We’re seeing a trend of late, where matters in healthcare once deemed to be civil in nature are turning criminal. We see it for nearly every polarizing health issue, from abortion to opioids. And it’s affecting vulnerable patients the most.
We have two separate systems in place, civil and criminal, because we have different standards of behavior. Civil laws determine whether undue harm was caused by one party to another. Criminal laws determine whether someone committed a crime. The threshold is distinctly different. If someone is caught driving ten miles over the designated speed limit, that person committed a civil infraction of traffic laws. But if someone is caught speeding well in excess, say thirty or forty miles over the speed limit, while driving recklessly, that person committed a crime. The extent of the violation determines the applicable law. That’s why traffic laws have distinct civil and criminal laws.
The same logic applies to healthcare. We have civil penalties for undue harm or malpractice and we have criminal penalties for crimes that transpire in the clinical context. The difference between the two, for something to go from civil to criminal, is mens rea, or a requirement of criminal intent.
Criminal intent implies certain violations were committed deliberately – literally as an act of crime. Normal civil violations, such as malpractice claims, offer physicians protection against liability. That protection doesn’t apply for criminal violations. And that’s the point. It explains why the sudden push by regulators, prosecutor offices, and federal agents to investigate otherwise civil matters as criminal is so pernicious.
Steve Yaskin is CEO of Health Gorilla and probably the only non-lawyer who has read the entire 21st Century Cures Act, and decided that there was a business buried in it. If we are going to fix the data access problem and then move that data to where it is needed in the patient care experience, it’s a good bet that Health Gorilla’s health information network will be a big part of that future. Steve told me about the company, its technology for patient identity and matching (among others), and what it means to be an official QHIN exchanging data using FHIR. Will consumers and providers on their behalf demand access to data? Steve & Health Gorilla have raised over $80m to bet “yes”, and are doubling revenue every year–Matthew Holt
I’ve been thinking about writing about Bluesky ever since I heard about the Jack Dorsey-backed Twitter alternative, and decided it is finally time, for two reasons. The first is that I’ve been seeing so many other people writing about it, so I’m getting FOMO. The second is that I checked out Nostr, another Jack Dorsey-backed Twitter alternative, and there’s no way I’m trying to write about that (case in point: Jack’s Nostr username is: npub1sg6plzptd64u62a878hep2kev88swjh3tw00gjsfl8f237lmu63q0uf63m. Seriously).
It’s not that I’ve come to hate Twitter, although Elon Musk is making it harder to like it, as it is that our general dissatisfaction with existing social media platforms makes it a good time to look at alternatives. I’ve written about Mastodon and BeReal, for example, but Bluesky has some features that may make sense in the Web3 world that we may be moving into.
And, of course, I’m looking for any lessons for healthcare.
Bluesky describes itself as a “social internet.” It started as a Twitter project in December 2019, with the aim “to develop an open and decentralized standard for social media.” At the time, the ostensible goal was that Twitter would be a client of the standard, but events happened, Jack Dorsey left Twitter, Elon Musk bought it, and Bluesky became an independent LLC. It rolled out an invite-only, “private beta” for iOS (Apple) users in March 2023, followed by an Android version in mid-April (again, invite-only). People can sign up to be on the waitlist. There are supposedly over 40,000 current users, with some million people reportedly on the waitlist.
For a while now Innovaccer has been aggregating data from different databases around health systems (think different EMRs). They have been overlaying information over that data to clinicians and providers for thinks like care gaps. Now they are bringing in claims data to look for patients or plan members, and of course they have their own AI chatbot to help make that data more accessible to clinicians and administrators. Chief Innovation Officer at Innovaccer Anil Jain, who in a former life was at Cleveland Clinic spinoff Explorys (a data pioneer that got sucked into IBM), told me about Innovaccer’s tech and where the providers and payers using their tools are now — Matthew Holt
I first became aware of Casey Quinlan in 2017, when she published an article in Tincture, which I was helping to edit. In it, she discussed how she’d had her medical history and advance directive tattooed on her chest, out of frustration with the lack of health information exchange in healthcare. As she said, “ALL. THOSE. FUCKING. FORMS. ON. CLIPBOARDS.”
Well, I thought: she sounds like an interesting person.
I started following her on Twitter, enjoying her outspokenness and agreeing with many of her points of view. Then early in the pandemic Matthew Holt started THCB Gang podcast, and I got to participate in many of them with her as a co-panelist. It was sometimes hard to get a word in edgewise, but when she was on we always knew it was going to be an extra-lively session. And the stories she could tell…
I never met Casey IRL. I never worked with her. I never even had a one-on-one conversation with her, unless you count Twitter replies. There are large parts of her life that I don’t know anything about. But, boy, the force of her personality, the strength of her will, the sharpness of her intellect, and the fearlessness of her spirit were always clear.
She fought her cancer as fiercely as she lived her life generally. We knew the end was inevitable, but it nonetheless was hard to imagine. There have been outpourings of support on Twitter, on CaringBridge, and elsewhere. I have to mention in particular the efforts of Jan Oldenburg, who was there with her near the end and also took on the various bureaucracies on Casey’s behalf when Casey was no longer able to.
Casey’s passing is a loss to her friends, her followers, and the patient community at large. And to those of us who got to know her even a little bit.
Chances are, you’ve read about AI lately. Maybe you’ve actually even tried DALL-E or ChatGPT, maybe even GPT-4. Perhaps you can use the term Large Language Model (LLM) with some degree of confidence. But chances are also good that you haven’t heard of “liquid neural networks,” and don’t get the worm reference above.
That’s the thing about artificial intelligence: it’s evolving faster than we are. Whatever you think you know is already probably out-of-date.
