Aug 24

HTTP Server Error 503

No available server to handle this request.

Withdrawal pangs beginning.

Aug 17

The Real Secret to Controlling Health Care Costs

Let's say you're diabetic and you're seeing your family physician for your annual checkup. Your doctor can likely tell you how you're doing compared with a year ago in managing your chronic disease.

Now, let's look at the same situation not just for you, but for the physician's entire practice. With an average size panel, that same physician has at least 100 diabetics. If you were to ask how ALL of the diabetics were doing in managing their condition, i.e. on average were they getting better or worse, there's only a tiny chance of getting an answer. Why? Because the information needed to answer the question is in the wrong form, scattered across hundreds disparate paper records which 97% of small medical practices still use. And by the way, most of the total cost in our health case system has to do with management of chronic diseases: diabetes, hypertension, etc.

In this, a medical practice is like any other business which keeps all of its records on paper. It can track down any individual transaction if it needs to, but it's basically helpless when it comes to overall measurements of performance. And that's the big problem.

What would make a difference is if the physician had patient data in electronic medical records (EMR's). Whatever the value of an EMR for an individual patient (worth a lot of discussion elsewhere), EMR's which permit data aggregation are indispensable to assessing overall performance. It's a significant peculiarity of the world of routine individual and family medical care that such aggregate performance measures are not only unavailable, but not regarded as interesting or important. No one would run a business of any size this way.

With the right kind of EMR's (not merely billing documentation modules for insurance purposes, which is what most of them are today), it would be straight-forward to determine measures of the health of a particular population or sub-population. Why does this matter? Once you can measure performance, it opens up the possibility of reforming payment systems to pay for outcomes (outputs) instead of inputs (office visits, lab tests, etc.). If a physician can improve the stability of the diabetics in their panel, they could be paid more. Even if we wanted to bas payments on this today, we couldn't; but with the right IT infrastructure we could.

Health care professionals live within a system which creates perverse incentives to do the wrong thing, and as human beings they are not exempt from the economic pressure which results. But if you change the incentives by paying to create greater health, I am convinced physician behavior would change.

Therein lies the real hope for controlling medical costs. This seemed so brilliantly obvious once it was explained to me, I marveled that it was not more widely understood, or really, understood at all, except in a few rarified provinces.

The culture of the practice of medicine is enormously resistant to this approach. There are lots of reasons.

There's a huge amount of scar tissue among physicians from generations of IT failures in health care. There's a huge amount of suspicion and misunderstanding about IT among practicing docs. You hear things like "I don't want to be turned into a data entry clerk, and I don't want some machine between me and my patients." It reminds me of what I heard from managers and executives a generation ago about personal computers. "I'm not going to spend my time typing typing at a keyboard. That's for secretaries and clerks. It's wasteful and inefficient and to what benefit."

Another contributor to the problem is an over-insistence on medicine is an art. No doubt there are plenty of hard cases in which experience, human judgment and intuition are terribly important. But there are plenty of opportunities to routinize health care and to use IT to help measure effectiveness. We have to get serious about this if there is any hope of controlling health care costs.

Comments [9]

Aug 17

Useful Krugman op-ed on relevance of Swiss model of health care to the US

Let's keep one central fact in mind about health care. The USA is the ONLY developed country in the world that doesn't provide health care coverage for all of its citizens. This is shameful and has to be fixed. Paul Krugman's NYT op-ed today reviews three principal ways other nations fullfil their basic responsibilities.

(1) Government owns and operates the health care system, like the U.K.

(2) Health care is delivered in a private system, but government pays most of the bills, as in Canada and France.

(3) There is a private system for providing health care and paying for it through insurance, which uses regulation and incentives to achieve coverage goals, like Switzerland.

The approach we're likely to see is somewhere between a weak form of #2 (private insurance with a public option) and #3. As of this writing, it is beginning to look like the public option is off the table for lack of support. As Krugman points out, there's no chance we'll wind up like the U.K. (which is not to say the U.K. system is a bad one). We might wind up like the Swiss and, with one huge exception, this would not be such a bad thing.

