Will Silicon Valley's digerati "solve" healthcare?

Light Holiday reading. I'm hotspotting off my iPhone from my Mother in Law's farm in northern Alabama.

I've cited/reviewed Peter Thiel's book "Zero to One" before. Here, here, and here.

apropos, excerpt from the current issue of Harper's:

Come With Us If You Want to Live
Among the apocalyptic libertarians of Silicon Valley
By Sam Frank

… I came across the Tumblr of Blake Masters, who was then a Stanford law student and tech entrepreneur in training. His motto — “Your mind is software. Program it. Your body is a shell. Change it. Death is a disease. Cure it. Extinction is approaching. Fight it.” — was taken from a science-fiction role-playing game. Masters was posting rough transcripts of Peter Thiel’s Stanford lectures on the founding of tech start-ups. I had read about Thiel, a billionaire who cofounded PayPal with Elon Musk and invested early in Facebook. His companies Palantir Technologies and Mithril Capital Management had borrowed their names from Tolkien. Thiel was a heterodox contrarian, a Manichaean libertarian, a reactionary futurist.

“I no longer believe that freedom and democracy are compatible,” Thiel wrote in 2009. Freedom might be possible, he imagined, in cyberspace, in outer space, or on high-seas homesteads, where individualists could escape the “terrible arc of the political.”…

Blake Masters — the name was too perfect — had, obviously, dedicated himself to the command of self and universe. He did CrossFit and ate Bulletproof, a tech-world variant of the paleo diet. On his Tumblr’s About page, since rewritten, the anti-belief belief systems multiplied, hyperlinked to Wikipedia pages or to the confoundingly scholastic website Less Wrong: “Libertarian (and not convinced there’s irreconcilable fissure between deontological and consequentialist camps). Aspiring rationalist/Bayesian. Secularist/agnostic/ignostic . . . Hayekian. As important as what we know is what we don’t. Admittedly eccentric.” Then: “Really, really excited to be in Silicon Valley right now, working on fascinating stuff with an amazing team.”

I was startled that all these negative ideologies could be condensed so easily into a positive worldview. Thiel’s lectures posited a world in which democratic universalism had failed, and all that was left was a heroic, particularist, benevolent libertarianism. I found the rhetoric repellent but couldn’t look away; I wanted to refute it but only fell further in. I saw the utopianism latent in capitalism — that, as Bernard Mandeville had it three centuries ago, it is a system that manufactures public benefit from private vice. I started CrossFit and began tinkering with my diet. I browsed venal tech-trade publications, and tried and failed to read Less Wrong, which was written as if for aliens.

Then, in June 2013, I attended the Global Future 2045 International Congress at Lincoln Center. The gathering’s theme was “Towards a New Strategy for Human Evolution.” It was being funded by a Russian new-money type who wanted to accelerate “the realization of cybernetic immortality”; its keynote would be delivered by Ray Kurzweil, Google’s director of engineering. Kurzweil had popularized the idea of the singularity. Circa 2045, he predicts, we will blend with our machines; we will upload our consciousnesses into them. Technological development will then come entirely from artificial intelligences, beginning something new and wonderful.

After sitting through an hour of “The Transformation of Humankind — Extreme Paradigm Shifts Are Ahead of Us,” I left the auditorium of Alice Tully Hall. Bleary beside the silver coffee urn in the nearly empty lobby, I was buttonholed by a man whose name tag read MICHAEL VASSAR, METAMED RESEARCH. He wore a black-and-white paisley shirt and a jacket that was slightly too big for him. “What did you think of that talk?” he asked, without introducing himself. “Disorganized, wasn’t it?” A theory of everything followed. Heroes like Elon and Peter (did I have to ask? Musk and Thiel). The relative abilities of physicists and biologists, their standard deviations calculated out loud. How exactly Vassar would save the world. His left eyelid twitched, his full face winced with effort as he told me about his “personal war against the universe.” My brain hurt. I backed away and headed home.

But Vassar had spoken like no one I had ever met, and after Kurzweil’s keynote the next morning, I sought him out. He continued as if uninterrupted. Among the acolytes of eternal life, Vassar was an eschatologist. “There are all of these different countdowns going on,” he said. “There’s the countdown to the broad postmodern memeplex undermining our civilization and causing everything to break down, there’s the countdown to the broad modernist memeplex destroying our environment or killing everyone in a nuclear war, and there’s the countdown to the modernist civilization learning to critique itself fully and creating an artificial intelligence that it can’t control. There are so many different — on different timescales — ways in which the self- modifying intelligent processes that we are embedded in undermine themselves. I’m trying to figure out ways of disentangling all of that. . . .

“I’m not sure that what I’m trying to do is as hard as founding the Roman Empire or the Catholic Church or something. But it’s harder than people’s normal big-picture ambitions, like making a billion dollars.”

Vassar was thirty-four, one year older than I was. He had gone to college at seventeen, and had worked as an actuary, as a teacher, in nanotech, and in the Peace Corps. He’d founded a music- licensing start-up called Sir Groovy. Early in 2012, he had stepped down as president of the Singularity Institute for Artificial Intelligence, now called the Machine Intelligence Research Institute (MIRI), which was created by an autodidact named Eliezer Yudkowsky, who also started Less Wrong. Vassar had left to found MetaMed, a personalized-medicine company, with Jaan Tallinn of Skype and Kazaa, $500,000 from Peter Thiel, and a staff that included young rationalists who had cut their teeth arguing on Yudkowsky’s website. The idea behind MetaMed was to apply rationality to medicine — “rationality” here defined as the ability to properly research, weight, and synthesize the flawed medical information that exists in the world. Prices ranged from $25,000 for a literature review to a few hundred thousand for a personalized study. “We can save lots and lots and lots of lives,” Vassar said (if mostly moneyed ones at first). “But it’s the signal — it’s the ‘Hey! Reason works!’ — that matters. . . . It’s not really about medicine.” Our whole society was sick — root, branch, and memeplex — and rationality was the only cure.

In the auditorium, two neuroscientists had spoken about engineering the brain, and a molecular geneticist had discussed engineering the genome. A coffee break began, and a jazz trio struck up Charlie Parker’s “Confirmation.” Nearby, church bells rang noon. I asked Vassar about his friend Yudkowsky. “He has worse aesthetics than I do,” he replied, “and is actually incomprehensibly smart.” We agreed to stay in touch...

The entire (subscriber paywalled) article is a hoot. These people are at once incredibly intelligent and utterly, mind-rollingly naive. Lots of Silicon Valley VC money is being thrown at health care these days. Most of it will come to naught.

Another morsel:

Michael Vassar had predicted a “fairly total” cultural transition beginning within the next decade. This might sound insane, unless you buy into the near-term futurology emerging from outlets like TechCrunch and Wired, and from venture capitalists like Palihapitiya, Srinivasan, and Marc Andreessen.

