Monthly Archives: June 2009

Are There Economies of Scale in Medicine?

I’ve been listening avidly to all the different points of view about health care reform, and the only conclusion I’ve come to is that almost anything is better than what we have.

On Bloomberg the other day, I heard a call for a systemic approach to the practice of medicine from Dr. Eliot Fisher, Director of the Center for Health Policy at Dartmouth. He said there are always better outcomes where groups of doctors collaborate and practice together, as in the Mayo Clinic, the Cleveland Clinic, or even less renowned group practices such as in Grand Junction, Colo. The efficiencies come when a group of physicians are all responsible for a patient’s continuity of care, and when they share information such as that possible with electronic health records (EHRs).

Dartmouth has studies that show these kinds of group practices cut costs, and yet we have relatively few of them in the US. Most physicians still practice in groups of four or less, usually four of the same specialty. And fewer than 20% of these small practices have EHRs. In fact, in Arizona, where EHR adoption took off after Gov. Janet Napolitano mandated it, another article just said doctors who had bone to EHRs were abandoning them because they were costly to support and impossible to learn. Your basic family practice guy or pediatrician, practicing what the docs call “Hamster Medicine,” where he/she has to see 60 patients a day for five minutes each just to support his office, does not have the time or money to shut the office down to train people on an EHR.

So I dread what will happen when these small practices are forced to implement a complex EHR like GE Centricity, which is both the market leader and the product with the worst user interface. GE has already started a lobbying campaign on behalf of its product, part of which consists of interest-free loans to physicians to install it.

The learning curve for Centricity is steep, especially for the bi-lingual staff of many medical offices, where wages are low and turnover is rampant. I have a physician friend who wrote an EHR himself, and then left that product with his old practice (where they love it) to move to another state. There, he found a group that had chosen Centricity not just for the single group, but for the entire region — and nobody could use it! They had abandoned entire parts of it because no one knew how it worked.

That’s shameful. That won’t lower costs. Lower costs will only come from software that works like Amazon.com or Yahoo — interfaces that make it simple for users to pile in mountains of data without even realizing they’re doing it. And to keep the costs down and the learning curve short, the data should be kept in the cloud.

This is, of course, horrifying to the privacy advocates, who have never run a medical office. Well I have, and I can tell you that when the doctor’s fax machine is overflowing with test results, they spill out on to the office floor or sit there in a pile, and anyone walking by can see them, until some harried front office person collects them and (perhaps) misfiles them in the wrong patient folder.

How do I know this? Because not only have I run a medical office, but I helped a group practice install an EHR, and one of their “pain”points and biggest reasons for going electronic was the loss of patient records due to misfiling or non-filing.

What other business runs as inefficiently as a medical office? None. What other business is more dependent on paper? None.

What other business could become 1/16 of the American economy without being forced into business process automation? None.

But forcing EHRs down the throats of sole practitioners isn’t the answer to reigning in costs. Collaboration is. Collaboration is also the answer to many medical errors and misdiagnoses. I’m not saying that we should “crowdsource” the practice of medicine–although that’s happening through various online Health 2.0 sites that consumers rely on when they have insufficient access to care — but I am saying it might be time to streamline these small practices, put them in groups, and allow them to talk to each other over lunch about the same patient. That way I wouldn’t have to tell my internist what my cardiologist said, or wait for the cardiologist to fax over my results to him.

Any kind of information exchange would help. And whose ox does this gore, unless it’s the commercial real estate companies who have been building small medical offices?

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A Different Kind of Crowdsourced Design

In November, we’ll be hosting the Fourth Annual Arizona Entrepreneurship Conference, with a roster of great participants, cool networking opportunities, and even good food. But a web site that doesn’t brand the conference or do it justice. I put it up last year i a hurry, and I looked at it this year and hated it.azec So I called Brent Spore.

Brent’s one of the most creative people I know, and he had just started a web show called Starving Designer. to harness the power of the social graph to improve design.

Now this isn’t the old form of design competition, where you ask people to submit designs and you choose one, thereby honoring one participant and disappointing all the rest. Rather, Brent is using each design as a teaching tool, and a way designers can learn from one another, or non-designers can learn what makes a good design. It’s collaborative, not competitive. It’s transparent, open, and real time. And you can participate as much or as little as you want. Everyone learns, and often no one gets paid, as these sites are often done pro bono or for very little.

You should probably watch the evolution of our design on Brent’s own site.

