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Tuesday, January 13, 2015

Thank you, Jonathan Bush and athenahealth

And, thanks to everyone who attended. In particular the inspiring Alexandra Drane. I met Alex last September at Health 2.0 in Santa Clara, after seeing her moderate the "Unmentionables Panel."

I shlepped my big cameras last night, but decided it would be inappropriate to do any photography, like I do at many Health IT events. Nor will I ID any of the other attendees. Suffice it to say that it was A-List company. It was a freewheeling night of robust and frank discussion. I am honored to have been invited to sit among and interact with so many  supersmart and accomplished people.

The dinner topic was about risk and failure, and what we can learn from them that helps us be more likely to be successful long-term. We, each in turn, had to take the floor, cite who were were and what we did, and recount one of our biggest failures.

Mine was a doozy. Had nothing to do with health care or business more broadly. It was about the time in the mid-1980s when I inadvertently blew up Lee Greenwood's University of Tennessee Homecoming game nationally-televised performance (ABC-TV) of his hit song "God Bless the USA." I was working with the Neyland Stadium field audio contractor, manning the sound board at the 50 yard line. Accidentally knocked out the audio mixer atop the rack of slave amps and outboard signal processing gear that drove the array of massive speaker sets we always ringed around the breadth of the stadium track. We lost the first 45 seconds of his performance before we found and fixed the simple problem. Someone, probably me, had bumped the amber on/off rocker switch on the mixer unit. In the bright mid-day sunlight, none of us could see that it was off. Given its criticality and vulnerability, it should have been hard-soldered "on" so that you'd have to pull the plug to shut it down.

I got fired. You fuck up in front of 100,000 stadium fans and millions more on national TV, there's no "fix the process, not the blame." They had to physically restrain the UTK marching band conductor 'Doc" Julian from assaulting me in full view of the sell-out crowd. Seriously; he was a legendary neck-vein-popping hothead (to state it politely) in the best of circumstances. He wanted a piece of me. I'd probably have gone to jail to boot had we tangled.

I was aghast. Worse, this was my alma mater. My crewmates were my friends. The crew manager, Alan, was the keyboard player in our band.

So, yeah. Painful to publicly recount that. I could have cited the time my little Knoxville bootstrap A/V company got blindsided by a material structural change in the high school ACT Exam that was the topic of our flagship "exam cram" video product -- a revision that rendered my entire fulfillment center inventory obsolete in an instant. I could have spoken of the time I presented one of my technical papers at an EPA Radiochemistry Technical Conference in Oak Ridge, only to get mercilessly, humiliatingly skewered during the Q&A. Or, I could have recounted the time in 1992 when the West Knoxville entreprenuerial industrial diagnostics company, wherein I served as the Technical Editor/Writer, lost a microprocessor assembly language FFT algorithm patent infringement civil suit jury decision we'd been assured by management would never happen, and regarding which we had zero contingency plan.


Someone brought up Daniel Kahneman last night. Yeah, the relative functions and merits of "Fast and Slow Thinking." Cognitive heuristics and attendant bias liabilities. I have all of his books.

Risk and failure. Cognition and contingency. Expertise and concomitant overconfidence.

From the lyrics in one of my songs, "What Do I Know?"

What's there to see
In the Land of The Blind,
Where they're all 20-20,
Having made up their minds?
Well, two cheers for The Mystery,
Otherwise, it's all history.
If it's all just so clear,
What're we still doin' here?

LOL. I shamelessly ripped that idea off from Chapter 14 of the Hastie-Dawes book "Rational Choice in an Uncertain World."

14.4 Two cheers for uncertainty

Imagine a life without uncertainty. Hope, according to Aeschylus, comes from the lack of certainty of fate; perhaps hope is inherently blind. Imagine how dull life would be if variables assessed for admission to a professional school, graduate program, or executive training program really did predict with great accuracy who would succeed and who would fail. Life would be intolerable – no hope, no challenge.

Thus we have a paradox. Although we all strive to reduce the uncertainties of our existence and of the environment, ultimate success – that is, a total elimination of uncertainty — would be horrific... [pg 326]
Indeed. Imagine that we could know everything? What would be the point of even living out our human lives?

I trained at the outset of my white collar career in forensic analytical science. I'm a hardass when it comes to hewing to the scientific method. But, as I said last night, frankly, the more I study and learn, the less I feel I know.

"If you're not confused, you've not been paying attention."

