"Medical bridges to nowhere"?

The man against meaningful use
Frustrated by the government creating 'medical bridges to nowhere,' Patrick Soon-Shiong seeks to take healthcare into the 21st century
April 2, 2014

Seeing as healthcare generally lags at least 10 years behind other industries in the realm of adopting technology, it takes a lot to say a health company is doing groundbreaking work. But NantHealth executives believe they've nailed it.

NantHealth, the brainchild of medical researcher, professor, surgeon and self-made billionaire Patrick Soon-Shiong, is a company aimed at solving the interoperability crisis and connecting the industry in the most powerful of ways – a direct response of discontent with the federal government's EHR Incentive Program.

With Chief Executive Officer Soon-Shiong at the helm, a near $1 billion investment and some of the best minds in the industry, the folks at NantHealth have built a cutting-edge, cloud-based and bi-directional clinical operating system, agnostic to any device or electronic health record.

The operating system, tied to 12,000 miles of fiber optics, is now being deployed nationwide...

The idea to develop this company came to him after the federal government gave the green light to the EHR Incentive Programs, allocating some $34 billion for health IT and EHRs, a decision he considered a grave misstep for the industry.

In fact, he met with President Barack Obama back in 2008 with one single plea: "Please, do not fund electronic medical record systems that will create what I call, 'medical bridges to nowhere,' and, unfortunately, they've done exactly that," Soon-Shiong said, speaking at a Clinton Foundation event this past January.

"My concern is with the way meaningful use has been set up is to capture processes," he added. "What we really need to do is capture outcomes."...

Props to Healthcare IT news for this story. "What we really need to do is capture outcomes." Indeed. Recall my HIMSS14 interview with Fred Trotter, wherein he cited this very problem.

"12,000 miles of fiber optics"?

Interesting. Tangentially quite timely for me (in a roundabout way that will take time to dot-connect back to healthcare and Health IT), having just finished Michael Lewis' new book "Flash Boys" which just came out Monday. It is a compelling read. I bought both the hardbound and Kindle editions. The hardbound edition is available at CostCo for 15 bucks and change (I got mine via Amazon Prime for about the same price).

Over the past decade, the financial markets have changed too rapidly for our mental picture of them to remain true to life. The picture I’ll bet most people have of the markets is still a picture a human being might have taken. In it, a ticker tape runs across the bottom of some cable TV screen, and alpha males in color-coded jackets stand in trading pits, hollering at each other. That picture is dated; the world it depicts is dead. Since about 2007, there have been no thick-necked guys in color-coded jackets standing in trading pits; or, if they are, they’re pointless. There are still some human beings working on the floor of the New York Stock Exchange and the various Chicago exchanges, but they no longer preside over any financial market or have a privileged view inside those markets. The U.S. stock market now trades inside black boxes, in heavily guarded buildings in New Jersey and Chicago. What goes on inside those black boxes is hard to say— the ticker tape that runs across the bottom of cable TV screens captures only the tiniest fraction of what occurs in the stock markets. The public reports of what happens inside the black boxes are fuzzy and unreliable— even an expert cannot say what exactly happens inside them, or when it happens, or why. The average investor has no hope of knowing, of course, even the little he needs to know. He logs onto his TD Ameritrade or E* Trade or Schwab account, enters a ticker symbol of some stock, and clicks an icon that says “Buy”: Then what? He may think he knows what happens after he presses the key on his computer keyboard, but, trust me, he does not. If he did, he’d think twice before he pressed it.
 
The world clings to its old mental picture of the stock market because it’s comforting; because it’s so hard to draw a picture of what has replaced it; and because the few people able to draw it for you have no interest in doing so. This book is an attempt to draw that picture. The picture is built up from a bunch of smaller pictures— of post-crisis Wall Street; of new kinds of financial cleverness; of computers, programmed to behave impersonally in ways that the programmer himself would never do personally; of people, coming to Wall Street with one idea of what makes the place tick only to find that it ticks rather differently than they had supposed...
 
HIDDEN IN PLAIN SIGHT

By the summer of 2009 the line had a life of its own, and two thousand men were digging and boring the strange home it needed to survive. Two hundred and five crews of eight men each, plus assorted advisors and inspectors, were now rising early to figure out how to blast a hole through some innocent mountain, or tunnel under some riverbed, or dig a trench beside a country road that lacked a roadside— all without ever answering the obvious question: Why? The line was just a one-and-a-half-inch-wide hard black plastic tube designed to shelter four hundred hair-thin strands of glass, but it already had the feeling of a living creature, a subterranean reptile, with its peculiar needs and wants. It needed its burrow to be straight, maybe the most insistently straight path ever dug into the earth. It needed to connect a data center on the South Side of Chicago* to a stock exchange in northern New Jersey. Above all, apparently, it needed to be a secret.

