A purpose


We went for a walk yesterday. Griffin carried a stick.

Humans go for walks to “clear our minds” or “get in touch with nature.”  Dogs already have clear minds. For them, the freedom of a walking trail without security of a leash or the familiarity of a daily walking route can, it seems, be confusing.  “What am I here for?”  “Where are we going?”  “What’s our goal?”  Griffin (see photo above) promptly found himself purpose in the form of a big stick to carry.  “Now I feel so much better,” he seemed to say.


Clay Christensen writes and speaks about this,  and as we ambled through the Albany Pine Bush yesterday, I realized that Griffin explicitly understood that having clarity of purpose was far better than the freedom (and ambiguity) that the vastness of opportunity offered.  The task was now clear: find a big stick and safely deliver it back to the car.  In choosing this task, he became focused, engaged and (dare I anthropomorphize?) proud.  He looked up at us as if to say “see what I have? Do you approve?  Is it big enough?”  Rather than randomly running through the woods, criss-crossing the path, distracted by new scents, distant chipmunks and blowing leaves, he maintained a steady trot with head and tail held high, and a steady gaze straight ahead, maintaining his placement squarely and very intentionally in the middle of the path.

And just as Griffin seems to seek the freedom of ambiguity yet ultimately prefer the comfort of structure, humans thread this needle every day and seem have different levels of comfort with the unknown.

An aside:

Teaching family medicine residents and medical students last week, I was struck by this variability.  Some young physicians are perfectly happy to know that they don’t know the cause of a patient’s condition, so long as it is either resolved or not caused by something ominous.  Indeed, more than one-third of the time that patients seek medical assistance,  physicians are unable to ascribe a clear diagnosis.  As I expressed to the first-year medical student last Tuesday, “if you’re not comfortable with uncertainty – don’t pursue a career in family medicine. You’ll be better off in a subspecialty like ophthalmology.”  This was not meant to deprecate subspecialists, but to recognize that the people who choose subspecialties are generally less comfortable with the unknown or unknowable.  While my counsel was expressed to her, I was also advocating for her future patients.  There is nothing worse than a primary care provider who needs to know the right answer to every question.  Indeed, cascades of testing and intervention are emotionally, physically and financially harmful.  In many cases, a physician’s personal discomfort with uncertainty is the cause of the cascades that are so common that we accept them as an unfortunate but immaleable reality. The key, therefore, is to match individuals with the work they will do most comfortably.  Some dogs would roam the forest happily.  Griffin is a dog who prefers to carry a stick.  Some physicians are comfortable with uncertainty, so will be very comfortable in primary care, while others would suffer as primary care providers, ordering too many tests, advising too many interventions, and as a byproduct of all of this, putting their patients in harm’s way. Perhaps this is the tip of a different iceberg: just as Malcom Gladwell has questioned whether we’re choosing the right law students, is it possible that we’re choosing the wrong medical students for careers in primary care?

Physicians are just a subset of humanity.  Non physicians express this variability too.  The motto of my undergraduate alma mater, Hampshire College, is “Non Satis Scire.” Translated:  “To know is not enough.” Hampshire attracts students who are less focused on getting an A+ and therefore demonstrating what they know (indeed – there are no grades at Hampshire).  Rather, Hampshire’s focus is on helping students solve problems.  This prepared me incredibly well for a career as a family physician.

Which problems should Hampshire graduates solve?  This question may be at the core of Hampshire’s rebirth.  Some have argued that Hampshire should choose an identity (social justice, environmental science, computer gaming) and focus its resources on being the best at one thing.  But Hampshire has decided instead to venture forward with confidence and – yes – uncertainty.  This will prepare its current and future students well for what lies ahead in life.  They’ll find their own stick, perhaps after a bit of chipmunk chasing.  Life isn’t a race.

I found my stick, which aligns well with the specialty that chose me, family medicine: help others achieve optimal health and happiness.

What’s yours?




The Rapid Cycle Mini-RFP

Like many businesses, our organization has problems to solve.  We have good people, products and processes but on occasion we decide that we need more than we have.  Our Chief Strategy Officer sometimes reminds me that my vision for our achievements might not be aligned with our capacity.  Perhaps this is the role of the CEO – to think a bit bigger than we are.  But that’s another blog post.  The point here is that we may need help sometimes.

When businesses develop strategies to solve problems, they generally adopt one of a handful of approaches:

  • Hire a person or people
  • Buy something
  • Build something
  • Try something (pilot / proof-of-concept or POC)
  • Partner with another organization

RFPs are generally reserved for big projects and evoke thoughts of 45 page .pdf documents with tens of questions and months-long processes of evaluation.

For the record, we never do POCs or pilots.  We do projects, and all projects have phases of implementation.  Phase 1 is always first, and while we can certainly kill a project at any stage, “phase 1” sends an implicit message that we’re optimistic that there will be a second phase and others thereafter.  We’re not ambivalent about moving ahead with anything.  “POC” and “pilot” send a message of ambivalence.

