Category Archives: Health Care

Toxic Assets Take a Back Seat to Health Care Reform

WASHINGTON - MARCH 31:  (L-R) TARP Special Ins...
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Elizabeth Warren made an appearance on  Morning Joe this morning and woke me up at 5 AM PDT with the force of a revelation: those toxic assets are still on the books of the banks.  The banks, which have taken so much of our children’s futures in the form of TARP money and similar bailouts, have won — not by asking for money, taking it, and using it to fix things, but by taking money and doing nothing.

Remember the good old days, before we got sidetracked by euthanasia, pulling the plug on granny, and letting illegal immigrations hijack our health benefits and take them back to their home countries? (Yes, I heard that all being discussed in the Town Halls I watched yesterday.) Well, we were talking about boring stuff like mark-to-market, an obscure little accounting rule that says you have to call your pig a pig when you take it to market and you can’t call it a Ferrari.

The banks are still accounting for their piles of pigs (or maybe pig droppings) as Ferraris, because Congress now allows them to do so. And they will not sell those assets, even to the government, because to do so would mean they’d have to acknowledge them on the books as pigs, throw away those glamorous photos of  Ferraris that adorn their annual reports, and quietly slink away with their pig tails between their legs, giving the field over to newer, smarter banks.

I was with the conservatives on this issue.  I didn’t want us to bail out the banks. But we did, because we thought the system would collapse if we didn’t. OK. So we put off the collapse for two years, but–my fellow Americans — while you are all worrying about death panels and tax-supported abortions, don’t take your eye off the world around you. Multi-task if you can.

Because 30% of the homeowners in the country are now under water.  Job losses, while not accelerating at such a rapid rate, are still happening, and more and more people can’t pay their mortgages.  The gigantic economic re-set is not over, as the next wave of adjustable mortgages come due in 2010.

This means more foreclosures, along with the imminent collapse of the commercial real estate market as well.  Who needs office space when you are laying off workers and can’t get a credit line to keep your business alive?

What will happen? Bank failures at long last. I’ve got my bets on who goes down first as Congress, now threatened by its constituents with full scale revolt, fiddles with health care while the financial underpinnings burn. One set of lobbyists has replaced another.

At least when we spend money overhauling the health care system the money will reach individuals. Following Elizabeth Warren on Morning Joe was Joe Califano, who was around when Medicare was passed. What he said? No one could have predicted forty years ago the revolution in medicine that led to the explosion in life expectancy. We can’t predict what will happen when the next wave of innovation in neurology and cancer research make life even longer. So the only way to control costs is to keep people out of the sick care system.

So let’s put our eye back on the ball. Focus on ourselves. Let the banks fail, but the people succeed. Survive the re-set in the economy, which is believe is permanent, by getting in shape. I will see you at the gym.

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Will “Free” Work in the Electronic Health Records Market?

Health records want to be free. At least that’s what PracticeFusion, a two-year-old company that makes SaaS  electronic health records (EHRs)  and practice management software thinks. Never mind that people might be scared to put their health records on the internets, PracticeFusion’s hypothesis was that doing a deal with Google to put ad words on medical records would allow the company to offer its product free to physicians, who were not adopting EHRs because they couldn’t afford the investment of time, money and support.

Fast forward a couple of years, during which EHRs have still not been widely adopted (about 17% of doctors have them, most of the market leading products really suck, and docs say EHRs actually slow them down) and stimulus money has come into the picture to incentivize physicians to automate.

Marc Benioff, the king of Saas, has decided somehow health care will be a market for him, and has invested an  undisclosed amount of money in PracticeFusion.  According to the press release, the patient health record will launch on Force.com, Salesforce’s enterprise model.  This makes sense, because of HIPAA compliance, secure servers, etc.

The press release also announces this as a “cloud computing initiative.”

Oy, the buzz words have changed mightily in the last two years. But what will the doctors do now? Except for the free part, nothing has changed.

