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Friday, October 9, 2015

Health 2.0 2015, a reflection

First, make note of this. Next up for Health 2.0 in the Bay Area:

Health 2.0 WinterTech 2016: Focusing on Digital Health Investing
After a sold out inaugural 2015 event, Health 2.0 WinterTech is back and bringing together the top tech companies, investors, entrepreneurs, policy makers, and more to discuss investing in the health tech landscape. Come hear about the products, players and partnerships that are coming together in innovative and unexpected ways in the new era of health and wellness tech. And of course it wouldn’t be a Health 2.0 event without showcasing the latest LIVE tech demos!

Health 2.0 WinterTech is the only event dedicated to health tech and investing during the nation’s leading investment mecca, JP Morgan Week. Join us in San Francisco’s financial district January 13th!

We’ll be joined by Bryan Roberts, Partner at Venrock and Owen Tripp, CEO of GrandRounds, plus many more!



Having to leave on Monday and Tuesday around 10:30 a.m. to run up the 680 to Pleasant Hill for radiation tx and back meant I had to miss a ton of great stuff. I'd get back in time for the 2 p.m. sessions, tired and hungry (and subsequently racing to the men's room all afternoon in the wake of all that water I'd had to drink; it's been high tide in my britches all week). Today I'll do Calypso tx 24 of 45. I'm scheduled to finish up on November 9th.

The opening Keynote on Monday. I'll say it again: Chelsea Clinton was amazing.

No teleprompter, no notes. She never looked down. And, she never flubbed so much as a syllable. Impressive young woman. I hope they post these Keynotes publicly in embeddable video format.

Next up, 3 p.m. Mission City Ballroom presentations session:


The ever-fabulous Susannah Fox, now CTO of HHS, on the panel.

Presentations by Conversa Health, Noona Healthcare, CareSync, Vida Health, Ayasdi, and Heal.

The latter one, Heal, was of particular interest to me, in a totally unexpected way.

Basically, an independent contractor gig model "Docs-to-your-Door" house calls service ("All doctors are provided through an independent medical practice").  Midway through the presentation they called one of their docs (a runway "spokesmodel"?) up to the stage.

"Oh, [bleep!]..."

He didn't really speak, IIRC. Clearly just a stage prop (loved the Little Black Bag, btw).

apropos of things I've written elsewhere:
I am effectively without a Primary these days. After I retired from the REC, sold the house in Vegas in September 2013, and moved over to Contra Costa County, I ended up in the Muir system. My new doc there is a nice young Internal Med D.O. whose answer to everything is to refer me to a specialist -- even to get a dad-gumbed scrip refilled! (He referred me to a "pain management specialist.") e.g., from one of my TCHB comments:
True recent story.

“Hello, my name is Robert Gladd. My new primary care physician referred me to your office for an evaluation regarding the renewal of my back pain medi…

THEM (curtly cutting me off):
“Who is your insurance.”

“Uhh… Blue Cross/Blue Shield”

“Is it a PPO?”


“What is the Subscriber number?”

“Uhh… I’ll have to get it… OK. Here it is, G123456789.”

“The doctor will need your medical record prior to your first appointment.”

“No problem. My prior primary care physician in Las Vegas, the one who wrote the prescription, gave me my entire last progress note in a text file exported from his EHR. I have it on a UBS flash drive.”

“You’ll have to fax that to us before we can book an appointment.”
“Do you have a primary care physician?”…

I just might put my USB flash drive in my scanner, hit “scan,” and fax them the scanned image, just to throw a bit of sand back in their gears and obtusely make the salient point they’ll never get.
It's Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request.

I note on the EOB that Muir charged me and my BC/BS $436 for each primary care visit (Cheryl and I are now on high-deductible HSA). I dutifully underwent the PT regimen he wrote me for (it helped a bit). I dutifully do my exercises. My cut of the nearly $3k for that was just shy of $1,200. My paid OOP for 2014 came to about $3,600 (welcome to the ACA). For a lot of people, that might be extremely painful in its own right.

Knowing that I would have another annual visit coming up, I went into Muir's portal to schedule it and request a lab draw order (blood and UA panels) to avoid another $436 charge for a pleasant (MU-compliant) 30 minute 99213 chat just to essentially pick up a lab slip and incur yet another charge for the f/up.