There’s an opportunity for organizations to use a process that’s smaller than a big RFP and bigger than a solution-focused decision.  It’s the Mini-RFP.  We’ve done a handful of these and they’ve worked incredibly well. The whole thing takes 3 weeks.

Here’s how to do it

  1. Week 1
    1. Day 1:
      1. Define your problem. This isn’t as easy as you think.  We use a modified A3 strategy approach.  You can use any approach, but be careful not to be looking for faster horses.
      2. Pick an online survey tool you like.  SurveyGizmo, Google Forms, Microsoft Forms, or Survey Monkey are all just fine.
      3. Write a set of questions that capture basic business demographics.  You can re-use these every time.  Name, URL, contact info, how long in business, etc.
      4. Write a short statement about the problem you’re trying to solve.  Work hard to make sure that it aligns with step 1 and do your best to avoid describing a product that you’ve seen that you think solves your problem.
      5. Write a set of questions that asks respondents how they would propose to solve your problem:  what do they have (people? product(s)?, processes?) that solves your problem.  It’s important to avoid leading questions that align with a particular solution you may subconsciously have in mind.
      6. Show the RFP to a friend.  Ideally, give them edit rights and ideally this person doesn’t have first-hand knowledge of the problem you’re trying to solve.  They need to be able to look at this fresh with a “beginner’s mind.”  Tell them to go ahead and fix whatever they think needs fixing in the form.  No permission required.  No time (or need) for “suggested edits.”  You’ll be pleased and surprised (and humbled) to see how your initial prose made assumptions that you didn’t see.  Let your friend fix them and leave your ego behind.
      7. Add  “Brown M & M” questions.  While the rationale here is a bit different from what Van Halen did, the idea is the same.  You need to know if the respondents are paying attention and have sufficient domain knowledge.  We use these questions when we post upwork jobs and they work incredibly well to weed out folks who respond by pasting in paragraphs from other proposals.  Instant proposal rejection is what you’re looking to enable here.  Be creative here and have fun.  One recent RFP asked if BTC, XLM, ETH or neo4J had a role in the project. We asked submitters to avoid googling for an answer.  This question was asking two sets of questions:  a) How much of a nerd are you?  (We wanted nerds) – Do you know what BlockChain is?  – Do you know the difference  between cryptocurrency and a graph database? b) Do you know that blockchain probably plays no role in this project?  (But a graph database might.)  Successful respondents get the right answer in 30 seconds because they have domain knowledge.  These should be easy questions for the right people and impossible questions for the wrong ones.  (If you use the right survey tool – you can see how long they took between questions.)  This isn’t a tortoise/hare issue.  Perhaps we’ll need to have a chat with Malcom about that.  We love tortoises.
    2. Give them 3 – 4 days to reply.  We often launch on monday.  Close Friday.
  2. Week 2  Process, review, rank, have phone calls with a few of them to get a better sense of who the people are and if you are likely to work well with them.  Pick a “winner” by Friday.
  3. Week 3
    1. Monday.  Send the lead applicant a contract. Negotiate rapidly.  Lawyers may slow you down.  The more you have templated ahead of time – the better – so at least on your side, there are no legal delays.
    2. Friday.  Execute the agreement.  Go!


I have been an occasional Twitter user for a long time.  Indeed, I’ve used Twitter since long before you even knew Twitter existed.  I say this with some confidence, as Jack Dorsey posted the first tweet in March, 2006.  My first tweet was four months later in July 2006. I am Twitter user #1922.  Today there are over 130 million twitter users.

Twitter is an effective medium to communicate short messages to many people.

It’s also an easy way to say something  – or imply something – that you didn’t quite mean, or didn’t get to explain deeply enough.

Blogs are better.

This post is about why I should have blogged instead of tweeted.

In ~ 2004 there was a platform called blogger, created by Evan Williams.  With Blogger, one could craft blog posts and plop them on the Internet for everyone to see.  This was a new idea.  I experimented (beginning in 1999) with the medium and found that it was a good way for me to communicate with people, provoke thought, and offer insight into the work I was doing.  One day I posted an essay about EHR usability that (I thought) nobody read. Three months later, my boss called me and told me that the EHR company whose software I critiqued was unhappy with the post and asked me to take it down.

I declined.

The next day, the President of that company called me.

We had a wonderful conversation.  Then he hired me to help fix his product.  The rest is history.  My life has been very different.  This episode launched a career.  Who knows what would have happened had I not posted that critique.  I took a risk.  I wrote something provocative and it worked out for the better.

Tweets are shorter and offer less context.  A blog post (like this) gives us time to think, offer insight and provide background.  Elon Musk has cost himself many millions with careless tweets, and some (many?) people have even lost their jobs due to things they have posted online.