In five years, an estimated 5.9 billion people will own smartphones. Anyone who can code, or who has something to sell, can be a free agent on the global marketplace. You can work from anywhere on your laptop and talk to anyone in the world; you can receive goods anywhere via drone and pay for them with bitcoins — that is, if you can’t 3-D print them at home. As software eats everything, prices will plunge. You won’t need much money to live like a king; it won’t be a big deal if your job is made obsolete by code or a robot. The rich will enjoy bespoke luxury goods and be first in line for new experiences, but otherwise there will be no differences among people; inequality will increase but cease to matter. Politics as we know it will lose relevance. Large, gridlocked states will be disrupted like any monopoly. Customer-citizens, armed with information, will demand transparency, accountability, choice. They will want their countries to be run as well as a start-up. There might be some civil wars, there might be many new nations, but the stabilizing force will be corporations, which will become even more like parts of a global government than they are today. Google and Facebook, for instance, will be bigger and better than ever: highly functional, monopolistic technocracies that will build out the world’s infrastructure. Facebook will be the new home of the public sphere; Google will automate everything.

Thiel and Vassar and Yudkowsky, for all their far-out rhetoric, take it on faith that corporate capitalism, unchecked just a little longer, will bring about this era of widespread abundance. Progress, Thiel thinks, is threatened mostly by the political power of what he calls the “unthinking demos.” ...

It's a long article. Worth the price of subscribing. I had some great, head-shaking laughs.

UPDATE

Is 2015 the Year We All Sequence Our Microbiomes?
Intriguing inventions for a healthier New Year

This is the era of an app for everything and everything in its app, and health is no exception. It makes sense: When you can try to monitor or improve anything with technology, why not use your devices to better yourself? 'Tis the season of resolutions after all. And while a lot of new health technology is silly, frivolous, or just plain doesn't work, there's some fun and useful stuff out there too...

Full Atlantic article here.

OK, WE GOTTA GO BACK TO SOME MOROZOV

The Perils of Willpower
 At great risk of oversimplifying things, we can say that one way to make design more self-conscious and more sensitive to critiques of solutionism is to replace its fetish for psychology (and, increasingly, neuroscience) with a fetish for philosophy—both moral and political. Worrying about usability— the chief concern of many designers today— is like counting calories on the sinking Titanic. This obsession with usability, with making technology invisible and unobtrusive, has created a world where we are hardly aware of how much energy our households consume. It won’t take long until we discover that our smartphones, in their quest for usability, also hide an equally disturbing reality : that massive toxic dumps of electronic waste usually find their way to cash-strapped developing countries.

The triumph of psychology over philosophy is not limited to industrial design; policy designers and social engineers have succumbed to this trend as well— all in the name of science, for psychology and neuroscience are presumed to be more scientific than philosophy simply because they run experiments and tests. But the fact that matters of morality do not lend themselves to easy measurement does not mean we should disregard such concerns and recast them in neuroscientific and psychological terms. Nowhere is this tendency more evident than in discussions of willpower, in which once highly complex and painful decisions about right and wrong are now recast as instances of strong or weak will— which we can address by managing our willpower reserves carefully, much as we do our bank accounts. 

The very idea of willpower is enjoying a renaissance in psychology departments and partially explains the recent fascination with nudges and gamification. The basic idea is this: we have a fixed amount of willpower to spend on our decisions, so using it to pursue one course of action might make it harder for us to pursue another. Thus, if we convince ourselves not to have this delicious but high-fat cookie now, we won’t be strong enough to choose walking over driving an hour later. We can’t decline the cookie and the car simultaneously.

John Tierney and Roy Baumeister assert in their recent book about willpower that “decision making depletes your willpower, and once your willpower is depleted, you’re less able to make decisions...”

Morozov, Evgeny (2013-03-05). To Save Everything, Click Here: The Folly of Technological Solutionism (pp. 313-314, 338-339). PublicAffairs. Kindle Edition.

Yevgeny's book is a blast. I've cited it before.

DEC 29TH UPDATE

I finished the Yevgeny Morozov book. A wonderful read.

Mad Men, Faded Denims, and Real Phonies 
All these attempts to fix the human condition— to reduce our biases by quantifying everything, to circumvent the frailties of our memory by recording everything, to rid us of our lowly, provincial interests by getting technology companies to serve us a more nutritious information diet, to get us to do the right thing by turning everything in life into a game— are indicative of Silicon Valley’s unease with imperfection as well as its glorification of the powerful tools at its disposal. Our geek kings do not realize that inefficiency is precisely what shelters us from the inhumanity of Taylorism and market fundamentalism . When inefficiency is the result of a deliberative commitment by a democratically run community, there is no need to eliminate it, even if the latest technologies can accomplish that in no time. 

Silicon Valley’s greatest ambition, though, is to ensure that all our social interactions —and even ourselves— exist under the yoke of authenticity. The fear of appearing inauthentic, of being a fake, has propelled nearly as much technological innovation as pornography. As already noted , the quantifying urge of self-trackers, especially their desire to publish these numbers, should be seen as part of this quest to ensure— once and for all— that they are not just authentic but also original. We might all be thinking the same thoughts, using the same apps, and wearing the same T-shirts, but it’s quite reassuring to know that at least our DNA, daily caloric intake, sleeping patterns are different. 

But— and this is the implicit promise of self-tracking —perhaps if you track all those physical things long enough, you’ll uncover some deeper numerical pattern, something that will allow you to discover who you really are. As Gary Wolf notes, “Behind the allure of the quantified self is a guess that many of our problems come from simply lacking the instruments to understand who we are. Our memories are poor; we are subject to a range of biases; we can focus our attention on only one or two things at a time.” And what will it take to discover “who we are”? Well, says Wolf, a bunch of self-tracking gadgets— reporting to the health -care industry or marketers on Madison Avenue— would do the job . “We don’t have a pedometer in our feet, or a breathalyzer in our lungs, or a glucose monitor installed into our veins. We lack both the physical and the mental apparatus to take stock of ourselves. We need help from machines.” Had Sigmund Freud lived long enough, he would have probably been replaced by a pedometer: in this brave new world , who needs psychoanalysis— the obsolete practice of narrative imagination —to “take stock of ourselves,” when the algorithmic option looks so tempting? ... Morozov, op cit (pp. 313-314).

Below: a Facebook friend hipped me to this.

Mouthbreathing Machiavellis Dream of a Silicon Reich

One day in March of this year, a Google engineer named Justine Tunney created a strange and ultimately doomed petition at the White House website. The petition proposed a three-point national referendum, as follows:

1. Retire all government employees with full pensions.
2. Transfer administrative authority to the tech industry.
3. Appoint [Google executive chairman] Eric Schmidt CEO of America.

This could easily be written off as stunt, a flamboyant act of corporate kiss-assery, which, on one level, it probably was. But Tunney happened to be serious. “It’s time for the U.S. Regime to politely take its exit from history and do what’s best for America,” she wrote. “The tech industry can offer us good governance and prevent further American decline.”...

If the Koch brothers have proved anything, it’s that no matter how crazy your ideas are, if you put serious money behind those ideas, you can seize key positions of authority and power and eventually bring large numbers of people around to your way of thinking. Moreover, the radicalism may intensify with each generation. Yesterday’s Republicans and Independents are today’s Libertarians. Today’s Libertarians may be tomorrow’s neoreactionaries, whose views flatter the prejudices of the new Silicon Valley elite...