He refused. Had some Muir employee call me the following week with the news. Didn't respond (for the record?) to my portal email.

I told her to cancel my appointment request...
Yes. This young man depicted above is my now-former PCP.

Some time after the events just recounted, my long-time scrips for Lisinopril and Simvastatin were expiring at Walgreens. I logged into the Muir patient portal and requested Rx refills renewals. He assented, but sent me a reply noting -- wait for it -- that I'd need to get labs done soon, "to make sure various things like liver and kidney function, etc, are normal."

OK. Duh. Hel-lo?

Some time later I again logged into the Portal to make an appointment to (waste more 99213 money and several hours of my time and) get the lab order.

Nyet. Nada. Nope. The "schedule an appointment" function was greyed out. No physician to choose from.

After several subsequent logins with the same result, I sent an internal email via the Muir "customer service" webmail template.

About a week later I got a terse reply notifying me that my doc was no longer with Muir, which explained my inability to make an appointment online.

OK, I guess I'm the last one to know.

A subsequent phone call confirmed the departure development. "We sent you a notice by postal mail."

Maybe I missed it, but I doubt it (unless it'd inadvertently gotten tossed, had it looked like their usual self-congratulatory computer-labeled marketing junk mail).

Moreover, it begs a fundamentally relevant HIT question:
What precisely, then, is the point of your having a secure patient portal?"

From the Doc's LinkedIn page (I'm not overtly "outing" him by name here, but, y'all are adroit digerati gumshoes...):
Physician with a valuable blend of expertise in healthcare technologies and medical applications including digital heath, EMR/EHS systems, wearable/mobile technology, and telemedicine. Deep understanding of the value of integrating medical care with leading-edge healthcare technology to build more effective healthcare systems, make healthcare more accessible and manageable, reduce healthcare/physician practice costs, and improve patient outcomes aligned with value based care.

Insightful and strategic thinker with a passion for pioneering new categories of products, services, and systems to improve healthcare choices and interactions. Collaborative leader who thrives on challenge, is energized by technology innovation, and is recognized as a highly knowledgeable advisor and resource to peers, clinicians, and practice staff. Builds and maintains strong, credible relationships with physicians, C-level executives, hospital administrators, and specialists.

  • Guided colleagues and administrative staff through challenging EPIC EHR system implementation and rollout; worked directly with EPIC consultants to develop custom system enhancements to improve usability and functionality.
  • Key member of the e-Biz Committee; advise the Digital Health Department in development of a secure patient access portal, physician website, and mobile applications.
  • Dramatically improved the effectiveness of a patient weight loss program for more than 200 patients by incorporating wearable technologies like Fitbit and Jawbone, as well as health applications like My Fitness Pal to empower/motivate patients, help them manage and track their program, and integrate health coaching and dietary/exercise changes.
"Builds and maintains strong, credible relationships with physicians, C-level executives, hospital administrators, and specialists."

That's rich. One phrase you will not find anywhere on his professional bio is "patient-centered care."

I remain without a PCP.

Whatever. My Rad Onco doc has given me some names and phone numbers to check out. And, perhaps I'll give Muir the air gun and take my bidness across town to Sutter Health. They were pretty impressive at the 2015 Lean Healthcare Transformation Summit in Dallas, I have to say. My daughter (also as yet without a local Primary) had a recent transient acute problem and went to Sutter nearby. She was effusive about the care and concern she was accorded.


As I noted in my pre-conference prologue post on October 3rd, we've been exuberantly talking of "transforming" the health care system" since I first came to health care analytics in 1993. It always seems to just loom over the horizon. But, maybe it's just that we're "boiling the frog slowly," and that the sum of incremental improvements tally up across time to comprise what can legitimately be called "transformation." Certainly health care digitech is incredibly more sophisticated now than it was 22 years ago, and growing ever-more rapidly so -- the entire point of the Health 2.0 Conference.
I found the session entitled "The New Consumer Health Ecosystem" quite interesting. Interesting demos by Cloud DX, Withings, Sandstone Diagnostics, and Sensoria.
More broadly, consumer digitech has incontrovertibly transformed our lives in myriad ways, and the digital innovation ferment is now bleeding over into the health care space at a fever pitch in the wake of the significant national health policy reforms of the Obama years.