But there’s a positive side too.  A provocative tweet can have broad impact, can demonstrate thought leadership, and can generate conversations that make the world a better place.

Message:  be a careful but provocative tweeter.  If you choose to use this medium.

Yesterday I tweeted something (now deleted) that was provocative and perhaps not careful enough.  It described a conversation I was having with an employee of a hospital who saw the work that our organization does to improve health in our communities (and reduce hospital volume) as deliberately “harming hospitals.”  I asked if flu shots deliberately harmed hospitals too.  He didn’t reply – and I thought I was oh-so-smart.  Later in the day, I tweeted it, and a handful of people piled on about how hospitals are the problem.

But here’s the thing that I didn’t (couldn’t) say within the boundaries of a tweet.  Hospitals are NOT the problem.  Gosh – we need hospitals.  We need hospitals to be healthy.  We need hospitals to be able to invest in people, products, and infrastructure so that they are there for us when we need them – even though we hope we don’t need them.

There is a problem with the policies of how we pay hospitals today.  Yes.  There is a mindset that the hospital employee expressed that I wanted to question. Yes. Public policy that improves the health of our communities will result in reduced fee-for-service revenue for the hospital.  This can result in “harming” the hospital, but I am certain that the intention is not that that the hospital be harmed.  The intention is that the hospital migrate to new ways of doing business – to be more than a building with beds in it, but a part of the health (not necessarily the care) of a community.  To one who is part of an organization that is being unintentionally harmed by the improved health of a community, this may seem intentional, and it may feel like the hospital needs to be compensated for this harm.  My snarky response to this person (and tweeting it) was disrespectful.  I wanted him to reconsider his thought process, but perhaps I should have reconsidered mine.

What’s it like to work in an organization whose purpose is to try to put itself out of business?  We’ve not yet created a sound business model wherein the hospitals can survive in the context of falling fee-for-service revenue, but we’re asking them to do so.  That’s not good policy, and this hospital employee was just describing the world from his perspective.  This is a good thing.  My next move should have been to listen, learn from him, affirm his position and then (perhaps – if he was in a position to learn from me) offer my perspective so that we could think together about how we might solve public health problems.  Of course he doesn’t want people to be unhealthy so that they go to the hospital.  It was unfair of me to imply this (even if it was a logical extension of what he said) – it was a move appropriate for a college debate competition, not a collaborative conversation.  I’m a bit ashamed that I said what I said.  In his defense – we’ve seen very good examples of the hospitals in our community changing for the better, and the hospitals we work with are indeed migrating their work toward better health and away from more care.  It’s not easy, and I shouldn’t have poked my finger in the eye of someone doing their best to bridge the gap.  #TweetRegret  #honesty  #humility  #Alldoingourbest



It’s not a beer

When we announced a few weeks ago that our IPA had executed our first contract, I found myself explaining what an IPA is and what it does.  An IPA is a business entity that assists multiple independent organizations to contract with managed care organizations (health plans).  But it’s uncommon (unheard of?) for an IPA to work with organizations that are not physicians.  We even had to update the Wikipedia entry on IPA to clarify that physicians aren’t the only ones who can create or join an IPA.

Where we are now

We have over thirty organizations participating in the IPA.
We have two executed agreements with health plans, and expect this to grow.
We have a technology platform that connects our community.

Where we are going (and why)

I re-read the 1990’s coffee-table Book “who moved my cheese?” recently, and am now reminded of the simple (yet complicated) lessons therein. The book provides a framework for how we respond to change. A key message is that change will always happen.  If we resist it, we will become angry, fearful and confused.  If we embrace it, we’ll find new opportunities and flourish.  Our IPA is focused on helping organizations embrace (rather than fear) the change that is happening.  These changes will, we hope, help us improve the health of hundreds of thousands of people in New York and beyond.  Our plan is to continue to build relationships on both sides of this work: growing the breadth and scope of the organizations who join the IPA, and growing the number of health plans with whom we partner.

While the metaphor of a well-oiled machine is overused, I reflect that the mechanics of Alliance are running well – primarily because we have learned to anticipate and embrace change.  Indeed, our comfort with change has become our secret sauce.  The challenges of early days of start-up disorganization and growth are well behind us, and while we’ll never be perfect, and the start-up of an IPA is non-trivial, our team is working together to do our best to serve our community.  I am honored and privileged to work with such a dedicated and talented group of people.

Conferences / Unconferences

Our (amazing) team at Alliance for Better Health is planning an event in June.  The purpose is to bring together people in our community who are using the Healthy Together platform, celebrate the community’s accomplishments, and strengthen the connections so that we can find greater success in the future.

