The Black Liszt

Author: David B. Black

  • Software Myths and Myth-Conceptions

    Elephants are hard to figure out for people who are blind, but at least blind people can touch the elephant. Software is invisible, can't be touched and isn't anything like things we're familiar with. It's much harder to figure out, which is why what passes for understanding of software is a collection of unrelated-to-reality myths.

    Elephants and Invisible Software

    What would we think of elephants if the vast majority of people had never seen one in any way, even a picture? What if the few people who had encountered an elephant were blind and their experience limited to touching one part, for example a leg or the trunk? 11
    And what if elephants were nonetheless a very important part of daily life, both personal and commercial? This is hardly thinkable, but that's what software is.

    Myth-conceptions

    Software is important and ubiquitous, but also invisible. The information we have about it is mixed, inconsistent and mutually incompatible. The vast majority of people, including programmers, resolve this by accepting a set of myths about what this unseen world is like. The myths tend to make sense and explain what software is about in a satisfying way. Most programmers, with their real but typically skewed experience with software, accept the same myths, but add details. The few programmers who can't or won't accept the common software myths find it difficult to communicate with the majority who hold firm to the myths.

    Software "myth-conceptions" of this kind aren't just stories, or ways of talking about software. They are widely shared concepts and metaphors that guide how software is designed, built and maintained. Since many of them have been imposed on software from the outside, they tend not to fit with the reality of software — like things designed for chipmunks, but imposed on elephants. The result is that the process of building software is really expensive and hard, with crappy results.

    I have, through hard personal experience over many years, grasped the mythical nature of many widespread thoughts about software. I hope someone will systematically lay out this world of myths that weighs down and perverts software. I have already described some of the myths in prior posts and hope to go into more depth in future posts.

    The Software Factory

    The job of a factory is to make high quality things. There are inputs, processes, stages, and work in process. At the end, you get what you expected, when you expected it. Let's make software work like a factory — a software factory! Hah! Here is more detail.

    Software is like a Building

    First you have to have a plan. You figure out what you need and work with an architect to lay out the details.  Then you put the job out to bid. You pick the best bidder by some criteria. The software builder gives you a plan with dates, and often expects partial payments based on progress. The builder gets permits and approvals.The site is prepared, the foundation is dug, footings are poured, the basement created, and the structure is built and the outside put on. The inside work is done — first the plumbing and heating, then walls, floors, appliances and finishes. Final inspections take place, and the building is ready for use.

    Sounds practically like software, right? Yup! This is one of the prime myths; its fit with reality is marginal. Acting on this myth is a prime cause of software development disasters.

    Software is just another thing to Manage

    Lots of activities involving different skills happen in an organization. They all need to be managed. Management is a skill that can be taught — that's what getting an MBA is all about, after all. Some organizations need to build software, just like they need to set up a new office in Chicago. It's just another activity that needs a skilled, experienced person to manage it.

    Not! Here's a post that goes into it.

    Advances in Software

    There's a widespread myth that software is one of those things that advances at a fierce rate. Maybe you were trained in a certain kind of software and were good at it, but after a couple of years you become hopelessly out of date and effectively unemployable. 

    For certain kinds of low-level software roles like Novell Sysadmin, this is an appropriate thought. But in general, it's dead wrong. Software advances incredibly slowly; often it moves sideways, and sometimes goes backwards. When software is created for a new hardware environment, it is often extremely primitive, with all the "advances" that have been thoroughly proven by widespread use simply ignored. Much of what is presented as software "advances" is little but a fashion.

    Software and Security

    Securing software is much like securing a building or country. You have to have a wall. The wall should be strong and high. It should have lots of defenses against being breached. It must be constantly monitored. The places where people can enter must have extra protection, and everyone who enters must have ID and submit to a search. There are well-understood methods for accomplishing all this, and conforming to accepted procedure is essential.

    That's the myth. The myth guides the vast majority of cyber-security thinking. It is pernicious and wrong. I've written about this already, and will write more.

    Modern Software Methods

    It's true (according to the myth) that software has been a chancy thing to build. There have been lots of delays, overruns and out-right failures. But now, with method X, we've put all that behind us. We finally understand how to create a flexible, dynamic process that puts all that behind us. We are all (for example) Agile with certified Scrum Masters.

    This myth has persisted for decades. All that changes is the value of X. This myth is a perennial favorite. I've written about Agile specifically here, and will write more.

    Software Innovation

    Software is an exciting field, with innovation constantly frothing about. Software engineers are highly creative people — after all, every line of software they write has never been written before! It's no wonder that the cup of software is just bubbling over with innovation.

    Nice thought. But the fact is, after all these years, software projects fail left and right. Managers grasp at all sorts of things in vain attempts to increase the odds of success. Innovation is all about making something better; the challenge in software is the struggle to rise to the level of adequacy.

    Conclusion

    The myth-conceptions go on and on. There are a myriad of "solutions" floating around for any given software problem. The vast majority of the solutions make things worse.

    There are in fact, fast, effective ways to build software. But the methods are flagrantly at odds with most of the myths that dominate the industry. So the methods remain marginal, employed mostly by small groups of outsiders who are desperate, and really want to win.

  • Hospital-based Innovation in Wellness

    I was shocked to discover on a recent visit that a giant but innovative local hospital system has implemented a break-through in wellness. They have adapted some of the industry's leading-edge employee wellness techniques and made them work for patients visiting their hospital, thus adding a whole new dimension in the way they make their patients healthy. Much like my previous report of a EMR interchange break-through, it's so radical and unexpected I wouldn't have believed it unless I had experienced it myself.

    Employee Wellness

    There has been growing recognition that healthy, happy employees are productive and good for business. There has also been growing recognition that being healthy goes way beyond responding effectively when you get sick. People increasingly understand that when you're active, fit, engaged and have good eating habits, you are more likely to be healthy and happy.

    There's an amazing Oak HC/FT company that's at the forefront of this movement, Limeade. Here's their summary of what they do:

    Logo

    You can see that they clearly understand the relationship between wellness and health.

    Limeade group

    Even the picture implies that getting people moving, fit and engaged is a major key to success.

    Wellness for patients in the hospital

    Hospitals are all about old-style health, i.e., responding effectively when people get sick. But some hospitals are really innovative. I visited one today, and the banner they had proudly hanging in a busy central hallway made their commitment to innovation clear.

    2016-10-06 09.57.15

    I admit I thought their innovations were limited to "just" making sick people better. Hah! They are actually pioneering the application of modern wellness techniques to patients visiting for treatment!

    Wellness techniques

    I guess it's worth reviewing briefly what some of the most important techniques are. I don't think it's mysterious; most people know what they are:

    • Exercise. Without exercise, good things don't happen. You've got to move those muscles!
    • Heart Rate. Yes, you can lazily move your muscles. But that's not exercise — you've got to elevate your heart rate, so that key muscle also gets exercise!
    • Mental exercise. Particularly as you age, exercising your mind in new ways helps keep you young. But even for young people, learning new things and thinking outside your normal comfort zone can give you a major boost.

    Wellness during a hospital visit

    It would be one thing for a stodgy old hospital to put up signs that encouraged wellness. No big deal! But that's not what these guys did. The very best techniques are ones that don't feel like a burden. They "trick" you into doing something you might think is fun, and along they way, something good takes place, like wellness in this case. It's called "game-i-fi-cation." And that's exactly what I experienced during the course of a normal, every-day visit for a diagnostic procedure at this amazing hospital.

    The game started before I got in the door. I was given the address: right on Fifth Avenue, that can't be too hard. But right away, I couldn't find it! I walked up and down the street, finding addresses that are larger and smaller than the one I had been given, and finally concluded that this numberless entrance was probably the right one.

    2016-10-06 10.02.30

    You might think that this is just someone having trouble finding an address. But it's really the low-key start of the game — they draw you in slowly. I looked and looked, and there just was no number! In retrospect, the conclusion is obvious: this is the building in which wellness is slyly delivered to improve everyone's health.

    I walked in and found myself in a huge open space. Where should I go?

    2016-10-06 10.01.45
    I walked and turned my head as I went and finally noticed the place where it had to be:

    2016-10-06 10.01.40

    This is surely it — it's clearly labelled cardio-vascular repeatedly, and I was having a heart test. Done. Still clueless about the wellness being delivered to me, I walked in and talked with the nice ladies at the counter. After they determined that I wasn't in the process of dying in front of them, they returned to what they were doing and eventually found out who I was and what I wanted. Oops. I'm in the wrong place. I should return to the giant hall and ask the guard.

    Eventually, the helpful guard pointed and gave directions involving walking, turning left and/or right, and going through various doors. Here's the view at this point: 2016-10-06 10.00.59

    It's a good thing I paid attention, because part of the game is the absence of signs and directions. The theme of finding the right building was intensified once you were inside. And I was beginning to get anxious. While I had left lots of time, this was taking a while, and I didn't want to be late.

    I followed the directions carefully and eventually found myself at another counter with friendly people. After identifying myself, I received another set of directions involving things like going straight that way until you get to the grey doors, then go through them and immediately turn right until you get to the end of the hall … well, leaving out details, I found another counter.

    Please pay attention to the pattern here, and notice the clear and obvious relationship to wellness techniques:

    • Exercise. Definitely.
    • Heart rate. I didn't walk that fast, but those clever people managed to get my heart rate up by inducing anxiety!
    • Mental exercise. Definitely. Finding the place was at least as good as a Pokemon search! Not having signs or directions is part of the plan! They're really committed to this wellness thing — imagine the trouble they took to assure that all the old signs were removed.

    Finally I got to what turned out to be the right place:
    2016-10-06 09.53.20

    But needless to say, my adventure wasn't over. What's a visit to a health professional without a good solid dose of papers with minuscule print, the obvious result of welfare work for lawyers and bureaucrats? But I got a break. Whoever designed the system decided that after such a large and unexpected dose of wellness, the patient should be given a light load of paperwork. 2016-10-06 09.03.03
    It was laughably small.