The workers were told only what they needed to know. They tunneled in small groups apart from each other, with only a local sense of where the line was coming from or where it was going to. They were specifically not told of the line’s purpose— to make sure they didn’t reveal that purpose to others. “All the time, people are asking us, ‘Is this top secret? Is it the government?’ I just said, ‘Yeah,’  ” said one worker. The workers might not have known what the line was for, but they knew that it had enemies: They all knew to be alert to potential threats. If they saw anyone digging near the line, for instance, or noticed anyone asking a lot of questions about it, they were to report what they’d seen immediately to the head office. Otherwise they were to say as little as possible. If people asked them what they were doing, they were to say, “Just laying fiber.” That usually ended the conversation, but if it didn’t, it didn’t really matter. The construction crews were as bewildered as anyone. They were used to digging tunnels that connected cities to other cities, and people to other people. This line didn’t connect anyone to anyone else. Its sole purpose, as far as they could see, was to be as straight as possible, even if that meant they had to rocksaw through a mountain rather than take the obvious way around it. Why?...

Every day there were thousands of moments when the prices were out of whack— when, for instance you could sell the futures contract for more than the price of the stocks that comprised it. To capture the profits, you had to be fast to both markets at once. What was meant by “fast” was changing rapidly. In the old days— before, say, 2007— the speed with which a trader could execute had human limits. Human beings worked on the floors of the exchanges, and if you wanted to buy or sell anything you had to pass through them. The exchanges, by 2007, were simply stacks of computers in data centers. The speed with which trades occurred on them was no longer constrained by people. The only constraint was how fast an electronic signal could travel between Chicago and New York— or, more precisely, between the data center in Chicago that housed the Chicago Mercantile Exchange and a data center beside the Nasdaq’s stock exchange in Carteret, New Jersey.

What Spivey had realized, by 2008, was that there was a big difference between the trading speed that was available between these exchanges and the trading speed that was theoretically possible. Given the speed of light in fiber, it should have been possible for a trader who needed to trade in both places at once to send his order from Chicago to New York and back in roughly 12 milliseconds, or roughly a tenth of the time it takes you to blink your eyes, if you blink as fast as you can. (A millisecond is one thousandth of a second.) The routes offered by the various telecom carriers— Verizon, AT& T, Level 3, and so on— were slower than that, and inconsistent. One day it took them 17 milliseconds to send an order to both data centers; the next, it took them 16 milliseconds. By accident, some traders had stumbled across a route controlled by Verizon that took 14.65 milliseconds. “The Gold Route,” the traders called it, because on the occasions you happened to find yourself on it you were the first to exploit the discrepancies between prices in Chicago and prices in New York. Incredibly to Spivey, the telecom carriers were not set up to understand the new demand for speed. Not only did Verizon fail to see that it could sell its special route to traders for a fortune; Verizon didn’t even seem aware it owned anything of special value. “You would have to order up several lines and hope that you got it,” says Spivey. “They didn’t know what they had.” As late as 2008, major telecom carriers were unaware that the financial markets had changed, radically, the value of a millisecond.

Upon closer investigation, Spivey saw why. He went to Washington, DC, and got his hands on the maps of the existing fiber cable routes running from Chicago to New York. They mostly followed the railroads and traveled from big city to big city. Leaving New York and Chicago, they ran fairly straight toward each other, but when they reached Pennsylvania they began to wiggle and bend. Spivey studied a map of Pennsylvania and saw the main problem: the Allegheny Mountains. The only straight line running through the Alleghenies was the interstate highway, and there was a law against laying fiber along the interstate highway. The other roads and railroads zigzagged across the state as the landscape permitted. Spivey found a more detailed map of Pennsylvania and drew his own line across it. “The straightest path allowed by law,” he liked to call it. By using small paved roads and dirt roads and bridges and railroads, along with the occasional private parking lot or front yard or cornfield, he could cut more than a hundred miles off the distance traveled by the telecom carriers. What was to become Spivey’s plan, then his obsession, began with an innocent thought: I’d like to see how much faster someone would be if they did this...

Michael Lewis was featured on CBS' "60 Minutes" last Sunday. If you missed it, watch it here (watch all of the "Overtime" segments as well). He was on NPR's "Fresh Air" yesterday. I sat in my car in rapt attention in the Fry's parking lot in the rain in Concord for almost an hour (I'd gone to find some 30 ohm resistors for a contraption I'm building).