I offered a thought this morning that perhaps this isn’t a conference, but an unconference.  I wikipedia-ed (it’s a verb, yes?) the term, hyperlinked it in my email and (after sending) went back to read the wikipedia entry.  It’s accurate and (I now know) expresses a long history of unconferences.  What surprised me is that one of the first unconferences in “modern” times was in 2003 and .. I was there!  Despite a dead website, I was able to find someone’s notes on my session @ bloggercon.  It’s funny how the world is a circle.

To me, the core of an unconference is not unlike the core of a nontraditional post-secondary education, and the core of a person-centered approach to health:  the goals are defined by the people who participate rather than by the people “in charge.”

  • Students at Hampshire College define their educational goals.  Faculty, staff, technical and physical resources are all there to support (and – yes – guide) students on their path.
  • Attendees at an unconference listen, learn, and direct the course of a community of co-participants.  Organizers are there to support (and-yes-guide) but the goals of the unconference are expressed by the participants, not dictated by the organizers.
  • People served by medical care providers, behavioral health providers, and social care providers are the ones who define their own goals.  Words like “noncompliant” or even “non-adherent” become laughably out of place once we understand who is really in charge.  We physicians are (I suspect) the worst violators of this imbalance of power, as we’ve been educated to “write orders” and “define treatment plans.”  Only recently have we discovered shared decision-making.  If “primum non nocere” is really our oath, perhaps we should converge it with “non satis scire” and offer some humility: audire ad primum non nocere, quod non satis sit scire.  (“Listen to do no harm, it is not enough to know.”)


A few days ago, I wrote about the convergence that seemed to be happening at Hampshire College.

Yesterday, the President and another Board member resigned.  There was cheering and excitement at Hampshire, facebook, and Slack.

Why was there cheering?  Because the President charted a course for Hampshire that many in the community felt was (so far) an unnecessary last resort.  Is it possible that Hampshire would some day need to partner with another institution?  Yes.  It’s possible – after other options are deemed infeasible.  The problem here is that the community doesn’t understand how/that Miriam Nelson sufficiently researched all other options, and how she deemed them infeasible so early in her tenure @ Hampshire.

She believed that what she was doing was good for Hampshire. Some members of our community were angry at her, and I understand that anger, but I never felt it myself.  In the same way, I don’t feel happy that she decided to step down.  This has been terribly difficult for her, I’m sure.

But this is bigger than her, or any one person (or even any group of people).  Now is the time to pull together, and her departure gives us that opportunity.  The convergence I described on Wednesday continues.  On campus, several members of the Alumni Advisory Group (AAG) joined the re-envisioning Hampshire Coalition meeting. It was eye-opening for me.  These folks are serious, dedicated, and working hard to make sure that all voices are heard.  That’s super important.

And now the really hard work is ahead of us.  Here’s a rough map of all of the groups that will need to converge on what the future Hampshire College looks like, how we fund it, and how we get there from here.  IMG_3761

The AAG met all day @ Hampshire yesterday, and we’ll do so most of today as well.  We’re a diverse team – with members from each of Hampshire’s decades, expertise in many domains, and (most important) diverse perspectives on how to interpret what’s going on at Hampshire and how to respond.  We are a microcosm of the Hampshire alumni community, and what’s fantastic is that we trust each other.  Since change moves at the speed of trust, this has enabled us to move swiftly toward consensus on many issues, and enables us to bridge connections between others through the growth of such a trust network.  Much more to do, and we wouldn’t be able to accomplish any of this without our canine member @Griffin.


Hampshire College: Convergence?

Yahoo! It’s Spring!

Wow.  It’s been too long since I’ve posted here.  I’ve been busy with my day job .. and writing elsewhere (some recent stuff referenced here)

Now .. the topic of today:

Hampshire College. It’s not in a good spot.  Lots of history here .. and here .. and here.  Yesterday’s Boston Globe article is a short summary of the most recent events.

Why do I care?  Because – well – Hampshire is an amazing place, doing amazing things, and the world needs it to be there forever.  I spent three years there as a student, and one year there (a few years later) teaching and working in the admissions office. I did well there, and that empowered me to do well in medical school, residency, as a faculty member and Associate Dean at Albany Medical College, etc.  What I mean when I say “did well” isn’t that I got good grades, because (for those of you who don’t know) .. Hampshire has no grades.  “Doing well”  in this context means (I think) that we move forward, have positive impact on the world, find happiness and share that positive  impact with others as widely as possible.  Hampshire discovered and fostered the “growth mindset” and reinforced it long before Carol Dweck started talking / writing about it. 

