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The Power of Small

flying cadeuciiEverywhere we turn these days it seems “Big Data” is being touted as a solution for physicians and physician groups who want to participate in Accountable Care Organizations, (ACOs) and/or accountable care-like contracts with payers.

We disagree, and think the accumulated experience about what works and what doesn’t work for care management suggests that a “Small Data” approach might be good enough for many medical groups, while being more immediately implementable and a lot less costly. We’re not convinced, in other words, that the problem for ACOs is a scarcity of data or second rate analytics. Rather, the problem is that we are not taking advantage of, and using more intelligently, the data and analytics already in place, or nearly in place.

For those of you who are interested in the concept of Big Data, Steve Lohr recently wrote a good overview in his column in the New York Times, in which he said:

“Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.”

Applied to health care and ACOs, the proponents of Big Data suggest that some version of IBM’s now-famous Watson, teamed up with arrays of sensors and a very large clinical data repository containing virtually every known fact about all of the patients seen by the medical group, is a needed investment. Of course, many of these data are not currently available in structured, that is computable, format. So one of the costly requirements that Big Data may impose on us results from the need to convert large amounts of unstructured or poorly structured data to structured data. But when that is accomplished, so advocates tell us, Big Data is not only good for quality care, but is “absolutely essential” for attaining the cost efficiency needed by doctors and nurses to have a positive and money-making experience with accountable care shared-savings, gain-share, or risk contracts.

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Facebook Is Bad For You. And Giving Up Using It Will Make You Happier

Giant Zuckerbergs
In the past few years, the fortunate among us have recognised the hazards of living with an overabundance of food (obesity, diabetes) and have started to change our diets. But most of us do not yet understand that Facebook is to the mind what sugar is to the body. Facebook feed is easy to digest. It has made it easy to consume small bites of trivial matter, tidbits that don’t really concern our lives and don’t require thinking. That’s why we experience almost no saturation. Unlike reading books and long magazine articles (which require thinking), we can swallow limitless quantities of photos and status updates, which are bright-coloured candies for the mind. Sadly, we are still far away from beginning to recognise how toxic Facebook can be.

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Is the Wearable Market About to Explode?

Screen Shot 2014-06-06 at 2.06.45 PM


With Samsung & Apple both making big announcements (if not actually putting out products) and more and more venture money going into trackables of all kinds–including $120m for “chip in pill” maker Proteus–in the last 10 days, there’s tons of hype about consumer tracking in lots of modalities. Qualcomm is the guts behind lots of the chips and technologies that these all use, and have seeded the market with their 2Net data utility layer. (FD I am on the Qualcomm Life advisory board but own no stock). But is the hype justified? Qualcomm Life’s President Rick Valencia is an optimist, and you’ll hear from him at Health 2.0 this FallMatthew Holt

Look around. Chances are, someone around you is wearing one right now. I’m not talking about a baseball cap or a pair of minimalist running shoes. I’m talking about a connected device—a “wearable”—a fitness band, a smart watch, a pair of smart glasses…of maybe even connected clothing.

Ready or not, the wearable market is about to explode.

Right now, fitness-related wearables dominate the market—about 90 percent according to a February CNET report quoting Accenture. But by 2018, the market will expand, to where three categories—fitness/activity trackers, smart watches and infotainment, health care and medical categories—will take over 70% of the wearable space says ABI Research. In that same year, you also probably won’t have to look too hard for someone with a wearable, research firm IDC says the number of devices out there will be 118 million.

I too think we’re only touching the tip of the iceberg with wearables. There’s a lot of opportunity out there, not just in form factors but what’s possible with function and value.

Consider fitness bands. They give users real-time feedback on performance and, if you can upload the data to the cloud, onto a platform where you can compare your latest event with previous events, they are a great way to gauge progress. In addition, these cloud-based platforms give wearable device makers a place to begin engaging with customers.

These fitness applications are great, but can we go further?