    And to put it in context, dealing with it was a good way to "cool down" after my adventure in exercise, heart rate elevation and mind stretching achieved by next-generation, gamified wellness techniques.

    With any luck, other hospitals will copy this amazing innovation. Who knows, maybe some of them already are!

    But that's how hospitals are!

    Yes, you're right. But it doesn't have to be that way. Retail stores, for example, compete for customers. They compete on multiple dimensions — product selection, quality and price, but also convenience and overall customer experience. There is no reason why hospitals couldn't pay some moderate amount of attention to the people who are, after all, their paying customers.

    Giant, multi-national companies like Ikea, which is many times larger than any hospital, show that it's possible. Ikea puts real effort into creating a good customer experience. Which includes helping customers go where they need to go. They have a mobile app which helps you. They have maps:

    Elizabeth_new
    And they have signs in the stores, even on the floor and hanging from the ceiling:

    111

    Hospitals aren't too big. Their executives are not under-paid. They just have to care.

  • The Real Scandal of the Hoboken Train Crash

    The real scandal of the recent train crash in Hoboken is not being discussed: the super-expensive PTC technology that was supposed to prevent it is obsolete and ineffective. A bunch of college kids using off-the shelf technology could build a far superior system in months for next to nothing. The problem isn't politicians and bureaucrats reluctant to spend the billions required to implement PTC. The problem is that PTC is built on computing technology that belongs in a museum, not supposedly protecting our lives.

    The Cause of the Crash

    What caused the crash? It's known that the train was going too fast and failed to brake, but as of this writing, more details are not known. Much of what you read about the crash provides some details of someone's experience, but shifts into blame mode. The current governor of New Jersey, Chris Christie, is a favorite target, but various parts of government and government bureaucracy such as NJ Transit also get pot-shots. This first-person account that was published is typical: 11
    After you're done wading through all the accusations, most writers get around to blaming the crash on the failure to implement positive train control (PTC), the government-mandated system that is supposed to prevent crashes like this.

    It seems crazy: why are these people dragging their feet implementing a safety system, when passenger lives are at stake??

    Failure to implement PTC

    PTC has been widely implemented. But not completely. Union Pacific, for example, has already spent about $2 billion implementing it, but estimates the total cost at about $2.9 billion, so they're not done yet. That gives us our first reason why PTC isn't universally implemented, and wasn't implemented on the tracks near Hoboken: It's wildly expensive!!

    Do you think PTC was designed by a bunch of modern, agile computer and software people? Or do you think it was designed by a bunch of lawyers and bureaucrats and regulators many years ago, and essentially unchanged today? Think hard, now!! Take a quick look at what goes on in PTC for example here and you'll get a feeling for it. It's wildly complicated!! Not to mention totally old-fashioned, and designed with paleolithic computing technology.

    Instead of thinking, "how can I use what's out there, make a few changes, and get going with this," the people were thinking all railroad all the time. In spite of strong overlap with other systems, like trucking, PTC "had" to be totally unique to railroads. That leads to a huge pile of PTC-specific technology that is no better than what was generally available many years ago, but unique — and therefore incredibly expensive and time-consuming to design, build and support. As a result, there isn't exactly a robust, competitive marketplace for PTC. Thus the time and expense. Thus the fact that it hasn't been deployed. Q.E.D.

    PTS and Military Procurement

    Clearly the people who designed and mandated PTC came from the same school of thought that dominates military procurement. Remember $640 toilet seats? That wasn't a myth. There's lots more where that came from. Here's a list from a book on the subject: 1items
    The point is whenever there is lots of money made from government procurement, companies and officials will collude to make all sorts of special requirements that standard equipment can't meet, so that the companies that play the game can make the "special" versions of whatever and have big revenues with bigger profits.

    Sadly, that's exactly what's going on with PTC. It's a bad system. It's many generations obsolete. It doesn't work. And it's hundreds of times more expensive than it needs to be.

    The alternatives to PTC

    What could be done instead? I briefly reviewed one approach in a post about the 2015 Amtrak crash in Philadelphia. The key idea is to stop following the military procurement model, and instead use modern, off-the-shelf technology that is updated and refreshed regularly, just like you update your smartphone.

    There are existing systems built for the trucking industry that could be adapted for trains. Here's a proven one that's hardware-based: 1smart

    Here's another one that makes smart use of cloud technology, 1convoy

    which means that all the super-custom requirements for recorders that can withstand having boiling oil poured on them can be thrown out. Just as well, a system could be built completely from off-the-shelf components, making good use of powerful networking technology that can be installed on the miles of track on which it's not already available for a fraction of the cost of the super-custom, super-expensive PTC alternative.

    A bureaucrat who was all wrapped up in the existing regulations could come up with all sorts of objections to this approach. They would all be bogus. Do you use a 20 year old computer? No vendor would support it. But in the isolated world of PTC, decades-old equipment is par for the course. One of the event recorders in the Hoboken train was installed in 1995. It didn't work. Not because it crashed, but it failed at some unknown time earlier. And no one knew.

    By comparison, I have home security cameras from a Google company called Nest. They only cost a couple hundred dollars each. You connect them to the internet and they just work. Here's the key: when one stops working or communicating for any reason, I get an immediate notification! So I can do something about it. This is an inexpensive consumer device. A train safety device that is probably hundreds of times more expensive, using obsolete technology? Not available. This is one illustration among many. We should just get over it and vote for safety and effectiveness. We should throw out PTC and everything associated with it, and get something modern that actually works.

    And, not exactly by the way, save lives.

    Postscript

    PTC is yet another example of the "what not how" style of government regulation that fails everywhere it's applied. It fails in train safety, in computer security and everywhere else it is applied.

  • Healthcare EMR: Why Portability Matters

    With all the attention and billions of dollars spent on EMR's (electronic medical records), most people are ignoring a crucial feature lacking from EMR's: portability. This abstract-sounding concept is practical, and could be implemented if the industry leaders deigned to do so. Without portability, EMR's are an incredibly expensive, doctor-dissing burden. Effective EMR portability would directly lead to many of the tremendous advantages in patient service and health that old-style, non-portable, legacy EMR's are incapable of delivering.

    What is Portability?

    A portable EMR has these key attributes:

    • It's yours. You own it. It's not owned by some giant entity, sitting behind the impenetrable walls of a remote data center.
    • It's controlled by you, just like you control your email.
    • Others can help you update it and you can make it available as you choose.

    Having a portable EMR is like having a portable personal computer: something that is so small and light but also powerful that you carry it with you everywhere. It's yours! It's got all your stuff!

    More specifically, a portable EMR is an app with all your healthcare data and history stored in it. I've talked about this before.

    Of course, just like you don't want to lose your contacts and photos if you break your phone, you wouldn't want to lose your medical records if something went wrong. So it would be backed up to the cloud, and automatically synced to any of your devices. This isn't magic; your email probably works this way.

    Sometimes you use an app that asks your permission to access your data, for example your email contacts; if you give permission, the app would read your contacts and do something with them, for example send them an invitation. The portable EMR app would ask your permission when you went to a doctor's office or other medical facility, and if you gave it (why wouldn't you?), the medical people you're visiting would have all your records. No need to arrive early and fill out pages of medical history on paper! Similarly, when you leave, whatever they did would be added to your portable EMR, instead of being locked up tight in the hospital's EMR.

    That's portability: a safe, secure, accurate, comprehensive EMR that is yours, that you carry with you, and that you and your providers use to assure you get the best medical care, totally informed of your conditions and history.

    Why Portability matters

    The value of owning your medical record and carrying it with you resembles the value of owning your money and carrying it with you in a wallet — it's there for your use when you need it, and you can get others to help you. You can walk into a restaurant you've never seen before and get a meal — if you've got your wallet with you and can pay for it. Similarly, if something bad happens to you while you're traveling, say, your portable medical record contains all the background information about you a medical provider who has never seen you before would need to give appropriate help.

    To give you the best care, your doctor needs comprehensive and accurate information about your current medical situation and your medical history. A mistake or omission in your medical record can lead to anything from not helping to disaster.

    Existing, non-portable EMR's have multiple versions of your medical history, versions that are almost always incomplete, inaccurate and inconsistent.

    When you start an encounter with a medical professional, you are likely to be asked to fill out an extensive form to present your medical history. Then someone else is likely to repeat the exercise verbally and/or go through your written answers. The older you get, the more history you're likely to have, and the more likely it is you'll something out or simply forget something. The error or omission may not seem important to you, but it may be crucial to dealing with your current medical situation. Key parts of the misinformation will end up in the provider's EMR, making the problem worse.

    What if your favorite doctor changes medical systems, or you for any reason need to go to a health system that is not your usual one? Then you're in for one of two equally awful ordeals: (1) start over in the new system as though you just stepped off a spaceship newly arrived from a galaxy long, long away; or (2) get involved in the you-hope-you-never-have-to-do-it-again experience of getting your records transferred. Think I'm exaggerating a wee bit? Put on your sarcasm-protection jacket and wade through my recent experience of doing just this and think again.

    Portability leads to other good things

    An EMR that supports portability is capable of exporting all the information about you it has in a format that lends itself to easily updating your personal, portable EMR. Similarly, it is capable of importing the information in your EMR, resolving conflicts and redundancies as part of the import. Guess what!? This is exactly what EMR's need to interchange information among themselves! You know, the EMR interchange capability that the government has been trying to ram down vendors' throats to little effect for years now. Building portability into EMR's is the vast majority of the work required to achieve inter-EMR interchange! What an idea!

    Vendors, can we have a portable EMR? Please? Pretty please???

  • Innovation: the Barriers

    It's hard to be an innovator. You have to come up with cool new stuff, make it work, and get people to use it. Not easy! Depending on your situation, there can be barriers, active and passive, to being a successful innovator. Lots of people in business and government love to talk about how they're innovative, and how they foster innovation. Hah! In all too many cases, what they actually do is build and sustain barriers so strong and so high that innovation is nearly impossible.

