Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the Government and Corporate America want them to have.

Up until this point, the momentum has been with the payers, Medicare and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash is becoming.

It will come down to this, a kind of “straight face test” for health care: Would patients pay for this?

The Annual Wellness visit, better named “Medicare’s Non-Physical” and some forms of “Population Management” are examples. Both are great ideas; an annual health review and planning session as well as doctors maintaining an overview of, and reaching out to, high risk groups of patients – in theory neither would be anything to argue with.



Optimized-roblambertsnew2015 was a hard year for my father.  He’s a remarkably healthy 89 year-old, with no diabetes, no hypertension, and (most importantly) he’s got a sharper mind than I do on most days.  Perhaps that’s a low bar to cross, but it’s pretty good for him.  I think this is from all the crossword puzzles he’s done over the years.

Dad’s troubles started around the middle of the year when he started having low back pain. This pain progressed from mild pain to being so severe that he required a wheelchair to get around the house.  This is the man who, a year after breaking a hip, was impossible to keep off of a stepladder to fix something on his roof.  It was a big change.  After trials of conservative treatment, he was eventually diagnosed with a compression fracture of his lumbar spine (presumably from steroids he took for an inflammatory problem).

Given the severity of his pain, he ended up going to a back specialist to get a procedure to fix the compression fractures and, presumably, reduce his pain.  Unfortunately, his pain increased and changed after the procedure.  It got so bad, in fact, that he ended up being hospitalized in November for pain control.

The hospitalization was confusing for both him and me.  It wasn’t clear if his pain was from a problem in his back, as it had moved to his leg.  Yet while in the hospital he didn’t get any radiological study to determine the source.  Plus, he’s quite resistant to the effects of narcotic pain medications.  I really don’t like to intervene on behalf of family members unless it’s absolutely necessary, but I finally ended up talking to the hospitalist who was quite nice, but not much help.  Dad was being discharged to rehab the next day and I still wasn’t clear on what was wrong after a week in the hospital.


Screen Shot 2016-01-05 at 1.50.48 PMSix months ago, I made the decision to join a digital health startup, after directing the inpatient EHR roll-out at the University of California San Francisco (UCSF) Benioff Children’s Hospital. This may not seem that surprising: there is a lot of discussion lately of the growing dissatisfaction among doctors with the healthcare system, and “digital dropouts” leaving medicine to work in tech.

The difference is that I am neither 28 nor right out of residency. I’m a 40-year-old healthcare executive who is squarely mid-career, and I did not make the change for the usual reasons: the lure of money, job dissatisfaction, etc. I loved my job at UCSF, and in fact, I continue to see patients there. So why did I leave a promising academic career for a riskier role at a startup? Because we need more seasoned clinicians at the front lines of digital health to get us to scale. Our institutions have made huge financial investments, and now it’s time for us to make a more personal commitment.


Screen Shot 2015-11-25 at 11.58.31 AM

I’ve had the great privilege of presenting our virtual care company, CirrusMD, to potential customers and investors at some of the premier health technology conferences this fall, making the cut for both the Health 2.0 Traction event and this week in the finals of the mHealth Summit and HIMSS Venture+ event. (Breaking: we won the mHealth Summit and HIMSS Venture+ mature startup company award!)

Still, we often get an initial response, “Who needs another telemedicine company with the likes of Teladoc and American Well raising big rounds this year?” One writer even went so far as to share the thought in Forbes on the fragmentation of the digital health landscape after Health 2.0.

I want to take the opportunity to use an analogy to explain why were are different from other telemedicine offerings on the market, and why we are getting such great traction and recognition. In fact, we’re working to “unfragment” the healthcare landscape by closing up some very loose ends that occur in a typical telemedicine experience.


Over the last half decade, the Federal Government has successfully convinced a majority of physicians and hospitals to begin using electronic health records by providing $30+ billion dollars in subsidies to those who use an ONC Certified electronic health record (EHR) according to the “Meaningful Use” guidelines.

Although the physician community usually consists of a multiplicity of dogmatic opinions, on the subject of Meaningful Use (MU), there is now near unanimous agreement that the MU train has not succeeded in achieving its intended purpose, which was to improve quality or reduce the cost of healthcare. Earlier this month, 111 medical organizations, led by the AMA, sent a letter to Congress asking that MU Stage 3 be delayed and MU Stage 2 be redesigned.

Dissatisfaction with MU even extends to the Chief HIT Geek, John Halamka, M.D., who has concluded MU “Stage 2 and Stage 3 will not improve (health) outcomes” and has called to “Replace the meaningful use program with alternative payment models and merit-based incentive payments.”

In an attempt to objectively assess the MU program, I put together a list of reasons to help me determine whether the MU program should be continued or terminated:


Screen Shot 2015-11-10 at 9.34.40 PM

Leonard Kish, Principal at VivaPhi, sat down with Ed Park, COO of athenaHealth, to discuss how interoperability is defined, and how it might be accelerating faster than we think.

