BLUF – in October, Circulo acquired my little company, Huddle Health. We are now fully integrated into Circulo – and it’s time to describe the rationale for our convergence and some of what comes next.
Years ago, I was on the faculty at Albany Medical College. We had a course called Health, Care & Society wherein students were challenged to learn and think about ethical issues, health policy principles and engaged in conversations on the role of medical providers in our communities. It was a “soft” class that many students seemed to feel was peripheral to what they would do as physicians. They didn’t take the course as seriously as biochemistry, pharmacology, or anatomy.
And this is a symptom of our problem.
Physicians are taught medicine – not health. This is why it’s called medical school and not health school. Our training prepares us well to diagnose problems, respond to those in need, order testing and treatments, prescribe medications and other therapeutics. Notice that much of what we are doing is reactive – focused on managing illness rather than optimizing health.
Over the last few decades, we’ve marketed medical services as the center of our communities’ health lives. But medical services are not the center of any community – and with good reason. As Clay Christensen expresses, our people, products, and processes weren’t designed to optimize health. Rather – they were designed to optimize care (and the revenue that care creates).
This is hard for many of us to really understand. “You mean my doctor wants me to be unhealthy?” Well – no – of course not. We hope. Some consider Fee-for-service to be evil. I won’t go that far. Let’s stick with “misaligned incentives.”
Why does this happen? More volume = more revenue. Incentives generally aren’t aligned.
But there is hope, Luke Sykwalker. As more medical service providers have migrated to value-based payment, interest in health (rather than just care) has grown.
This is good! But it’s just one step on a long path.
Over a decade ago, Eric Dishman described the “shift left” as a way to “get more people on the end of the health continuum with lower levels of chronic disease, lower levels of functional impairment, lower costs of health care, and a higher quality of life.”
His focus was the self-evident migration away from the hospital and toward the home as a focal point for health, but allowing for other service locations and other kinds of services along the continuum. Rather than waiting for problems to worsen enough to merit a trip to the medical office or hospital, Eric argued that the shift left would also enable us to prevent problems – reducing both cost and suffering.
Iora Health started 10 years ago and developed an extraordinary model of person-centered care. Iora’s visionary leader, Rushika Fernandopulle, led the company through a series of saltatory phases of growth and discovery.
ChenMed was built on the foundation of a small practice in Miami and has grown to serve thousands of members in the southeast and mid-Atlantic markets.
Oak Street Health launched in Chicago and focused on value-based person-centered primary care for Medicare Members.
VillageMD empowers primary care practitioners to participate in value-based payment arrangements.
Aledade has built a broad network of independent and medium-sized primary care practices that share analytics infrastructure, processes, and other resources to optimize care experience, quality, and cost.
Each of these companies is taking a different approach, and while one might view them as competitors, we see them as co-travelers – bushwhacking through the forest of fee-for-service in search of a better model.
Most medical providers haven’t let go of fee-for-service, in part because they don’t have the opportunity. These companies (and a handful of others) have forged a way to the future. Yes – they compete a bit with each other, but as a group, they demonstrate to the majority of others a better way.
Huddle Health was created to learn from our predecessors, question the healthcare industry’s assumptions (who/why/how problems are solved), and work hard to meet the needs of the people we serve. Especially members of underserved communities – Medicaid Members and the uninsured. Learning from time that several of us spent at Alliance for Better Health – we knew that we need to focus on social determinants of health as a key element of our work – not just bolted-on as an adjunct or afterthought – but at the core of our work. What we had was a great team and a great model. There is a better way.
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Circulo was created to express two guiding principles: first, information technology in general and automation, in particular, is an essential component of the future we seek to create. Things that weren’t possible in the days of paper are possible now. Yet, much of the technical infrastructure created has remained focused on maximizing efficiency and, therefore, the volume of care rather than optimizing health. Therefore, we have demonstrated that technology and automation could change things, but so far, we’ve aimed them at the wrong targets. Second, the needs of Medicaid members and the uninsured have not been well addressed. We can/must/will do better. We need to reinvent Medicaid. There is a better way.
See a theme? Me too.
Our shared sense of urgency, our impatience to make things better, and rejection of the status quo are the ties that bound Huddle Health to Circulo.
We are now one team – committed to making the world a better place as Circulo Health.
Stay tuned for the next post – how we will do this!