California libertarian software developers inhabit a small and shallow world. It should be no surprise then, that, although [Peter] Thiel has never publicly endorsed Yarvin’s side project specifically, or the neoreactionary program in general, there is definitely a whiff of something Moldbuggy in Thiel’s own writing. For instance, Thiel echoed Moldbug in an infamous 2009 essay for the Cato Institute in which he explained that he had moved beyond libertarianism. “I no longer believe that freedom and democracy are compatible,” Thiel wrote...

Read the entire piece.

"I no longer believe that freedom and democracy are compatible."

Let that sink in for a moment.

Recall the recent unsuccessful ballot effort by one of these billionaire Silicon Valley dudes to break California up into six new states, carving out the "best" for himself and his digerati brethren.

"iState" was to be simply known as "Silicon Valley," and I have no doubt that these people envisioned eventually moving the nation's capital from DC to it. (I now live in east bay Contra Cost County "Western Merlot.")

More Yevgeny:

Katie Stanton, a former Google executive who briefly worked for the Obama administration and currently works for Twitter, compared her experience in Washington to that of “a vegetarian trapped inside the sausage factory.” Her ex-boss, Google’s Eric Schmidt, lambasts Washington as “an incumbent protection machine [in which] the laws are written by lobbyists” (this antilobbyist sentiment has somehow never prevented Google from rapidly expanding its own lobbying operation in Washington, DC). 

So many geeks are impatient with politics because they think that it involves nothing but talk. For them, deliberation is the cancer in the body of modern democracy, and it would be so much more productive to replace talk with action, with doing things, for all this chatter is of little to no use. After all, no great apps have ever come out of a committee meeting. So Beth Noveck, the open-government advocate and author of Wiki Government, tells us— in the kind of language beloved by administrators— that “it is overdue to rethink the legitimacy of attenuated participation in a small number of representative institutions.” Got it? [Morozov, op cit, p. 133.]

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Critics have maligned the plan as a naked attempt by Draper and his elitist Silicon Valley buddies to cut the riffraff moochers out of their tax base (the new Silicon Valley state would have the highest per capita income in the nation), while sending 10 new U.S. senators — as many as eight of them Republicans — to Washington. Some have called it “radical-right libertarianism.” 

- 6 Californias? How about 7 Rhode Islands?

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More to come...

On the bubbleliciousness of mHealth?

"We’ll put sensors in snow cones, aggregate all the data, optimize, and then we’ll know everything about who prefers what kind of snow cone, and we’ll correlate that with their health prospects and their career prospects, and then we’ll sell that [sic] data!"

Only kidding. It was just funny. Not that there's no grain of truth there. From "Nerds on the Knife Edge" in the current issue of The Baffler.

On the same riff, see Evgeny Morozov's trenchant "To Save Everything, Click Here."

...That smart technology and all of our social connections (not to mention useful statistics like the real-time aggregate consumption of electricity) can now be “inserted” into our every mundane act, from throwing away our trash to making tea, might seem worth celebrating, not scrutinizing. Likewise, that smartphones and social-networking sites allow us to experiment with interventions impossible just a decade ago seems like a genuinely positive development. Not surprisingly, Silicon Valley is already awash with plans for improving just about everything under the sun: politics, citizens, publishing, cooking...

Morozov, Evgeny (2013-03-05). To Save Everything, Click Here: The Folly of Technological Solutionism (p. 5). Public Affairs. Kindle Edition.

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More to come...

#WinterTech 2016: Venture Capital in #HealthIT

My new issue of The New Yorker just arrived in the snailmail today. Couldn't resist. Snapped that with my iPhone and uploaded it.

A fun day. Long, but fun. Up at 5, down the 4 and on the BART by 6:30, back home by 7:30 pm (then back up at 6 to shlep my daughter to BART for her trip to Vegas this morning).

No rice milk this time. I guess that's progress (Matthew Holt and I share this complaint). I had some half & half containers from my Friday night stay at the SFO Doubletree with my outbound wife, but I didn't toss 'em in my briefcase. I just eschewed the coffee. Rice milk, soy milk, skim milk, I've tried them all. Fuggedaboudit.

Our hosts...

I awoke to the news, prior to heading for BART, that HHS is apparently killing the Meaningful Use initiative this year -- ironically, via a bitter and cynical post on THCB (no less) by Margalit Gur-Arie.

Meaningful Use Is Dead. Long Live Something Better!

At the J.P. Morgan Healthcare Conference in San Francisco, Mr. Andrew Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS),announced on January 11th that “The meaningful use program as it has existed will now effectively be over, and replaced with something better”, and later clarified onTwitter that “In 2016, MU as it has existed– with MACRA– will now be effectively over and replaced with something better”. Meaningful Use is dead. Just like that. No apologies. No nothing. As someone who’s been lamenting the havoc wreaked by the program on both doctors and patients, I should be elated nevertheless. Well, I am not.

Let’s start with appearances. The J.P. Morgan Healthcare Conference is the “largest and most informative healthcare investment symposium in the industry which brings together global industry leaders, emerging fast-growth companies, innovative technology creators, globally minded service providers, and members of the investment community”. In other words the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck. Was this conference really the best place to make such momentous announcement?

Besides, why would these extractors of wealth be interested in the fate of something as obscure as Meaningful Use?...

Meaningful Use is dead. Long live something better! And what is that better something? It is paying physicians for outcomes. It is the use of evidence based medicine. It is interoperability and “user-centered” design. It is Accountable Care Organizations, value, patient centeredness, coordination and such. It is also the making of markets “by leveling the technology playing field for start-ups and new entrants”, because when Epic makes money, nobody on Wall Street or in Silicon Valley gets a piece of the action. It is about engagement and analytics and population health, calculations, penalties, incentives and lots of new technology things. It is “like the second generation iPhone”.

After collectively sinking billions of dollars in Certified EHR Technology over the last five years, hospitals and doctors will now be expected to foot the bill for new software and computer products to support the lifestyles of a new generation of Silicon Valley entrepreneurs and the insatiable greed of the old generation of Silicon Valley investors. Why? Because the next app is sure to fix health care in America. It’s always the next one. There is always “something better” you can buy. Planned obsolescence, which is fueling the obscene fortunes of Silicon Valley and destroying life everywhere else, has finally arrived to the $3 trillion health care sector. It took a bit longer than the folks at J.P. Morgan expected, I’m sure, but we’re in business now. Let the good times roll…

I've cited Margalit recently here and here. Notwithstanding my perplexity and qualms with respect to some of her recent positions, she deserves to be taken seriously. No one can rationally assail her humanity.

Moreover, no one can seriously question my Street Cred when it comes to "Meaningful Use" dubiety (irrespective of my belief in the inevitability of and net utility of digital IT). "Clinic Monkey," anyone? I was working at a REC when I posted that (the REC work was the impetus for this blog, and regarding which I took considerable crap from one of my senior superiors).

So, yeah! The Onerous, Wicked Regulatory MU Witch is now apparently dead (don't pop The Bubbly just yet). Where does that leave us? I guess now we'll excoriate the fruits of the incentives of the "free market," as Margalit has argued.

"...the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck."

Feeling the "Bern," much?

One prominent billionaire featured right off the bat at WinterTech:

Vinod Khosla. 1982 Sun Microsystems co-founder. Current Principal, Khosla Ventures. Estimated wealth ~$1.7 billion. From my notes during his interview with Indu: "We're bumbling around trying to figure out what works."

