevada Health Information Exchange (NV-HIE)" Seriously? This is all taxpayer money. You can't "copyright" anything.

Gotta love this. Go to the home page. What do you see today (11/20/13)?

Really Johnny-on-the-spot. July 3rd, 2013? Is anyone home?

But, perhaps the vendor's product will be just fine.

Appears that someone at Nv-HIE is reading my blog. Home page today:

Well, good.


Ten days 'til we find out whether HHS Secretary gets tossed under the bus. Below, from an NPR story (they got some stuff wrong) the fiasco in one graphic (my annotations in red).

I've posted the entire "Red Team" deck here (ugly scanned pdf). I am reminded of my earlier post on the "Agile Software Development" hokum.

"KatrinaCare" indeed.

AND THE HITS JUST KEEP ON COMIN' website 'didn't have a chance in hell'
The failure rate for software development projects is high generally, particularly large ones like, says Standish Group data
Patrick Thibodeau, October 21, 2013 (Computerworld)
WASHINGTON -- A majority of large IT projects fail to meet deadlines, are over budget and don't make their users happy. Such is the case with

The U.S. is now racing to fix, the Affordability Care Act (ACA) website that launched Oct 1, by bringing in new expertise to fix it.'s problems include site availability due to excessive loads, incorrect data recording among other things.

President Barack Obama said Monday that there is "no excuse" for the problems at the site.

But his IT advisors shouldn't be surprised -- the success rate for large, multi-million dollar commercial and government IT projects is very low.

The Standish Group, which has a database of some 50,000 development projects, looked at the outcomes of multimillion dollar development projects and ran the numbers for Computerworld.

Of 3,555 projects from 2003 to 2012 that had labor costs of at least $10 million, only 6.4% were successful. The Standish data showed that 52% of the large projects were "challenged," meaning they were over budget, behind schedule or didn't meet user expectations. The remaining 41.4% were failures -- they were either abandoned or started anew from scratch.

"They didn't have a chance in hell," said Jim Johnson, founder and chairman of Standish, of "There was no way they were going to get this right - they only had a 6% chance," he said...


In the United States, 2 million people are infected with drug-resistant “superbugs” every year, and at least 23,000 die as a result. Such numbers, journalist Maryn McKenna suggests, will seem trivial if we reach the point when all antibiotics are no longer effective — something that’s on track to become a reality.

Considering the full implications of a post-antibiotic era, McKenna concludes that it wouldn’t be so different from the apocalypse. And to know what we’re facing, we need only look at where we’ve come from:

Before antibiotics, five women died out of every 1,000 who gave birth. One out of nine people who got a skin infection died, even from something as simple as a scrape or an insect bite. Three out of ten people who contracted pneumonia died from it. Ear infections caused deafness; sore throats were followed by heart failure. In a post-antibiotic era, would you mess around with power tools? Let your kid climb a tree? Have another child?
To start with, McKenna writes, the loss of antibiotics will mean the end of modern medicine as we know it, impeding everything from surgery to chemotherapy to the far more prosaic:
At UCLA, [Dr. Brad] Spellberg treated a woman with what appeared to be an everyday urinary-tract infection — except that it was not quelled by the first round of antibiotics, or the second. By the time he saw her, she was in septic shock, and the infection had destroyed the bones in her spine. A last-ditch course of the only remaining antibiotic saved her life, but she lost the use of her legs. “This is what we’re in danger of,” he says. “People who are living normal lives who develop almost untreatable infections.”...
A huge potential problem for human health.

OBSERVATION is a half-billion dollar site that was unable to complete even a thousand enrollments a day at launch, and for weeks afterwards. As we now know, programmers, stakeholders, and testers all expressed reservations about’s ability to do what it was supposed to do. Yet no one who understood the problems was able to tell the President. Worse, every senior political figure—every one—who could have bridged the gap between knowledgeable employees and the President decided not to.

And so it was that, even on launch day, the President was allowed to make things worse for himself and his signature program by bragging about the already-failing site and inviting people to log in and use something that mostly wouldn’t work. Whatever happens to government procurement or hiring (and we should all hope those things get better) a culture that prefers deluding the boss over delivering bad news isn’t well equipped to try new things.
From and the Gulf Between Planning and Reality

More to come...

Saturday, November 16, 2013

NYeC 2013 Digital Health Conference Day Two

Day two, final day, actually. Wish they could do a 3-day conference. I think there's certainly enough material.

