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Remembering Thomas E. Kurtz

By MIKE MAGEE

This has been a challenging week for me, but not for the reasons you might think. Compartmentalization skills have allowed me to push the 2024 Presidential election into the back reaches of my mind as I worked to complete teaching a course on “AI and Medicine” at the Presidents College at the University of Hartford. The complexity of AI, its risks and potential benefits, are staggering. So it was comforting for me to remember how far we have come with data and information in my own lifetime. That reminder came wrapped in the loss of one of the great pioneers in the field.

The week of my final AI lecture began with the announcement of the death of 94 year old Thomas E. Kurtz. You may not have heard of him, but you likely recall his seminal invention, the first computer programming language for the masses–BASIC (Beginners’ All-purpose Symbolic Instruction Code). As Bill Gates himself reflected this week, “The approachability of BASIC and time-sharing began what the PC and the internet took to a whole new level.”

Bill would know. His high school had a teletype connection to the original time-sharing main frame computer at Dartmouth. But Gates was not alone or first in line. As Kurtz remembered, “I once estimated that even before Bill Gates got into the action at all, five million people in the world knew how to write programs in BASIC. There was something like 80 time-sharing systems in the U.S. that offered BASIC as one of their languages. And it was all over the world. I even got a letter from somebody in Siberia.”

It wasn’t until 1978 that Gates teamed up with Microsoft founder, Paul Allen, and received permission to install BASIC in the first customizable personal microcomputer, the MITS Altair 8800.

Kurtz was the son of German immigrants, and displayed high aptitude in mathematics early in life. He graduated from a local college in Illinois in 1950, and by 1956 had earned a PhD in statistics at Princeton. He was recruited to Dartmouth that same year by the chairman of Mathematics, John Kemeny, who had previously been a research assistant at Princeton himself under none other than Albert Einstein. Kurtz launched a new field at Dartmouth that year – computer science.

He was starting at ground level – or more accurately, below ground level since the solitary computer the university possessed was housed in the basement of College Hall where it filled an entire room. Training students in computer science required hands on engagement. As Kurtz explained some years later, “Lecturing about computing doesn’t make any sense, any more than lecturing on how to drive a car makes sense.”

In later interviews, Kurtz make it clear that his idea didn’t meet with applause at the outset. He admitted, “The target (in computing) was research, whereas here at Dartmouth we had the crazy idea that our undergraduate students who are not going to be technically employed later on should learn how to use the computer. Completely nutty idea.”

Two barriers at the time were computer language and computer time. The main frame on campus ran on complex FORTRAN and COBOL which only a few experts had mastered. And if you wanted access, you had to wait in line.

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Tatiana Fofanova demos Koda Health

Tatiana Fofanova is the CEO of Koda Health. She is dealing with one of the most difficult parts of health care. How do you get patients wishes in the case of end of life or other critical illness made in advance and delivered to medical professionals? Koda Health has not only figured out how to get this option to patients but also include the responses into Epic and other EMRs so that clinicians can see advanced directives and much more. She gave me a full demonstration of what is a very important and necessary tool — Matthew Holt

THCB Gang Episode 145, Thursday November 21

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday November 21 at 1PM PT 4PM ET are regulars delivery & platform expert Vince Kuraitis (@VinceKuraitis) &  JL Neptune MD, now at Memora Health, digital health investment banker Steven Wardell (@StevenWardell); and longtime startup and corporate digital health exec Adam Kaufman (@adkaufman) who also writes the Bearing.on Health newsletter.

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

Epic’s Consumer Strategy Is Bold. Its Tactics Push The Boundaries.

By SETH JOSEPH

This is part 3 of Seth’s series about Epic that has generated much interest and a little controversy and we are happy to host it on THCB. Part 1 and Part 2 were published on Forbes earlier this year.

According to people in the room, Judy Faulkner’s vision on stage at Epic’s 2022 User Group Meeting was epic, in the grandest sense of the word. 

The company, which had grown as a unified clinical and billing EHR system, was now laying out a roadmap in which it would be the digital front door for all things consumer facing. A massive panoply of capabilities including, according to Epic’s own subsequent documentation, customer relationship management, provider finders and online scheduling, online check-in, patient financial experience, and many others. 

Core to enabling all of this was shifting how patients interact with MyChart, the patient-facing application that allows individuals to access their health records. 

Historically, each MyChart account was ‘tethered’ between an individual and a hospital system and represented a simple portal for the individual to view her records. If an individual had been seen at multiple different hospital systems, then she would have multiple separate MyChart “instances”, or entirely separate accounts and logins. 