Nonetheless fragmentation "shards" and care delivery "sand in the gears" remain largely the norm for most patients, and may in fact get worse prior to abating materially (if mitigation actually happens).
Sand-in-gears note: Had I a "lab-on-a-chip" iPhone app and its ancillary input gear, I'd pee in a cup and draw a small aliquot of blood into a pipette and do my own blood and UA panels right here at the house.
"Interoperababble" remains the norm. We've seen a couple of apps during this Conference purporting provide "seamless patient-centered end-to-end interoperability." One hopes. But, I'm not prepared to accept that proffer at face value just yet.

Perhaps we'll look back in another 20 years or so and nod approvingly at the visibly significant, beneficial (and equitable) transformation (if I'm still around, I'll be about 90 and likely a relatively high UTIL person).

After all, the U.S. Interstate Highway System transformed both national ground travel and commerce as well as the socioeconomic distribution patterns of living.

Completion of the Interstate Highway System took 40 years.

ONC kicked the RECs to the curb after just four. Beltway policy ADHD. What a waste.

Going forward, minimally, I urge you to study the two books spotlighted at Health 2.0 2015. They were put on the agenda for a reason.

Amazon link
Amazon link
There are many, many more. Anyone who follows this blog knows that I cite and review in considerable depth dozens of books relevant to the breadth of issues we face.

Beyond tech (including the nascent "transformative" deluge of "omics" data and analytics, and the incipient, overlapping AI/IA and Robotics worlds, where perhaps "humans need not apply"), what of vexing "disparities"? What of dysfunctional healthcare organizational cultures? What of clinical pedagogy? (The AMA Deep Dive on Wednesday had some nice thoughts on that.)

What of principles of "Leadership"? Are they, as Stanford's Dr. Jeffrey Pfeffer argues, largely counterproductive "BS"?

What of the so-called "Art of Medicine"? Is there a significant "Doctor Crisis"?

What if...what if...what if? What is "The Future of Healthcare Futurism"?

A quick side trip to THCB.

Healthcare Startups – Why Now and So What?
Oct 9, 2015

I’m part of a growing trend of academics, programmers, and clinicians taking the startup path to try to make healthcare a better place. In fact, record breaking amounts of venture funding are pouring into healthcare with 2014 seeing $4.13 billion in digital health venture funding and 2015 showing no signs of slowing.  Established tech companies not typically associated with healthcare including Apple, Samsung, Google, and IBM are getting in on the act with substantial investments.  It seems that nearly every hospital and insurer is launching its own incubator or innovation fund. 

The real question is why, after decades of lagging behind nearly all other industries in the adoption and use of information technology, does healthcare seem to suddenly be such a hotbed of activity? 

The answer: data matters [sic] like never before in healthcare...

If value-based financial reimbursement becomes a permanent fixture in our health system, such collaborations will become the norm and not the exception.  Why? Because “value” in healthcare can only be achieved when healthcare’s various stakeholders work together to keep people healthy throughout their continuum of care.  Data will be the engine driving these partnerships forward and new companies may be formed to meet emerging needs.

In time, healthcare will realize the same levels of innovation, efficiency, and capability that the US high tech industry is globally famous for.  And for a nice change of pace, billions of dollars will be exchanged not in the pursuit of better ad placement or market timing, but in turning data into better human health.
Good post. Read all of it.

Couple of product demos by presenting companies:



[M]aking the argument that what used to be taboo may now finally be gaining the attention it deserves…topics like sex, divorce, death of a loved one, a bad boss – everyday new evidence arises that these life factors don’t just influence health – they can define it. With the silver tsunami so too will come new challenges – and opportunities…like the isolating grip of caregiver stress, financial fraud and abuse of seniors, and the opportunity to do death well. And if the definition of health needs to be expanded to include life because when life goes wrong, health goes wrong – then maybe the ultimate disease management program would be the one that got you a job. We’ll be talking about all that – plus the role empathy can (MUST) have in consumer driven design.