Liquid neural networks were first introduced in 2020. The authors wrote: “We introduce a new class of time-continuous recurrent neural network models.” They based the networks on the brain of a tiny roundworm, Caenorhabditis elegans. The goal was networks that were more adaptable, that could change “on the fly” and would adapt to unfamiliar circumstances.
Researchers at MIT’s CSAIL have shown some significant progress. A new paper in Science Robotics discussed how they created “robust flight navigation agents” using liquid neural networks to autonomously pilot drones. They claim that these networks are “causal and adapt to changing conditions,” and that their “experiments showed that this level of robustness in decision-making is exclusive to liquid networks.”
Casey Quinlan, our friend and frequent THCB Gang member, died today. She may have gone quietly but she for sure lived her life way out loud. It’s not unexpected; she was diagnosed with a recurrent stage 4 cancer two years back, and I was lucky enough to have dinner with her on a rare east coast trip last June. She was hoping to come to the West Coast late last Fall but was too sick to make it. It looked like things were getting better and she was on THCBGang in February but soon things turned and she spent the last few weeks in hospice. She leaves a huge hole in the patient advocacy movement and a huge wave of love from her friends today on Twitter. And she remains the only person who has come up to me after I gave a talk and shared a shot of bourbon from her hip flask at 9 am! The talk was about the US health care system. So we both needed it! We’ll miss you Casey… Matthew Holt
Ines Vigil, SVP Transformation & Services, Clarify Health Solutions talked with me at HIMSS23. A quick discussion about what Clarify Health does, and why the health system needs a huge database of 330m patients. Quick clue is that payment negotiations and benchmarking of clinical performance is the biggest demand, and Ines now actually heads up a consulting group that providers need to be overlaid on that data–Matthew Holt
Live and in-person once again, HIMSS 2023 attracted more than 30,000 attendees to the exhibit halls and meeting rooms of Chicago’s sprawling McCormick Place. Although no one person could possibly absorb it all, below are some harbingers of the health care future that stayed with me.
Size Doesn’t Count. Exploring the remote byways of the cavernous exhibition areas, it became clear that it’s not the size of the booth, but the impact of the product that counts. At a pavilion highlighting Turkish companies, for instance, R. Serdar Gemici stood in front of a kiosk that might fit into a walk-in closet.
The display listed an impressive roster of clients for a chronic care management platform, prompting me to stop to learn more. The smartphone user interface for “Albert,” the namesake product of Albert Health, the company Gemici co-founded and leads, immediately impressed me as one of the simplest and yet comprehensive I’d seen. (Indeed, the company website boasts of the “world’s simplest health assistant.”) Albert Health has begun working with England’s National Health Service and large pharmaceutical companies, though I found myself wondering how the name resonates in the Turkish- and Arabic-language versions the company touts.
HIMSSanity 2023! (Photo:HIMSS)
Another far-off cluster of kiosks hosted a company called Dedalus, which promised an interoperable, whole-person care platform. A demo included a graphic showing a breadth of holistic personalization and collaboration capabilities I’d not seen elsewhere. It turns out that while Dedalus only entered the U.S. market in late 2021 – which explains why, as the nice woman showing me the presentation noted, Americans mostly haven’t heard of it – Italy-based Dedalus Global’s software and services are used in more than 40 countries by over 6,700 health care organizations.
Oh.
Size Does Count. When I sat down with Dr. Jackie Gerhart, Epic’s vice president of informatics, and Seth Hain, senior vice president of research and development, at their very large and very busy booth, I had in mind Epic CEO and founder Judy Faulkner’s reputation as a tough, my-way-or-the-highway businesswoman. But Gerhart and Hain were so nice and down-to-earth, earnestly extolling the company’s culture of collaboration, that it was initially as disorienting as watching Elon Musk help a little old lady across the street. (A colleague assured me that, yes, this is actually the way many Epic employees act.)
Nonetheless, Epic remains a 500-pound gorilla, with a third of the hospital electronic health record (EHR) market. Its Cosmos platform, containing records from over 184 million patients and 7 billion encounters in all 50 states, is the largest integrated database of clinical information in the nation. The company is currently working to integrate Microsoft’s ChatGPT generative AI with Cosmos’s data visualization capabilities, which presents fascinating possibilities.
Ask around, though, and you’ll discover that not all hospitals are comfortable with Epic’s control of information. There will certainly be competitors, perhaps including the Mayo Clinic Platform.
A colleague related that many years ago big tech firms marketing their own EHRs warned prospective customers that choosing Epic meant relying on a company that might not be around very long. Instead, those competitors aren’t. Underestimating all those nice (and perhaps some not-so-nice) people at Epic would be a serious mistake.
A month ago an oncologist called and asked me to see one of my heart failure patients whose chronically swollen legs seemed unusually blue but not cold.
Before I could get him in to see me, he ended up seeing a colleague, who called me up and said the man’s legs were cool and there was no Doppler in that office to check for pedal pulses. The man was sent for an urgent CT angiogram with runoff.
The test was perfectly normal. He had clean arteries.
When I saw him, the legs were less blue than they must have been and they felt OK but he had what looked like a shingles rash around his right elbow. There was some surrounding swelling and redness, so I prescribed an antiviral, an antibiotic and prednisone and arranged to see him back.
My diagnosis was erythrocyanosis. I have never seen a case but my instinct when I saw him was that this was a peripheral thermal regulation problem. So, a little bit of searching on the Internet gave me the diagnosis.
In follow up, the legs looked fine and the elbow rash was drying up nicely.
None of my research suggested a reasonable treatment option for his condition. But he was getting better so I didn’t have to worry about it at that moment.