Well, that about sums up the entire space, no?

He also noted -- as have many others -- that "health happens between doctor visits, i.e., 99.9% of the time." Hence the utility of 24/7 quantified self monitoring apps.

Id'ing those that will have both clinical utility and market profitability is the problem.

Some random shots from the day.

Rebecca Lynn, founding partner, Canvas Ventures

Below, athenahealth CEO Jonathan Bush.

Far and away the most spirited talk of the day. No introvert here. No Siree. I got to meet him last year. Gained significant new respect for the guy.

He's pushing an interesting initiative these days.

Help Us Build a Hospital In the Cloud

...[A]s my company, athenahealth, expands beyond the ambulatory (outpatient) care space and builds out its cloud-based services for hospitals and health systems, we’ve quickly realized that this entrepreneurial spirit is badly needed. If we’re going to disrupt the status quo and truly wow the hospital market with a new way of doing things, we need that innovator’s passion, and we need it now.

Inpatient facilities – from tiny critical access hospitals to leading academic medical centers – are starved for innovation when it comes to IT. They’re running on clunky, monolithic systems that were never built for the internet. Many of them weren’t even designed for a clinical setting. Rather, they were built as general ledgers, tracking financials long before they were tracking diagnoses.

At athenahealth, we refuse to play this old-school enterprise software game of highly-customized solutions, massive upfront implementation fees, and multi-year installation timelines. Instead, we’re ushering in something entirely new. We’re replacing on-premise solutions with the nimbleness of the cloud, and closed systems with an open platform built for partnership. Now, we’re looking for cloud-based partners to join us on that journey.

The entrepreneurs that are tackling the inpatient space already are, for the most part, operating on its fringes. I don’t blame them. The pain of selling into a large health system can take years off your life. Hospital workflows are complex, inconsistent, and puzzling even to their own doctors. But if we want to extend athenahealth’s health information backbone across the continuum of care, we need help. Below are just a handful of the big, hairy problems we’ve observed in the inpatient space. Let this serve as an open call to entrepreneurs (from healthcare, or not!) to step up to the challenge of solving them...

He proffered some significant optimism that we will in fact soon see significant true "interoperability" (supplanting what he called the incumbent "intra-operability"), that what I have irascibly called "interoperababble" may soon wane.

I hope Health 2.0 will openly publish the video of his keynote. It was excellent.
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GETTING UP TO SPEED ON THE VC JARGON

I've never had any personal need to be well-versed in venture capital processes and terminology. I started and ran two for-profit corporations -- one Sub-S (really just a glorified sole proprietorship) and one C-Corp (my A/V studio business) -- both of them bootstraps that ran on their own with no outside money (albeit chronically cash flow strapped).  I also founded one 501(c)(3) and one 501(c)(6), both of them bootstrapped as well.

WinterTech comprised a blizzard of VC jargon to get familiar with.

"Seed Rounds," "Angel Investors," Series A Rounds," Up Rounds," "Down Rounds," "Term Sheets," "Valuations," "EBITDA," "The Verticals," "Mark to Market"...

At least no one said "the Spend." And, there were only two passing references to "Uber" -- both of them dismissive.

Some of this jargon stuff goes to the financial sector more broadly, and I did do a 5-year stint in subprime risk modeling and management, so I have a bit of surface familiarity with some of the FIRE-speak in general. See, e.g., my old posts "Tranche Warfare" and "The Dukes of Moral Hazard." Nonetheless, the VC world is a specific domain. With a roughly $5 billion investment churn going on this year in the health care space, it is worth our attention.

I'd like to find a good layperson's book on the topic, now that I'm a relative chump-change "Crowdfunding Investor" in a startup being launched by my niece's husband Dr. Jeff Nyquist.

Jeff holds a PhD in Neuropsychology from Vanderbilt. A principal initial focus of his technology is brain injury mitigation within the collision sports (e.g., football, hockey, soccer) via virtual reality-based neural training, specifically occipital lobe visual cortex enhancement -- technology historically rooted in part in the naval combat air "Top Gun School" peripheral vision acuity methods.

(No, it's not a "Lumosity")

Writer Gregg Easterbrook ("The Game's Not Over") recently noted that, while NFL brain injuries are getting all of the media attention of late (~200 concussions a year), there are approximately 200,000 concussions a year in high school football alone, and the first wave of liability litigation judgments is starting to roll in. High school football -- which feeds the NCAA to NFL pipelines -- may well become uninsurable. Any technology that can be scientifically shown to reduce concussion risk (in addition to other cognitive benefits) may be quite valuable.

Hence my new interest in the VC world. I hope Jeff and April will be successful with all of this. Adroitly navigating the VC minefields will no doubt become a factor at some point.

Pretty good VC overview on the Wiki. 

BTW: See the documentary "Something Ventured."

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A REFLECTIVE CAUTIONARY INTERLUDE

"The processing of information is not the highest aim to which the human spirit can aspire, and neither is competitiveness in a global economy."

From Leon Weiseltier, "Among the Disrupted," a year ago in The NY Times.

...Aside from issues of life and death, there is no more urgent task for American intellectuals and writers than to think critically about the salience, even the tyranny, of technology in individual and collective life. All revolutions exaggerate, and the digital revolution is no different. We are still in the middle of the great transformation, but it is not too early to begin to expose the exaggerations, and to sort out the continuities from the discontinuities. The burden of proof falls on the revolutionaries, and their success in the marketplace is not sufficient proof. Presumptions of obsolescence, which are often nothing more than the marketing techniques of corporate behemoths, need to be scrupulously examined. By now we are familiar enough with the magnitude of the changes in all the spheres of our existence to move beyond the futuristic rhapsodies that characterize much of the literature on the subject. We can no longer roll over and celebrate and shop. Every phone in every pocket contains a “picture of ourselves,” and we must ascertain what that picture is and whether we should wish to resist it. Here is a humanist proposition for the age of Google: The processing of information is not the highest aim to which the human spirit can aspire, and neither is competitiveness in a global economy. The character of our society cannot be determined by engineers.

“Our very mastery seems to escape our mastery,” Michel Serres has anxiously remarked. “How can we dominate our domination; how can we master our own mastery?” Every technology is used before it is completely understood. There is always a lag between an innovation and the apprehension of its consequences. We are living in that lag, and it is a right time to keep our heads and reflect. We have much to gain and much to lose. In the media, for example, the general inebriation about the multiplicity of platforms has distracted many people from the scruple that questions of quality on the new platforms should be no different from questions of quality on the old platforms. Otherwise a quantitative expansion will result in a qualitative contraction. The new devices do not in themselves authorize a revision of the standards of evidence and argument and style that we championed in the old devices. (What a voluptuous device paper is!) Such revisions may be made on other grounds — out of commercial ambition, for example; but there is nothing innovative about pandering for the sake of a profit. The decision to prefer the requirements of commerce to the requirements of culture cannot be exonerated by the thrills of the digital revolution.