Scientific progress is like mountain climbing: the higher you climb, the more you know, but the wider the vistas of ignorance that extend on all sides...

I have begun to imagine human knowledge and ignorance as tracing a graph of asymptotic divergence, such that with every increase in knowledge, there occurs a greater increase in ignorance. The result is that our ignorance always exceeds our knowledge, and the gap between the two grows infinitely greater, not smaller, as infinite time passes.

Ignorance was a great human breakthrough, perhaps the greatest of all, for until our prehistoric but anatomically modern ancestors could tell the difference between ignorance and knowledge, how could they know they knew anything? The actual date, the actual occasion, the actual individual who first became conscious of the difference between knowing and not knowing are all beyond historical recovery, but some such moment surely had to have come long before the invention of writing. And how different was that moment in the life span of the human species from this moment?...

One thing [Bertrand] Russell was right about is that Earth and the human species alike have finite life expectancies: “The whole temple of man’s achievement must inevitably be buried beneath the debris of a universe in ruins.” You may die never having learned the one fact that would have changed everything for you. In just the same way, extinction may befall the human species with key questions still unanswered and perhaps even unasked. And as that moment nears, will science have been superseded by something that differs from it as much as it differs from philosophy or philosophy from religion? When we reflect on how slightly, on the one hand, our genome differs from that of the chimpanzee and how greatly, on the other hand, our knowledge surpasses that of our genetic cousin, can we not imagine that a further minor genetic alteration might bring into existence a being whose knowledge and modes of inquiry dwarf ours as much as ours dwarf those of the chimpanzee?...
Ponder that last sentence in particular. From Jack Miles' "Why God Will Not Die."

"Singularity," anyone?

@08:54 “We are now actually re-programming biology. It’s a whole different paradigm for health and medicine."

Next up, on Thursday, "Health 2.0 WinterTech Conference."

Another fun, informative day in the city. My shutters will be a-clickin' this time.

Athenahealth Moves Into Hospital Market With Acquisition Of Atlanta Startup RazorInsights

Athenahealth  is getting into the hospital market. The company which provides cloud-based billing and electronic health record software services to nearly 60,000 office-based medical professionals bought RazorInsights, an Atlanta start-up that sells EHRs to rural and community hospitals. “It gives us a head start. We’re paying a few million dollars to skip the prototyping,” says Jonathan Bush, athenahealth’s CEO.

Taking baby steps is a prudent approach. The outpatient to inpatient transition via acquisitions can be treacherous. Allscripts watched its fortunes dip following its purchase of Eclipsys, as it struggled to integrate the two sides.

With the exception of its $293 million acquisition of Epocrates , a mobile drug reference tool for physicians, athenahealth has a history of making small purchases and quickly assimilating them into its branded suite of software. In 2008, it bought for nearly $8 million, and folded it into its patient portal. In 2011, it purchased Proxsys for $28 million; it is now part of its care coordination and population health management offering. “This [RazorInsights] is not a bolt on,” says Jeremy Delinsky, athenahealth’s chief product officer...
Below, having just spent an evening in the company of a number of venture capital execs at Jonathan's dinner, I found this interesting.
Does VC involvement undermine interoperability?
While venture capitalists have long been involved in healthcare, the more than $6.5 billion reported to have been invested last year raises the stakes for the VC community and the healthcare industry. New healthcare companies and ventures, flush with investor cash at such a high level, are in the midst of a happy honeymoon phase.

But things could get difficult quickly for VC-backed health IT startups. Healthcare is no longer just another vertical for institutional investors. Now, it's a major bet dominating many firms' portfolios, which means they'll want a competitive advantage even more than they have before. 

Unfortunately, VC investors and the healthcare world want different things from health IT. In theory, smart VCs know that the health IT industry is pushing for interoperability, but in practice, they're likely to resist any solution that doesn't give startups a proprietary edge...
Yeah. "Opacity = Margin." Rather axiomatic to private markets, all the lovely allusions to "transparency" notwithstanding. Another problem I see, apropos of the theme of Jonathan's dinner topic Monday night, goes to the increasing compression of the entrepreneurial success/failure cycle. Moreover, in that regard, I have to wonder about VCs' requisite, problematic motives: these firms are not charged with beneficently "transforming healthcare" -- adding "value" writ large -- their necessary priorities go to "valuation," -- making money, irrespective of any net benefit to society. The "Built to Flip" IPO path remains solidly with us. Social value is swell if it happens as one result, but it cannot be a VC priority. "Fail early, fail often," romantically charming as it may sound as a theoretical motivational ideal for young entrepreneurs, seems to me fundamentally at odds with the venture capital imperative.