Progress is impossible without change; and those who cannot change their minds cannot change anything.” ~George Bernard Shaw
I was asked by a member of my new team (more on that to follow) to share some resources that might be helpful as we migrate toward perfection. Rather than plopping this into a Slack message – I’ll share here so he’s not the only one to benefit.
Since humans are imperfect, any convergence of humans will also be imperfect – as will the products of our shared work. Nonetheless – our goal will always be to make our work product(s) as close to perfect as possible.
Step 1 – figure out where is the organization is now
This is a review of the people, products and processes in place. Are teams in place? are they well aligned? Is there clarity of vision?
For this step – we use the Strengthsfinder 2.0 – available here (digital – test only) or here (hardcover book – includes test). It’s important to really understand what this does (and what it doesn’t do) – and how to use it well. If you don’t have someone with experience guiding you through administration of this – please read this first.
We use Strengthsfinder to identify team balance. Hiring managers will often subconsciously hire others like themselves. This is human nature and natural and unavoidable – without a tool like Strengthsfinder. Consider the strength domains:
Likes attract likes. So a strategic hiring manager will hire strategic thinkers, a “relationship building” leader will hire more relationship builders, etc. The key here isn’t that one strength is better than another. Rather – great teams have balance.
Here’s a team I worked with a few years ago. Each row is a person. Can you guess what the CEO’s strength profile looked like? Yup. Relationship/Execution. No Strategy. Where did the org suffer? Strategy. They were DOING but there was no North Star. The teams were confused and challenged.
And then .. a year later – after some strategic hiring – still biased toward relationships but much more balanced:
Teams that have this balance will support each other well, build trust and develop interdependencies. as they traverse from competition to collaboration. Strengthsfinder is therefore the foundation of organizational maturity. What’s next?
Step 2 – chart a course to Stage 4 of the Tribal Leadership model.
David Logan, John King and Halee Fisher-Wright published this book as a product of work to best understand how to differentiate high-performing companies from those who are more challenged. Here’s the visual:
Ask someone how things are going – and you get the phrase quoted in each stage above.
Very few orgs live at stage 1 (they’d just die) .. nor do many live at Stage 5. The vast majority of organizations live at Stage 3 – which is normal – but suboptimal.
At Stage 3, we put energy into competing with each other internally – in order to find affirmation from superiors and/or stand above our peers.
At Stage 4 – we put all of that energy into collaborating with our peers – maintaining internal drive (yeh – ok – another book) and achieve great things together. Here’s the fun/fascinating part. Many visionary leaders live at stage 5. They don’t notice/understand that their teams live at stage 3. But a rule of thumb is that communication across more than one level is impossible. When a Stage 5 leader communicates their vision, their aspirations, their objectives, level 3 teams hear “compete with each other” and work hard for affirmation – so leaders need to learn to speak in language that their teams can hear. If a team or team member is living at stage 2 (angry) – then we need to offer affirmation and encourage the egocentrism of stage 3! This is counter-intuitive – given that stage 4/5 culture is our goal. But nobody leapfrogs from 2 to 4 .. we need to maximize stage 3 to motivate the traverse to stage 4:
Step 3 – optimize, integrate, maintain focus. Are we finished yet? Well – no. But we’re started. And that’s good. Other stuff to weave in:
All presentations/decks need to follow the Presentation Zen model. (Website here)
Use “problem A3” to solve problems. Use a “strategy A3” (available here) to define strategy. The best book on how to use these is here. A deeper dive is here.
Schedule meetings for 25 or 50 minutes. Never longer. Never back-to-back. Related: 18 minute TED Talks.
Know why you are meeting and use a framework to eliminate wasteful meeting time and get stuff done.
The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and starting on the first one.” ~Mark Twain
I’ve been writing a blog post on this topic for a few months.
It’s gone through several iterations and has survived a half-dozen friendly editors. This post isn’t that post, which still needs honing and will follow in the coming days. This post is the personal prelude – the why that perhaps is important to share before the what.
My decision to go to medical school was long-delayed. Indeed – I took no science classes in college – assuring myself that I would not follow the path of my father and grandfathers – all of whom were physicians. Yet the magnetism of this profession was compelling, once I let it pull me. I vividly recall wanting to do work that was useful and helpful. Auto mechanics seemed appropriate. I rebuilt my VW’s engine (twice) and helped others fix their cars.
But something was missing.
The human part.