This is a blog. It’s not a facebook post, slack channel or shared strategic plan. It’s a set of observations that I’m choosing to share with you. I’m just one person. F83, P10 (That’s Hampshire-Speak for:  “I entered Hampshire in the Fall of 1983 and I’m the parent of a former Hampshire student who entered in 2010.”  I give money to Hampshire. I’m ready to give more. Some of my guiding principles for this post, and how I’ve tried to approach the current challenge:

  1. Be generous and assume best intentions. Decisions have been made. We don’t really know all of what went into the decisions. We may learn more. We may ultimately disagree with these decisions. But I refuse to judge anyone as evil, malignant, incompetent, etc. These words just don’t help. I’m going to assume that everyone here has the best interest of Hampshire in mind.
  2. Engage with shared success as the primary goal. It’s not important to be right. It’s important to listen, learn, seek understanding, and find the right path forward together.
  3. The Hampshire College that has been is not the Hampshire College that will be. Product-market fit has not been achieved in recent years. Many people will be unhappy with the changes that will need to happen.  These changes include:
    1. Administration / administrative overhead will need to change – ideally get (much) leaner.
    2. Hampshire’s educational offering(s) will need to better align with the wants/needs of incoming students. Yes. This means that some faculty won’t stay. We may love them as humans, but if they teach stuff that not enough students want to learn – isn’t it our responsibility to invest in different mentors? This concept may threaten long standing principles of academia.  So be it.  This is Hampshire.  We should do the right thing, not necessarily the traditional thing.
  4. There are some elephants (frogs?) in the room. Resolving them is going to need to be part of any cogent solution.
    1. The discount rate has been going up (and up). Translated: students who can pay full tuition are a small minority of incoming classes. The College therefore operates at a loss.  While many colleges operate this way, Hampshire’s investments (endowment) doesn’t generate sufficient revenue to cover this gap.  The endowment itself is restricted.  It can’t be used to cover operating expense. Hampshire needs to attract more students so that it can be more selective, and (at the same time) bring in more students who can pay full tuition.  
    2. Some students have not done well at Hampshire. Ideally, Hampshire is the right place for students who will excel in an educational environment that offers more freedom in exchange for more responsibility. Accepting students who can’t manage this responsibility puts everyone in a tough spot: students struggle, retention is reduced, cost is increased (see above – as discount rate goes up), and demands on faculty are enhanced (causing the College to hire support staff – and pressure to reduce faculty: student ratio). The Hampshire of the future will need to attract the students who will excel at Hampshire. Hampshire needs to be the positive choice for those who will flourish, rather than the negative choice for those who don’t fit in elsewhere.  It’s always been hard for Hampshire to find these students, but I believe that this is the only way for Hampshire to be sustainable long-term:  get more selective.  Focus on excellent applicants, not just unique ones.

What’s next?

I feel convergence in the air. There is growing consensus that an independent option may very well be viable. I see three key vectors – the latter two of which are converging:

  1. Strategic partner. I’m assuming that this is the University of Massachusetts. Sure – other options are being considered, but UMass makes more sense than any other institution. Much to work out here, and there is huge risk that the true identity/purpose of Hampshire is lost in a merger (acquisition) with (by) UMass.  
  2. The Re-envisioning project. Watch this as a good overview. It’s good. Lots of thinking and selfless collaboration went into this initiative.
  3. Hampshire2020. This project is smaller and quieter. Here’s their v1 deck. I hear there’s a V2 deck but I’ve not (yet) seen it. 

You’ll notice that the re-envisioning project and Hampshire2020 are similar. They’re both great starts, but both of them rely on huge fundraising efforts to save the day right now.  (See http://give.savehampshire.org for links to fundraising activities, and also support Davis Bates as he takes a 17 mile fundraising walk this week).  Without a massive influx of $$, Hampshire can’t stay open in a form that will be attractive to the two populations most important to its future:

  1. Donors. Humans, alumni (also humans!), foundations, and corporations. People give money for many reasons – but “save this dying ___” is rarely a compelling message. Rather – “make an investment in this ___ so that the world will be a better place” is generally much more successful.  A healthy Hampshire College is indeed something that many could / would support.  We need a clear, believable plan.  My former boss (yes – that’s another story) Vinod Khosla offers what I think is the best overview of how to pitch an investor.  We need to pitch investors with a strong story about how we’re going to make the world better with a new Hampshire College. 

  2. Students. Hundreds of thousands of these people select higher education options every year.  Yes, there are fewer of them now, but there are still plenty of them, and plenty who would love Hampshire.  Simply put, they are the customer.  They make these choices based on a set of factors that are important to them, just like the customer at a restaurant, car dealership or online bookstore. I would argue that we need a core set of product management principles to be applied here.  I’ve seen very little of this in the re-envisioning project – and only tips of this iceberg in Hampshire2020’s proposal.  What are the market requirements? What resources do we have available to meet these requirements? How is our product differentiated?  I’m concerned that we’re a bit too focused on the asset we have (the current faculty, curriculum, structure) and not the one we need.  There’s compelling evidence (enrollment is the key metric, of course) that our current product isn’t well aligned with the market.