And therein lies a consoling irony of our situation. The machines may be more neutral about their uses than the propagandists and the advertisers want us to believe. We can leave aside the ideology of digitality and its aggressions, and regard the devices as simply new means for old ends. Tradition “travels” in many ways. It has already flourished in many technologies — but only when its flourishing has been the objective. I will give an example from the humanities. The day is approaching when the dream of the democratization of knowledge — Borges’s fantasy of “the total library” — will be realized. Soon all the collections in all the libraries and all the archives in the world will be available to everyone with a screen. Who would not welcome such a vast enfranchisement? But universal accessibility is not the end of the story, it is the beginning. The humanistic methods that were practiced before digitalization will be even more urgent after digitalization, because we will need help in navigating the unprecedented welter. Searches for keywords will not provide contexts for keywords. Patterns that are revealed by searches will not identify their own causes and reasons. The new order will not relieve us of the old burdens, and the old pleasures, of erudition and interpretation...

Wafts of Morozov, absent the sharp elbows. Well, sharp enough:

...the discussion of culture is being steadily absorbed into the discussion of business. There are “metrics” for phenomena that cannot be metrically measured. Numerical values are assigned to things that cannot be captured by numbers. Economic concepts go rampaging through noneconomic realms: Economists are our experts on happiness! Where wisdom once was, quantification will now be. Quantification is the most overwhelming influence upon the contemporary American understanding of, well, everything. It is enabled by the idolatry of data, which has itself been enabled by the almost unimaginable data-generating capabilities of the new technology. The distinction between knowledge and information is a thing of the past, and there is no greater disgrace than to be a thing of the past. Beyond its impact upon culture, the new technology penetrates even deeper levels of identity and experience, to cognition and to consciousness. Such transformations embolden certain high priests in the church of tech to espouse the doctrine of “transhumanism” and to suggest, without any recollection of the bankruptcy of utopia, without any consideration of the cost to human dignity, that our computational ability will carry us magnificently beyond our humanity and “allow us to transcend these limitations of our biological bodies and brains. . . . There will be no distinction, post-Singularity, between human and machine.” (The author of that updated mechanistic nonsense is a director of engineering at Google.)

Recall Morozov's take-no-prisoners beef with digital "Solutionism"?
__

RANDOM WINTERTECH 2016 NOTES & QUOTES

• Good presentations by "The Validation Institute," "Digital Reasoning," and "SoftServe."
• "Cutting costs in health care invariably means cutting someone's income." (My old mentor Dr. Brent James made that point to us more than 20 years ago during our IHC QI training.) Another allusion along this somewhat paradoxical line went to "keeping patients out of the hospital through closer attention to lifestyle metrics."
• "New API's will relegate EHRs to 'middleware'."
• "Early childhood factors are critical." (Yeah, you don't have to tell it to the parents of kids in Flint, Michigan these days. apropos of "The Upstream.")
• "It take 10 years to build a (VC fueled) company." If that's even the goal for a lot of startups (rather than the vestigial dot.com "built-to-flip" ethos)
• Irony: openly avowed "Marxist" Health 2.0 co-founder Matthew Holt schmoozing amiably and knowingly with the VC Big Dogs...

One presenter demo'ed an app purporting to generate a general personal "health score" once seeded with some basic info, after which the score would get "refined" by the addition of various social media metrics (the creepy phrase "digital exhaust" comes into play in this regard). Someone used the "FICO score for health" analogy in response.

That gave me the groans. See Morozov's "Your Social Networking Credit Score."

Another VC panelist spoke glowingly of potential "opportunities" devolving from the inexorable rise in patients' "OOP" (out-of-pocket expenditures, something I came to know acutely in 2015). With OOP rising to perhaps as much as 35% of health care billings, perhaps "financial services" were a potential investment growth area.

Yeah, what could possibly go wrong there?

Back during my subprime banking days, I launched the Photoshop and mused similarly, back around 2004...

...These days, like so many of my 76 million-strong Boomer cohort (~28% of the U.S. population, defined more or less as those born during the period from 1946 through 1964), I keep one suitcase mentally packed at all times. My Dad is now 88 and lingering in a nursing home in central Florida, enfeebled by dementia. My Mom is 82 and still independent, though only marginally mobile. The enervating encroachments of age similarly impinge increasingly on my wife’s parents back in rural northern Alabama.

Consequently, we minimally expect four distressing phone calls at random intervals in the coming years, imploring us to get back home quickly. For us this means at least three short-notice round-trip cross-country airline reservations (along with car rentals)—four times. Twelve last-minute seats (my wife, our son, and me), just to pay respects and help tend to the affairs of the parents when the times come. And, our daughter and her son just moved here to Vegas from Florida, so make that perhaps five round-trip seats each time. I just checked online prices: five immediate family last-minute "lowest fare" round-trip seats, Vegas to/from Orlando, and Vegas to/from Huntsville, Alabama, roughly $13,000 retail covering all four parents. So much for all of my DiscoverCard available credit (and part of another card, or a chunk of my savings).

There are tens of millions of Boomers facing similar circumstances.

Airline bereavement fare policies

Four adjectives become evident after a bit of research: complicated, confusing, contentious, and air carrier-specific. Just what you don't need when you’ve just gotten "The Call." For someone living beyond driving distance from loved ones, what would be extremely beneficial at such a time would be the ability to make one call that gets you on the next available flight at advance reservation discount rates, complete with rental car and lodging at the destination as required.

The  rapidly growing "stored value" concept

The bank where I work is getting tepidly into the "stored value card" arena, an expanding area of retail financial services. During a recent weekend, as I pondered this nascent offering and our associated hand-wringing over issues such as the chump-change prospects of someone getting auth'ed to pump a buck too much gas at Quik-Mart, the NextFlightHome idea bubbled up in my mind. Essentially a stored value product, also not conceptually distant from "insurance." You know you're going to have to book these trips. Why not avail yourself of a service that will get you the lowest price at the least hassle when the time inevitably comes. Moreover, if your credit rating warrants, you can even spread the payments conveniently -- making it in effect a (competitively priced) credit offering should you choose not to store the value up front.

Mitigating the "I-gotta-get-there-now" hassle factor

What is that worth? Air-carrier bereavement rate policies typically require authentication documentation confirming that you are in fact "immediate family" and that a next-of-kin has indeed passed on. NextFlightHome perhaps doesn't even care. It's your account, your money; you can use it as you wish. You can always reload. The built-in activation waiting period precludes using the service as an end-run around regular retail airfare rates, and, should you have opted for and been approved for the revolving credit payment option, your account must be in good standing to book an itinerary. We've even provided for that, with our credit insurance cross-sell ancillary product, and the fact that we provide shamelessly copied positive incentives such as "payment points" and other non-punitive inducements (e.g., sweepstakes entries) for keeping accounts current...

Just an idea. We continued on with easier ways to fleece people. I left a year later anyway to return to health care. Subprime was just too jive.

The "financial services" idea proffered at WinterTech surely went to stuff like getting patients to apply for financing in advance of treatment. That's not exactly news. Think "Bosley Hair Transplants" or "Clear Choice Dental Implants," etc. "We'll even discuss financing options with you..."

Back about four years ago I had to have a periodontal cadaver/bovine jaw bone graft px. Had to pay for that sucker up front before they'd even book the chair (about 5 grand). At least my AMEX "points" got me a Kindle reader out of that encounter.