And yet – when I finished residency and joined the faculty in the Department of Family and Community Medicine at Albany Medical College, I knew that something was still missing. My idealistic view of our profession was conflicting with the real-world experience: payment was an overlay on nearly everything we did – influencing what we document, how we document, and what decisions we made for (with?) the people we serve. One example: the annual physical. It’s a tradition that still hasn’t died – yet it offers almost zero value, yet the annual physical occupies as much as 20% of the work that’s done in primary care today.
In addition to doing things that are unnecessary – we still don’t do necessary things with sufficient frequency. Consider that about 65% of people in the United States who should have colon cancer screening actually get it. Organizations that accomplish rates of 75% are deemed wildly successful. How has 75% success (a “C” in most educational institutions) become synonymous with great achievement? This makes no sense to me.
Finally – service. While this 2010 video may be starting to show its age, much of the egocentrism of care delivery organizations persists. We medicalize normal variants of human experience, we ignore (or fail to act on) social determinants of health, and we schedule interactions where/when/how it best meets the needs of the providers (most often physicians) rather than the people who are being served. This 2019 Advisory Board survey found that net promoter score for primary care in the United States is -1.2 and notes that “… more respondents said they probably or definitely would not stay with their provider over the next 12 months (45%) than said they definitely would (40%).”
We must do better.
I’ve written previously about why words matter. Some have asked me why I don’t care about care. Oh my. I do! We need a great care delivery system that’s efficient and effective and compassionate. But “care” is not why our professions exist. It’s not (and should never be) our why. Rather – our why is health. If there are better ways to facilitate health than care (there are) we should embrace those alternate paths – rather than propagate the idea that more care = more health.
And recall that the WHO defines health as “complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
So our goal is (and should always be) to put ourselves out of business and facilitate the achievement of health in the people we serve.
This is why – in two posts to follow – I’ll explain why my next career engagement will be the pinnacle of my life’s work – to realize the idealism with which this all started. The world is finally ready for what comes next: the turn of our wheel to change the words and – by extension – everything we do. I will no longer be a primary care physician. My future – and ideally the future of many others – is to practice primary health.
I suspect that you have seen the drawing and blog post describing the difference between equity and equality. It’s a compelling image. Obviously, the shortest child, given equal access to view the baseball game will benefit rather little from such equality.
Yesterday, along with several dozen others, I volunteered at a local county Covid-19 vaccination site. The experience was both uplifting and concerning.
Uplifting: despite an allocation of vaccine that was (much) less than expected, the team – a hodgepodge of retired and semi-retired doctors, nurses, county employees, lawyers and other non-clinical people assembled to build our community’s immunity to SARS-CoV-2, the virus that causes Covid-19. I was impressed with the dedication, attitude, and commitment of the team from the county health department. I was touched by the gratitude expressed – as hundreds of people patiently and thoughtfully filed into the facility to get their vaccines. After giving the vaccine – I was thanked by many for “saving my life.” Alas – my part was was likely the smallest contributor to this – yet, of course, the most poignant 7 seconds – as I delivered the vaccine to its final destination. Indeed – the hope of this event was itself infectious: after giving our first injections, I reflexively attempted a high-five with the nurse (who happened to be a former colleague of mine) at the next station. She appropriately offered her elbow as a substitute to the high-five. It was a good day – filled with good moments that serve as a tangible milestone toward the end of the pandemic.
Concerning: in this county that is ~ 75% white, I saw very few people of color. 100% of the people who received their vaccine from me were white. All of them arrived by car, and all of them had signed up to be vaccinated by using the Internet. While one might argue that the underserved members of our community had an equal opportunity to sign up for the vaccine (now look back at the drawing above) – I would offer that they certainly didn’t have equity. Indeed – a sobering observation one of my volunteer colleagues shared with me was that we saw nobody from the neighborhoods adjacent to the facility we were in – everyone we were vaccinating seemed to be from the suburbs.
I offer this observation without judgment. The state and county leaders are focused on getting as many people vaccinated as possible. Vaccine supply is limited. They are doing their best – and I don’t think we can/should change the great work they are doing, or question their motives and commitment to health equity or social justice.
Yet we – as a community – can do better. We need to create an adjunct to the programs that now exist – to allocate vaccine explicitly for the underserved and implement outreach that meets them where they are: create equity.
So we will. With the counties, the federally qualified health centers, and community-based organizations – we’ll begin work yesterday to create this equity and get our underserved communities protected.