    If you look at my earlier posts on innovation, you may think that I'm a cynic. The reality is that I'm an enthusiastic, life-long believer in innovation. My sarcasm is targeted exclusively at the hollow, creativity-killing rhetoric that too often passes for support for innovation.

    Active barriers to innovation

    What about big companies who innovate? That's mostly rumor and self-promotion, rarely a reality.

    What if you're a small company trying to innovate? The barriers are mostly put up by the large businesses that dominate the field in which you want to innovate.

    Will the big business itself innovate? In spite of all the talk, probably not. It's likely they want to be seen as modern, with it and innovative. It's highly unlikely that they actually want change. This post goes into some detail about the reality behind giant companies that supposedly are great innovators. Why can't big companies innovate? Who knows, but I think the attitude of the pointy-haired boss is a hint:

    Dilbert

    There is lots of information and a few stories about how to out-fox the giants that want to keep you down in my book on building a growing business from a startup. But it's tough. The big guys hold most of the cards.

    Passive barriers to innovation

    Governments are the main source of "passive" barriers to innovation. The barriers are usually in the form of regulations — regulations that can quickly morph into active barriers once you get caught in the cross hairs of one of these innovation-killing agencies.

    You think those regulations are no big deal? The current code of federal regulations is massive, and getting bigger every day. Here's a quick glance at its size:

    CFR

    Of course, no government agency will ever admit that what they are doing is preventing innovation. They are protecting consumers! Enforcing fairness! Doing good stuff, the peoples' business! That's what they say. Sometimes it's even true. But in most cases, what they are really doing is protecting existing businesses and professionals from competition. They do this by putting increasingly burdensome and expensive barriers to new products and services entering the market, and competing with the establishment.

    Regulatory barriers to innovation are everywhere, in nearly every industry. Why isn't there a huge outcry? Simple:

    • The companies and people that are on the "inside," benefiting from the barriers, vociferously support "protecting consumers" or whatever the b.s. cover story is.
    • The people who would benefit from the innovation don't see the innovations, because they don't exist yet, and so can't really lobby against the barriers.
    • It's just the way things are. Who has the energy to "fight City Hall," particularly when the innovative benefits don't exist yet because of the barriers?!

    The barriers are everywhere, preventing innovation or worsening convenience and price. The barriers are in old, tangible things like a store being able to sell liquor or a car company being able to sell its cars. More importantly, they're in newer, life-issue things like nearly every aspect of healthcare.

    Barriers to innovation in healthcare are massive, and getting worse. The barriers aren't called that, of course. The government agencies are protecting our health and privacy! But when you lift the covers, it is easy to see that what is really going on is a rapidly metastasizing federal bureaucracy that prevents life-enhancing products and drugs from being invented, and massively increasing the cost and slowing down the relatively few innovations that squeeze through the gauntlet.

    Conclusion

    We're clearly in the middle of an innovation bubble. Everyone says they want it. Companies and government agencies claim to be fostering and promoting it. I'm someone who has worked in the innovation trenches for decades. I try to innovate myself, and help others to do it. It's not easy. That's why I get so cynical about all these innovation-smothering institutions who are so loudly in favor of innovation. Their words say one thing and their actions say another. All their innovation amounts to is a pile of marketing rhetoric, an attempt to make themselves appear to be modern.

  • Healthcare EMR Interchange Breakthrough!

    Two of NYC's largest and most renowned hospital systems have collaborated to produce a true breakthrough in EMR interchange! This is no joke: while at this early stage there are minor physical assists, the data being exchanged is fully electronic! This provides a model that can be replicated everywhere, even by systems that are less resource-rich than New York's finest.

    Amazingly, I can't find any press releases or news stories about this game-changing break-through. But I know it's true and the systems are operational, because I've experienced it myself. My prior dissections of this issue here, here, here and here are now rendered obsolete. Read on for the details.

    Background

    As I've described before, I'm being treated for a kind of cancer at one of the world's best hospitals, Mt. Sinai. I'm getting excellent care and doing well. The doctor who is treating me specializes in my kind of rare disease.

    I got a letter saying that my doctor was leaving Mt. Sinai. I found out that he's going to Northwell Health, another large, excellent health system in my area, and I decided to follow him there.

    My task was simple: I was already scheduled at Mt. Sinai for an MRI to track my cancer's progress, and with my doctor to assess the results. Everything was covered by my insurance plan. All that had to happen was to shift the appointments and move my records.

    That was when I discovered the amazing advances in EMR interchange between the hospitals, even with integration of insurance! I'm so excited about this, I'm tempted to give you all the details. But I'll just give the highlights.

    Transferring the MRI appointment

    I already had an appointment for an MRI at Mt. Sinai, as ordered by my doctor and pre-authorized by my insurance company. All I had to do was shift it over to Northwell. I can tell you from personal experience that making the shift was easy, because of the amazing electronic integration of the two systems. There were a couple minor bumps in the road, but hey, most everything is amazing. Some highlights of the process:

    • I called Mt. Sinai. After a while, I found the person who told me I had to call Northwell.
    • I traded phone calls with Northwell, and found that they needed a "script" (prescription) written by a doctor, and they couldn't access the one at Mt. Sinai.
    • A couple more phone calls got me the script; only a couple!
    • While most people at Northwell were unaware of it, there was a radiology center convenient to me, where, after spending well under a half hour on the phone, I was able to get an appointment!
    • It turned out that the insurance pre-authorization couldn't be transferred. So during the course of just one morning, with multiple calls with me and a patient, helpful Northwell employee, I was able to re-get the pre-authorization! Let me stop here and show you this fabulous document I was able to get so quickly and with such little effort:

      Pre-auth 1

    Approved. Yay!

    But, nerd that I am, I did read on for "important information." Here's the most important part: Pre-auth 2

    Well, maybe they won't pay it after all. And I won't know until it's too late. Oh, well, we'll hope for the best.

    The highlight of transferring the MRI appointment

    I've saved the best for last. The Northwell radiology people really wanted the doctor's prescription. I could understand that; if I were a radiologist, I'd want it too. The process was so modern, so electronic (with a couple minor physical steps), it's a real showcase of EMR interchange.

    Here are the steps:

    • After some real effort, someone at Mt. Sinai wrote a new prescription.
    • They put the information into their electronic system, and arranged a UPS pickup. All they had to do was put the prescription in the envelope and get the right information on the cover.
    • Fully computerized UPS picked it up and delivered it right to me. Pronto.
    • All I had to do was scan in the prescription, and use a convenient SaaS service to send the digital image of the prescription via fully-electronic fax to the number Northwell wanted.
    • When received at Northwell, all they had to do was enter the information into their modern, interchange-ready EMR system. Done!

    Here is the transport mechanism. I have to show you, otherwise you may not believe me.

    Prescription

    We're not done with the wonders.

    I've had MRI's of this condition before. Naturally, the radiologists at Northwell wanted the prior scans, so they could see what had changed. All they needed was the images and reports from my prior scans. This was the real test of EMR interchange: could the Mt. Sinai system "talk" with the Northwell system and transfer the information? YES! IT COULD! Of course, this is leading-edge stuff, so there could be a couple minor improvements, but let's focus on the positive here.

    Transferring the MRI and report

    The process couldn't have been simpler. All I had to do was spend time on the phone with the Mt. Sinai people and before you know it, something arrived at my home. It was a package. If you look on the left of the package, you can see the evidence of a modern web interface having been used to create it: 2016-09-02 10.52.07

    Inside the package were two things. One was a modern, fully digital copy of my MRI, helpfully labelled. 2016-09-02 10.52.48
    The second was a direct output of a digital record, containing the analysis. 2016-09-02 10.53.14

    My job was simple: take them with me to the MRI appointment and hand them to the helpful people at the reception desk. Which I did, and they were happy to get them. In a flash, just a couple hours, the information was loaded into the modern Northwell EMR system. I could hardly believe it. Mostly-electronic transfer of fully electronic data from one EMR to the other!

    The glitch in the process

    I warned you there were a couple things that needed improvement. The radiologists at Northwell noticed that I had two prior MRI's, and Mt. Sinai had only sent one of them. Oops! Would I please get the other MRI? I guess it was hard for them to get it from Mt. Sinai themselves.

    So I called. After a while on the phone, I made it to the records department. Apparently, it's kind of secret, because an upset person demanded to know who had given me her number! But in the end, she transferred me to a person who could help. It was easy — all I had to do was fill out some forms and pay some money and they would take care of it right away.

    The helpful records person gave me the search terms to put into Google to find the form on-line. It was just a couple pages long. Here's part of the beginning: Record request 1

    I guess the form should have had a third page, because he had me squeeze onto the second page the address where the MRI should be sent, and my credit card information to pay the roughly $30 it would cost. I printed it, filled it out, scanned it in and faxed it to him. The same day — super-fast!

    OK, it's a glitch. But I was impressed at how he was able to send the MRI straight to Northwell! Unlike the previous one, which I physically brought myself. Of course, I didn't pay for it, and this one I did, so I guess you get what you pay for…

    Conclusion

    It's just like I said at the beginning: two modern, innovative health systems are demonstrating how easy and convenient (nearly fully) electronic EMR interchange can be, and how much it improves things. If someone had told me, I would have been skeptical. I may even have resorted to sarcasm in my response. But none of that here — I know by my own experience that it's true!

     

  • Investing in Healthcare Innovation

    There is a clear spectrum of innovation in healthcare. I've described the spectrum here, ranging from simple, blocking-and-tackling at one end to exotic AI-related things at the other end, with smart, data-driven ventures in the middle. The exotic end of the spectrum gets most of the money and attention, while the simple end is largely ignored. The middle of the spectrum is occupied by smart, data-driven people who see a problem in the way healthcare works today, and build here-and-now solutions to make it better. Even though there are sometimes structural obstacles to overcome, these entrepreneurs find ways to work with the system and overcome the obstacles, because their solutions benefit everyone involved: payers, providers and above all patients.

    Oak HC/FT invests in this kind of middle-spectrum venture, ventures that are bold and smart, but also practical with right-now benefits. Here are a couple of examples.