Achieving universal coverage per se does nothing to contain the escalating cost of providing that care. Without getting costs under control, the system will be completely unsustainable. Comprehensive health care reform requires changing the economic incentives away from fee-for-service and toward paying for results. If anything, this is going to be more difficult than achieving universal coverage. I hope to have more to say about this soon.

Comments [0]

Jul 26

Get the Artificial Intelligence Story Headline Right, Please

In the New York Times of Sunday, July 26 the headline, "Scientists Worry Machines May Outsmart Man", and photo caption, "This personal robot plugs itself in when it needs a charge. Servant now, master later?", succumb to the temptation to frame the issues facing the field of Artificial Intelligence as ones in which human hegemony over the planet is threatened by the machine. While this is a staple of bad (and some good) science fiction, the article itself, to say nothing of the underlying realities, points in a different, more mundane, but still important direction. So, stop taking the easy way out copy editors. The real problem is that new "smarter" computer-based systems may well display unwanted or harmful behavior. Think about autopiloted drones which run amok and drop their bombs on civilians or autonomous motor vehicles which jump the curve and plow into pedestrians. These are issues worth worrying about. The apocalyptic stylings of Kurzweil and others about the approaching Singularity only serve to distract attention from more relevant issues.

Comments [2]

Jul 20

Where were you when Apollo 11 landed on the Moon?

This morning on Twitter I asked "what were you doing when Apollo 11 landed on the moon." There were a fascinating range of replies. Here they are organized by age group.

Adults

Combat cinematographer in Vietnam watching kinescopes of Uncle Walter describe the landing

Working on a dissertation on Wittgenstein. He would've found the moon landing much more interesting!

Camping in the French Alps, listening to the news on the radio

In the Bronx. Watched Cronkite. Recorded sound w. alligator clips attached to TV speaker wires

On the launch team for Apollo 11, a summer hire for the Pad Section for NASA's launch support contractor Bendix

Sitting in the couch in middle of the night in Helsinki and was afraid of how deep they are going to sink.

Had a summer job sorting mail at main post office on 8th Ave in Manhattan

Teenagers

on a ship with my family, bound for Australia

attending a wedding reception where the TV was front and center. I was all of 12 but I recall it like it was yesterday.

I was 12, stayed up late to see it all...

was 11 yrs old, glued to the TV coverage and Cronkite's commentary.

was a 13 yo kid spending holidays in the countryside. Didn't have TV in the house and had to go to local bar to watch

Children

tracing the "Yellow Submarine" album cover in front of the TV at my grandparents' house.

watching tv in Spokane from the floor, a 1-year old with the mind of a 2-year old

learning to talk!

7 months old. So I suspect I was sleeping - or crying, or eating.

Comments [3]

Jul 14

The Curated Lazyweb on Super Auto Espresso Machines

My original Tweet:

Suggest espresso machine for home use, not prof. model? Short on space, fill from tap/filter. Want "Lexus", not Mercedes/Tesla. Thanks.

First, I learned the category of unit I want is a "super auto espresso" machine. That was super-helpful. It's a useful search term. Recommendations for manufacturers formed a long tail, reproduced here with a count of number of unique mentions.

Saeco 3
Rancilio Silvia 2
Nespresso 2
Kitchenaid
Handpresso
Gaggio
Braun
La Spaziale
Impressa
ECM Giotto
La Pavoni
De Longhi
Aeropress
Francis-Francis

I spent a bunch of time cruising links people supplied. Generally I find reviews to be the single most useful kind of information, but only if I think I'm reasonably matched to the reviewer. I respect coffee geeks but I am not one, and many reviews have a level of detail which is to me both irrelevant and overwhelming.

Many of these brands have many, many different models, which are hard to sort out. I did decide I did not need a ultra-expensive top of the line "all-digital" model selling for a 75% premium over the next model.

The Nespresso capsule system is ultra-convenient but can only use kinds of beans they sell. I'd need to do a taste test.

I wound up ordering a Saeco unit from Amazon, which had it in stock, again proving that the convenience of dealing with a trusted vendor that I know will ship it to me properly counts for a lot.