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Pharos Innovations Meets Isaac Asimov

Isaac Asimov once remarked that a sufficiently advanced technology was indistinguishable from magic.

Were he alive today, Mr. Asimov might also remark that both advanced technology and magic got nothing on Pharos Innovations, whose website reports a world-record 79% reduction in admissions for congestive heart failure (CHF) patient monitoring.

Pharos achieved this Nobel Prize-worthy result in CHF monitoring without actually using CHF monitoring devices, but rather just the telephone and that favorite tool of the frail elderly, the Internet. Most magical was the time this admission reduction took: 31 days.

On the graph below, you can see that the baseline ended December 31, 2007, while the full impact started February 1, 2008.

That means Pharos was magically able to find all these members’ contact information, write to them to announce the program, schedule the phone calls to the members to convince them to join the program, collect their information, conduct those phone calls, explain the system to the members, get them set up on the system, collect the information, get members to visit their doctors, and adjust lifestyles and medications…all during January.

Thanks to that lightning speed, there was literally a 90% decline between the December admissions rate and the February admissions rate, as this chart demonstrates.  Overall, this chart is a dramatic rebuttal to the conventional wisdom, which would state that:

  1. it takes a long time to make even the most minor improvements in a population through telephonic and Internet disease management, if indeed improvements are possible at all; and

  2. a trendline that is “unchanged” does not decline 25% like Pharos “unchanged” matched cohort trendline above.

In college Al was assigned a roommate who was like the bad seed from the Richie Rich comics, a kid who, among other things, would have a snifter of cognac before bed.  Once Al told this guy he was decadent.  “Decadent, Al?” he countered.   “Let me tell you about decadent.  I spent last summer at a summer camp –everyone was there, Caroline Kennedy, everyone – where we played tennis on the Riviera and then went skiing in the Alps.”

Al agreed he had a point.  “Wow, Lance, you’re right.  That was decadent.”

“Al,” he replied, “I haven’t even gotten to the decadent part yet.”

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Lost in the Health Care System?

Jack Cochran

“As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

“I’ve lived in the hell that is American health care…”

A devoted physician wrote these words in reaction to a recent blog post we wrote. And he is clearly not alone.

In our new book The Doctor Crisis, we report on the widespread unhappiness, frustration, dissatisfaction, and anger of so many American physicians.

We believe this crisis is real and growing; that it is an impediment to providing the care the American people need; that dealing with the doctor crisis is fundamentally patient-centered; and that the crisis has not been recognized for the fundamental threat it poses.

Our recent feature on The Health Care Blog elicited some powerful reaction:

Rob: ”In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership…”

Jeff: “Can validate what Rob has said. I’ve spent the last three years listening to physicians about the possible alternative futures for their profession, and the overwhelming desire was exactly as Rob said- an overwhelming impulse to flee…”

Some commentators wrote that doctors shouldn’t complain because they earn a lot of money, drive fancy cars and own nice homes. But that theme – accurate in many cases but certainly not all — gets us nowhere.

We think the rubber meets the road with this warning from Dr. Rob, ”…As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

Is Dr. Rob overstating it? We don’t think so. In fact, we think he has it exactly right. How can our system function properly if the level of job satisfaction among doctors continues to spiral downward?

Harris Interactive research describes the profession as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’ Has such extreme language ever been used to characterize the medical profession? Have doctors ever faced a time as turbulent as this?

Doctors are certainly not blameless as both Brian and Rob noted in their comments:

Brian: “…I’m concerned that you have framed your argument as though physicians are victims of the system rather than partial drivers of its characteristics …”

Rob: “…physicians as a group have been complicit in building this system, and so should bear a lot of the blame…”

So what needs to be done?

A crucial first step is for health care stakeholders to recognize and acknowledge the existence of the crisis. Doing so will get the doctor crisis on the national health care agenda. Unfortunately, the matter is  not currently a priority for many, if not most, provider organizations. That needs to change.