After having had dinner with Jonathan and his posse Monday night, and now seeing this, I have to say, I'm rather impressed.

Relevant to many of Jonathan's points in the video:
Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians
Thomson Kuhn, MA; Peter Basch, MD; Michael Barr, MD, MBA; Thomas Yackel, MD, MPH, MS, for the Medical Informatics Committee of the American College of Physicians

In the past decade, medical records have become increasingly synonymous with electronic health records (EHRs). However, although “EHR” is the current term of art used to describe computer-based systems that perform a broad range of functions related to documenting and managing patient care, this will not always be the case. Similarly, clinical documentation's definition has grown to encompass more than just physician notes. Existing technology, such as registries, portals, connected home monitoring devices, and provider- and patient-controlled mobile devices, as well as technology not yet in use or even built, is likely to integrate with or possibly even replace the EHR (as currently conceptualized) as a primary vehicle for viewing and recording clinical documentation. Although the term “EHR” is used throughout this paper, the issues addressed could reasonably apply to any future technology-enabled system of clinical documentation.

This position paper reviews the current and emerging purposes of clinical documentation, the drivers that may influence or distract from these purposes, and the opportunities and challenges that have arisen from EHRs. We believe that physicians must help define and prioritize the many important roles that clinical documentation serves today. Therefore, this paper proposes a set of guiding principles and actions that can be taken by clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups to improve the quality and value of clinical documentation and to better use this documentation to improve care.

The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians...

Electronic health records should be leveraged for what they can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families, and caregivers. These features are unlikely to be optimized as long as the format and content of clinical documentation are primarily based on coding and other regulatory requirements. Furthermore, under these circumstances, EHRs lose much of their potential to improve care and documentation and instead are relegated to doing nothing that could not be done with paper records—only less efficiently.

We are in danger of repeating history by overstructuring the clinical record and overloading it with extraneous data (2). Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care.

Cooperation is needed among industry health care providers, health care systems, government, and insurers to continue to improve the documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member.
Full paper link here. Between the opening paragraphs and the summary is a wealth of detail. (Nice that they cite Dr. Weed.) The "policy recommendations" sections are replete with the usual relatively noncontroversial "shoulds," but don't delve into the "hows." That is the tough part.

Relatedly, reported by Politico:
“HUMAN FACTOR” PROBLEMS PERSIST WITH EHRs: Although interoperability is the buzzword of health IT in 2015, another word persists: usability. Physicians still rage at the awkwardness of their electronic health records, whose improvement is one of the top objectives of the federal health IT strategic plan, Arthur Allen reports. The plan lists “encourag[ing] the application of human factors, health literacy, and user-centered design” of EHRs as a top objective — along with renewed attention to the “safe use” of health IT. Don’t count on the government to do much about it. Andrew Gettinger, acting director of ONC’s office of clinical quality and safety, sees the invisible hand playing the major role. “There is going to be more and more success for software that really demonstrates better clinician acceptance,” he said in an interview. “I think it would be speculative to talk about regulatory approaches.” Some experts attribute usability problems to the lack of human factors engineers in health IT. American universities have relatively few experts or programs for students, and EHR vendors, including large ones, often do not employ any. EHRs have led to a dramatic shift in the way doctors spend their time, and one the biggest concerns is the mental stress they create, says Raj Ratwani, scientific director at the National Center for Human Factors, located in the futuristic Intelsat building in Northwest Washington, DC. He followed 14 doctors from just before a new EHR was installed in their emergency department until four months later. After implementing the EHR, doctors spent 20 percent more of their time doing two or three tasks at the same time. Some hospitals say the HITECH Act was too rushed and vendors didn’t take human factors into account when designing EHRs.
"National Center for Human Factors"?

The National Center for Human Factors in Healthcare brings together a diverse set of human factors experts with clinical experts to improve quality, efficiency, reliability, and safety in healthcare. A part of the MedStar Institute for Innovation (MI2) and the MedStar Health Research Institute (MHRI), the Center’s home and “research lab” is MedStar Health, a $4.5B not-for-profit healthcare organization with 10 hospitals and 20 diversified healthcare organizations, the largest healthcare provider in the Baltimore & Washington DC region.


More to come...

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