In the Grand Ballroom, A/V actually managed to fire up some overhead fresnel floods, though the above-stage banks of pars remained dark. Lighting was marginally better. Marginally.

NYeC Executive Director David Whitlinger kicks things off, introducing the day's Keynote Speaker, Obama 2012 Re-election Campaign ("OFA") Director Jim Messina.

The air was thick with anticipation: would he address the obvious question surely on all minds -- what about the rollout fiasco? We know you're hear to regale us regarding the brilliant Obama 2012 tech smackdown of the hapless Romney-Ryan presidential bid, but how can essentially the same people screw up the PPACA launch so miserably?

He dispensed with it jokingly right up front. He had nothing to do with He would go on to later point out the major problem that is federal procurement. There was no was to simply hand off PPACA HIX to the OFA techies.

Yeah. We know that. But, still, federal procurement is a venerable beast, a long-known quantity. To get blindsided by its upshot remains rather inexcusable.

But, not his gig. Not his purpose here.

He did, in fact dazzle us with power of adroitly captured, analyzed, and managed data, and OFA's adept, central use of social media.

Romney-Ryan never knew what hit them. In fact, reports have it that they'd not even prepared concession speeches, so hubristically certain were they of victory on Election Eve. Pride indeed Goeth Before a Fall.

Above, the money shot graph. While Gallup and the other mainstream political media polls showed wildly variable swings in relative Ups/Downs, internal OFA analytics had the President consistently way up. Messina said he told the President, as election day drew nigh, that he was sure that Mr. Obama would be re-elected in an Electoral College blowout, that their finely-tuned Big Data analytics could not be wrong. They could drill right down to the front-door level, precinct by precinct, and capture every available vote. They could ID every Facebook friend and Twitter follower of every Undecided and leverage them for "personal validation" (i.e., you are most amenable to persuasion by your circle of friends).

OFA nailed it. It is a compelling tale. Once NYeC posts the video of Mr. Messina's keynote, I exhort everyone to view it.

What he didn't say, but what had to have been a factor, was a slick Rope-A-Dope element. To mix my metaphors, Romney was playing checkers against a pool shark. The pool parlor hustler always seems to be lucky and just one ball better than you, as he patiently cleans out your wallet (this once happened to me, long ago). OFA was content to work this principle against the poignant Mr. Romney. Fine, let Mrs. Romney measure the White House drapes. Stroke those conceits, actually. Send her the catalogs, gratis.

What are the implications for health care?

Mr. Messina showed us a color-coded data visualization "enrollment" map of Manhattan. Again, can the Obama Administration use the OFA techniques in the service of PPACA enrollment ends?

We shall see. Things are not looking all that swell at the moment.

Off to JFK for my flight home to SFO. Been a great experience. Thanks to NYeC for having me.

But, first, before I go, apropos of well-being and Health IT...


Got home late Saturday night. Took Sunday off from computer stuff. It was a Lowe's, Bed, Bath & Beyond, and Target kind of day with my sweetie, one ending with some nice Cabernet, a great salad, and the Denver-Kansas City game.

Let me pick back up on Day Two thoughts.

Below, saw my friend Salim Kizaraly, Chief Corporate Officer & Principal Consultant at Stella Technologies. We met earlier this year at the HIMSS California State HIT Day event in Sacramento. Really nice man.

They were attending to promote their new Caredination continuity of care application. I wish them the very best with this effort.

Above, Google Glass Man was in attendance. First encountered him back at Health 2.0 2013 in Santa Clara. He apparently didn't get the attire memo.

Below, Rachel Davis, MPA of the Center for Health Care Strategies, spoke during the afternoon concurrent session "Power to the People: Bringing Technology to Medicaid’s Most Complex and Expensive Patients." Yeah, our costly "frequent flyers" a.k.a. "hot spotters."

I was reminded of the great lunch conversation I had with Karen Tirozzi of Their model:
When patients and their families seek medical care, they often face critical challenges in their lives at the same time – they have little food, they have no job, they struggle to keep up with bills for gas and electricity.  Not surprisingly, these challenges affect their health.

With Health Leads, doctors and other healthcare providers are able to ask their patients: Are you running out of food at the end of the month?  Do you have heat in your home this winter?