LK: Ed, how do you define interoperability?

EP: Interoperability is the ability for different systems to exchange information and then use that information in a way that is helpful to the users. It’s not simply just the movement of data, it’s the useful movement of it to achieve some sort of goal that the end user can use and understand and digest.

LK:  So do you have measures of interoperability you use?

EP: The way we think about interoperability is in three major tiers. The first strata (1) for interoperability can be defined by the standard HL7 definitions that have been around for the better part of three decades at this point. Those are the standard pipes that are being built all the time.  So lab interoperability, prescription interoperability, hospital discharge summary interoperability. Those sort of basic sort of notes that are encapsulated in HL7.  The second tier (2) of interoperability we are thinking about is the semantic interoperability that has been enabled by meaningful use. The most useful thing that meaningful use did from an interop standpoint was to standardize all the data dictionaries. And by that I mean that they standardized the medication data dictionary, the immunizations, allergies and problems.


flying cadeucii The electronic health record (EHR) is now used by the majority of physicians during every patient encounter. The EHR has become the most important tool in our “black bag” and precisely for that reason, the EHR must be highly accurate and free of bias. As our most heavily utilized tool, the EHR must also be flexible and highly optimized so as to ensure it does not adversely impact the delivery of healthcare. Unfortunately, numerous surveys have found widespread physician dissatisfaction with EHR design.

The fact that EHR programming code is shielded from objective scrutiny by independent evaluators increases the risk that the EHR will contain errors and bias which could adversely impact our patient’s health, hinder our ability to deliver healthcare, “warp” the design of the healthcare system and drain financial resources from our patients and society.

EHR “errors” are well documented in the literature and are referred to as “e-iatrogenesis” or “technology induced” errors. “Bias” in EHR programming code is not discussed in the literature.


flying cadeuciiThe SEC has finally finalized its crowdfunding rule (presser) under the JOBS Act. The health innovation crowdfunding crowd has been waiting for these rules for quite some time, as has the rest of the crowdfunding fan club. (It’s only taken three and a half years.)

So, was it worth the wait?

The crowdfunding rule (full text) sets the stage for broader participation in early-stage investing and may empower crowdfunding platforms (“intermediaries,” in SEC-speak) to compete with angel funding platforms servicing “accredited investors” (SEC-speak for high net worth folks who can afford to lose their entire investment in a startup). It is a democratizing move consistent with the ethos of the internet and digital innovation.

Let’s look at some of the particulars and then think about whether this is a good thing for startup companies (“issuers”) that might want to sell securities rather than their products or promotional T-shirts, and for intermediaries — such as Kickstartr etc. — that might want to have a role in matchmaking individual investors with issuers. (Kickstartr itself has reportedly said it’s not interested in going down this path; IndieGoGo is interested, though.)


LudditeWe all know Luddites.  They proudly pronounce their rejection of Facebook and feign disgust about how they finally “broke down” and bought that awesome Motorola Razor they still carry. Maybe you are a Luddite or pretend to be because you can’t make Gmail work on your phone. So who was this Ludd and why is he the timeless symbol of rage against the machine?

My guess was that the original Ludd was probably some horse breeder that bet the farm against the future of the automobile. As it turns out, the Ludd story is not at all what you’d expect.

Legend has it that in 1779, a fed up British factory worker named Ned Ludd took his aggression out against the knitting machines he was employed to operate, smashing two of them to pieces with a hammer. In this one brazen act of defiance, he became the symbol of man’s rebellion against automation, technological displacement, the death of artisanship, and the worsening conditions of the working class.

Not long after, as the Industrial Revolution gained steam (terrible, I know) young Ned became the poster boy, quite literally, for factory worker uprisings each of which was punctuated with the destruction of machines.

The Luddites met in secret and their operations ranged from sabotage to all out warfare, including a battle with the British Army. They became so fearsome that industrialists had secret chambers constructed in their factories in which they could hide should the Luddites come knocking. Fearing that the name “Ned” lacked gravitas, his PR team apparently took to branding him King Ludd or General Ludd.


Screen Shot 2015-10-11 at 8.15.56 AM

I am an IT geek physician. I have my an EHR which I created and control.

Today, I wanted to understand my diabetic practice a little more, so I dumped all my HbA1c data out of my EHR and into a spreadsheet where I was able to manipulate the data and learn a few things about my practice.

I learned that:

If my patient had a HbA1c ≥ 8, the likelihood that the HbA1c would be < 8 at the next visit is 68%.

If my patient had a HbA1c ≥ 8, the likelihood the HbA1c would be even higher at the subsequent visit is 29%.

If my patient had a HbA1c ≥ 8, the average change in the HbA1c at the next visit was -0.7.

If my patient had a HbA1c < 8, the likelihood that HbA1c at the subsequent visit would exceed 8% would be 15%.