Now, Epic would ‘stitch together’ the health records and data from different hospitals on behalf of the individual in advancing what colloquially has been called Epic’s ‘national MyChart strategy’, and enable robust new functionality, creating compelling network effects between consumers and hospitals.

There were only a few problems with Epic’s strategy: first, many customers weren’t asking Epic to develop these capabilities; second, there were startups and incumbents already providing many of these capabilities; and third, the company was in a race with a federal agency, which was pushing for open standards and access that threatened Epic’s plans. 

But for a company that had slowly and steadily become the dominant health technology player, whose staff meetings for a period ended half-jokingly on a slide with the words “World Domination” on them, these problems were all fixable. 

The Promise Of Consumer Empowerment Tools

As modern history has demonstrated time and again, the ability to own or control the consumer entry point for technology can be a strategic advantage. Apple’s sleek product designs, user experience and tight ecosystem enable it to extract 30% of app developer revenues seeking to reach Apple’s users. Google’s dominance in search has positioned it to be the entryway to the internet for billions of consumers regardless of their ultimate destination, resulting in extraordinary revenue growth and profitability. 

In healthcare, the ability to meaningfully engage consumers through technology has long held promise of solving intractable problems, while also potentially positioning the firm that figures out how to do so as a new locus of power, similarly as Apple and Google above. Triaging care options for consumers, navigating them to lower cost services, facilitating payments, and providing modern convenience options are just a few of the hundreds of use cases that consumer-facing technology holds.

Key questions facing the firms seeking to find healthcare’s holy grail are how best to do this and where to start, as consumer habits and sentiment toward healthcare has proven challenging for tech companies to figure out. 

For instance, tech giants Microsoft and Google had both placed significant bets on ushering a new era of consumer empowerment in the late-2000s, with Microsoft HealthVault and Google Health. Known as patient health records (PHR), the two companies sought to enable consumers to access, aggregate, store and potentially share their health records. 

In retrospect, Microsoft and Google’s efforts were perhaps a bit too early, as both initiatives were shut down in the early 2010s, before an ecosystem of health technology adoption, connectivity and capabilities that could have feasibly supported their vision. And before consumers had a compelling reason to change their own use of technology to engage in their healthcare.

By 2022, however, the ecosystem had arrived. After the EHR Incentive program, more than 90% of doctors and hospitals had EHRs. The Covid-19 pandemic drove rapid adoption of telehealth by both physicians and consumers. Approximately $100 billion in venture capital had flowed into health technology innovation. New price transparency policies were shedding sunlight into formerly opaque and labyrinthine contracting practices. The 21st Century Cures Act put teeth into driving interoperability, introducing information blocking as a civil penalty with million dollar fines. One industry group published a report titled “Unbundling Epic: How The EHR Market Is Being Disrupted.” This author proclaimed The EHR Is Dead.

If the EHR was dead or being disrupted, then every EHR company needed a survival plan.

Epic’s Fear And Unfair Advantage

According to one hospital executive, it was this backdrop that concerned Epic’s leadership: with a rapid influx of new players and a shifting balance of power, Epic might be relegated to “just being the pipes” while others capitalized on new opportunities. Given the company’s rigid belief – proven correct time and time again – that it alone would deliver the best results for its customers and consumers, Epic thought such an outcome would be a disaster. 

To combat this risk, Epic by mid-2022 had a new strategy with MyChart and network effects at the heart of it. 

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Take a deep breath: Trump may not mean that much change–for health care, that is

By MATTHEW HOLT

At some point I had to crawl out of my hole and put pen to paper on the election debacle that just took place, and what the ensuing lunacy might be like for the health care system. So this is my attempt to do just that.

It’s really hard to understand why Trump won this election or why Harris and the Democrats lost. There was a lot of weirdness going on. Remember that before the vote Harris was generally praised for running a steady campaign, the Democrats had tracked to the right on immigration (trying to pass what IMHO was a horrendous bill ), and Harris kept talking about having a Glock, being a prosecutor and campaigned with a Cheney. The swing states (which vote at a much higher proportion than everyone else) all (with the narrow exception of Pennsylvania) voted for Democratic senators. For President they only went 3% against where they were in 2020. Even weirder was that hundreds of thousands of Trump voters didn’t appear to vote down the ballot at all. Yet nationwide the swing was big enough for Trump to win the popular vote. (If you really want to dig in, Charles Gaba has put together a great spreadsheet)

The simplest explanation is that the teeny middle in American politics voted against the incumbent. And the “middle” is getting teenier. In 1964 Johnson got 61% of the vote. Nixon (1972)  and Reagan (1984) won with nearly 60% of the vote. Obama’s big 2008 victory was with just 53% of the vote and he won by 7%.