Doing – not just talking.

I’m ready to dig in. I’m ready to join the coalition of great people working toward an independent Hampshire. I’m ready to invest my time and my money in this initiative.   What do I mean by “this initiative?”  I mean the coalescence of re-envisioning Hampshire and Hampshire2020.  I’m ready to bring what I’ve learned in ~ 30 years of work in health, health care, information technology, investing and government to help us converge.  Because we must.


Why we’re launching a Consumer Directed Exchange (CDEx) project

Consumer Directed Exchange

If your first question is “what’s Consumer Directed Exchange?” please feel free to google it and come back.

Last week, Alliance for Better Health launched the first regional effort in the United States toward facilitating CDEx for Medicaid Members.

Here’s my short (?) version of what/why/how

We consumers (people?) are becoming increasingly aware of the information that others have acquired about us.? We implicitly trust Facebook, Google, Apple, etc. to keep our information safe, and share it with others only when we choose.? As health care has evolved from paper, there is now an extraordinary quantity of our health information that is stored digitally in hospitals, medical offices, and (yes – see above) Apple, Google, etc.? When a provider of health care services needs your health information so that they can better serve you (or serve you at all), they can sometimes access this information through traditional means of health information exchange. There are several ways to do this, and I won’t cover them today. A short overview is here. Note that there is a difference between the activity of health information exchange (the verb) and an HIE (Health Information Exchange – the noun).

We usually give permission for care providers to exchange our information. The Health Insurance Portability and Accountability Act (HIPAA) and the important but often overlooked HITECH Modifications to HIPAA provide the framework for how, when and why our information is shared. A key feature of the regulations is that they apply to HIPAA Covered Entities (CEs) and Business Associates (BAs). The HITECH mods made big changes to the definition of a BA, and in so doing, made it very important for a BA to have robust security & privacy technical and process infrastructure. By making these changes, HHS shifted the responsibility for a BA’s behavior from the CE to the BA, so long as a business associates agreement (BAA) is in place. Before the mods, a CE needed to be certain that the BA had the right infrastructure in place, so they developed big spreadsheets with workbooks that every vendor would need to complete in order to document how mature they were. With the modifications, this shouldn’t be necessary, as the BA is now legally liable for any breach, rather than the CE, so the BA just needs to attest to the CE that they do have such infrastructure. Alas, old habits die hard, and most CEs (unfortunately) still make their vendors do the security workbook, or complete Hitrust certification as evidence of appropriate infrastructure. This isn’t wrong, but it’s also not necessary, and it creates thousands of hours of unnecessary work on both sides, as vendors need to complete security workbooks and then the security workbooks need to be reviewed, approved, or rejected/revised, etc.

But what if the food pantry, homeless shelter, city mission, or community health worker needs this information in order to help you? Traditionally, these folks are not CEs – nor are they BAs (they don’t have the security infrastructure or policies in place in order to satisfy the requirements of a BAA) and therefore the CEs and BAs (and their lawyers) don’t feel comfortable sharing health information with them.? With good reason, as they lack the infrastructure required to keep information safe. These entities are therefore called Non-covered entities (NCEs).

In addition to the NCEs, information sharing between CEs and between BAs is sometimes less fluid than we would like. Have you ever arrived at a care provider’s office and found that the information that was supposed to be shared with them by another provider wasn’t there? Labs, imaging reports, a consultation report, a discharge summary .. all of these are often simply unavailable despite our expectation that they would/should/could be. We all have anecdotes – so I’ll share one: in 2015, my dad was having a procedure in San Francisco (at the “Best Hospital in the world,” and his physician in Boston (at the “Other Best Hospital In the World”) was to send dad’s records over. Both hospitals have electronic health records. Both hospitals had dad’s written permission to communicate with each other. When dad arrived .. guess what? No records. The SF hospital demanded that we hand them paper. Citing HIPAA, they refused to accept electronic transfer.  No, I’m not making this up. The solution? From my home in New York, I logged in to the patient portal for the Boston hospital (with dad’s username/password) downloaded them to my computer, “printed” them to a pdf file, logged in to my Doximity account, and faxed them to the San Francisco hospital. They accepted a fax.  This is consumer directed exchange. Albeit a perverse version of it.

When traditional methods fail, we use consumer directed exchange. Would most people have been able to do what I did? Probably not. Certainly not Medicaid members – who have neither the technical tools nor the e-fax capability of Doximity.

How can we make this all easier for everyone?

If knowledge is power – how do we make sure that the information upon which knowledge will grow – is available and portable? If I want my health information to be shared with ____, how can I make that happen quickly and easily?