Above, the fabulous Alexandra Drane, moderating. Really loved this session. My favorite, actually. Yes, the human emphasis amid all this glitzy tech stuff. Not that tech was absent. to wit:
"...the role empathy can (MUST) have in consumer driven design"

This was of particular interest to me in light of one of my recent reads -- in the context of others I've cited concerning the inexorable advances of AI, IA, and robotics:

Empathy is the foundation of all the other abilities that increasingly make people valuable as technology advances. It’s inevitable. For the past two centuries, many office workers, factory workers, and others could go through their workday, and some still can, without engaging in social relationships at all. But as machines rapidly take over the largely mechanical, nonsocial elements of work, our most valuable roles become more intensely social. We’ve seen that we are most fundamentally social beings— that we evolved into creatures that cannot survive or approach happiness or be productive without social relationships. Empathy is the first element of how all that happens, the basis of every significant relationship. And as the stories of the two doctors show, empathy is harder than it may seem, and it frequently doesn’t seem all that easy to begin with.

The term has been defined in various ways by dozens of researchers, but we all understand it well enough. It means discerning what some other person is thinking and feeling, and responding in some appropriate way. That definition encompasses much more than we often stop to realize. It goes far beyond just feeling someone else’s pain. Spotting someone’s joy, anger, engagement, confusion, or any other mental state is just as important. Nor does empathy refer only to understanding someone’s mental state because you care about them and want to help. Helping isn’t always the appropriate response, and the ability to understand what someone else is feeling and thinking proves extraordinarily valuable regardless of whether that someone is a colleague, boss, customer, prospect, competitor, police officer, doctor, patient, an unknown counterparty in a trade, someone you want to marry, or someone who’s trying to kill you.

The notion that empathy is growing more important in today’s economy isn’t just theory. Employers around the world are saying explicitly that they value it and want more of it. When journalist George Anders scanned an online employment board for job listings that paid over $ 100,000 a year and that specified candidates with empathy and closely related traits, he found over a thousand of them. They weren’t primarily from philanthropic institutions; instead, they were from the likes of McKinsey, Barclays Capital, Abbott Laboratories, Raytheon, Mars, Pfizer, and other major mainstream employers. Those results reinforce the findings of an advisory group of top British educators and CEOs who were asked to recommend changes to secondary education in the United Kingdom. They concluded that “empathy and other interpersonal skills are as important as proficiency in English and mathematics in ensuring young people’s employment prospects.” The group urged that these skills be taught to all secondary students, “but with the process of learning these starting much earlier in school life.” The competencies “should be embedded throughout the curriculum.”

Even infotech employers, creators of the screen-centered world that devours ever more of our time, want more empathy. The chief technology officer of one of the United Kingdom’s largest retailers says what he needs most now are “people who are empathetic and collaborative.” That’s because the technology they’re creating is increasingly for consumers, not for internal use, and a team has to build it together, so his infotech product designers need to sense the thoughts and feelings of consumers and of each other: “I can’t have a great IT architect who has to be locked in a room,” he says. Charles Phillips, CEO of the enterprise software company Infor, which makes giant programs for giant organizations, told me that “empathy— understanding what the customer is really feeling— is a key skill for us” and will differentiate them in the industry. Maybe, but when Bill McDermott, CEO of a direct competitor, SAP, published a book soon thereafter, a whole section of it was called “Empathy.” And Meg Bear, a high-level executive at yet another enterprise software company, Oracle, says “Empathy is the critical 21st-century skill.” She calls it the skill “I need to develop in myself, my teams, and my children” and concludes that “empathy will be the difference between good and great.”

Those employers are not speculating. When Jim Bush was in charge of American Express’s call centers, he told me how he took the revolutionary step of throwing out the scripts that come up on the screens of the workers who answer your phone calls, and that cause most of us to hate the experience. Instead, he had the screens display information about the customer, and the service rep could say what he or she wished— a change, he said, that “brings their personality to life and brings one-to-one connections, which are what ultimately build and sustain relationships.” To make the change work, AmEx had to change the way it recruited those employees, focusing not on candidates with call-center experience but on those from top hotels and cruise lines, for example— people “who love to build relationships and are able to empathize and connect with customers.” Not too surprisingly— except, apparently, to those in the industry— the change worked. Customers were far more likely to recommend American Express to a friend, profit margins rose, and employee attrition dropped by half, which in a company of that size meant millions of dollars of incremental profit. Empathy was at its heart. As Bush observed, “Customers know instantly when a service professional really cares.”