Biden won in 2020 with just over 51% and Trump will end up winning while likely getting just less than 50% of the vote. This isn’t an overwhelming mandate. It’s a small minority of voters switching because they are pissed off with the status quo. This year the bug bear was inflation, which really wasn’t Biden’s fault even though he got the blame. It also appears that a decent slug of Arab-Americans and far left Democrats stayed home or voted for Jill Stein because of Gaza.

And let’s not forget the impact of the Electoral College which reduces turnout outside of swing states (not exclusively). Surely if we had a popular vote in which every vote counts, turnout would be higher, including in the big 2 states that are Dem strongholds (NY & CA).

However, even if you think it’s inconceivable that a majority would vote for Trump because of what happened in 2016 to 2021 (especially on January 6, 2021!), apparently that’s not enough of a disqualifier. He’s going to be President.

So what happens next? Particularly in health care.

My expectation (and hope) is that this is a snake eating its own tail. There are so many repugnant egos circling around Trump that it’s more than likely they’ll turn on each other, and little to nothing gets done. That doesn’t mean nothing will happen.

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THCB Gang Episode 144, Thursday November 14

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday November 14 at 1PM PT 4PM ET. Today we have also a special guest – former Permanente Medical Group CEO Dr Robbie Pearl @robertpearlmd. Robbie has been diving into AI in his latest book ChatGPT-MD and we’ll be chatting about that as well as his forecasts for health care post election.

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

THCB Gang Episode 143, Friday November 8

Joining Matthew Holt (@boltyboy) on #THCBGang on Friday November 8 are THCB regular writer and ponderer of odd juxtapositions Kim Bellard (@kimbbellard); Principal of Worksite Health Advisors Brian Klepper (@bklepper1); patient safety expert and all around wit Michael Millenson (@mlmillenson); and digital health investment banker Steven Wardell (@StevenWardell). There may well be a discussion about an election.

You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

Inventors (and Innovators) Wanted

By KIM BELLARD

I thought about writing about the election, but I’m too anxious – and a little terrified – about it, so I’ll take a pass. I was intrigued by Oracle Health’s promise of an AI-driven, “next-generation” EHR, or the news that OpenAI was introducing ChatGPT search, but I felt that each was inevitable and yet that both would prove underwhelming in the short term.

So I decided to write about invention.

The November issue of IEEE Spectrum magazine is all about invention, starting with the tantalizing overview Why the Art of Invention Is Always Being Reinvented. “Invention doesn’t come from some innate genius, it’s not something that only really special people get to do,” says Stephanie Couch, executive director of the Lemelson MIT Program

Still, authors Eliza Strickland and Peter B. Meyer warn, “…the limits of what an individual can achieve have become starker over time. To tackle some of the biggest problems facing humanity today, inventors need a deep-pocketed government sponsor or corporate largess to muster the equipment and collective human brainpower required.”

Tell that to UTEP student Tayia Oddonetto. While an undergraduate, she had an epiphany. “During class, the professor said that if someone discovered how to turn brine, water with a high salt concentration, into something of value, it’d be revolutionary for the planet. At that moment, I told myself I was going to be the one who found the solution for brine, and that thought has never left me.”

And she did it. Instead of the more common reverse osmosis (RO) method of desalination, which at best converts 85% of salt water into fresh water and leaves a problematic 15% of concentrated brine, Ms. Oddonetto used something called salt-free, electrodialysis metathesis. As the press release describes it: “Salt-free electrodialysis metathesis treats brine by passing it through ion exchange membranes, thin sheets or films, and electrical currents that work to separate salt from water at the molecular level.”

Her approach produced over 90% fresh water, and generated higher levels of valuable metals and minerals that can be repurposed across several industries including technology, health and food.

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Patty Hayward, Talkdesk

Patty Hayward is GM of Healthcare and Life Sciences at Talkdesk. Talkdesk runs the technology for contact centers that helps companies across health care connect and manage their consumers. You’ve probably unknowingly used their technology when you call (or now text or email) your health plan, your provider system or call into one of those numbers on the drug adverts. Patty told me about the business of technology for contact centers, and how the transition is happening between voice to text and for that matter from on-prem to cloud. They’re also deeply integrated with Epic. Pretty interesting view into a not-often-thought-about part of the puzzle.–Matthew Holt

Andrea Ippolito, CEO, Simplifed

Andrea Ippolito has combined her personal experience as a mum struggling with breast feeding, and her professional career as an entrepreneur and engineer at Athenahealth building integrations with EMRs. She’s now the CEO of Simplifed which has built a network of lactation consultants, and much more, and has placed it in the workflow of that most important part of health care — pre and post partum. How did she do it and what’s it like? She told and showed Matthew Holt.

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