Health Leads enables healthcare providers to prescribe basic resources like food and heat just as they do medication and refer patients to our program just as they do any other specialty.  We recruit and train college students— Health Leads Advocates – to fill these prescriptions by working side by side with patients to connect them with the basic resources they need to be healthy.
That is a wonderful effort. I hope they bring it to the west coast. Our conversation, and Rachel's presentation reminded me of a Reporting on Health webinar I'd attended, which led me to this book, The Upstream Doctors: Medical Innovators Track Sickness to Its Source.
[P]hysician Rishi Manchanda says that our health may depend even more on our social and environmental settings than it does on our most cutting-edge medical care. Manchanda strongly argues that that the future of our health, and our health care system, depends on growing and supporting a new generation of health care practitioners who look upstream for the sources of our problems, rather than simply go for quick-hit symptomatic relief. These upstreamists, as he calls them, are doctors and nurses on the frontlines of medicine who see that health (like sickness) is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls. They see, rather, that health begins in our everyday lives, in the places where we live, work, eat, and play. Upstreamists know that asthma can start in the air around us or in the mold in the walls of our homes. They understand that obesity, diabetes, and heart disease partly originate in our busy modern schedules, in the unhealthy food choices available in our stores, and even in the way our neighborhoods are designed. They recognize that depression, anxiety, and high blood pressure can arise from chronically stressful conditions at work and home, and that such conditions can even affect our DNA. And, just as important, these medical innovators understand how to translate this knowledge into meaningful action. If our high-cost, sick-care system is to become a high-value, health care system, the upstreamists will show us the way.
 Yeah. I have this in my Kindle reader on my iPad.
In this book, I argue that the future of health care depends on growing and supporting more “upstreamists.” These are the rare innovators on the front lines of health care who see that health (like sickness) is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls. They see, rather, that health begins in our everyday lives, in the places where we live, work, eat, and play. Upstreamist practitioners — who may be doctors, nurses, or other clinicians — know that asthma can start in the air around us. They understand that obesity, diabetes, and heart disease partly originate in our busy modern schedules, in the unnatural food choices available in our communities, and even in the way our neighborhoods are designed. They know that ailments such as depression, anxiety, and high blood pressure can arise from chronically stressful conditions at work and home. They see how policies that afford or deny opportunity, fairness, and justice can be reflected in patients’ faces as well as in their DNA. And, just as important, these caregivers understand how to translate this knowledge into meaningful action. The upstreamist considers it her professional duty not only to prescribe a chemical remedy but also to tackle sickness at its source. I use the term “upstreamist” intentionally because I want to expose the shortcomings in the way we have come to define health and the role of medicine in improving it. There aren’t nearly enough of these pioneers, but if you look around in health care today, you’ll find them. They work in small practices and community health centers, in hospitals and large health care systems. Their stories are not widely known, though in some places these innovators have been around for a while as known and beloved neighbors. The upstreamists care for patients, but they also redesign the way clinics and hospitals improve health for people and entire neighborhoods. They leverage emerging technologies, build partnerships with patients and the community, draw on skills and approaches outside of medicine, and lead and participate in teams of health care professionals and community-based partners. Together, they demonstrate that medicine can do better when it works to improve health where it begins: in the social and environmental conditions that make people sick or well. If our high-cost sick-care system is to transform into a high-value health care system, the upstreamists’ paradigm and practices will make the difference.

I could not agree more with these sentiments.

Below, another excellent concurrent session I attended, the "Better Healthcare by Design" panel.

How Data Visualization, Behavior Change Techniques, and User-Centered Design Can Create Successful Products
You may have been hearing about the importance of ‘good design.’ But what does that really mean? How can better design make a difference in healthcare? How can it create more intuitive and delightful products, services, and experiences? What trends should you be paying attention to? This panel will feature lightning talks by four healthcare-focused designer-panelists, followed by discussion and a brief Q & A. Each speaker has a unique perspective with regard to healthcare: they are specialists in human-centered design, service design, behavior change, data visualization and self-tracking—some are patients, and some consultants—but everyone has had extensive experience designing for healthcare. Over the course of the panel we’ll explain why you should care about design, we’ll highlight a few inspirational examples of successful design in healthcare, and we’ll give you a few tips you can start using tomorrow to nudge your organization toward a design mindset.
 In sum, this was mostly about "usability," a word that implies much more than simply cute, easy-to-navigate apps UX. Panelist Steve Dean spoke in some detail regarding the need and methods for assuring "participatory design." One wishes that the EHR vendor community had paid more attention to this idea. A principal beef among clinicians remains the too-frequent IT-centric, workflow-clueless focus of Health IT (though, in fairness, things are better now than when I started with the REC initiative).