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Why You Want Health Care Reform

In March, the Coastside Family Medical Clinic, a local clinic serving the population of Half Moon Bay and its surrounding area, abruptly closed its doors, leaving 8,000 patients without a  primary care doctor.  The Clinic ran out of money because 1)insurers took too long to re-imburse for services, 2)many patients had no insurance, and 3) the Clinic didn’t have adequate financial management systems to weather these storms, which hit all medical practices from time to time because insurers delay payment to maximize profit.

But it also left the patients without their medical records, and without a way to get them back. The Clinic went into bankruptcy, and the medical records are stuck in legal limbo. Remember, it’s now August.

By law, a clinic that goes out of business is required to make sure its records find their way either to patients or their doctors. But how to do that without funds? And within the boundaries of the Privacy Act regulations.

It takes an extraordinary amount of labor and resources to go hunting for records. It’s time consuming,” [the bankruptcy trustee] said. “This is a hot potato … There’s a lot of people who want to volunteer for a few afternoons, but no volunteers are willing to step up and take responsibility.”

This case doesn’t lend itself to an easy fix,” the judge said. “We’re a bunch of bankruptcy people suddenly becoming health experts.”

The trustee went further to explain that there were 37,000 total records, representing 8,000 patients. Only 3000 are actually active, but how do you know which ones without the doctors and nurses?

How would you feel if those were your records? You’d feel that it would be nice if they had been online, and you could have easy access to them to pass them on to the next physician. It would also be nice if there were an entity that had the power to step in and make it happen, like a Regional Health Information Organization. Read up on RHIOs, which are part of the National Institutes of Health’s plan to modernize health care delivery.

After all, those are your records. And it would be nice if you still had a doctor to take them to, especially if you were a mom and your children were treated at the clinic.

Yes, it would be nice if we had a system for continuity of care, in which clinics didn’t go out of business, or insurance companies refuse to pay. That’s what health care reform is REALLY all about. It’s not about costs, or about public plans, or about rationing, or about any of these other bogus red herrings.  It’s about you, your health, and your ability to see a doctor, own your own records, and get the right care. No matter who pays.

Right now, a combination of the profit motive, late payments from insurers, uninsured people needing care, rising costs, and probably mismanagement can leave you and your children out in the cold,  whether you are with or without insurance.

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Who Makes Money in the Cloud?

This is my seventh AlwaysOn Stanford Summit. I thought it looked a little smaller, but Tony Perkins told me at lunch that they had 850 people on the register, and that they had sold out of CEO Showcase spots.  I can see that, because the showcases seem packed.  There are many startups in the world.

Here’s my friend Rafe Needleman, CNET Editor whose writing I’ve been following for ten years through various incarnations as a tech journalist,  moderating the next panel on Rainmakers in Cloud Computing. The participants are Kenn Comee, CEO of Cast Iron Systems, Monica Lam, Co-founder of MokaFive, Juan Carlos Soto, VP, Sun Microsystems, Chip Hazard, General Partrner, Flybridge Capital Partners, Michael Stein, CEO of Darkstrand, Michael Peachey, Chief Architect & Dir. Cloud Computing, TIBCO.

Over lunch, several people talked to me about cloud computing.  Most didn’t know what it meant. Some language: “outsourcing,” “the mainframe is back and it’s sexy,” “hosted applications,” “pay as you go,” “software subscriptions.”

There has been a technological shift in the last five years that has changed “utility computing” to cloud computing and in ten years the software business and the cloud will be synonymous, some of these panelists say. Desktops have been virtualized, and almost all desktop apps can be put up in the cloud.

We can now “pay by the drink.” It’s the mainframe all over again, shared computing power with a “thin client” that looks like a browser. But will enterprises want to shift all their digital data to the cloud? Not quickly, and not to the public cloud. But private clouds will run in ways that look like the public cloud.

What are the big opportunities for making money on cloud computing? Infrastructure is actually one of them, and new kinds of apps enabled by the cloud will help the business user who doesn’t know how to deal with IT.

What’s the next new Salesforce.com? The landscape of horizontal software-as-a-service is pretty built out. But there will be needs for new infrastructure that will help IT departments run apps in a private cloud. The side benefit is that the cloud is an enabler of application development, as Dave Winer can already tell us. Disaster recovery and backup will cross the boundaries from the enterprise to the cloud.