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Doctors and Nurses in a Twit about Technology Destroying Healthcare

Bill CrounseEvery workday morning I spend 30 minutes or so reviewing my Twitter feed.

By following a select group of top healthcare news observers and thought leaders, I find that Twitter works pretty well as a filter for the news events and topics that matter most to me. Over the past couple of days, I’ve been alerted to some articles about nurses and doctors who are, shall we say, quite frustrated with electronic medical records and what they perceive as a decline in the physician-patient relationship.

One of the articles that caught my attention was about a nurses’ union, National Nurses United, that has launched a national campaign to draw attention to what they say is “an unchecked proliferation of unproven medical technology and a sharp erosion of care standards” in today’s hospitals.

Of course, their agenda and real concern seems quite transparent. It is not so much about technology itself as it is a decline in the number of Registered Nurses directly involved in caring for patients at the bedside.

The nurses’ union campaign seems to resonate with another article I came across last week about the lost art of the physical exam. That article from Kaiser Health News and the Washington Post extols some very legitimate concerns about doctors who rely too much on lab tests and medical imaging to arrive at a diagnosis instead of talking to, touching, and examining the patient.

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The Perfect Storm: Health Reform and America’s Hospitals

Clinic Construction

When the Cleveland Clinic announced job and expense reductions of 6% in 2013, the healthcare sector took notice.

Did the world-renowned hospital and healthcare research center, with 40,000 employees and a $6 billion budget, really believe it did not possess the heft to take on the increasingly turbulent sea changes in American healthcare? Or was this yet another stakeholder using Obamacare as cover to drive draconian change?

Both sides of the political aisle were quick to make hay of the announcement, with conservatives blaming reform for eliminating jobs while liberals questioned the timing of the cuts when the Cleveland Clinic was posting positive growth. The answer from Eileen Sheil, corporate communications director, was apolitically straightforward: “We know we are going to be reimbursed less.” Period.

The question of reimbursement reform and the unintended consequences of the Affordable Care Act are weighing on the minds of hospital executives nationwide as independent, regional and national healthcare systems grapple with a post-reform marketplace. The inevitable conclusion that the unsustainable trend in American healthcare consumption is now at its nadir seems to have finally hit home.

These days, America’s hospitals are scrambling to anticipate and organize around several unanswered questions:

  • How adversely will Medicaid and Medicare reimbursement cuts affect us over the next five years?
  • Can we continue to maintain our brand and the perception that any employer’s PPO network would be incomplete without our participation?
  • Can we become a risk-bearing institution?
  • Can we survive if we choose not to become an accountable care organization (ACO)?
  • Will the ACO model, by definition, cannibalize our traditional inpatient revenues?
  • Can we finance and service a hard turn into integrated healthcare by acquiring physician and specialty practices?

Go It Alone or Join a Convoy?

Mergers and acquisitions remain in high gear in the hospital industry—“the frothiest market we have seen in a decade,” according to one Wall Street analyst. “Doing nothing is tantamount to signing your own death certificate.”

Many insiders believe consolidation and price deflation is inevitable in healthcare. Consolidation, however, means scarcity of competition. If we operate under the assumption that scarcity drives costs higher, we may not necessarily feel good about consolidation leading to lower costs unless mergers are accompanied by expense cuts that seek to improve processes, eliminate redundancies and transform into a sleeker, more profitable version of one’s former self.

Bigger may not always be better, but bigger seems to have benefited a select group for the last decade.

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Really? Online Reviews Could Help Fix Medicine

Screen Shot 2014-06-04 at 10.36.41 AMA basic principle of health care is that everyone strongly favors transparency – for everyone but themselves.

“Sunshine is the strongest disinfectant” is the oft-used expression that supports putting information out in the open for all to see. That said, every stakeholder in health care gets a bit nervous about exposing their own data.

They are quick to cite the potential downsides – that patients will not be able to understand the limitations of the information, that risk adjustment will be inadequate to explain why their performance looks below average, that they may actually be below average.