Yeah: subprime health care tx financing, right down to your deductibles and co-pays. Margalit will have an aneurism.
__

I Google-searched for news coverage of WinterTech. Next to nothing there. Interesting.

One nice find, though:

Digital health firms, say goodbye to easy venture capital
By Beth Kutscher  | January 13, 2016

Digital health startups have benefited from easy access to capital over the past few years, but the market is about to get a lot tighter.

Analysts and investors watching the space offered a sobering take Wednesday during one of the biggest industry meetings of the year, the J.P. Morgan Healthcare Conference, which is largely considered the event that sets the tone for the next 12 months...

Even digital health companies that are far from being candidates for stock market listings are likely to see a pullback in funds, and could find themselves raising less money from investors than they did in earlier financing rounds.

“There's going to a reset of expectations across the board,” Francis said.

Ruchita Sinha, director of healthcare for GE Ventures, had a similar prediction.

“There will be a correction,” she said. “There's a strong sense of realism coming back into the market.”

A common sentiment at the conference among health systems and their venture capital arms was that technology entrepreneurs don't really understand their business. Many of their new tools try to solve a patient problem but create more work for providers and don't necessarily fit the way they do business...

Good article. Nice summation of the day. I was surprised that it was really the only substantive piece out there. Beth wraps up:

“There's a growing debate [in the digital health world]: Do I want tech investors or do I want healthcare investors? And the answer is, you want both,” said Jeff Tangney, CEO of Doximity, a networking and recruitment site for physicians. Doximity raised $54 million in 2014 in a Series C round led by DFJ Growth, and through funds managed by T. Rowe Price Associates. “It's the rare breed that does both,” he said.

Given the market turmoil and contractions of late (I simply can't bring myself to open my latest IRA statements), I don't doubt that health care space VC dollars may well contract in 2016.

CODA

A great, concise resource. At $0.99 on Amazon (Kindle edition), a tremendous value.

Be Prepared For Callbacks 

Memorize your deal facts, know whom you’ve contacted, and be prepared to talk about your deal at a moment’s notice. These are some of the questions you should expect: 

• What is the value proposition for the investor? 
• What makes your deal different? 
• Who are your competitors and why are you better? 
• Why are you going to win? 
• What is your revenue model and what is your current revenue run rate? 
• What events will positively or negatively impact revenue? 
• How does the current business/ political environment affect your business? 
• Do you benefit, suffer, or is the impact negligible, and why? 
• What is the average ROI for your customers? 
• How do your customers measure the results of your product? 
• What is your sales cycle? 
• What is the length of time from identifying identifying customers to receiving a signed contact? 
• What is the average cost per unit? 
• Where does this funding round get you? 
• Breakeven, cash flow positive, and so on? 
• What were your sales last year? 
• What are this year’s sales? 
• How much money has been invested? 
• Who are your investors? 
• What is your burn rate? 

If you cannot provide direct and simple answers (that is, three sentences or less) to each of these simple questions, you still have some homework to do. Beyond rote memorization, you need make sure your answers sound natural, not “canned.”

Don’t Recreate History 

Do not waste time showing off your encyclopedic knowledge of the history of technology and communication. Investors have heard about this thing called “the Internet.” They know the history of communication. They know all about the telephone, telegraph, fax machine, electricity, and stirrup. Tell them what they don’t know. 

Venture Capitalists Don’t Know Anything About YOUR Deal! 

Focus on that fact. Your plan needs to educate the reader as to the how, what, where, why, and when of your company. This is basic college freshman year term paper stuff. On the following page I’ve listed some of the basic questions your plan needs to answer. 

Basic Questions Your Plan Needs To Answer 

• What do you sell? 
• How much have you sold? 
• Whom do you sell to? 
• How do you sell? 
• Where do you sell it?
• How do you price it? 
• What market pain do you solve? 
• What is the stage of your product development? 
• What is the compelling reason the market will buy your widget? 
• What is your revenue model? 
• How do you make money? 
• Why are you going to win? 
• Who are your competitors and how are you different from them? 
• What are your milestones? 

If the reader cannot divine the answers to these questions from a cursory look at your plan, the reader probably will not get these answers from a deeper study of your plan because your plan will not receive a deeper study. You must immediately and explicitly address each of these questions. Failure to do so will likely send your plan to the trash pile.

Highly recommended. Great jargon glossary at the end. I loved his advisory acronym GYHOOYA (Get Your Head Out Of Your Ass). Meaning, be realistic and honest when dealing with the VCs if you hope to stand the slimmest chance of success. Early on in the book:

Simply put, entrepreneurs need to be realistic; venture capital is not for everyone; they need to operate in an industry (with a product) that has the chance to become a “billion dollar baby;” they need to seek the right investors at the right time; they need to have a “hook,” that is, give investors and customers a compelling reason to act (invest and buy, respectively); they must have a business that builds real assets on the balance sheet (cash); they must close deals and book sales; they must offer a solution that solves a real pain point (and not offer a solution looking for a problem); they must compile a world-class management team; and they must be imbued with persistence, doggedness, resourcefulness, and creativity.

For a comprehensive deep dive, this book below looks excellent (if pricey at $47.19 Kindle), based on my read of the Amazon preview and the comments.

____________

More to come...

If I knew then what I know now... pondering the Naked Emperor

Recall, from our prior post,

"Let's Admit the Emperor Has No Clothes- It's Time to Redesign EHRs to Improve Patient Care"

Aside from the fact that time travel and its 20/20 hindsight cognitive fruits are only possible in Hollywood, it's not clear from the Healthcare Innovation Council REBOOT response precisely who is this "Emperor." HHS Secretary Sebelius? CMS Administrator Tavenner?

Yeah, I know, it's likely not aimed specifically at anyone in particular, it's probably just a "witty and original" totemic pejorative metaphorical allusion expressing frustration with bureaucracy. Quite fashionable these days, to be sure.

Anyone who has followed this blog knows by now that I am no reflexive HHS/CMS/ONC cheerleader (far from it), but this unevenly composed letter is so chock full of empty, repetitive echo chamber chants, blinding glimpses of the motherhood-and-apple-pie obvious, a buffet serving of red herrings, and outright misstatements of fact as to compel me into a bit of prefatory snark and Photoshop mockery.

Serious item-by-item critical pushback to ensue shortly. Stay tuned.
__

UPDATE

"We believe that the root cause reasons why EHRs aren't delivering on their promises include:

• [1] EHR design issues: EHRs, to date, have been fundamentally designed to create electronic versions of paper medical records. EHRs focus on data collection mostly for regulatory compliance and financial reporting, not to assist physicians, nurses and other clinicians in providing higher quality more efficient patient care. As a result, the EHRs are not designed to reflect or facilitate the way in which providers deliver patient care, and thus disrupt, rather than enhance, patient care; and
• [2] EHR implementation issues: EHR implementations are often led as IT "projects" by teams that do not obtain robust, meaningful, future-focused input / involvement from nurses, physicians, pharmacy and other clinicians who provide patient care. The end result typically is that EHR implementations don't make life better for EITHER the clinician or the patient. Sadly, more often than not physicians, nurses and other clinicians find EHRs make it more, rather than less, difficult to provide better patient care."