Re: journalistic style. Is it ‘health care’ or ‘healthcare?’” I use the rules of the “AP Stylebook” for journalists with few exceptions, but one of those is that I write “healthcare” as a single word. I don’t have a strong feeling either way , but the one-word variant saves space without sacrificing (although I acknowledge that (“medicalcare” or “hospitalcare” don’t work).
The difference between these two terms is about more than house style or personal preference. The term healthcare–one word–refers to an industry and the system of providers within it. But health care–two words–is about improving health and caring for people, especially when it comes to treating populations. The current trend toward population health is about making communities healthier by supporting preventive care and wellness. The goal is to provide health care–in order to keep people out of the healthcare system.
And while I can’t deep-link to the AP Style Guide (paywall) … they offered a tweet about this almost exactly two years ago:
We've changed our style to one word for “homepage.” We added “smartwatch” and “timeshare” as one word. But: “health care.” #APStyleChat
The short answer is that “healthcare” has taken on more meaning as a closed compound word to describe the system/industry/field than is captured in the two separate words “health” and “care.” “Health care” does not sufficiently capture the increasing demand for nuance and specificity in referring to topics surrounding the practice and facilitation of services to maintain or improve health. Healthcare represents the political, financial, historical, sociological, and social implications of a system that provides health care to the masses.
I disagree with Jodi and Victor that “healthcare” refers to an industry and a system of providers, though this opinion often appears when one does a google search on this topic. I also disagree with Jodi that “the goal is to provide health care.” No. The goal is to improve health. Sometimes the way we do that is to provide medical care, but let’s not assume this is the only way to improve health. Indeed, we know it’s not.
But I agree with most of what Jodi writes and her conclusion is spot-on: words matter.
I don’t believe that “healthcare” should be used at all. There are many (better) ways to describe the industry: the people, the providers, the practitioners, the care delivery organizations, etc. Indeed, lumping this all together, as Victor argues, loses the nuance and specificity that these other terms express.
: regard coming from desire or esteem a care for the common good
:CHARGE, SUPERVISION under a doctor’s care
: a person or thing that is an object of attention, anxiety, or solicitude The flower garden was her special care.
: to give care care for the sick
So it’s clear that health and care are different. Alone, this isn’t reason to avoid a neologism. Indeed, many words do just that woodpile, headache. As Victor notes above, a closed compound word is one that combines two things (usually nouns) that now assumes a new meaning by itself: basketball, keyboard, popcorn. I’ll acquiesce that if folks are arguing that “healthcare” is a benign compound word that describes an industry, they’re grammatically correct. But we choose not to use many words and phrases that are grammatically correct. (I’ll avoid the hot water that a few examples here would get me into.) Grammatical correctness can’t be only bar; the words need to help us say something meaningful.
Indeed, the words we use convey the world we see (or the world we wish to have).
Words matter.
Let’s look past the naiveté of “benign compound word.” This is the point that Victor and Mr. HisTalk seem to miss: when we separate the words, we share an important message, reminding ourselves and those with whom we communicate that health and care are not synonyms. As a physician, I see the semantic conflation every day in my peers and (sadly) in our medical students and residents. One of my hypotheses is that it is the very egocentrism of our profession(s) that cause us to conflate health with care. If people could be healthy without us – what are we here for? We remind ourselves (and our communities) of our importance by suggesting that care is a necessary precedent of health.
“Of course we don’t do that” you say …
Consider the so-called “annual physical exam.” This is well documented (summaries here, here and here) to increase the quantity of care, yet cause no positive health improvement. Yet its tradition has taught generations that more care = more health. Think about the phrases we use: (that Covid-19 is making us reconsider) … “come back to the office if you’re not better in 2 weeks.” “I can’t refill your prescription because you haven’t had your annual physical.” “It’s probably nothing but I need to do some tests so let’s schedule one office visit for the tests and another to discuss the results.”
This is “healthcare” – the compound word. In connecting these concepts linguistically, we propagate the flawed principle that care causes health, and while care may in many cases be necessary, our goal is better health. There are many examples of how more care is not more health. Great health economists and health journalists have documented this eloquently.