This is the core problem we’re working to solve: we plan to make it easy for anyone to share their health information with whomever they please. Here’s how:

  1. Verify that you are who you say you are.
  2. Give you access to as much of your health information as we can access on your behalf. For our initial launch, this will be whatever is in our regional Health Information Exchange, Hixny. But we’re building this solution so that it can access other data sources too, and we hope that the tool we build will be used by others – both nationally and internationally – as our code will be shared under an open source license, and can be used freely by other organizations. This will not be a proprietary solution.
  3. Help you share the information. It’s yours. Once you control it, you can do anything you like with it. You can print it, share it with the person sitting next to you, even tweet it (but we don’t recommend twitter as a transfer mechanism, btw). We’ll help you choose the best method. The key is that you are doing the sharing. There is no “consent” or “authorization” or anything else that is part of this exchange, because no CE or BA is doing the information exchange. The consumer is directing the exchange. As they should.

Our hypothesis is that with better access to information, better decisions can be made – avoiding unnecessary or harmful interventions. We’re excited to launch this initiative regionally, and hope to see it spread across the nation.

Apple, Cerner, Microsoft, and Salesforce

… all rumored to be in the mix to acquire athenahealth.


Why not?

a) Apple doesn’t do “verticals.”? It’s that easy.? Apple sells products that anyone could buy.? A teacher, a doctor, my mom.? Sure – they have sold high-end workstations that video editors can use, but so could a hobbyist filmmaker. Likelihood of Apple buying athenahealth?? ~ .01%

b) Cerner?? Nah. While (yes) they have an aging client-server ambulatory EHR that needs to be replaced by a multi-tenant SaaS product (like the one athenahealth has built), they have too much on their plate right now with DoD and VA and the (incomplete) integration of Siemens customers.??Likelihood of Cerner buying athenahealth?? ~ 1%

c) Microsoft.? Like Apple, it’s uncommon for MSFT to go “vertical.”? They have tried it. (Who remembers the Health Solutions Group?) But the tension between a strong product-focused company that meets the needs of many market segments, and a company that deeply understands the business problems of health (and health care) is too great.? The driving force of MSFT, like Apple, is to sell infrastructure to care delivery organizations.? Owning a product that competes with their key channel partners would alienate the partners – driving them to AMZN, GOOG and APPL.??Likelihood of Microsoft buying athenahealth?? ~ 2%

d) Salesforce.? I’d love to see this.? But it’s still unlikely.? athenahealth has built a product, and they (now) have defined a path to pivot the product into a platform.? This is the right thing to do.? Salesforce “gets” platform better than everyone (aside from, perhaps, Amazon).? But Salesforce has struggled with health care. They’ve declared n times in recent years that they are “in” to really disrupt health care, and with the evolution of Health Cloud, and their acquisition of MuleSoft, they have clearly made some investments here, but the EHR is not the “ERP of healthcare” as they think it is. (Salesforce’s success in other markets has been that they dovetail with – rather than replace – the ERP systems to create value and improve efficiencies.)? ?The way that Salesforce interacts with the market is unfamiliar (and uncomfortable) to most care delivery organizations.? So if Salesforce “gets” platform, and athenahealth wants to be a platform when it matures, could these two combine?? It’s the most likely of the three, but I still see the cultures of the two companies (I know them both well) as very different, and not quite compatible.?Likelihood of Salesforce buying athenahealth?? ~ 10%


a) Phillips.? ?They have enough $$, are getting into population health, have IoT “last mile” business alignment, and understand the need to migrate from FFS to value on a global scale.

b) Roper / Strata.? Yeh – you didn’t think of this one! Roper owns Strata Decision.? Cost accounting fits well into the revenue cycle roots of athenahealth.? Strata is getting deeper into the role that clinical activity (and deviations from best practice) plays in cost.? Dan Michelson (Strata CEO) understands the EHR market incredibly well.

c) Amazon.? Platform.? ABC.? 1492.? I’ll say no more.? If you don’t know what I’m talking about, LMGTFY.

d) Value Act.? Elliott’s not the only big player that may have interest in owning this real estate.

e) IBM. Yup. Could happen. They have made significant investments in health (and health care). Unlikely but possible.

I’m sure there are more.? This will be interesting.? athenahealth has a vibrant culture, fantastic people, a strong, devoted customer base, and an active developer community.? Remember:? this is a revenue cycle company, not an EHR company.? The EHR is a new game they’re playing.? It’s an important one, but Todd and Jonathan got into this business with the goal of solving business problems for their customers.? That vision remains.? It turns out that a healthier population is (or should be) good for business, and an EHR is (for now) part of that picture.? But as the needs of the market evolve, athenahealth will evolve.? They’ve demonstrated this well, and this agility is what will cause them to be successful in the long-term.

Funding Disruptive Innovation

“Innovation” is a provocative word.

For some, it invokes an eye-roll of disdain: “why can’t we just get our work done?” They pexels-photo-1038914.jpegrhetorically ask.? Sometimes, the way we are doing things is just fine.? Why distract ourselves with new variants of people, processes, or products just for the sake of doing something new?

