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Anthem's blank space - diminishing returns on cyber attacks

I remember when I first read about Chef Thomas Keller’s attentiveness to the law of diminishing returns. The idea is simple, with each bite, you get a little less enjoyment out of whatever it is you are eating. Some of Keller’s most famous dishes are only one or two bites. Leave ’em wanting more, he says. Well, as it turns out, the same is true for hacking.

The more it happens, the less we care.

In 2014 nearly everyone was hacked. Home Depot was hack. Target was hacked. Sony…well you know about Sony.


Celebrities are also a popular target. Jennifer Lawrence smartly said anyone who sought out photos of her was effectively abetting the hackers. By the time Taylor Swift was hacked in early 2015, the general reaction was…well…rather ho-hum.

News broke this week about the attack on insurance giant Anthem. It could be misconstrued as flippant, or know-it-all’y, but I think my reaction could best be summed up thusly:


It’s not that I don’t care, or that I’m not sympathetic - I do and I am. I’m just not surprised. So much of healthcare data secured by obscurity — think: fake rock hide-a-key. And, inside any give healthcare organization, hundreds if not thousands of people have access to datastores. Sure, there’s some notional security and there are, sometimes, audit trails. But it may simply be unrealistic to expect sensitive data, in the hands of large corporations, to ever be completely secure.


After the Sony attack, security researcher Steve Gibson remarked on his Security Now podcast on the challenges of securing Sony. Gibson suggested it would be nearly impossible for anyone to secure such massive, interconnected, multi-platform infrastructures. The same is undoubtedly true for large healthcare organizations.

Not to sound all Eyeore about it. I’ve just accepted that my health information, once it leaves my body, is vulnerable to attack. But here’s the good news — maybe no one cares? Sure none of us want our social security number and birthday circulating around. It’s an inconvenience and financial risk. But did anyone really care that Taylor Swift was hacked? Maybe the law of diminishing returns means we, as a society, are bored of hacks. And once we’re board, and there’s no real threat, then the target for the hackers is greatly diminished.

Improving community health with more people and less cost

I've been wrestling with the uncomfortable realization that most of the innovation efforts in healthcare really just incremental improvements. Sure, we're making wait times in the ED shorter, and we've made the imaging centers look like fancy hotels. We're also making seriously and important strides at reducing harm and improving quality. But these are all just incremental improvements. They are iterations on the same thing. A new way to register, round or operate on someone are still the same basic things we've been doing forever.

To be fair, that may be perfectly ok. And, it is certainly noble to improve quality, reduce harm and make experiences more humanistic.

Hold that thought in your minds along with this: In ever design session I've been a part of for the past two years, providers and patients alike all want one thing — more people.

We are dying for more human contact in healthcare. We call them navigators, ambassadors, concierges. We want them to help us get appointments. We need them to help advocate for us when we cannot advocate for ourselves. We want them to be our scribes because...well, because EMRs. We want more people so we can have more time to spend with patients. And we've gotten to the point where we hire them to help us decipher our healthcare bills.  

I've been trying to reconcile how we might have our cake and eat it too. How can we have more people and simultaneously less cost? Or —and here's where some patented thought technologies come in to play —what else could we do with all the expensive people we already have? 

You see, while we're busy craving more bodies, we're also getting much better at moving things out of hospitals which are notoriously expensive, dangerous and hard to operate. Inpatient stays are down. Surgeries require less and less time in the hospital. We've moved a lot of things to outpatient settings. So what do we do with all the people we're committed to employing?

It seems some wisdom from a trip to Africa inspired the folks at City Health on exactly how to crack this nut. I really like the idea of community health workers. Now add on the idea of using our existing healthcare workforce as community health workers. Wooohhaaa!

But Wait, you're shouting. Where are you going to get these people, Nick? We're staffed so lean already. Right, but are we using our people wisely? By being ready to redeploy hospital employees, especially when we know utilization is going to continue to decrease, feels like smart planning to me. Plus, hospitals are already set up to take in payments from payors and redistribute it in the form of income to employees.

Here's the deets from NPR:

Thats how the idea for City Health Works was born. Kaurs husband, Dr. Prabhjot Singh, partnered with Kaur to get the project off the ground. The pair raised about a million dollars from three sources: The Robert Wood Johnson Foundation also a supporter of NPR, the Robin Hood Foundation, and Mt. Sinai Hospital, where Singh works.“


We really need an ambassador, somebody that really understands the clinical environment, but is deeply embedded in the community- Prabhjot SinghSingh says a lot of the people he sees in his clinic at Mt. Sinai are in really bad shape. "People youd expect to see in the hospital. People you couldnt imagine are in such a late stage of illness," he says.


Its this population City Health Works really wants to help. The idea is to get patients to the clinic before they get so sick, and then help them stay out of the clinics going forward."We really need an ambassador," he says. "Somebody that really understands the clinical environment, but is deeply embedded in the community."

via An African Village Inspires A Health Care Experiment In New York : Shots - Health News : NPR.