No one gets as nervous about public reporting as my health care provider colleagues. We worry that everyone else may game the system, cherry-pick patients, or that we might lose patients if the data look less than perfect. It’s safe to say that number of physicians who hate the idea of public reporting is greater than the number who support it.

All of which makes it that much more fascinating that some provider organizations have recently begun putting all their patient experience data – including every patient comment about every doctor – on their Find-A-Doctor web sites. “Every” actually does mean every – the good, bad, and ugly (after removal of those that might violate patient confidentiality). And they are tied directly to the physician who delivered their care.

Why would they do this? The initial response from some commentators was that they were trying to “out-Yelp Yelp” – that is, control the information that was appearing about them on the Web. In truth, the initial idea was less about controlling information than providing more of it.

Rather than living with on-line comments generated by a small subset of patients motivated by who-knows-what to write in, organizations like the University of Utah decided that they would survey all patients electronically, and post all their comments.

And they would take the chance that more data would provide a better sense of the truth.

The University of Utah health care system was the first in the country to go down this road, and they were rewarded for their creativity and courage with a very pleasant surprise. The result over the last few years has been astounding improvement in their patients’ experience with their physicians.

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Apple Enters the Healthcare Software Ecosystem

Apple Senior Vice President of Software Engineering Craig Federighi

I am writing this from the Apple Worldwide Developer Conference (WWDC) here in San Francisco, where I got to substitute for John Halamka at the Keynote (now I keep having urges to raise Alpacas); John missed the most amazing seats [front row center!].

There were many, many, many (I can not recall a set of software announcements of this scale from Apple) new technologies that were announced, demoed and discussed, but I will limit this entry to a few technologies that have implications for healthcare.

If you remember the state of digital music, prior to the introduction of the iPod and iTunes music store, that is where I feel the current state of the healthcare app industry is at; there is no common infrastructure between any of the offerings, and consumers have been somewhat ambivalent towards them as everything is a data island; switching apps causes data loss and is not a pleasant experience for patients.

Amazingly there are 40,000+ apps on the App store at Apple alone, showing huge demand from users, but probably a handful can talk to each other in a meaningful way; this is both on the consumer and professional side of healthcare.

Individual vendors such as Withings have made impressive strides towards data consolidation on the platform, but these are not baked into the OS, so will always have a lower adoption rate. If we take the music industry example further, Apple entering a market with a full push of an ecosystem at their scale, legitimizes the technology in ways that other vendors simply can’t match.

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Robots Are Coming and They Plan to Treat You like a Moron

Robots are coming
People hate to hear it, but the robots are coming and it’s only a matter of time before they start competing for skilled, white collar jobs.

Nurses are vulnerable –but before you get excited and start attacking me– so, too are consultants and bloggers. So get used to it, and figure out how you’re going to co-exist with and leverage the bots.

One of my pet peeves about robots is when their programmers try to make them act human by intentionally making them imperfect or have them simulate (feign?) empathy.

For example, I can’t stand it when the voice recognition airline rep talks in a sympathetic sounding voice when “she” can’t understand what I’m saying.

But apparently we’ll be seeing more of these little “humanizing” tricks, thanks to research from MIT that concludes that people like this kind of stuff. From the Wall Street Journalwe learn:

  • People like their therapy robots to be baby-faced
  • We feel emotionally closer to robots that sound like our own gender
  • When robots mimic our activity (like folding their arms) we like it
  • And then there’s this one:

“One study showed that people rated online travel booking and dating services more positively when the service communicated clearly that it was working for the consumer (e.g., “We are now searching 100 sites for you”) than when they simply provided search results. Surprisingly, having to wait 30 seconds for results but also receiving this communication of effort slightly increased users’ satisfaction, compared with receiving results instantaneously. Being made aware of the website’s willingness to work on their behalf made people feel that the service was sympathetic to their needs.”

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