Bullet 1: While still true to a degree with respect to Big Iron "legacy systems" (such as -- hel-LO? -- the ones they cited as data sources from their interviews) that is a dated argument. It becomes less true, more dated with each passing month. Newer EHR developers are working furiously to come up with workflow-compatible applications.

Bullet 2: Any organization large enough to have an "IT department" has to deal with this internal political problem whatever the hardware and software systems being deployed. This, too, is old news. See my July 2010 post wherein I cite the Haugen-Woodside book "Beyond Implementation: A Prescription for Lasting EHR Adoption."
__

Continuing...

"The following themes emerged from those discussions, which question the ability of the current breed of EHRs to improve patient care and question the implementation methodology used by many providers that doesn’t have sufficient focus on improving patient care:

• [3] Improving patient care should have been the primary focus for EHR planning/implementation, as directed by Congress in the ARRA. Instead, CMS’ and healthcare providers’ focus has been to "just get EHRs up and running" in a way that meets CMS’ “meaningful use” requirements so that they can get “meaningful use” dollars, without regard to how that affects patient care. CMS should change its “meaningful use” requirements to require measureable improvements in patient care in the short-term.
• [4] The primary caregivers, nurses, were often not involved in EHR planning or had limited involvement with boundaries and limitations when nurses identified specific patient care needs.
• [5] EHR planning was primarily from the IT perspective, not from the clinical care perspective.
• [6] The EHR was not designed to provide a longitudinal view of the patient’s story over a period of time, with trending capabilities for improved decision making.
• [7] The EHR is cumbersome and requires too many clicks to obtain needed patient information.
• [8] The EHR does not facilitate patient knowledge, education or input.
•  [9] Quality of documentation has decreased, not increased, after EHR implementation.
• [10] The EHR is primarily an electronic documentation tool that unfortunately also isn’t, but could be, a "brain partner" decision support tool that aids clinicians in providing and improving patient care.
• [11] EHRs should be interoperable so that EHR patient records are accessible to all care givers (subject to appropriate security and privacy), which was another direction to CMS by Congress in the ARRA.
• [12] The efficiency and effectiveness of care delivery business processes need to be reviewed and  re-engineered prior to, not after, commencement of the EMR implementation."

Bullet 3. First, you should noted the repeated confusion of the roles of ONC and CMS in this letter. to wit:

‘‘SEC. 3001. OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY.

‘‘(b) PURPOSE.—The National Coordinator shall perform the duties under subsection (c) in a manner consistent with the development of a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that—

‘‘(1) ensures that each patient’s health information is secure and protected, in accordance with applicable law;

‘‘(2) improves health care quality, reduces medical errors, reduces health disparities, and advances the delivery of patient- centered medical care;

‘‘(3) reduces health care costs resulting from inefficiency, medical errors, inappropriate care, duplicative care, and incomplete information;

‘‘(4) provides appropriate information to help guide medical decisions at the time and place of care;

‘‘(5) ensures the inclusion of meaningful public input in such development of such infrastructure;

‘‘(6) improves the coordination of care and information among hospitals, laboratories, physician offices, and other entities through an effective infrastructure for the secure and authorized exchange of health care information;

‘‘(7) improves public health activities and facilitates the early identification and rapid response to public health threats and emergencies, including bioterror events and infectious disease outbreaks;

‘‘(8) facilitates health and clinical research and health care quality;

‘‘(9) promotes early detection, prevention, and management of chronic diseases;

‘‘(10) promotes a more effective marketplace, greater competition, greater systems analysis, increased consumer choice, and improved outcomes in health care services; and

‘‘(11) improves efforts to reduce health disparities. [ARRA pg 116]

While both ONC and CMS are agencies under the HHS umbrella, CMS's role is more purely administrative -- i.e., managing the disbursement of the Medicare and Medicaid Incentive funds. It is ONC that is charged with setting and guiding HIT policy priorities under ARRA. The phrase "National Coordinator" is found 70 times across 26 pages of the law, and the combined "Medicare" "Meaningful Use" is found 19 times across 8 pages.

Having noted that, it is a fair point to observe that the Meaningful Use program did indeed glom onto a "Body Count" focus to a great degree (I have to confess to our having recruited some duds early on at my REC). Nonetheless, to a significant extent this signup focus was strategic and in keeping with ARRA intent (aiming for tipping point "Network Effect"). Recall this emblematic "Bend The Cost Curve Graphic"?

It is premature to expect much in the way of "improved clinical outcomes" yet, in light of the magnitude of the huge scope of such a transformative project. Even for complex patients seeing their doctors, say, 4 times a year, any emergent outcomes trends for better or worse are unlike to be evident at this point. This expectation was baked into the HITECH planning assumptions. Criticizing the lack of "improved outcomes" in 2013 is either disingenuous or naive.

Bullet 4: I assume the interview data on this lament came from inpatient settings. It is probably true. Bullet 5: Redundant. See my response to #2. Bullet 6: At least in outpatient settings, longitudinal flowsheets are by now EHR staples, so this is to a great degree a misstatement of fact. Even Vista does flowsheets.

Bullet 7: "The EHR is cumbersome and requires too many clicks" Which "EHR"? There are as of today (May 28th) 1,947 ONC "complete" certified EHR systems. Did HIC collect data on this complaint? Say, how many workflow clicks for each num/denom MU measure, stratifed by EHR product?

I rather doubt it.

Bullet 8: Building in patient education / input functionality is in fact part of the ONC plan. Stage 1 functionality necessarily focused on data capture health care clinicians and staff.

Bullet 9: That allegation is so vague as to be worthless. And, is likely not true.

Bullet 10: The "brain partner" thing. Premature to expect at this point, I would think. Not that's it's not a desirable function. See my various postings (Down in the Weeds') on Messrs Weeds' "Medicine in Denial."

Bullet 11: The "Interoperability" misnomer. Yes, I agree, and have posted so repeatedly. But, here we bump up against the inevitable for-profit market conundrum: Margin = Opacity.

Bullet 12: It's not (workflow/BPM) a before or after thing. To the extent that it's "before," we really just mean that it has to be part of the HIT project planning. We've known this for a long time (e.g., DOQ-IT, 2005 - 2008).
__

Continuing...

Bullet points 13 through 19 comprise a (cherry-picked?) summary of studies critical of the effort. I observed in my prior post: 

In meta-analytic fashion, they cite seven studies [bullet points 13 - 19] critical of Health IT deployment, but only allude to aggregate concerns contained in these reports. Seven critical reports across four years? Is that unusual for any large government initiative of comparable complexity and magnitide?

Bullet point 20 simply involves some speculative hand-wringing regarding the recent ONC de-certification of two EHR products and its potential for disruption in the industry should more vendors get decertified. That concern is to an extent reasonable (though I bet HHS is gonna march lockstep carefully past that minefield). My views on the shallowness of the ONC CHPL certification methodology are well known by now to regular blog readers.