What pizza apps tell us about healthcare consumerism

Fact: in the early days of the web, Google was born and it was almost a service for ordering pizzas via fax.  Fact: a recent study showed that the number one thing people want an app for is....wait for it... ordering pizza. 

Fun link: Push For Pizza ... this is a real thing.

What does this tell us about the world (besides our love for pizza)? When we know what we want (pizza), we want to literally push a button and have all the rest —ordering, payment, delivery —taken care of for us. Uber did it for cabs. Netflix does it for movies.

Maybe it's time for Push for Doctor?*


*Yes, I know there are lots of home health and house call apps. But are any of them as dead simple as Push For Pizza?


touching my brain - from MRI to 3D print

As a proof of concept, we started playing around with going from an MRI to a 3D print. It turns out the process is pretty straight forward once you cobble together the right collection of software tools. For an ambitious first print, we used an MRI of my ocular orbits where one of the sequences continued a nearly complete image of my entire head. It took the printer 72 hours to render a slice of my head from my left hear to about a third of the way through my skull.

Here's the coolest part. I can touch my own brain. See those little wrinkles and those raises and gullies? Those are mine. That's my brain. Sitting in my skull. I can run the tip of my finger over the profile of my actual brain, as it sits between my skull and it's protective layers.

The pictures don't do justice to the feeling you get when you start running your fingers over the surface of your own brain. It's stunning!


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MedX 2014 and the Ghost of Tom Joad

Well the highway is alive tonightBut nobody’s kiddin’ nobody about where it goes I’m sittin’ down here in the campfire light With the ghost of old Tom Joad

Springsteen - “ghost of Tom Joad”

When talk moves to action, the world changes.

This isn’t a new revelation. People whisper their discontent and then someone speaks it out loud and then two or three people shout it.

And then someone does something.

Throws a rock, refuses to move, demands to be included…

This year’s Medicine X was the barracks for a new army. An army fighting for one of the most important social justice movements in the United States - the movement towards participatory medicine.

Participatory medicine is about the right for patients to be at the center of their needs, to pull in providers, designers, pharmacists, inventors, apps, hackers, makers, therapists, artists and caregivers of their choosing to build something which works for them.

MedX 2014 was a convening of healthcare stakeholders who have collectively moved past the point of debate. Should patients be included? - it’s not a thing this group needed to discuss anymore.

Instead MedX 2014 was full of people - patients, doctors, administrators, designers, makers, doers of things - who were busy…well…doing. MedX 2014 was a gathering of freedom fighters; crusaders fighting for a new social justice of inclusiveness.

I don’t often quote song lyrics. It can be sophomoric. But in this case, I find Springsteen’s Ghost of Tom Joad stuck in my mind after MedX 2014.

Now Tom said “Mom, wherever there’s a cop beatin’ a guy Wherever a hungry newborn baby cries Where there’s a fight ‘gainst the blood and hatred in the air Look for me Mom I’ll be there Wherever there’s somebody fightin’ for a place to stand Or decent job or a helpin’ hand Wherever somebody’s strugglin’ to be free Look in their eyes Mom you’ll see me.”

Well the highway is alive tonight But nobody’s kiddin’ nobody about where it goes I’m sittin’ down here in the campfire light With the ghost of old Tom Joad


HOWTO for hospitals: host a live MedX viewing for patients and staff

UntitledI've written before about Stanford's Medicine X event. It's a rare breed - a conference to which I feel a deep emotional connection. Those of us closely connected to MedX often say its where magic happens. I don't know any other event like it; with it's energetic empowered ePatients, innovative partners like IDEO and an anchoring academic medicine focus.

I remain convinced it is the most important event healthcare executives are not attending. Look, I get it. Payment changes are coming, volumes are down, we're all scrambling to get on top of HCAHPS...who has time?

Then again, how can you afford not to be a Medicine X? Why are we sitting in meetings to talk about raising patient satisfaction scores when the top ePatient minds and participatory medicine speakers are convening in a few short weeks?

But, I'm aware not everyone can drop what they are doing. So if you cannot make it to Palo Alto in September, my suggestion is to register for the Global Access Program - it's a free way to view the conference live over the internet.

Here's my HOWTO for hospital leaders:

  • Register for MedX Global Access
  • Get a large TV or projector + good audio system
  • Wheel the TV or projector into your cafeteria or lobby
  • Launch the stream
  • Invite patients, families, staff, leaders and medical staff to come watch

Easy, right?


charges, costs and reimbursement - a difference WITH distinction

  We need to stop confusing charges with costs. If we want to affect what we pay for healthcare, relative to value, we need to talk about costs.  If we are talking about consumers' ability to price compare, average reimbursement is more relevant. Charges are made up numbers.


CMS is touting this:


But are charges the right thing to focus on?

What each provider gets paid, their reimbursement, may be more relevant to most healthcare consumers. As a country, concerned about healthcare's rising costs and its total percent of GDP, perhaps we should be asking providers to get clear and open about true costs.

algorithms man...woah!


This New York Times site can determine your home town based on 25 questions.

Wouldn’t it be cool if we applied the same algorithms to determining health conditions? What if 25 questions could reasonably predict someone’s risk for serious illness?