    Aspire Health     1 Aspire

    Aspire Health uses analytics to identify patients who may be approaching the end of their lives, often as shown by increasingly serious health problems. In the normal course of events, these patients would spend an increasing fraction of their time bouncing from one facility to another, each provider doing his or her best, but each acting in completely isolated silos. With Aspire, the patient has the opportunity to have a dedicated care team that meets with them and their families, understands their situation and their desires, and takes charge of each aspect of their care from that point on, making adjustments as required. The Aspire team is a true, takes-charge primary care team, assuring that your needs are met. Typically, patients spend more time at home and less time in hospitals and ER's. The result is that patients and their families are much happier and less stressed, with a primary care team that takes responsibility and gets things done.

    Limeade     1 limeade

    At first glance, Limeade may not seem like a healthcare company. But what else would you call a company that works with a group of employees to encourage them to eat, exercise and generally act in ways that promote health? While many diseases just happen to people regardless of their actions, many others either start or are exacerbated by behaviors. Limeade applies analytics and smart technology to identify, support and promote healthy behavior. Result? Employees that are not only healthier, but happier and more productive. Everyone wins.

     Quartet Health     1 Quartet

    Quartet Health applies analytics to identify people who have behavioral problems and significant non-behavioral health problems that could be interacting with each other to make things worse for the patient. They pay special attention to these patients, and apply an evolving set of automated tools and human intervention to understand the interaction among the issues. In particular, they identify particular combinations for which intervention can make things better for the patient, and then guide the concerned parties to take the actions that will lead to a better outcome, involving the patient and care providers as appropriate. Net result: patients get healthier than they otherwise would have been. And by the way, costs are lower.

    VillageMD     1 village

    When you have a problem, the first person you're supposed to see is your primary care doctor. Founded by visionary, award-winning Dr. Clive Fields, VillageMD has done extensive longitudinal analytics on patient outcomes, and discovered things the primary care physician can do to improve care while reducing costs by an average of over 20%. Having proven the methods in their own practice, VillageMD is now delivering their techniques to other primary care practices in a highly systematic, targeted way. Everyone wins: payers pay less, patients are healthier, and primary care doctors have greater impact and make more money. The VillageMD techniques are evolving and becoming more powerful with additional experience.

    Conclusion

    Oak HC/FT has invested in excellent companies in healthcare. The four companies briefly described here are particularly good examples companies in the center of the "simple-to-exotic spectrum" that I have described. These companies deliver here-and-now results using advanced but non-exotic technology combined with win-win business models. Companies like this that use "big data" in practical ways are out of fashion in the world of healthcare IT investment for reasons that are a mystery to me. All I can say is that they're all the rage in the world of Oak HC/FT.

     

  • The Healthcare Innovation Spectrum: From Washing Hands to AI

    There's a spectrum of ways to innovate in healthcare. On one end is simple stuff, like making sure things are clean and germ-free. On the other end is exotic stuff, like using AI: Artificial Intelligence and Cognitive Computing. Obvious questions: (1) where is the money going? (2) where is the value? (3) Is the money going where the value is? Simple answer: the "smart" money is going to exotic gee-gaws, ignoring near-term value and patient health.

    Where the Money is going

    The money is clearly going to exotica. Ignoring for the moment the billions IBM and others are pouring into what they call Cognitive Computing, VC's are investing heavily in healthcare-directed AI. See this:

    AI healthcare 1

    We're talking serious money here:

    AI healthcare 2

    While there are loads of conferences, trials, talks and articles talking about the great future here, there is an obvious conclusion to be drawn: while the money is being spent now, the benefits (if any) are in the future.

    That's about all you need to say about it.

    The middle of the spectrum

    While things like AI are clearly at one far end of the spectrum of healthcare innovation, there are intelligent, educated things in the middle of spectrum. Lots of people are pursuing these innovations with great energy. I've discussed an example of one such approach here.

    The Oak HC/FT portfolio company VillageMD is another clear example of data-driven innovation in healthcare. No new math or fancy computers are required. "Just" educated, dedicated people looking at the data and making required behavioral changes based on those facts. The founder of VillageMD, Clive Fields, just won a major award for his work, using all-organic and natural intelligence — no artificial ingredients! Guess what: it's here and now! The outcomes of real patients are being improved as you read this!

    The basic end of the spectrum

    On the other end of the spectrum from AI, we've got things that shouldn't need "innovation." They should be standard practice. They have huge impact. They are the shocking, scandalous modern equivalent of antiseptic surgery — things that no one seriously disagrees with, but which the important experts and leadership type people somehow can't lower themselves to pay serious attention to. Or when they pay attention, it's with actions that do nothing to solve the problems.

    A good candidate for the poster child of this end of the spectrum is what the CDC calls healthcare-associated infections, HAI's. In other words, getting sick from going to the hospital. Here is the CDC's summary of the situation:

    11 HAI

    I don't know about you, but this makes me sick. 75,000 preventable deaths in a year, preventable using non-exotic methods. No Cognitive Computing required! There are cures, demonstrated at multiple hospitals that have put serious effort into it. This article summarizes the efforts and approaches, ranging from simple changes of cleaning practices to fancy new machines.

    Conclusion

    There's a clear spectrum of innovation in healthcare, ranging from blocking-and-tackling basics at one end, to exotic new things based on various forms of Artificial Intelligence at the other end, with smart, non-exotic, data-driven methods occupying the middle ground. Most of the "smart" money appears to be going to the fancy exotic end, with results sometime in the indefinite future, while the rest of the spectrum trundles along, largely under the radar, delivering results to patients today.

  • Big Data vs. Little Data

    All the attention, hype and money is pouring into Big Data. It's the way to get big budgets, lots of attention, and big salaries. Delivering real value to normal human beings is so mundane an aspiration that it is beneath the dignity of those involved with something IMPORTANT like Big Data to notice.

    That's where Little Data comes in. If you want practical benefits that can be enjoyed this year or next that improve the lives of normal human begins, then you should start putting effort into Little Data.

    Little Data and Big Data

    The most important thing about Big Data is not that it's big. It's usually not so big! What's important is that in the world of Big Data, what you mostly think about is Data and the fact that it's Big. It's a data-centric perspective, with all sorts of specialized software, equipment and knowledge. It's also a faith — everyone involved is certain that wonderful things will soon pour out of the Big Data pipeline — once we get this, that or the other thing worked out. Of course, we can't be sure what those wonderful things are — that's what's so great about Big Data, it affects everything!

    Big Data has gotten so Big that it has become a ripe target for parody, as in a recent Dilbert cartoon:

    Dilbert Big Data

    The most important thing about Little Data is not that it's little. Although it almost always is. What's important is that you mostly think about the people your organization serves, where and how they waste their time or get frustrated, and how to use computers and data to make things better for them. The problem is first identified, and then the relevant data is rousted up, organized, and made part of the solution.

    Here's the big problem: all the money, attention and prestige go to Big Data. Little Data? I suspect you've never heard of it before. Getting involved with it is not likely to be a career or prestige-advancing event.

    Little Data examples

    Here's an example of "pure" Little Data I encountered. I use USAA as my bank. I needed to send a wire. I went on-line to remind myself what the requirements were.

    USAA wire

    I gathered the necessary data and called the number they gave. The result of calling was a blizzard of Little Data efficiency and convenience.

    The first thing I heard was "I see you're calling from a number in your profile, David. Would you please say or enter your PIN code?" That's nice. It's a feature they've had implemented for a while. Saves time and makes me feel like they know me, even though I know it's all just software.

    After I entered the PIN code, I heard "I see you've been on the USAA website looking at wire transfers. Would you like to send a wire today, David?" Wow. Would I like to send a wire. WOULD I?? I sure would like to send a wire, USAA, thanks for putting two plus two together to make my interaction with you just that much more convenient. So I said "yes."

    Then I was immediately transferred to a wire transfer specialist, who already knew who I was and the wires I had already sent. Since I was sending a large wire, she went into a couple further security checks, and away we went.

    This is a single small example. It's not game-changing or earth-shaking by itself. But imagine if all organizations looked at things from their customer's point of view and found ways they could save time and increase convenience for them, like USAA obviously does. Little Data can change the world, very much for the better.

    Big Data Suppresses Little Data

    Every institution is surrounded by an extended thicket of barriers to customer service and efficiency that could easily be flattened by Little Data efforts. In most institutions, the thicket of barriers is ignored, while all the attention goes to the vague, never-ending moonshot of Big Data. The generally excellent Mount Sinai hospital system in New York is a good example.

    Mount Sinai has "mounted" a major effort in Big Data. They have been named one of the world's top ten innovative companies in Big Data!

    1 Mt Sinai

    Mount Sinai is the focus of a feature story in the New York Times promoting one of the many new books on Big Data.

    2 dataism

    The story leads with a profile of a new hire at Mount Sinai, "Dr. Data."

    Dr. Data leads a team of Big Data specialists working on important things that will transform medicine and health care! Soon! Well, someday, anyway.

    3 comput

    Meanwhile, what about the many patients who have problems now and are being treated at Mount Sinai now? Can we squeeze a bit of Little Data goodness out to help them? Apparently not.

    I've described some of my personal encounters with the lack of common-sense efficiency at Mount Sinai here and elsewhere. You can read about the important appointment I had with the specialist to determine whether life-threatening potential side effects of the cancer drugs I was taking were ramping up. The appointment was confirmed by email and robo-call. I travel a couple hours to get there. I check in. So sorry, the doctor is on vacation! More details here.

    More recently, I needed a refill for a prescription by this specialist. These are the drugs that I have proven are wrongly recorded in my Mt Sinai EMR, though I'm confident that my cardiologist somehow, somewhere has the correct data — she's on top of things. I tried the on-line system to get the refill. Fail. I got on the phone, holding more than 20 minutes before being cut off. I tried the phone again later, talked with one human briefly, but was eventually dropped after more than 30 minutes. No robo-voices telling me that I was in a queue, that the wait was approximately whatever; nothing.