First, he held a live design session. Then he took all the comments, incorporated them, and began posting the results on Flickr and Twitter. People offered comments. He tried them and posted them, and took more comments. Because he got so many people who had been to the conference to participate, the comments were like a focus group.

You should read his post to see how he got from what you saw on top to what’s below:
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I’m exceedingly happy with it; especially with all the community input. As soon as we get the copy moved over, it will launch. Remember, you saw it first here:-)

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Flow and Wellness for Facebook and Twitter

There is brilliance in the wisdom of ancients. Especially in India, I’ve found information that guides my life in the 21st century world of the Internet.

Last January, I was lucky enough to meet a Sanskrit scholar in Vrindavan, a town between Delhi and Agra. He is part of the Jiva Institute, an organization I’ve advised over the past ten years. Jiva Institute runs a public (private) school in Faridabad, a “chain” of Ayurvedic health clinics, and an ashram for the study and preservation of ancient Sanskrit and Vedic manuscripts. Their resident Sanskrit scholar, Dr. Satya Narayana Dasa (“Dr. SND”) is coming to Rutgers next month for a visiting professorship.

Just in time for his visit, here is a current paper of his on the principle of flow in life. Notice that flow comes in two “stages.” Also notice that the theory of flow is applicable to the recent Iranian elections, and also to the stalemate in Congress over issues like health care reform.

Flow and Wellness
-Dr. Satya Narayana Dasa, M.Tech., IIT Delhi, PhD (Sanskrit) Agra University
Cultural Director, Jiva Institute
Visiting Professor, Rutgers University

Scientists believe that material creation is a manifestation from a very highly concentrated point of energy. Experiments with a large hadron collider in a special 27 km long tunnel in Switzerland built for this purpose. have already been started to simulate the beginning of creation.

In Vedic literature this highly dense energy point is called Prakriti, which means great product or great action. It can also be translated as the great flow.

Prakriti is the great source, from which the universe flows and towards which everything seems to be flowing—the immanifest state of matter. In fact being very subtle, it is matter in the state of energy. All gross perceptible and subtle imperceptible matter manifests from this energy or primordial matter. When turned into manifest, matter has the tendency to flow towards its source. Water flows into the ocean, flames move up towards space and any object thrown up into the air falls back on earth.

Prakriti itself is in a flow in the form of creation, existence and annihilation. Like Prakriti, the source, all its products beginning from atoms up to the galaxies, are flowing in some cycles.

The Importance of Flow

Flow is necessary for the universe to continue. Flow is progress and is pleasurable. It is compared to swimming along the stream. Working against flow is troublesome. The normal tendency of matter is to follow the natural flow.
Human beings, however, have the ability to be in the flow or out of flow. Consciousness has the property of choice. We can choose to be in the flow of the Samsara, the material world, or get out of it and enter into the flow of love. These are the two available choices.

As Prakriti is the source of material objects, Supreme Consciousness is the source of individual conscious energy. The real inherent drive of all conscious beings is to be in flow with Supreme Consciousness. However, without knowledge of our real source, we are tempted to mistake it for Prakriti and struggle within the realm of matter. Even in this realm, we can feel comfort and peace if we are in flow with our own material nature (which is part of the big nature, the Prakriti). This happens when we function according to our acquired nature with complete absorption, without being distracted by the result.

Csíkszentmihályi calls this flow. In the Bhagavad Gita it is called Yoga (Yogah Karmasu Kaushalam). This flow (Niskama Karma Yoga) is not some kind of reclusive meditation, but can be a part of one’s daily activities in the office, at home or in the sports field. It is the Yoga of Action and not the Yoga of Renunciation.

For individual wellness as well as that of society, flow is needed. If there is no flow, there will be frustration, dejection, insecurity, anger, violence, corruption and terrorism. And since individuals make up a society, without flow the entire society will be disturbed and out of rhythm—it will be full of unrest as can be seen at the present times. To bring flow into one’s life is, therefore, a necessary step.

The Highest Form of Flow
Interestingly Sri Krishna speaks of another type of flow, the spiritual flow, which is superior to the flow described by Csíkszentmihályi. As human beings we have a material body and a soul distinct from it. Material body is the product of Prakriti; it is good to be in flow with the Prakriti. But it’s even better to be in flow with the Supreme Consciousness—the source of our individual consciousness—the soul.