Starling Health was present, demoing their inpatient bedside "call button" app.


I'm still weeding through my stash of exhibit hall literature, looking for serious nuggets amid the predictable marketing hype.  

"Strategic Interoperability." Seriously?

Well, this conference went by quite quickly. Poof, it's Friday night. Off to ramble about mid-Manhattan.

I ended up in an Irish pub on W. 46th street, just across the street from where my 1964 band's manager the late Mort Browne had his office. What he saw in us naive 18 yr olds back then I'll never know.


On the bar in the pub was the day's edition of The New York Post.

Oh, yeah, that.

A Bushmill-fueled conversation ensued with the fellow sitting next to me at the bar. Duncan is a Morgan Stanley desk trader. He launched into a bitter tirade against Obama and the PPACA and government more broadly. It was equal parts textbook Tea Party, Wall Streeter anti-Democrat animus, and Ayn Rand. I just let him rant on; a little bit of Socratic probing here and there, but, it was clear I wasn't going to make much of a dent in his attitude, so I kept my responses and questions pretty non-combative. I was just out to have a bit of R and R anyway.

Man! the venom.

Whatever. "Duncan, I'm just in Healthcare Technology, man, I'm not in Policy."


He did ask me a tech question. He said he pays for concierge medicine, and is very worried that the feds will force his doc to go electronic even though the practice does no 3rd party billing.

Pretty paranoid. Pretty simplistic.


Fifty years before Obamacare, JFK had his own health care debacle.

In the spring of 1962, President John F. Kennedy launched a bold effort to provide health care for the aged—later to be known as Medicare. It culminated in a nationally televised presidential address from Madison Square Garden, carried on the three television networks. It was a flop. The legislation foundered amid charges that it was an attempt to socialize medicine and a threat to individual liberty—the same charges President Obama encountered over the Affordable Care Act five decades later...
...In the end, Kennedy's attempt to play both the outside game and the inside game failed. Such defeats led to the kind of appraisals that President Obama now faces as his approval ratings and personal ratings hit new lows. "There is a vague feeling of doubt and disappointment about President Kennedy," wrote James Reston in the New York Times. "He has touched the intellect of the country, but not its heart. He has informed but not inspired the nation. ... [H]is problem is probably not how to get elected, but how to govern." Fifty years later, it’s a fitting description of another president in the midst of his own health care fight.

Below, this is funny. SNL "Second Term Paxil"



Great conference, really appreciate the invite. The two keynote addresses alone were eminently worth attending for. Moreover, getting to meet the conference photographer Béatrice de Géa was a personal thrill. She is awesome. Some snips from her online portfolio:

See "A Conversation with Béatrice de Géa."
NP: Tell us a little about yourself.

BDG: I was born in the French Alps and partially raised in the U.A.E. I studied Art and Fashion Design in Paris. I met my first love in an airplane flying to California and few months later told my father I wanted to go study in California. I moved to Los Angeles in 1994. My desire was to become a reporter, but fell in love with photography after my first class. It was my way of writing.

NP: How did you discover photography?

BDG: By accident. I was under pressure to get a work permit so I had to quickly get my degree. I picked a photography class, remembering how much pleasure it was to use my mother's Foca camera when I was 13 to snap pictures of our family pets. I got an F on my first class. I didn't speak English well enough. The Depth of Field concept was first a grammatical mystery before a technical one. I met my mentor, a local photojournalist, when I was at school. He taught me a lot without telling me what to do...respecting my stubborn personality. I became very passionate about it, realizing I was really meant to do this. I felt constantly challenged and satisfied.
Lucky us.

Check this out. Béatrice:

Amazing, sensitive piece of work. Given that my late Dad spent seven years in nursing homes befuddled by ever worsening dementia, I can completely relate.


I have to confess to having been distracted and troubled during the week by the typhoon disaster in the Philippines. I remain aghast over the horror these people are enduring.

We go on about our comfy lives, attend our glitzy conferences, indulge in our entertainments (I watched the entire Alabama-Mississippi State football game from my JetBlue seat on the way back to SFO from JFK Saturday evening).

The lyrics in Sting's "Driven to tears" (which I have just about finished learning for my solo acoustic book) come to mind.
Hide my face in my hands, shame wells in my throat
My comfortable existence is reduced
To a shallow, meaningless party
Seems that when some innocents die
All we can offer them is a page in a some magazine
Too many cameras and not enough food
'Cause this is what we've seen
Driven to tears
Driven to tears
Driven to tears...