    What could I do? Fortunately, I'm signed up for primary care at OneMedical, so I emailed (!!!) my doctor, explained the issue and sending the data, and the next day my refills were waiting for me at my pharmacy. OneMedical is an example of a health organization that puts effort into Little Data. Mount Sinai apparently thinks that putting effort into trivial issues like mine, whose fixes don't result in fawning newspaper feature stories, are beneath their dignity. All the effort needs to go to Big Data!

    Conclusion

    I like numbers, data, analytics and computers. I firmly believe they can be wielded to make our lives better. But while we're mounting forever-in-the-future moonshots with Big Data, it would be great if we could have a concerted effort to deploy Little Data to improve everyone's lives in the here-and-now. After all, whatever healthcare-transforming wonder Big Data comes up with, you're still going to need patients showing up to appointments with people who are actually there!

  • Innovation Stories

    I worked at Oak Investment Partners for a long time until retiring from it at the end of 2015. Here is part of my page on the Oak website in 2015:

    2015 12 17 David B. Black - Oak Investment Partners

    During that time, I had the opportunity to dive into hundreds of tech companies over many cycles, and the further opportunity to be an insider at dozens in which we invested. I learned that what most people tell you about how to be a successful entrepreneur often doesn't match up well with the winning companies I saw.

    So what's a person to do?

    One thing you can do is read my book. It won't tell you how to win (that's on you), but it will clearly identify some of the most important success patterns to follow, and some of the popular failure patterns to avoid. It has dozens of examples from real life to illustrate the points.

    Here are some of the companies in the book and the points or patterns they illustrate.

    CRM co., OpenData, Sybase: Do NOT make your execution match your strategy! If you're going to invade a country, don't attack everywhere, pick a beach.

    Captura/Concur: Don't let perfection get in the way of making your product usable.

    Web services company: Pick something that you can finish, well and quickly.

    Smartdrive: When you think you're really focused, try making the focus even narrower.

    Inktomi: Don't move on to the next battle until the current one is totally wrapped up; mostly wrapped up may not be good enough.

    Workflow companies, collections: The customer defines the problem, not you.

    HNC/FICO: Using a platform to attack a narrow but important problem set.

    US Auto Parts: Does the customer have a problem right now?

    G-Market/E-Bay: Cross-border issues are more than language.

    Bank processors e.g. Fiserv: Customers aren't fond of risk.

    Nextpage: Are your benefits tangible?

    Fastclick: Can you deliver results quickly?

    Rebelmouse: Make each step towards a vision be usable.

    Athena Health: Adding a whole new service can be 1+1=3

    Radisphere to Candescent Health: Giving your customers to someone else can be a great idea!

    Company A: Using end-user products in a product/service can save time and money.

    Video Ad Network: Sell it first, then build and deliver it seems backwards, but it beats everything else in the right situation.

    Maestro Health: You don't always have to program everything; sometimes having people do some of the work is a big win.

    Evident: Methods that are great in one domain maybe be failures in a different one.

    The Innovator’s Dilemma book: Listening to your customers can hold you back.

    Smartdrive: Picking the right group of customers to listen to is key.

    TxVia, Feedzai: Building a tool and delivering an application or service with it can be an overwhelming advantage.

    MobiTV: Do you have large customers? The power relationship determines the outcome.

    Huffington Post: Pick a direction, go quickly, stop for nothing.

    Conclusion

    I'm kind of slow. It took me more than ten years to start noticing the patterns I've written about, and another ten years testing the patterns against the companies my partners looked at and/or invested in. But they've held up. I know I haven't discovered all the relevant patterns or explained the success of every company, but I also know that I don't read about the things I wrote in the book, which is why I took the trouble to write it. I hope new generations of innovators will improve their odds of success by following the path of the winners.

     

  • Gartner Group: Showcase of Big Company Customer Service

    Giant, powerful organizations nearly always do two things really well:

    1. Wax eloquent about how concerned they are with respect, privacy and customer service.
    2. Treat their actual customers like disposable pieces of crap.

    I've seen lots of examples of this over the years. I've written about it, for example illustrating how HP disrespects its customers with simple things like hard-to-get-out-of email subscriptions you never subscribed to. I've just encountered an even grosser example inflicted on me by the world's leading IT consultant firm, Gartner Group.

    Gartner Group

    I've known a number of Gartner employees over the years, and most have been hard-working, respectful, knowledgeable people. But Gartner is a big place. They purport to teach the world's companies how to do IT. So how does Gartner itself do IT?

    Here's the basic story with Gartner:

    2 Gartner

    In addition to thousands of employees, they're worth billions of dollars:

    1 stock

    Their range of activities is amazing. It's clear that they teach IT best practices to important companies all over the world:

    3 Gartner

    It's hard to believe that Gartner's own IT practices wouldn't themselves be world-class. Wouldn't you expect a music teacher to be a master musician?

    Gartner email

    Somehow I ended up getting spammed by Gartner. I'm not sure how. I got this email:

    1 gartner

    I didn't ask for it, and I don't want it.

    So I went to the bottom, and was assured that Gartner is committed respect, privacy and all the usual big-company boiler plate. And even better, I can unsubscribe!

    2 Grtner

    So what happened? Did I get that satisfying one-click experience that responsible spammers provide? You know, the one that immediately says, "you're out! But if you'd be so kind, please tell us why you're going?" You know, like this:

    11

     

    No. Apparently, Gartner emails are much too important to be simply unsubscribed from. When the page popped up, my eye first went to this, which by itself sets a new record for customer disrespect:

    44

    They know my information — they're emailing me! But filling out the form for me? I guess this standard practice is beyond the geniuses at Gartner. Or beneath them. Or they kindly want to make sure I'm qualified to live without their wisdom. Or something.

    Then I studied the top part of the page, which provided the detailed instructions that must be meticulously followed in order to unsubscribe. If you're not good at reading and following instructions, the penalty is eternal pounding by unwanted junk mail from Gartner:

    Gartner

    I have nothing more to say. Gartner, the billion-dollar advisory firm, leading the way, demonstrating the customer respect that big company customer service is all about. Also demonstrating how carefully crafted words are of supreme importance to such large organizations. Actions that match? Not so much.

  • Innovation and Experts

    Lots of people want to promote Innovation these days. Why not get in a top expert to help? Answer: if you want to innovate, ignore the experts! With rare exceptions, "experts" are the enemy of innovation, and supporters of the status quo.

    Experts

    If you're doing something new and want to do it right, it's natural to seek the help of someone who's been there and done that. If you want to do the thing in an innovative way, that's all the more reason to seek expert help; the innovation you need may already be out there, and who's more likely to know it than an expert?

    Turning to experts is what we do. At a basic level, that's why we have schools, degrees and certification programs. A person with an MBA is supposed to be much more of an expert about business than the average Jane or Joe. But an MBA is just an entry-level expert. What many people want is an Expert, or even better, an EXPERT!!

    An expert is someone who knows loads and loads about a certain portion of common knowledge. They can tell you what are the common practices in a given area, what they would characterize as "best practices." There may be some weird, fringe people out there working at you've-never-heard-of-it places who do things differently and make wild claims about what they do. But can you take the risk of going out on a limb and failing, when all the top organizations do X? Of course not.

    Experts are herd dogs. They get everyone to make roughly the same choices that everyone else makes, and go in roughly the same direction.

    Think about the process of selecting an expert. Don't you want someone who is generally acknowledged to be an expert? Who advises major organizations to do what the "leading" other major organizations do?

    Think about being successful as an expert. The vast majority of the potential fees come from major organizations. None of whom want to be told they're doing things all wrong. Most of whom would like validation, and maybe some minor tweaks. That's where the client list and fees come from.

    Experts want to be recognized, hired and paid by rich, mainstream organizations. Organizations want experts to help guide them to not stray too far from the pack.

    In other words, the vast majority of large organizations are like sheep traveling in a herd. If they wander off from the herd, they may get lost or hurt! Experts are like sheep dogs who bark and nip at the sheep who wander off or lag behind.

    If you want to innovate, the last thing you should want is a typical "expert."

    An expert on experts

    To get the real story on experts, let's turn to the person who is, above all others, THE expert on experts. Richard Feynman boils the subject down to terms anyone can understand:

    Science

    An "expert" is someone whose knowledge we are supposed to accept based on the authority of the expert. It's not our place to question it. The whole reason to get an expert is that we assume we can't possibly figure out what to do ourselves!

    A scientist reacts to assertions by the expert saying things like "why?" "How do you know that?" "Where are the experiments that prove that what you are saying is true?" Scientists don't take things on authority. Feynman is saying that experts are nothing more than people who say, with deep voices and calm authority, "This is the truth, my child." In any situation in which you are supposed to take things on faith, the natural reaction of the scientist is: you're definitely ignorant, and probably wrong. Why do you need the take-it-on-faith stuff if you can prove it? Science replaces faith in people (i.e. experts) with reliance on facts, proof, numbers and math.

    Experts and flight

    One of the best examples of innovation and the expert effect is the history of manned flight.

    One of the most famous experts of his day was Samuel Pierpont Langley:

    330px-Samuel_Pierpont_Langley

    He built and launched a couple unmanned planes that flew thousands of feet. He was famous. He got major funding from the government, and everyone expected him to succeed. He was the ultimate expert in aviation.

    There was just one problem. His planes all crashed. Here's one that "flew" right into the Potomac River in 1903:

    330px-Samuel_Pierpont_Langley_-_Potomac_experiment_1903

    Nonetheless, belief in the expertness of the wonderful expert Langley remained so great, in spite of his complete and utter failure to even come close to controlled manned flight, that his reputation remained high and all sorts of aviation-related things are named in his honor, from medals to airports.

    We all know who actually figured out how to make a flying machine: the Wright Brothers.