We have evolved language to reflect our evolving (improving?) sensitivity to race, religion, sexual preference and gender. For example, when I am careful to clarify or seek clarification of preferred gender pronouns, I send an explicit message of my awareness of the importance of these preferences to many people. It’s a movement. When we all do this, we remind each other to move past our decades of assumptions so that we can speak (and think) in a manner that is inclusive and respectful.
So the separation of health and care is a similar movement. It’s a linguistic statement that reminds us of a policy goal: these are different concepts and they must be separated culturally, politically and economically. If we are successful in doing so, we’ll make different (better) decisions that will improve health and reduce unnecessary care.
This is why it’s so important to cleave “healthcare.”
Prognosticators offer narratives of what the post-pandemic world will look like, and we see leaders invoke Rahm Emanuel (or was it Winston Churchill?) in their expressions of how they will “Gretzky” this.
Here’s my take. None of this is particularly prescient, but I’ve been asked a few times what I think comes next. My real answer? I don’t know. Some guesses below – all brought to you by the letter p.
Place – where things will happen will never be the same. The assumptions we have made about where things need to happen will evaporate, as many of them already have.
Where do we see a physician? I can vividly remember telling a group of medical students as recently as three years ago that they would practice virtually. They disagreed, parroting what they had been told by their mentors: this “video medicine” thing would never work. “The patients need to come to the office.” What have we learned from the pandemic? At least 40% of the time, a video conversation is just fine.
Where does learning happen? E-learning has been around long enough that we know not to call it e-learning. It’s education. Education happens when people test hypotheses together, make commitments, finish projects. Learning stuff isn’t education. We know that much! Non Satis Scire. If you’ve not listened to this episode of Hidden Brain, please do so. We’ll wait for you here.
Where does business happen? Sign a document. Have a meeting. Meet with the Board of Directors. Hire an employee. Notarize a document. Get married.
Poverty – we have seen only the tip of this growing iceberg. The economy won’t recover right away, and we know that despite the science that SARS-CoV-2 infects all humans equally, we also have learned that COVID-19 harms the underserved much more than it does others. Is the pandemic going to (finally) cause us all to screen for and make the necessary investments to address social determinants of health? I sure hope so.
People – “social distancing” is in fact a misnomer. We’re physically distancing. Social connections can, should and must continue to be close. Vivik Murty’s new book teaches us that we need each other.
We need connections, we need to listen, to love, and learn from each other. We needn’t be in the same room for this to happen.
My uncle turned 85 last month and our extended family all gathered for the affair – from California, New York, and Austria. This wouldn’t have happened before: those of us who weren’t present would have “missed” the party.
Video conference meetings @ work are vastly better than conference calls. Now that there is an expectation that we see each other, the fidelity of conversations is better. Indeed, in many cases, I’d argue that it’s better than a big meeting room with people 18 feet apart. We can see each others’ faces. The nuances of reactions / responses are not lost.
I’ve had a few conversations recently with elected state officials, and I’m reminded that speaking plain language always helps. Here goes:
We all agree that fire stations are a good thing, right?
And we agree that we don’t want them to be busy …
So if the firefighters are always watching Three’s Company reruns, that would be good. We still pay for the fire station. We still pay the salaries. Happily.
Therefore – paying firefighters more for fighting more fires would be silly: their financial success would align with hardship in the community.
But this is how we pay medical providers: more sick people = more $$.
We have a social compact: everyone agrees that we should pay for fire stations (infrastructure) and firefighters (humans) to be ready for fires. We all pay for this with our taxes. It’s the most efficient way for us do this.
Shouldn’t we have a social compact that would cause everyone to agree to pay for hospitals and medical offices (infrastructure) and medical providers (humans) This would be efficient and effective. Then if the medical providers were idle most of the time – it would be because the community is healthy. Nobody would complain of reduced revenue due to low volumes of emergency department visits. Kinda like what Maryland did. Seems simple. Why not?
.. and now for something completely different. For me, writing a blog isn’t about getting clicks, earning ad revenue (no ads here) or getting tweeted. I write here to share insight that may be helpful to others. I started writing this in 1999. Topics vary, but I don’t think I’ve blogged yet about car repair. My last big home improvement project (replacing the tank water heater with an on-demand tankless one when the former died suddenly) was well covered on Facebook. I think my rationale there was: “hey friends, look what I did!” Facebook is good for that. Many people have made the tank-to-tankless conversation. The Internet didn’t need to learn that someone else did it.