If you want to see the raw Tweets you could try searching on Twitter for something like "@mkapor espresso".

Comments [3]

Jul 13

Prospects for Chrome OS

Farhad Manjoo thinks the Google Chrome OS is doomed. In this case, I think he's being short-sighted.

His reasons (with my rejoinders):

1. Linux is hard to love.

This hasn't stopped Apple from being successful with OS X which is built on a similar code base. It can be done.

2. We aren't ready to run everything on the web.

We don't have to be. If enough people want to run enough things on the web, it will give Google a foothold, which is all that is needed to start. Building a successful OS is a 10 year plus proposition and needs to be judged in that light. More apps will come later. Eventually Photoshop or equivalent in web browser will absolutely happen.

3. Microsoft is a formidable opponent.

They used to be really formidable. Now they are old(er), tired, and a victim of their own success. Google can really give them a fight.

4. Google fails often.

True. But an OS is the sort of project that plays to its strengths. Mostly about engineering (though they do have to get front end right).

5. The Chrome OS makes no business sense.

Over a 10 year period, Chrome OS and the evolution of Google apps for the Web will eat into $20-30B/year of Microsoft revenue for windows and Office. That's a huge market and Google is going to take a big piece of it, even as total market size shrinks.

Comments [2]

Jun 28

Ruminations on the Future of Newspapers

When by happenstance Nicholas Kristof of the New York Times became my 10,000th follower on Twitter, I made a little joke about it; he kindly reciprocated and also asked me about he future of newspapers.

I don't have a crystal ball, but I do have a perspective coming from 30 years of watching disruptive innovation via information technology overturn old industries and give rise to new ones.

Newspapers as we've known them are doomed. The conditions which supported their business model have disappeared. This is sad for people in the business and those who love newspapers, but it would be a giant mistake to equate the death of newspaper with the death of journalism. This kind of over-identification obscures important questions of how journalism will be reinvented in the Internet era, and what kinds business models will sustain it.

Nothing is certain, but appetite for news continues to grow. Firms do make money using the Internet. We are in a fertile period of experimentation out of which it seems likely to me, workable new forms for reporting the news will emerge.

If experience is a guide, opportunities are more likely to be seized and defined by startups than incumbents. This theme was identified by Clay Cristensen in "The Innovator's Dilemma" and holds true in this case. New cost structures, new use of tools and infrastructure, new ideas about what content bundles are meaningful will all play a major role in what emerges,

It's a difficult and painful time for those in an industry which is failing, and an exciting time for new entrants.

Comments [17]

Jun 22

iPhone 3GS impressions

The 3GS is my first iPhone. I put off getting one until now, because of concern that the lack of physical keyboard would make composing email difficult.

Overall, I am just thrilled, even though there are a couple of ways in which it is still short of what I really want.

On the plus side, the iPhone is a joy to use. Its look and feel is nothing short of elegant and the experience is delightful. The redesigned menuless UI is incredibly intuitive. It makes my Blackberry feel medieval in comparison.

Apps I have downloaded: Tweetie (thank you for the Re-Tweet button), Pandora, Ocarina. I'm a happy guy.

On the minus side, while the iPhone can be set to poll for mail at intervals as frequently as 15 minutes, it lacks true instantaneous push email like a Blackberry. The sense of being always connected and up-to-date is just not there for email.

UPDATE: I was unaware it's possible to configure the iPhone to get real push email. Thanks, Dave!

Web browsing, while a huge step up from other mobile browsers, is still less than ideal. Many web sites won't display properly because there is no support for Flash. Some web sites don't display properly for other reasons which I haven't investigated.

The small screen size is a problem even with the convenient multi-touch expand gesture. If I make the text large enough to read, a single line will typically not fit on screen, requiring me to rotate to landscape mode.

I haven't put it to the test yet with regards to battery life and ATT coverage, both of which are known issues.

On the whole though, the iPhone and I have become inseparable (though I am bigamous -- still carrying my BB for email and Verizon service).