    11

    These guys built bicycles in Dayton, Ohio! No fame. No government money. In no way were they experts. But: they were scientists! In the true sense of the word — in Feynman's sense. Here's a bit of what they did:

    22

    In other words, they figured out what the real problems were, did designs, built prototypes, ran tests, and … innovated!!!  Here is one of their flights in 1904:

    1904WrightFlyer

    The rest of the story tells us a huge amount about innovation and experts. Briefly, no one believed them! They went for years trying to get government interest. Years later they were celebrated as heroes, but at the time, even the local government and press ignored them. Finally their accomplishments were accepted in 1909, when they flew up and down the Hudson River for half an hour in front of an estimated one million people, circling the Statue of Liberty.

    No one could believe that these non-expert nobodies could have solved a problem that stumped the nationally recognized, accepted experts.

    Conclusion

    If you want to know what to do, you have two basic paths.

    One is to hire an expert to tell you basically what everyone else is doing. It's a good way to be "safe," and avoid innovation of any kind. But nothing stops you from crowing about how innovative you are, at least compared to the sheep staring at your back legs!

    The other way is to be a scientist and figure out what the real problems are and how to solve them. Then do it. It's what innovators do.

    You pick. I know what my choice is.

     

  • Healthcare Innovation: How to Achieve EMR Interchange

    EMR interchange has been a major goal of the tens of billions of dollars that have been spent to buy and install EMR's. The theory is that making it easy for the next medical provider you see to have access to your complete health record will improve health. It might! But the current methods for achieving integration are not working. Not. Working. It's easy to understand why they will NEVER work, and what can be done to achieve the same result.

    Not to be mysterious about it, here's how: forget EMR interchange. It's not working because it's hard and none of the people who build and control EMR's really want it to work. Instead, enable a new generation of personal EMR's. It's literally hundreds of times easier.

    My EMR vs. Integrated EMR's

    Everything is great if I go to a single integrated hospital system that uses a single EMR. I go from place to place in the hospital complex, and everyone knows who I am, where I've been and what's going on:

    1 EMR_0005

    No problem.

    The problem happens when I go to an office, a clinic and a hospital. They each have EMR's. What all the "experts" think is best, backed by tens of billions of dollars, is for the systems to talk with each other. What I suggest instead is MyEMR app, which gets the latest information from each EMR and uploads everything to the next place I visit. Here's the choice:

    1 EMR_0004

    They look pretty similar, right? There are three unique lines (data paths) connecting my EMR to each of the places I've visited, and there are three unique lines connecting each of the providers (H-C, H-O and C-O).

    When the numbers grow, they start looking not quite so equivalent. Let's look at six distinct EMR's. With My EMR, there are just six possible connections:

    1 EMR_0001

    But if the six have to interchange with each other, we're up to 15 possible connections.

    1 EMR_0002

    Hmmm. Not a good trend. What about when the number gets bigger? What if 100 EMR's had to talk with each other? How many unique connections (data paths) would there be then? Here it is:

    1 EMR_0003

    You may say there aren't that many vendors. But getting two different installations of EMR software from the same vendor to talk is still a lot of work! Not to mention the fact that there are many different versions, configurations and customizations of each piece of software. The real number is likely to be much larger!

    Conclusion

    Just installing an enterprise EMR tends to be an incredibly expensive, years-long disaster. There's a good reason based on simple arithmetic that many years and tens of billions of dollars have yet to achieve any meaningful amount of interchange between EMR's — there's a combinatorial explosion. The same arithmetic strongly favors the personal EMR approach.

    Incentives also favor the personal EMR as the center point of integration. How eager is one hospital CEO to make it real painless for patients to go to the competitor? Patients, on the other hand, are highly incented to want the data in their hands; not only would it save endless hours filling out paperwork and avoiding yet another history interview with its inevitable misinformation, but it's likely to help their providers avoid errors and keep them healthier. Of course, the vendors and systems have a death-grip on patient data, and really don't want to give it to patients, regardless of what they might say. But at least sending data to personal EMR's is a solvable problem without a combinatorial explosion of work to get it done.

    I want a personal EMR!

  • Healthcare Innovation: Getting Data out of EMR Prison

    EMR's have a few problems. Selecting and installing them is too often a multi-year disaster. Getting information from one of them to the other is supposed to be routine, but is in fact a rarity. And the data in them is too often incomplete, inconsistent and/or just plain wrong. How can we get our data out of EMR prison and free it to be fixed up and actually useful?

    The position of the EMR prison wardens and guards is clear: you can pry your data from my cold, dead hands.

    What we'd like

    A personal EMR is the solution to many EMR problems, among them interoperability. If data in my own EMR, corrected and completed by me, were uploaded to a provider's EMR, all the data would be up to date with almost no labor.

    What we'd like is to have our personal EMR app log into the provider's EMR, download the data, let us fix it and complete it, and then upload the corrected and completed results. Not too hard.

    What we're up against

    The great Lords who build and operate the grand and glorious EMR's have their own ideas about letting us dusty peons gain access to our own data. Put simply, they're against it. But they'd rather not say they're against it. In fact, supported by legions of government bureaucrats, they insist that our data is fully available to us. All we need to do is follow a few simple procedures, and it can be ours!

    Oh, great! Maybe I am being too cynical here. Maybe there really is a way I can take my data out of prison for a walk in the wild.

    I recently accompanied someone close to me for a procedure at what is now called Northwell Health, formerly various other names including North Shore-LIJ.

    Northwell health

    I got all sorts of documents from them in the course of the interaction, and went through them to find out how I could get my friend's information from the EMR. Here's the main document:

    1

    Getting the data

    First and foremost, can I get my data? You betcha! It says so right in the very official document I was given:

    1

    Hooray! I can get a copy! Uh-oh, I hope this doesn't mean just a paper copy. Let's see:

    2

    Okay, I can get an electronic copy. So where's the API? Where does my app plug into the EMR? Let's see:

    3

    Oh, no!!!! In writing! Somehow I suspect they don't mean emails are fine. But at least after I go through all the nonsense I guess I get my data. Let's read further:

    4

    What do you mean "may deny access"??!! It's my data!! Wait. It gets worse.

    5
    Nice. I get a redacted version of my own stuff.  Unless they just feel like giving me a summary. Like what, this? "You came in to the hospital. You were sick. You felt like crap. We worked hard. You felt better, and left." Like that? What can I do to actually get my data? Here's how:

    6

    Very comforting! Instead of an API, it's a nightmare, obviously intended so that no one actually ends up with their own data.

    Correcting the data

    Maybe they're better about correcting the data. I showed elsewhere how crappy the data tends to be, and how paper-reliant even places with fancy EMR's are. You'd think they'd want all the data they have to be correct and complete, so they can do Big Data and get the much-vaunted benefits of the tens-of-billions-of-dollars-worth of EMR's we've bought, right?

    I'm tired, so I'm not going to drag this one out. Here's the deal with correcting EMR data:

    Rights p3

    In other words, NFW.

    Bottom line

    The conclusion is simple: my data, the data about me and my health, is imprisoned in an EMR. The prison guards say, sure, you can visit, any time. Just submit your request in writing in the proper way, and you'll get your data real quick. Maybe. What if my data is sick and needs healing? Forget it.

    They say loud and clear that I have a "right" to my data. But it's clear that they'll do everything in their power to make sure that right is never exercised.

  • How Blockchain will Deliver Value

    Blockchain is already a huge phenomenon. But it has issues. Can blockchain fulfill its promise? Can it have a big impact on financial services, healthcare and perhaps other industries? You betcha! Here’s how.

    Blockchain is big

    First it was BitCoin. Now it's blockchain, which is what people call the "underlying technology" of BitCoin. Although that's about as accurate as calling the combustion engine the underlying technology of the car, only leaving out the gas tank — it won't work!

    In any case, expectations among investors are riding high. Here's a snapshot of investor interest:

    Blockchain

    Obstacles to blockchain's success

    Probably the biggest problem with blockchain is that it's just a kind of database with a peculiar set of characteristics. Just having a database doesn't make everyone involved in a problem suddenly decide to digitize everything in the same format, make the same calls to the same API's and respond to everything appropriately. So the problem is often one which blockchain simply doesn't solve.

    There's also a deep obstacle. It's one that is obvious to any technical person and makes common sense, but for reasons that elude me, is rarely discussed among blockchain investors and enthusiasts.  The problem is the community validation protocol that assures the integrity of the ledger. As part of BitCoin, the problem is cleverly solved by miners, who are incented to provide this service by being paid in BitCoin. When you take BitCoin out of “blockchain” and apply blockchain to other applications, you take away the payment mechanism for miners to do their job. This fact alone has a long string of ramifications, among which is the integrity and security of the "distributed ledger."

    History of other advanced technologies

    The obstacles to success for blockchain are serious. I wonder what we could learn from looking at history? Perhaps there are other abstruse, advanced technologies that also overcame serious obstacles and became smashing successes. Maybe we could learn from them and see how blockchain could similarly enjoy the great success that is so widely predicted for it.

    There are several historical parallels that could be applied to block chain. One that seems relevant is neural networks.

    HNC Software was started in 1986 to exploit the incredible power of neural networks. "Neural," like what's in your brain, get it? It's like smart computers! The bright boys of HNC got contracts and were solving all sorts of important problems in multiple fields. Sort of. Around 1990, the CTO of a credit card company, Household International, brought them in to solve his company's fraud problem. After a while, with the data and help of Household, they got something good going.

    Household let them get data from other card companies to make their models even better, and soon HNC was rocketing. They went public, became the card industry's standard solution, and eventually merged with FICO.

    I was active in the card industry when they were rapidly growing, and I knew a couple of the people whose names were on the patents. Everyone accepted that HNC's solution trumped everyone else's because, after all, it was based on that amazing new technology … neural networks!

    Looking under the covers

    If you took off just the top sheet, you would see that HNC had devised carefully controlled training protocols to overcome the over-training that frequently hobbles neural networks. Clever!