In addition to what employers are seeing in their own companies, other evidence shows that empathy pays. Belinda Parmar, a U.K. technology commentator who says she wants to “transform the corporate world to ensure empathy is at the heart of all business,” cites research finding that “waiters who are better at showing empathy earn nearly 20 percent more in tips” and “debt collectors with empathy skills recovered twice as much debt.”

Columbia University business professor Rita McGrath has even divided the history of business management into three eras, the first two of which were the eras of execution (making the earliest large organizations work) and expertise (the development of management theory and science in the twentieth century). Now, she says, “we are in the midst of another fundamental rethinking of what organizations are and for what purpose they exist. . . . Today many are looking to organizations to create complete and meaningful experiences. I would argue that management has entered a new era of empathy.”

Colvin, Geoff (2015-08-04). Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will (pp. 77-81). Penguin Publishing Group. Kindle Edition.
"[M]aybe the ultimate disease management program would be the one that got you a job."

Yeah. But, again, you gotta consider at length where things are heading. Books such as "The Rise of the Robots," "Machines of Loving Grace," and "Humans Need Not Apply" -- to cite just three I've recently reviewed -- argue that close to half of service sector jobs (about all we have left in the U.S.), including those of white collar "knowledge workers," may be soon vulnerable to automation.

It's useful to recall that unemployment at the height of the 1930's depression was about 25%.

Citing "Four Futures" once again:
...One thing we can be certain of is that capitalism will end. Maybe not soon, but probably before too long; humanity has never before managed to craft an eternal social system, after all, and capitalism is a notably more precarious and volatile order than most of those that preceded it. The question, then, is what will come next...

Much of the literature on post-capitalist economies is preoccupied with the problem of managing labor in the absence of capitalist bosses. However, I will begin by assuming that problem away, in order to better illuminate other aspects of the issue. This can be done simply by extrapolating capitalism’s tendency toward ever-increasing automation, which makes production ever-more efficient while simultaneously challenging the system’s ability to create jobs, and therefore to sustain demand for what is produced. This theme has been resurgent of late in bourgeois thought: in September 2011, Slate’s Farhad Manjoo wrote a long series on “The Robot Invasion,” and shortly thereafter two MIT economists published Race Against the Machine, an e-book in which they argued that automation was rapidly overtaking many of the areas that until recently served as the capitalist economy’s biggest motors of job creation. From fully automatic car factories to computers that can diagnose medical conditions, robotization is overtaking not only manufacturing, but much of the service sector as well.

Taken to its logical extreme, this dynamic brings us to the point where the economy does not require human labor at all. This does not automatically bring about the end of work or of wage labor, as has been falsely predicted over and over in response to new technological developments. But it does mean that human societies will increasingly face the possibility of freeing people from involuntary labor. Whether we take that opportunity, and how we do so, will depend on two major factors, one material and one social...

There are therefore four logical combinations of the two oppositions, resource abundance vs. scarcity and egalitarianism vs. hierarchy. To put things in somewhat vulgar-Marxist terms, the first axis dictates the economic base of the post-capitalist future, while the second pertains to the socio-political superstructure. Two possible futures are socialisms (only one of which I will actually call by that name) while the other two are contrasting flavors of barbarism...

These four visions are abstracted ideal types, Platonic essences of a society. They leave out many of the messy details of history, and they ignore the reality that scarcity-abundance and equality-hierarchy are not simple dichotomies but rather scales with many possible in-between points. But my inspiration, in drawing these simplified portraits, was the model of a purely capitalist society that Marx pursued in Capital: an ideal which can never be perfectly reflected in the complex assemblages of real economic history, but which illuminates unique and foundational elements of a particular social order. The socialisms and barbarisms described here should be thought of as roads humanity might travel down, even if they are destinations we will never reach. With some knowledge of what lies at the end of each road, perhaps we will be better able to avoid setting off in the wrong direction.
Read the entire article. A book under the same title is forthcoming.

Lots to ponder.


On the pending threatened federal shutdown and debt default. "The 7.9% Solution."

Gotta go. Calypso RadOnco tx day 25 of 45 (It's Monday the 12th). Four weeks to go.

More to come...

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