Issues?  Quality.Rafe says all these web apps can be built for next to nothing, because they’re built on Amazon Web Services and running in the cloud. But many of them aren’t making any money. So there will have to be a rationalization to optimize how clouds work (Ken Comee). Then many things running in the cloud will die, but the best ideas will percolate up.

Infrastructure. Michael says that GE is trying to deploy a SmartGrid for utilities, but it can’t figure out how to run that in the cloud because the backbone of utility companies has data rates that will bog down the traditional internet. The cloud will get too crowded, and there won’t be “room” to put everything on the internets. Moving a terabyte of data on Amazon Web Services is no fun. So Sun has tried to bring many of the concepts of running your own  datacenter into how you would run your own cloud so you are not on the public cloud.

So the networking side of cloud computing has a lot of opportunity.

Security. How far can people in the enterprise go with an app before the iron hand of IT comes down on them? That depends on the application. People will then develop private clouds for niches like HIPAA compliance. There will be many clouds ooptimized for different market segments.  That would be happening today but for interoperability issues — which will be solved. Security is the number one reason enterprise apps are afraid to go to the cloud. 75% of enterprise people  wouldn’t move their apps because of it.

To what extent do security issues like the break-in at Twitter undermine the premises of cloud computing? Most of the apps Twitter used were in the Cloud, like Google docs, and the hacker came right in and got all their data. But the panelists agreed that security policies at Twitter have been lax, and that even if the docs had been on internal servers, a hacker could have gotten them given Twitter’s security policies.

There are no HIPAA compliant clouds out there today, although there are SAAS-based EHRs. As a user, I’m not worried about someone taking my medical information, but I am very worried about Google mining my data, or my insurance company. This is a reason for a private cloud and locked down security.

Return on Investment. From a VC standpoint, it takes a long time to run a subscription business past the Valley of Death.  Time to revenue for a cloud business is very long, because revenue comes in a stream, not a lump. Driving sales has to be very swift and very focused.

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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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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 Healthcare ClueTrain Manifesto

Doc Searls is in the hospital in Boston instead of at SuperNova 2008. I’ve been following his blog as he goes through his various tests, and ends up with pancreatitis (a painful inflammation of the pancreas) brought on my one of the tests. He then has to take morphine. He then gets fluid in his lungs, which often happens to people in bed.

You get the picture. I’m not revealing any private information here; Doc is blogging about his hospital stay, even down to telling us what he would have said today at SuperNova.

But I, as the widow of a physician, a mother, and an unlicensed practitioner of American healthcare system mechanics, want to use this moment not only to wish Doc the best, but to draw a lesson: NEVER GO TO THE HOSPITAL ALONE. Take an advocate with you, and try to make sure that person is a New Yorker and very aggressive. Ask a million questions, and get your loved one the attention he/she needs.

The American health care system, while technologically still advanced, is — from an actual care perspective — woeful. You would care more actual “care’ in a tribal village. The nurses are interchangeable, harassed, and consumed by paperwork. The doctors are on a revenue generation treadmill, and the big decisions are made by insurance companies or government agencies. And even though the bioscience and medical device fields are right up to date, the IT support for health care professionals is not. You can thank privacy laws for that. Paper records are the straw that breaks the system’s back.

My son-on-law’s mother just got prescribed a chemotherapy agent that nearly killed her, when a newer, more benign drug existed. The older drug was cheaper, so they tried it first. They only switched when she couldn’t tolerate the cheap drug. Me, I was given a blood pressure drug that triggered bronchospasm, because it was the cheapest.

In addition to those horror stories, there are all the clinical errors that cause “iatrogenic” conditions — meaning you got them from being in the hospital. I suspect Doc has a few of those. A friend of mine went into the hospital for back surgery and emerged with a staph infection that nearly killed him and required intravenous antibiotics administered at home for a year.

I was so scared to have my hip replaced that I started a blog when I checked into the hospital, so if they killed me there would be a record of it on the Internet and my family could benefit from the long tail.

Fortunately, I didn’t die, and people from all over the world thank me for that blog.

Doc, get well soon. Everyone else, watch your back or get someone else to watch it if you have to be hospitalized.

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