Michael Lewis, welcome back to FRESH AIR. So you say the image of the stock exchange, with traders hollering on the floor, that really hasn't existed in reality in several years. The markets, you say, trade inside black boxes in heavily guarded buildings in New Jersey and Chicago. What are those black boxes? What are those buildings?

MICHAEL LEWIS: Well, the most sensational building is the New York Stock Exchange building in Mahwah, New Jersey, which it's a fort. To get to it, you go through, you know, guards and German shepherds, and it feels guarded. And inside the building is the matching engine, the place where buyers and sellers meet on the New York Stock Exchange, not on the floor of the New York Stock Exchange.

There are no human beings - it's just signals going into a box, computer signals. The building is enormous, and the question is sort of why is so big if the exchange is now just a box instead of thousands of people shouting at each other. And it's enormous to house the equipment of all the high-frequency traders who want to be near the exchange so they can get information from the exchange more quickly than you or me.

GROSS: OK, when you say more quickly than you and me, it sounds like there's a messenger running from the exchange to the office of the broker, which is exactly not what's happening. How do you get the edge in terms of time, of getting it a nanosecond before the other people do?

LEWIS: It's a couple of millisecond edge they're usually looking at, and the way you do it is just - is to minimize the physical distance between you and the actual exchange so that the cord that connects your box, that is making your trading decisions, you the high-frequency trader, that leads to the actual exchanges is just shorter than everybody else's cord. So you get closer. And high-frequency traders pay the exchanges vast sums of money to be close to the exchange so they can get the signals from the exchange before everybody else, so they can find out what prices are, where they've moved before everybody else.

GROSS: And these signals are traveling on fiber-optic lines.

LEWIS: Correct, so it's - you know, it's a matter of physics. I mean, there's - light traveling over distance still takes time. It's time that's kind of incomprehensible to the human mind, but to a trader in the stock market now, the difference between getting the information in three milliseconds as opposed to four milliseconds is the difference between knowing the prices before everybody else and not.

GROSS: And why does that give you the edge?

LEWIS: Well, if I get price changes before everybody else, if I know a stock price is going up or going down before you do, I can act on it. If you're coming in to buy, you know, the shares in Proctor & Gamble, and you think the price is 80, and you're saying I'm going to buy Proctor & Gamble for $80 a share, and I'm sitting there are a high-frequency trader, and I know that the price of Proctor & Gamble is actually lower, it's gone down, it's 79, I can buy it a 79 and sell it you at 80.

So it's a bit like knowing the result of the horse race before it's run or getting advance word on where the ball is going to land in the roulette wheel. And it's hard to get your mind around because the amount of time, the time advantage of a high-frequency trader, is so small. It's literally a millisecond or two. It takes 100 milliseconds to blink your eye, so it's a fraction of a blink of an eye.

But that for a computer is plenty of time.

GROSS: Right, because we're talking about computer time, not human time here.

LEWIS: I think that was one of the big things about this story that made it so mind-bending and, you know, in some ways difficult to tell, is that to understand the stock market, in fact all the financial markets these days, you have to stop thinking, kind of seeing the world through the eyes of a human being and try to see it through the eyes of a computer and see - and think about how a computer thinks about time.

I mean for a computer, a millisecond is a lot of time. For a human being it's imperceptible. A computer can make hundreds of trades in a millisecond. A human being can't do anything. So yes, it's the markets are now in a funny way perceived through the minds of computers...

Yeah. Two applications of digital fiber optics, one beneficent, one rapacious.  Below, some inklings of where I might be trying to go with all of this.

Just a few of my latest reads.

NQF: "Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors" (draft NQF report)

Risk adjustment—statistical methods to account for patient-related factors when computing outcome measures—is used to make more accurate evaluations about quality of care. NQF’s current policy recommends the adjustment of outcome measures for clinical factors, such as severity of illness and co- morbidities, recognizing that patients who are sicker and have multiple conditions have a higher likelihood of worse outcomes, regardless of the quality of care provided.

Increasingly, policymakers and other leaders have raised the question of whether performance measures used in accountability applications, including public reporting and pay-for-performance, should be adjusted for sociodemographic factors in order to improve the accuracy of performance results. There is a substantial body of evidence that sociodemographic factors influence a variety of patient outcomes and some processes...

apropos, recall my January 2014 post “When it comes to health, your zip code matters more than your genetic code.” "Digital Divide"? Socioeconomic divide?

Just getting going here.
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More to come...