But I don’t know that anyone’s done what I did yesterday and I can’t imagine that I’m the only one who has experienced the predicament. So a blog is the best way to share a new solution to a common problem. Others will search for the topic and some day, someone will use the information I post here and their life will be better. That is (ideally) what blogs are for.
The problem. We have two cars and a two-car garage. As anyone with a two-car garage knows, (especially with 20 years of accumulation) this is by definition a tight fit. A few weeks ago, the passenger mirror housing of our 2017 Toyota Highlander was damaged (the identity of the driver is not relevant to our story). The mirror itself was ok, but the plastic parts and the turn signal light were broken. This mirror has a “puddle light” (shines down on the ground when entering/leaving @ night) and is heated and has a blind-spot monitor and has a camera for the parking assist camera system. There’s a lot in this thing.
A new mirror assembly, part# 87910-0E292 is $1290 from Toyota or $863 from Toyotapartsdeal.com. I found some used for ~ $500. Why so much? Because of all the “stuff” this mirror has in it – especially the camera, which can be purchased separately for many $$.
There are aftermarket mirrors for as little as $65, but they just have the mirror. No camera, no wiring for the camera, no blind spot monitor. Some have heat, which is valuable here in Upstate NY, and others even support motorized folding, which could have prevented this, but I’m not sure how we’d integrate that feature and control it from inside and these mirrors were missing features we have. The car’s computer complains when stuff it expects (camera especially) are not there.
As I looked carefully at the Toyota parts manual and studied the Toyota service manual (I purchased online access to it for 2 days to do my homework) it became clear to me that the parts I needed (the plastic backing, the plastic “visor” and the (mostly plastic) turn signal light) were all identical to those in the “basic” model of this mirror, part #897810-E143. $244 from the dealer and $173 from Toyotapartsdeal. What’s the difference (other than $690) The less expensive mirror has few of the extras: no puddle light, no camera, no blind-spot monitor (really just a light that connects to the computer). The plastic housing is the same with two exceptions: a) At the base of the housing, there is a hole into which the assembly for the puddle light and camera fit. b) In the back of the housing, there is a hole for where the camera wiring harness plugs into the wires that come from the door.
Here’s a photo of the hole in the bottom. The lower right corner is gone (due to the collision with the garage door frame) and in the upper right you can see some of my practice cuts. More on that shortly. This hole needs to be precise, so the camera housing fits in properly. Misalignment of the camera is bad: it will mess up the collision avoidance system and the images that the parking assist monitor won’t work. The other hole isn’t as important: just need to have a hole there so the cable can be attached/detached.
So the absence of a ~ 3″ x 2″ hole in the bottom of a plastic part is the difference between spending $173 or $863.
I ordered the $173 part. The first thing that happened was that the (very good) support team at Toyotapartsdeal.com noticed that this wasn’t the right part for my car and sent me a message:
The proper RH mirror is 87910-0E292 @ $863.21 and the cap is 87915-0E040-A0 @ $52.90.
Would you like to change your order?
My reply:
I don’t need the cap – I have one and it’s not damaged – all I really need is the black plastic housing and the partToyota calls the visor – neither of which it seems I can buy separately. All of the electronics work – so I’ll swap out the innards from the mirror I have and will need to cut a hole in the bottom for puddle light and camera. Oh well. Not perfect but better than spending an extra $700!
They checked again (I got the same email the next day) and called them to make sure we were on the same page.
The package arrived on Saturday morning.
Step 1: disassemble the new mirror to get the parts I want. The key to this step is to remove the mirror itself from the housing. This is easy but must be done right or you’ll break the mirror. Youtube helped some here, but if you try this, do it like this and not like this. The second way – you’ll break the mirror. I broke the mirror when I removed it from the new assembly, but fortunately, when I removed the old mirror from the old assembly, I didn’t break it (used method #1) so all was well. Be careful. Use your hands, not tools. Hold firmly. I also warmed it with a heat gun and sprayed some WD-40 in there too – thinking that softer plastic (subfreezing in the garage) and some lubrication might help. Too many variables to know what caused the better outcome. It worked.
Step 2: remove four torx screws. I’m guessing that these were torx #8. Pretty tight but came out after some coaxing. This holds the back housing to the visor – trapping internal parts: the mirror arm, turn signal light and the mounting base with adjustment motor/electronics. Once these four screws are out, the whole assembly can be (very carefully) separated with some plastic auto clip removal tools like this. $12 on Amazon if you don’t have the kit sitting somewhere in your garage (which is why it’s so full).