    But seeing what was really going on was an eye-opener. Underneath all the neural net stuff was a large and growing body of … get ready … human-created rules! Little snippets of code, each of which would identify a certain pattern of fraud. As new fraud was discovered, humans at HNC (mostly) would add a new rule to the set of (when I last saw it) thousands of rules. The latest set of card transactions, both legit and fraud, would then be run through the training system, and the neural network would be trained to balance the output of all the rules and combine them into a single probability score.

    Net-net: the rules did the fraud recognition, the neural networks weighted the rule outputs into a combined final score for a given transaction.

    The message of HNC and the understanding of the market was clear, however: the HNC solution was better than anything else, it was based on near-magical neural networks, and life is good.

    Applying the lesson

    HNC provides an excellent model for how blockchain can succeed in the market. They'll do it the same way neural networks did. Investment and attention will go to important problems; the problems will get solved by stubborn, hard-working people who are motivated to get something that works, and don't really care about the extent to which what people call blockchains are involved. The marketing people will promote the magical elixir of blockchain, everyone will ohhh and ahhh, and no one will care what's under the covers, so long as it works.

    It worked for neural networks and HNC, and genuinely frustrated the fraudsters. The same pattern can work for blockchain.

  • Healthcare Innovation: EMR’s and Paper

    EMR's are essential. They are going to bring healthcare into the digital age — finally! Healthcare organizations are spending billions of dollars to implement EMR's, and the government is doing the same.They're preparing the ground for the incredible benefits of Big Data and Cognitive Computing!

    There is no doubt that the money is being spent. EMR's are certainly being implemented. Are they working? Eliminating paper? Not so much. One thing they are certainly doing is making doctors spend less time with patients and more time with computer screens.

    I could go wild with statistics, but all this got tangible for me when I accompanied a family member to a surgical procedure with a top-flight provider at a first class facility in Manhattan recently.

    Here is the notebook of papers that accompanied the patient everywhere:

    Notebook

    Some of the papers were computer-generated, but most were not. We spend loads of time fielding questions whose answers had already been entered into various systems — including the provider's! Various papers whose text had nothing to do with medicine had to be signed — papers concerning regulators, administrators and lawyers.

    I heard the dialog in other booths, with huge amounts of time trying to get information out of the memory of patients and onto paper. Here is a nurse doing her job:

    Nurse paper

    I could see that there were also lots of computers all over the place. Not that it mattered.

    It turns out that the medical care was excellent, and the procedure successful. Good news! Would eliminating the paper have made it better? Hard to see. If the medical history had already been available, would it have saved some time? Well, the medical history was all available — the provider had already gotten everything required and entered it into his own system before agreeing to conduct the procedure! So everything done at the hospital was just a bunch of wasted effort anyway, whether it was on paper or on computer! Could the provider's EMR have transferred the information about the patient to the hospital's EMR for this scheduled procedure? Maybe. But it didn't happen, and we know from government statistics that it rarely does.

    Tens of billions of dollars are being spent implementing EMR's so we can experience the wonderful benefits of getting rid of paper. Sounds good, but I suspect that no true science or even engineering has been done here. How do we know things will be better in the gold-plated EMR future? Has anyone done patient outcome studies? How about time utilization studies? Has anyone tried alternatives? After all, EMR's can't possibly be a goal — who cares about EMR's except EMR vendors? EMR's can only be a means to an end; and the only end worth anything is better patient care at lower cost.

    What we know for sure is that we're achieving higher costs by implementing EMR's. We're not eliminating the paper. Too much of the data that ends up in the EMR is crap, and too much is missing or wrong. We're not getting accurate data into a single place. We don't have a clue whether we're making patients healthier as a result; we don't know whether we could make patients healthier by spending the money in a different way. Maybe it's time to apply some fresh thinking here.

    I'm computer guy. And a facts kind of person. I know that computers and software can make things better for everyone in medicine. I'm NOT saying we should forget this new-fangled computer thing. I'm saying we could get dramatically better results for a fraction of the money we're spending.

  • Healthcare Innovation: EMR’s and Data Quality

    Tens of billions of dollars are being spent to implement EMR's in healthcare. There's still a long way to go. Everyone seems to agree that EMR's will make things better than they were with paper. But it's hard to imagine that things will be better if the data is incomplete, inconsistent, and simply wrong.

    The big strategic thinkers and powerful people who push EMR use ignore this issue. I guess it's a detail, beneath them, unworthy of their notice. But for anyone who lives in the world of software, numbers and math, data quality is the foundation on which everything is built. Ever hear of "bad data in, bad data out?" It's true!

    I can run some personal tests on this issue because I'm being treated for a kind of cancer at one of the world's best hospitals, Mount Sinai. I'm getting excellent care and doing well. Mount Sinai is completely up to date with EMR's. It's clear from my experience to date that my excellent care has nothing to do with the EMR — arguably, the good care I'm receiving is in spite of the EMR.

    Let's look at some details. I recently waded through the hospital website to access my medical records. If whoever designed the website had tried to make it difficult for patients to access their records, they couldn't have done much better.

    I finally managed to get a PDF for an encounter. The document makes clear that the hospital's computer graciously deigned to share information with me, the patient:

    1 note

    The document makes equally clear that information is missing. What information isn't here? We have to guess. What an attitude.

    2 may not

    Think of an incredibly unpleasant, arrogant class of professionals. What did you come up with? My guess was lawyer. Even with lawyers, when you fire them and request your files they give them to you, minus snarky notes about how things "may be" missing.

    There was a section with my name and address. Also how to communicate with me:

    3 phone

    They included the identical number for Home and Mobile. You think the computer could have checked for that? This is one of the fatal flaws of the whole EMR approach: the patient is barred from entering and/or correcting his own data! In a sensible, modern system, I would have received an email or text asking me if this information was correct, and asking me to correct it if it's not. But an Enterprise EMR system with layers of security, bureaucracy, administrators, regulators and lawyers involved? Maybe next century.

    Now we get to my meds. Here they are. Notice anything?

    4 meds

    You may notice that information is missing from the second drug, losartan. What I noticed is that the dosage is wrong. What I have actually been prescribed is 100 mg tablets. This record is from the encounter with the cardiologist who prescribed the drugs! If it's wrong, anything can be wrong!

    In my case, it makes little difference, since I'm on top of things. But not everyone is so fortunate, and this is just the kind of error that could, with a different patient and drug, have awful consequences.

    Now let's look at my "social history."

    5 alcohol

    It's wrong too. And I'm not allowed to correct it. If I did use alcohol, it's missing the amounts. But I don't use alcohol. If it were correct, it would be incomplete; but it's incorrect.

    Finally, let's look at my plan of care:

    6 plan of care

    An appointment. But that's wrong too! The appointment I actually have is for a diagnostic procedure, not what's written here, and the follow-up with the doctor is just missing.

    Bad data wrecks everything

    You want benefits from Big Data? Nothing good comes from data that's bad, no matter how big it is.

    There is very little data exchange among EMR's, in spite of all the tens of billions of dollars that have been spent. Here is the latest stat from the government:

    14 percent share

    Do you think that's bad? In principle I think it's bad, until I consider all the inconsistent and incomplete piles of crap data that's sitting out there in EMR's. Then I think of the lack of interchange as being more like keeping the bad data in isolation so it doesn't wreck anything. And who's allowed to fix it? I'm certainly not allowed anywhere near it, even though it's my data.

    Conclusion

    What's the solution? Make health care providers spend even more time bent over computer screens than they do today, which is already excessive?

    The core problem is that our whole approach to hospital, health care and provider automation is rooted in the ancient approach to "enterprise software" that was created in the days of mainframes, and lives on in the incredibly expensive, ponderous and user-hating world of modern healthcare IT. The data will become accurate, complete and high-quality when the systems are built correctly, using modern techniques, and when they interact with all concerned parties — including patients!! — to get their jobs done.

  • Innovation: From Startup to Success

    I've recently published a book whose subtitle will soon become the title: "From Startup to Success." It's a tiny voice in the hurricane of books, conferences and attention paid to Innovation. Anyone doing something new that somehow involves computers and software would benefit by paying attention to this book. It identifies success patterns that aren't found elsewhere.

    1

    Software-fueled Innovation

    We currently benefit from more than 150 year's worth of general-purpose innovation. Trains, planes, cars, phones, refrigerators, prepackaged ice cream, etc. The innovations are now a broad array of products and services offered by major organizations. You go to business school to learn how to run and staff such organizations.

    A sizable fraction of today's innovation is built on and using computer hardware and software: the internet, smart phones, Amazon, Google, Facebook, Uber, and a host of others. The new generation of innovation is software-fueled innovation. It's still innovation, but it's different because of the software.

    Software makes it different

    Airplanes were invented by the Wright brothers, who were experts in bicycles. Anyone could see everything important about the device they built, and even basically understand it. The same holds true for all the innovations up to and including early computers: you could see the card readers, the plugs, and the vacuum tubes. But then things got tough.

    Once complex circuits could be built on a chip, you could see the chip, but not the millions of electronic devices on it. Even worse, you can't see the software that may process billions of instructions on the way to getting something done. You can view the "source code" of a piece of software, but how many people can read it with understanding? Software has piled up over the years, so that today, new software is built on the foundation of millions of lines of code that is in older software, the foundation without which the new software could not operate. Even most modern software "experts" have never seen that code that's "under the surface" of what they write. They don't understand it and couldn't write it themselves.

    Software is a new world, invisible to the majority of normal people, and only partly visible to the vast majority of people who call themselves programmers. Software is a new world, and startups that are fueled with software have new rules for success. Well, not entirely new rules. But they're different enough that most startups don't understand them. Why?  No one is teaching the rules of success for software-fueled startups — least of all business schools!

    That's why I wrote the book. I don't know all the answers. But I have figured out a bunch of them from twenty years of closely examining software-fueled startups, partly as a programmer, but mostly as a technically-oriented investor.

    Applied common sense

    Many of the things I point out in the book sound like simple common sense. But it's not common at all. For example, "solve a problem a customer knows he has" sounds like the dumbest of not-needed advice. But in practice, it's one of the least-commonly-followed dicta you can imagine! Here's an excerpt from the book on that subject.