The final bullet points

"Strong nurse, physician and clinician EHR involvement will help achieve the following patient care improvement objectives:

• [20] Improved focus on EHR design and implementation that starts by mirroring the way care is actually delivered by nurses, doctors and other clinicians. This basic design then would move to new, information enhanced processes that not only help clinicians do their jobs easier, but measurably improve patient care safety and quality.
• [21] Discovery and integration of ways to enable a richer, more engaged and meaningful patient/caregiver relationship versus one that requires increased clinician time for record keeping instead of patient care.
• [22] Redesigned EHR processes that ensure nothing falls through the cracks in care transitions (e.g., medication reconciliation,) which are a major source of patient safety issues.
• [23] Rethinking, redesigning and re-engineering nurse, physician and clinician workflows to take full advantage of the capabilities of the new (and evolving) EHR tools to result in improved healthcare processes and care experiences."

In reading through this entire piece, I couldn't help but notice one or another permutation of the phrase "nurses, doctors and other clinicians" occurring repeatedly -- 15 times to be exact (in an 8 page proffer). "Clinician(s)" specifically 22 times.

Roger that. 10-4. We got ya. These are hardly original thoughts. Repeating them multiple times doesn't serve to strengthen the argument.

Bullets 20 and 23: Well, in #20 we're gonna re-design HIT to align to the way clinicians actually work (see #1 also), but in #23 we'll be modifying ("redesigning and re-engineering") clinical workflows to align them with HIT capabilities. Okee-Dokee.

Truth is, it has to be a PDSA improvement mix of tactics. We've known that for quite some time. See, e.g.,  the substantial AHRQ.gov workflow document repository. It goes back at least 20 years.Truth is, "the way clinicians actually work" is not cast in granite; it has to change with the technological times. Health care is not unique in this regard.

Finally,

Bullets 21 and 22: Well, NO ONE is arguing against any of that. The HIT literature of the past decade is full of such recommendations.
___

IN CLOSING;
A FEW SUMMARY BROAD CONCERNS I HAVE WITH THIS LETTER

• Who, precisely is is to be in placed charge of "re-designing EHRs" to produce the functionalities recommended by the HIC? The authors don't say. SOMEONE, SOME ENTITY will have to be in charge. And, while the tone here could not be more transparently anti-government, the private market imperative is fraught with its own adversities. Again, opacity (coupled with barriers to entry) = margin. That is simply an upshot of Efficient Markets 101. Transparency is the inverse linear correlate of Margin. And, it's worth noting in this regard, that Transparency would not beget us 1,945 ONC "Meaningful Use Certified" proprietary EHR systems (and 2 Open Source products, Vista, and Open EMR).
• Yeah, "frictionless, intuitive, Steve Jobs-ian" usability would be swell. Plug 'n Play. No Training Required. Total Ease of Use for the Busy Clinician. What's not to love?
  
  But it's a weak analogy. Jobs gave us great entertainment-oriented consumer products (and no one is a bigger "Mac Snob" than me), and, while there is in fact a smidgeon of emerging convergence, the kids now getting $3-5 million in Series A VC IPO money in the Bay Area for their cute small-footprint tablet and smartphone apps are not going to do squat about the industrial-strength IT architectural needs of clinical ambulatory and (especially) in-patient HIT. I've been hanging around the Health 2.0 crowd for nearly a year. I'm mostly seeing a euphoric DotCom Bubble v2.0.
  
  There are again investors to be fleeced. Google "Built to Flip."
  
  apropos, from The New Yorker (05/27/13):
  

  Evgeny Morozov,, in his new book "To Save Everything, Click Here," calls this belief [health care salvation via Health 2.0] "solutionism." Morozov, who is twenty-nine and grew up in a mining town in Belarus, is the fiercest critic of technological optimism in America, tirelessly dismantling the language of its followers. "They want to be 'open,' they want to be 'disruptive,' they want to 'innovate'...You might not be able to pay for health care or your insurance, but if you have an app on your phone that alerts you to the fact that you need to exercise more, or that you aren't eating healthily enough, they think they are solving the problem." [Changing the World, George Packer, pg 50]

  Hear, Hear.
• "...spend the remainder of the “meaningful use” funds on providing financial incentives for hospitals and other providers that demonstrate “meaningful improvements in patient care” through whatever means they choose, and leave it to the healthcare providers, not our federal government, to choose the most effective means to improve patient care."
  
  That begs a host of questions, starting with "what will constitute 'meaningful improvements in patient care'?" In science, someone -- in a position of some legitimate authority -- has to determine in advance what will constitute a "significant" improvement above baseline (for each clinical outcome measure of priority concern). These authors are utterly silent on the specifics here. We get instead gauzy Apple Pie sentiments.

I have agree that the "mad race for 'meaningful use' dollars" is real and unhelpful -- though that money chase incentive has peaked on the Medicare side (you'd have needed to attest for year one stage one in 2012 to preserve full 5-year $44k reimbursement potential, and 2013 attesters have additionally gotten hit with a 2% "sequester" cut).

ONE TEENY EDITORIAL NIT

"And thus far the Centers for Medicare & Medicaid Services (CMS) has spent over $12.7 billion of EHR stimulus monies." [page 1]

"These indictments of both our current breed of EHRs and the way in which EHRs are being implemented cry out for change in direction of the “meaningful use carrot” in CMS’ program that has already cost taxpayers $12.8 billion..." [page 3]

Emphasis mine. Was this not subjected to any proofreading prior to submission?
__

I have no reason to doubt the sincerity of these HIC people with respect to the envisioned widely-shared ends they proffer. But, I have good reason to be skeptical of their argument as it is set forth in their letter. Maybe they do in fact have detailed operational plans for implementing their vision. They failed to cite any here (nor does this response provide any links to such detail).

CODA

Who/what is the Healthcare Innovation Council, really? Let's begin with Mr. Kneipper.

He's a lawyer, not a clinician.

He's a Health IT/Ops Mgmt vendor. Co-founder, interim CEO of Anthelio. From the corporate website:

EMR Services

Hospitals and physicians are rapidly implementing electronic medical records (EMRs) in order to obtain the "meaningful use" EMR funding under the American Recovery and Reinvestment Act of 2009. EMRs, if properly implemented and utilized, have the potential to improve the quality, efficiency and safety of healthcare delivery.

Though the number of healthcare providers implementing EMRs continues to rise, they are still struggling with the complexity of implementations. We at Anthelio Healthcare understand that the providers may not realize the full value of their EMR implementations due to numerous challenges such as scarcity of skilled resources, interoperability issues and the lack of end-user adaptation.

Anthelio Healthcare, with its proven implementation methodology and its expertise with the leading EMR applications, is a valuable partner for hospitals to lead and support the EMR implementation. We provide EMR solutions for the leading vendors: McKesson, Epic, Cerner, GE, Meditech and Healthland. Our EMR service offerings focus on assisting healthcare organizations create an operationally optimized EMR environment...

Implementations Services

Anthelio Healthcare provides end-to-end implementation services for all leading EMR applications. Based on our extensive experience with EMR implementations, we have developed a propriety [sic] "HeLIX" methodology for implementation...  

"propriety"?

Essentially, they're a VAR for some legacy HIT products.

I found it curious that this Anthelio "Independent Council" has no independent web presence (it resides in a sub-folder on the Anthelio website). Haven't yet looked to see whether they've filed 501(c)(3) or 501(c)(4). Anyone want to guess?

No Trademark declaration (not even "TM" common law).

I could cybersquat all of those domains for about 50 bucks. And then mount one of them, with just some basic homepage content, for about $100 a year.
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