These folks have a point.? Sometimes we just need to do what needs doing.

And sometimes the way we’ve been doing it (or even what we’ve been doing) isn’t optimal.? “There must be a better way” says … someone.

That someone is the innovator.? The eye-rolls?? The innovator is used to eye-rolls.? And much worse.? Indeed, the innovator has been maligned, undermined, threatened, disciplined, and even fired for thinking about the better way.

There’s a good reason for this.? Most innovations fail.? When innovators dream of a better way, and therefore spend time thinking, working on projects that may or may not bear fruit, “wasting” valuable time and money so that they can .. what?? “Improve things!?”

Such is the healthy tension, especially in the industry known as “health care.”? Lives are at stake, so we must innovate with extraordinary care, lest we harm people.? There is good reason for this.

Or is there?

When I was in medical school, I was “spoken to” because I asked questions of a professor who was teaching us tradition that was (even at the time) not supported by science.? Thirty years later, what he was teaching us is now well-known to be inappropriate.? The path to better care (and more health) is asking whether there is a better way:? questioning the assumption that “we’ve got it right” and always challenging ourselves to look at things from another perspective.

As CEO of Alliance for Better Health, I serve with an amazing team of people who are helping our community change.? We are a New York DSRIP Performing Provider System.? New York’s DSRIP program is an experiment.? The hypothesis is that we can reduce unnecessary spending on acute care if we focus instead on the health of our population.? Healthy people don’t need to go to the hospital.? I would argue that this needn’t be just a hypothesis, as the data is clear:? we can.? The harder question is whether we will.? I’m reminded (again) of the old joke that my dad (the psychiatrist) used to tell:? “how many psychiatrists does it take to change a light-bulb?? Only one, but it needs to want to change.

The gap between what we humans can do (what we are capable of) and what we do (what we choose to do) is wide.? We can exercise more, but we do not.? We can stop eating trans-fats or foods with nitrosamines (both of which are well established to enhance the likelihood of disease) but we do not. People addicted to chemicals (nicotine, opioids, alcohol) can stop, but they do not always do so.? Why don’t humans do what is objectively better for us?? We seem to have a reason to preserve the status quo.? Why?? Why do we reflexively resist the people (or ideas) that ask if there’s a better way?

“People change in many different ways and for a multitude of reasons.? The psychology of change is a broad and fascinating subject in its own right.? In one sense, in fact, psychology is the science of change.”? ? – William Miller & Stephen Rollnick in Motivational Interviewing Preparing People to Change Addictive Behavior.?

So if innovation is about change, we need to understand the barriers to change.? Only when change is embraced will the benefits of innovation be perceived to outweigh the risks.? Now let’s get back to DSRIP and innovation.

Last week, we announced our second innovation award program.? Last year, we awarded over $5.5 million to members of our community.

The purpose of the program this year is to nurture a culture of innovation in our region, with an emphasis on disruptive innovation.


Why are we focused on disruptive innovations?? Take a look at the classic graphic that Clayton Christensen often uses to explain the theory.? Sustaining innovations improve existing products and processes, and improve the performance of existing markets.? Disruptive innovations create new markets.? They meet the needs of those who are not well served by the existing infrastructure, often because providing services to these folks is perceived by incumbents as low-margin and therefore not profitable.

Before you continue, please read this.? It’s important, and, yes, if you are applying for one of our innovation awards, there will be a test (your application) at the end of this.? As Christensen and team express, Disruptive Innovation is often invoked, but not always understood:

In our experience, too many people who speak of ?disruption? have not read a serious book or article on the subject. Too frequently, they use the term loosely to invoke the concept of innovation in support of whatever it is they wish to do. Many researchers, writers, and consultants use ?disruptive innovation? to describe?any?situation in which an industry is shaken up and previously successful incumbents stumble. But that?s much too broad a usage.

The difference between sustaining innovation and disruptive innovation may seem arbitrary for us and our innovation award program, but I would argue that it is not. The funding for this program is a small portion of the > $30 million that we are distributing the the community to help care delivery organizations migrate away from fee-for-service business models.? Most of this money is supporting improvements to current processes, workflow, and technology.? These are therefore, by definition, sustaining innovations.

The $4 million is therefore set aside to explicitly support activities at the low end of the health / health care market.? For example, social determinants of health are often addressed by community-based organizations.? Literacy, health literacy, housing, transportation, violence prevention and behavioral health are all matters that have enormous impact on the health of a community and the primary care and acute care services that are used.? But these issues are low-margin (or have no near-term revenue model at all) and are therefore ignored for the most part by care delivery organizations (the incumbents).

Our goal is to provoke investment of time, strategic thinking, human resource allocation, and (most important) interest in meeting the needs of this “low end of the market.”? This is disruptive innovation.