Therefore, being in the material flow, although superior to not being in it, is ultimately unfulfilling for the conscious or the soul. Csíkszentmihályi advises us to get into flow in our professional duties. But the paradox is that the material flow itself will, ultimately, prod one to get out of it! Sri Krishna has stated in Bhagavad Gita (4.33) that all material flows culminate in spiritual flow. Spiritual flow is the ultimate flow and most fulfilling. Having attained it, one never desires anything else (Bhagavad Gita 8.21).

To reach the ultimate flow, it is important to understand and experience the inferior or material flow. Material flow will bring only material wellness, but spiritual flow will grant the ultimate wellness for which we are striving unknowingly and sometimes knowingly.

Since we have a material body with material needs, it is necessary to fulfil those. But one should not remain engrossed only in gratifying the inferior needs. Even if one achieves flow while functioning at the lower level of Prakriti, sooner or later one will feel empty, because once the physical needs are fulfilled the real need of our real being—the soul—will come into play. This need can not be satisfied by any material situation, including the flow suggested by Csíkszentmihályi.

In essence, a human being can have three situations—a situation without flow, material flow and spiritual flow. The first situation is unhealthy. The second is good but only from the material perspective, and only if used as a steppingstone to spiritual flow. The third state is the state of perfection and supreme wellness.

Hey, Congress. Get with the flow! We have too many problems to keep on struggling.

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The Next Generation of the Internet, Part Two

Five more companies you may want to know about from Launch Silicon Valley. The general takeaway from this is the preponderance of peer-to-peer services as a way of lowering the cost of streaming content, and the general movement to the cloud.

Update: Here’s the second set of companies.

CellWand isn’t really next generation of Internet; it’s mobile voice apps accessed through abbreviated dialing codes (#taxi #home #pizza). It’s a pay per use app ($1.25-1.79 per call), partnered with carriers. They get big margins from loyal users, and use the wireless carriers, alcohol companies, and media partners for marketing. CellWand is live in Canada, and penetrates at 1 call per 250 mobile phone users. If they penetrate similarly in the US, that would be $1m/month revenue. They also use the carrier billing systems. They have locked up all the Canadian carriers


Surf Canyon
– delivers relevant personalized search results. It re-ranks results according to what you might have clicked on from the first search — on the fly, in real time. Another Firefox add-on, also works on IE. And for good measure, it also personalizes the sponsored links. Works with Bing, Yahoo, Google.

Dacast, a product of Andolis LLC believes the future of TV is multicast. The company has a peer to peer system to cut the cost of live streaming and unite all the Dacast users in an ecosystem. That allows for more appropriate advertising to users. So Datacast is free for content owners, cheaper to stream, and more carefully targeted. The company projects profitability by end of 2010. Every player wins: Advertisers get more clicks, users get free content, content owners get more money.

Wowd – is now in private beta. It turns the wisdom of crowds into useful work finding content, tagging itself “the web you want.”
“Wowd connects people to a planet’s worth of content.”

YOICS “Your Own Internet Connected Stuff”
Cloud IT services for the rest of us. Private bookmarks only available to you or people you are connecting to, using the internet as your own private LAN. This could also be used for security services, and you would be able to see it on any browser anywhere.

You can use it as a replacement for an FTP service. You can download the Yoics app, drag a file form your computer to it, and make it accessible to a selected group (like a graphic designer could do for clients).

It will be interesting watching these people get acquired by the already-existing companies in the internet space. I think none of them are really stand alones. Again, I’ve jumped to a conclusion here:-)

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Jumping to Conclusions: The Next Generation Internet

For many reasons, I’m interested in the next generation Internet. This morning, I’m at Launch SIlicon Valley, watching ten companies in this space present their concepts.

I haven’t finished listening, but I have already jumped to my conclusion. According to these presenters (who were quite good, by the way), the next generation of the internet solves problems created by the current generation of the Internet.

In other words, it’s full of refinements and improvements, rather than big technological jumps. A better process here, a better algorithm there, and lots of emphasis on smart phone apps or Firefox add-ons. The most interesting company by far was from China, which is definitely kicking our ass in next-gen internet stuff according to this presenter, the first Chinese company ever to present at this conference.