Step 3: measure, practice, cut. At this point, I did the same on the existing mirror on the car. What’s nice is that I didn’t need to remove the mirror assembly from the car, which means I didn’t need to remove the door panel, etc. I removed the mirror (see above) and the torx screws, and the cap (which wasn’t damaged so I didn’t have to buy a new one for $50. After disconnecting the wires (and taking photos so I could be sure that the wires go back in the same places), the visor, mirror and housing came off easily. Now I could carefully measure and create a paper template for the hole that needed to be in the base of the housing. I then practiced cutting holes in the plastic on the old housing – to see what was the best way to cut the hole with maximum precision and minimal local deformation. I tried a soldering iron with “knife” tip but a dremel tool with a tiny cutting wheel (like this) did the trick. These things break easily as they’re very thin. I had five of them and used all five. As you can see from the photo above – the opening has a little step-off shelf that the camera-puddle light assembly fits into. I did my best to recreate this with a dremel grinding tip. It almost worked: when installed, there remained a ~ 2mm gap at the leading edge of the camera assembly because the plastic clips that hold it into place didn’t “grab” tightly into the housing base. I probably could have made the shelf deeper but I didn’t want to make it too deep as this would have weakened the plastic – might have broken it.
Step 4: make things snug. To help this fit tight, I clamped the parts together and used epoxy to hold this thing in place forever. Yes. Forever. I won’t be replacing the camera assembly. Once the epoxy cured, I remove the clamp and was pleased to see that – while not perfect – it was pretty close. An astute observer would see that the little shelf the camera housing fits in is a bit rough – definitely not factory-made. Oh well. Can’t see it unless you bend down and look under the mirror.
Step 5: put it all back together. Place turn signal light in its little slot. Go to car. Housing goes in the back, visor goes in the front, sandwiching the arm and electronics. First, plug in the light .. then the camera – making sure the wiring harness goes through the right little slots so wires don’t get caught when mirror moves. Next, replace the four torx screws – pulling everything together. I screwed them all in halfway – then made sure all the plastic parts lined up well – then screwed them in the rest of the way. All good. Now replace the mirror: attach the wires for blind-spot warning light and heater, then snapping it into place with a gentle but confident push. Finally, the cap goes on the back and it’s done!
Tested. Everything works perfectly. The manual says we should recalibrate the collision avoidance system (camera alignment may not be the same). I don’t have the software for that – so if we do it- we’ll have to go to the dealer. Not sure how much that is or if it’s necessary. More homework. The images that the parking assist monitor creates are the same – no blurry gaps etc – so I think the camera – if not in the same position – is almost in the same position.
Total time from opening the box to completed project: 7 hours including dinner break, dog walk, thinking/practicing hole-cutting. If you have to do this, I suggest: a) practice hole-cutting ahead of time. If you have a friend with a router (ideally one mounted or mountable in a table) this would help make a perfect hole with the right step-off shelf.
If you want the parts I didn’t use/need – grab ’em on ebay. I’d rather not throw them out.
Final note: Toyota – why don’t you sell the plastic parts by themselves?! This would make such a repair quick, easy and very inexpensive. I’d have gladly paid $100 for these parts (that probably cost $5 to make) that we know you make every day but (for some reason) won’t sell unless they’re part of a $1200 (list price) assembly. Argh.
Today, The Department of Justice issued an announcement that was “the first ever criminal action against an EHR vendor.”
Criminal action
The core of the criminal action was something inevitable: the tension between better health and better profit. Here’s what I saw … all of which caused me to be not-so-surprised today when the news broke.
In 2008 I was the CMIO at Allscripts. Much of my work was focused on how our customers could use our products to improve the health of our patients. We implemented clinical practice guidelines in the software as a way to help clinical teams and patients make well-informed decisions that would improve their health. The company was doing well, but there was always pressure to find more revenue.
We had a small team that worked closely with pharmaceutical companies and generated revenue from these relationships. I wasn’t very involved with this team, but due to my ownership of many of the clinical decision support initiatives, I started getting invited to meetings we had with pharmaceutical companies. The first was an initiative that involved a company selling a statin drug. They wanted to sponsor a program in which we would use a clinical decision support notification to alert clinicians to patients who might be candidates for statin therapy but had not yet been offered a statin drug. On its face, this seemed appropriate: it invoked evidence based clinical guidance, the decision support didn’t recommend a particular medication, and the clinician could easily ignore the notification.