    Solve a problem the customer knows he has

    This one is so obvious it may sound like a joke; why would a company try to sell a solution to a problem a customer doesn’t know he has? It sounds insane! But it happens over and over again.

    People who come up with new things are often pretty smart. They tend to be imaginative, and see past the here-and-now. They can create abstractions easily, and find the commonalities among apparently unrelated things. They’ll see an obstacle or limitation in a business, or a way to make it much better. They’ll put together a way to remove the obstacle, overcome the limitation or implement the enhancement. They will typically be pretty excited about what they’ve accomplished. Then they’ll try to sell it, get frustrated, and before long they’ll be venting about stupid customers who can’t see past their noses, who will refuse an offer to pay a dollar to get five in return and who are otherwise mentally damaged. This is the typical result of solving a problem a customer does not know he has.

    The problem and the solution may be clear to you, with your skills and ability, and having walked the path of analysis and understanding that you have. But is it clear to the average customer, without either injecting him with brain-enhancing drugs or putting him through a multi-week education course?

    Should you be smarter than your customers? Maybe. But if you are so far "ahead" of them that you insist on selling them a scratching service for an itch they don't feel, maybe you're "too smart," and should get over it.

    This is one of the dozens of things that are obvious in theory, but hard to get in practice. The book has lots more.

    Common sense that doesn't work

    On the other hand, there are some widely accepted practices that are sure-fire ways to fail at a startup. Here are a couple that are described in detail in the book:

    • Understand the market. Bad idea. The "market" is what is there today. You're building something new.
    • Make your tactics match your strategy. One of the worst commonly-accepted notions. It seems to make sense, but it leads to failure.
    • Assure that you have a sound strategy. "Strategy" is a time sink that sucks valuable resources away from the effort to win. "Step Theory" (read the book) explains why.

    Conclusion

    I've had an insider's view of hundreds of software-fueled startups over multiple technology cycles. One of the most striking things I've learned is the winners do things the "wrong" way in the eyes of most experts. That's how they win! Of course, it's got to be the right "wrong" way that wins, not just any old wrong way; there are plenty of wrong ways that are losers…

  • Healthcare Innovation: EMR Procurement is Broken

    Computers and software get faster and less expensive at a dramatic rate. Healthcare systems implementing computers and software gets slower and more expensive at a dramatic rate. Why is buying the thing getting so much worse at the same time as the thing being bought is getting so much better?

    There is only one explanation: the procurement process used by the large organizations is broken. Badly. It doesn’t need “improvement” or “innovation.” Today's standard procurement system needs to be thrown out. We need to start over.

    Improving Computers: Incredibly complex, successful

    It's just unbelievable how much better, faster, smaller and cheaper computers get. The rate of improvement is unprecedented in human experience. Nothing comes close.

    Chart _0002

    Even software that used to be unavailable or expensive to buy is free! Think "open source," for example.

    Procurement of computers: Basically simple, a worsening mess

    Most large organizations are just awful at building, acquiring and implementing computer hardware and software. It's not getting better.

    Chart _0001

    How do these organizations respond to their screw-ups? They look closely at what went wrong, "improve" the process … and make it even worse.

    Back to paper

    Organizations really try to make it work. The US Coast Guard, for example, embarked on a project to plan the implementation of a leading EMR in 2010, and committed $14 million just to do some planning. Six years later they cancelled it:

    11 coast

    They knew something was really wrong, not just the usual wrong stuff. You know things are tough when they go back to paper:

    111 paper

    On the other hand, they can provide all the health services their members need with paper alone! Tells you something about today's EMR's, doesn't it?

    New York City's HHC EMR procurement

    NYC's public hospital system is big. They're also a pioneer in using EMR's. They've won awards because of it, and gotten $200 million from the feds for achieving full "meaningful use" status with it. They go way beyond just electronic recording; they manage diseases, do screening, and lots of advanced things. See this from a January 2013 HHC press release:

    1 EMR pioneer

    By their own report and by the judgment of important institutions, HHC has this EMR thing nailed!

    HHC has bigger problems than EMR. It is in big financial trouble, and it's getting worse. See this report from late 2013:

    2 big loss

    They've got an industry-leading, award-winning, value-enhancing, WORKING EMR, and huge financial troubles. Sounds like an ideal time to buy a new, system-wide EMR, right??!!

    Well, that's what they did. In same early 2013 press release in which they bragged about their wonderful existing EMR, quoted above, they announced they were buying a new one:

    1 new EMR contract

    A close reading of the press release leaves one wondering why they had to have a new one: the touted wonders of the new system line up pretty well with the wonders of their award-winning existing system. I guess they really hankered after that new-EMR smell. And with the big award from the feds, $200M of the $302M is already paid for, leaving just pocket change to pay for it!

    But then, less than a month after this press release, HHC issued an RFP for extensive additional services. Here is a list of the consultant skills they wanted to hire:

    1 required hiring

    Strange. I got the distinct impression from reading the press release about getting Epic that the $302 million covered everything. What's this about?

    The July 2015 board meeting of HHC had an update on how things were going. Things weren't working out too well on the cost side; those numbers are millions, by the way:

    1 764 million total

    Wow. Just a bit more that $302 million. Digging a little further in the Board minutes, we find a little about the $113 Million. Here's the summary:

    20 vendors

    Or maybe not — this $119 million is for consultants, not FTE's, and it's per year — the surprise on-going cost of getting that shiny-new-EMR-system smell into the hospital! And you have to notice that 20 vendors will be awarded contracts — because everyone knows that having lots of temporary people from lots of vendors working on a single project is the proven way to maximize coordination and minimize surprises. Sure.

    Oh well, at least things are "under control." Or maybe not. Just a month later, in August 2015 we learned:

    2 firing

    And the dates? Let's talk about something else, because "full operation by 2017 for all users" is history, along with the $302 million cost and lots of other things for this troubled system.

    Conclusion

    HHC is a nice, big, fat example — but it's not unusual. This is what EMR procurement is like, over and over again. The buyers just keep shuffling ahead to the painful and prolonged slaughter, like cattle. Few organizations are as smart as the US Coast Guard, and decide that paper is just fine. Big-organization procurement in general is broken, and EMR procurement in particular is badly broken. Every attempt to "fix" it seems to make it worse. The procurement process needs to be thrown out. We need to start over.

    But start over with what? I will summarize how in forthcoming posts. But it's not mysterious. It's just an application of the proven methods described in my books and summarized in various posts on this blog.

  • Healthcare Innovation: Can Big Data and Cognitive Computing Deliver It?

    Most people seem to agree that healthcare is ripe for innovation, and badly needs it. Lots of people are talking up two potential sources for that innovation: Big Data and Cognitive Computing.

    I'm strongly in favor of data, the bigger the better. But is the Big Data movement going to make a difference? I'm strongly in favor of cognition, computing, and computing that is smarter rather than dumber. But is the Cognitive Computing movement likely to make a difference? Here's a summary of some thoughts.

    Process Automation and continuous improvement

    Here is a description of the core process automation process implemented by a company I've invested in, Candescent Health. It describes the process that can and should be applied to all of health care.

    The point isn’t that there’s data and analytics – the point is that there’s a closed-loop process of continuous improvement where actions are based on rules. This is the framework that is required to make anything happen. Without it, you can’t put your proposed new clinical action into practice with double-blind A-B test and see if the results of your analytics actually deliver benefits in the real world! Or even just deploy it!

    How about just making the basics work?

    Here is the story illustrated by Mt Sinai hospital about how everyone focuses on “innovation” and fancy new things, when just having the computer systems run reliability has a huge impact on patients – and unless those systems run, the results of fancy new analytics can’t be delivered to benefit patients.

    If the car won't start or run reliably, who cares how good the fancy sound and navigation systems are?

    How about making the computers work?

    I love data and analytics. But doesn’t it make sense to focus on getting the operational computer systems to actually run well before moving on to the fancy stuff?

    Paying top dollar for computers doesn't make them work

    In fact, just about anything you do with healthcare data that is going to be brought to the front line of care requires functioning computer systems to be able to pull off – the big healthcare systems pay Greenwich CT prices and get trailer park results.

    Clean data isn't easy to get

    Both data warehousing and the fancy new Big Data movement share the under-appreciated problem of getting good quality data in analytics-ready form. Sounds simple, but the difficulties make progress a grinding crawl on many efforts. See this for example.

    Big data sets tend to have Big problems

    Massive data sets have built-in problems that make it hard to get actionable results.

    AI: How about under-promise and over-deliver for a change?

    Skepticism about Cognitive Computing in health care is warranted. There is a rich history of over-promise and under-deliver for AI efforts in general.

    Real-world solutions waiting to be automated

    Meanwhile, there are proven gems in the medical literature just waiting to be disseminated to the front lines of health care via point-of-care computer systems that are languishing in journals.

    What can make a difference?

    There are lots of practical, tangible ways to make things better, in spite of all the obstacles to change pervading our healthcare system. Here are some examples of people doing the right thing, all them with investments by Oak HC/FT:

    • Candescent delivers better imaging results with less expense by applying basic continuous-improvement workflow automation.
    • VillageMD delivers better results with lower cost by feeding back results and advice to PCP’s.
    • Aspire delivers better results at lower cost for end of life – by having one person be in charge, managing everything from the patient point of view.
    • Quartet makes a difference by applying behavior health as needed to help other conditions.

    These companies embody some common themes:

    • Knock down the silos, have a patient-experience-centric point of view.
    • Applying common sense has huge benefits.
    • Focus on delivering results to the front line (patient) is hard but necessary.
    • A system of continuous learning and delivery is a pre-condition to delivering any results of analytics for patient benefit.

    Conclusion

    The big hot topics in healthcare of Big Data and Cognitive Computing are little more than fashion statements. Data, of course, is a good thing; so is having computers do smart things. But without doing some basic blocking-and-tackling and applying some practical common sense, a great deal of time, money and energy will be spent accomplishing nothing.

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