World’sLaw is a legal service. Its competitor is Legal Zoom, but these guys have attorneys, while Legal Zoom is only document preparation services.
By Jobi – a power search with saved search with timelines and keywords, language and location, domains and file types. It’s a power search built on top of Google
GazoPa similar image search. Uses features such as color and shape to find images, and uses the image itself, not just keywords, as the search key.
The founder actually drew a watch on his computer, uploaded it, and got photos of watches back. Even now, it has an iPhone app to upload pictures from your iPhone and search images.
With current mage search engines, if large volume of data, can’t return images quickly. But for them, the more data they have, the better they can return
Gliider – manages travel for you. It holds on to your travel information, replacing bookmarks, cut and paste, printed documents. ‘There’s no good way to hold on to my travel info when I am planning a trip.” It’s now in private beta, and is a Firefox add-on.
Gamexiu. Games and social networks are two fastest growing segments in China. 16,000,000 games, growing at 17% a year. 200,000,000 users are on social networks in China, and the virtual goods business is a $4 billion business. Most users are single children under 25, using social gaming as the way of getting companionship.
It’s the world’s first 3-D Internet social gaming platform. Completely integrates into other social networks, so is also distributed. The avatars can go anywhere across the web, and the application itself can be embedded in other social networks.
They are a social world similar to Second Life. It looks easier to bring the user into an immersive life than SL, however. And the selling of virtual items is huge!

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Ten Things You Need to Know About Banks and Credit Card Companies

Credit cards have developed into very complicated financial products. As a result, even if they printed the disclosure in 18 point type, you wouldn’t know what was going to hit you from behind. I have been trying to get out of debt recently, so I’ve been studying the issue. I am now doubling my dose of blood pressure medication and tranquilizers, and practicing yoga so often that I can no longer be gainfully employed. You will need to know what I’ve found out about banks and credit card companies, especially if you are not making them the focus of your life.

1. You cannot close a credit card account. I paid off a balance to Citibank because they had raised my interest from 0%, which I had signed up for, to 29.9% because my payment was one day late due to Wells Fargo’s automated bill pay and the US mail. I asked to close the account. I got the following:

Dear FrancineHardaway: We recently received a request to close your Citi Platinum Select Mastercard account. For your protection, your account has been permanently closed. The closed account cannot be reopened. Please destroy all cards with this account number by cutting the cards in half. A new account number has been assigned to you, and a replacement card will be mailed to you the next business day.

Never mind that I didn’t ask for a replacement card.

2. The card companies don’t want you to pay off the principal. There’s something called a “sweat box” business model for credit cards now. The companies don’t want the principal back. They want the fees. They want to keep the consumer paying.

3. Reforms won’t work because the credit card companies will find a way around them. Every previous effort at reform has just unleashed further ingenuity.

4. Card issuers can make a profit because the interest rates and fees will be so high that they will offset loss of the principal. This is predatory lending: lending with conscious disregard for the consumer’s ability to pay.

5. If you pay too much, they get nervous. In the same mail, I got this notice:

We want to be your number one credit card. We noticed that you recently made a large payment to your Starbucks Card Duetto Visa account and want to make sure we’re not losing your business. That’s why we want to remind you again of these low-rate reasons to stay –it’s our way of showing you that your business is important to us. Enjoy APR’s as low as 0% with check numbers 2993 and 2994. 2.99% APR for 24 billing cycles with check numbers 2995, 2996, 2997. (BTW, there’s a 3% transaction fee to do any of this, and a billing cycle may no longer be a month.)

6.The interest rate on the card does not tell you what the total cost of revolving a balance on a card will be. There are late fees, over-limit fees, annual fees, foreign transaction fees, interchange fees that are charged to the merchant and passed through to the consumer.

7. Convenience checks are subject to the cash advance fee.

8. The new thing is double cycle billing: The balance on which interest accrues is not the balance on this billing cycle, but on this one and the previous one. And if you are late on another card, or perhaps your cable bill, your credit card interest rate will go up. And perhaps your car insurance.

9. There are tricks about when a payment is posted. After 2 PM might count as the next day, and you may pay interest.

10. And then, all this can influence your mortgage refinance or loan modification.

Aurora Loan Services has carefully reviewed your loan for home retention options. Aurora has determined that we are unable to continue pursuit of said options. A home retention workout on your loan has been denied for the following reason(s): Your finances indicate an inability to afford the monthly payments.

Never mind that I am current on every single payment, mortgage or credit card, despite being over $150,000 “under water” on my home. I have no equity and could have “walked” a year ago, but didn’t.

Notice the reinforcement I get for trying to stick with my home payments and pay down my debt, the Suze Orman recommendation.

Take a lesson. The banks own the government, and me, and you. I am finished with them. I am going to get out of debt asap and put my money under a mattress, where at least it somebody eats it, it will be Buppy the Puppy.

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