But something didn’t feel right about this. How would the clinician know that this CDS was sponsored by a pharmaceutical company and some other CDS was not? Should we allow the sponsorship to be secret?
And then there was the company that wanted to sponsor an alert to remind the clinician that a given patient might have untreated hypertension (this company sold several antihypertensive medications) …
And then there were more. I found myself in heated arguments about the evidence basis for many of these opportunities with some of my non-clinical colleagues. In the end, we created an objective committee to review such requests. I don’t recall that any of these things got implemented in our systems at the end of it all – but I do clearly remember that there was pressure to do so, and the dollars that pharmaceutical companies were very tempting to the company.
I talked on occasion with my counterparts at other health IT companies and they told the same stories: tempting dollars, questionable ethics. Mature companies with strong clinical leadership didn’t succumb to these temptations. Epic was even public about their refusal to even entertain the conversations. Good for them! But I wondered about smaller, hungrier companies. Could they resist?
Fast forward a few years and I was at ONC, writing the text of what would become the 2014 Edition of the Certification Criteria for health Information Technology. I wondered how we could prevent pharmaceutical companies from tempting EHR companies to do such things. There were certification requirements for clinical decision support. I knew we couldn’t prevent the business relationships (our authority was to certify the software, not regulate the business operations) but we could make sure that the systems had a capability of informing the clinician (and by extension the patient) of why the clinical decision support guidance was in the system, and what the evidence basis was for the decision support. Here’s how we explained this in the 2014 Final Rule (highlights added):
Consistent with the HITSC’s stated intent, for EHR technology to be certified to this criterion we proposed that it must be capable of providing interventions and the reference resources in paragraph (a)(8)(ii)(A) of § 170.314 by leveraging each one or any combination of the patient-specific data elements listed in paragraphs (a)(8)(i) and (ii) of § 170.314 as well as one or any combination of the user context data points listed in paragraph (a)(8)(iii)(A) of § 170.314. We asserted that EHR technology must also be capable of generating interventions automatically and electronically when a user is interacting with the EHR technology.
Last, expanding on the HITSC’s recommendation that the source attributes of suggested interventions be displayed or available for users, we proposed that, at a minimum, a user should be able to review the: bibliographic citation (i.e., the clinical research/guideline) including publication; developer of the intervention (i.e., the person or entity who translated the intervention from a clinical guideline into electronic form, for example, Company XYZ or University ABC); funding source of the intervention development; and release and, if applicable, revision date of the intervention. We asserted that the availability of this information would enable the user to fully evaluate the intervention and enhance the transparency of all CDS interventions, and thus improve their utility to healthcare professionals and patients.
We got some questions about this – but (I hope) you can see that the goal here was to make sure that any user of an EHR could easily learn the evidence basis for CDS and who paid for it. We hoped that such transparency would diminish the likelihood that sponsored CDS would inappropriately influence clinical decision-making.
Such is the ambition (and true challenge) of the government regulator. The goal is to create a framework wherein innovation is anticipated and even encouraged, while safety is enhanced and fraud prevented.
Practice Fusion was a young aggressive company – funded by venture capital and run by Ryan Howard. Ryan is a dynamic, charismatic guy who sold a vision of an EHR that could be given away and would generate revenue from advertising (like TV or gmail) and the sale of insights to life sciences companies. I first met Ryan on a trip to San Francisco in ~ 2012, when he invited me to come to Practice Fusion to speak with the team about Health IT certification and the meaningful use incentive programs. Such conversations were not uncommon – it is valuable for ONC leaders to meet with the companies we regulated. They would occasionally come visit us in DC, but meeting them on their home turf, we can meet with the folks really doing the work, and they can hear from government leaders first-hand – perhaps enhancing their understanding of some of the “why” of federal regulations rather than just the “what” that they are otherwise exposed to.
My guess is that this was when the sponsored CDS started happening. A small team inside of Practice Fusion was created in ~ 2015 and they were led by a sales executive who worked with pharmaceutical companies to develop CDS programs.
You can see a list of all of the CDS that Practice Fusion (it seems) here. When I click on “learn more” – I get a 404 error. But there are examples like this (and screenshot below) that demonstrate both sponsorship and compliance with ONC’s transparency regulation. Note how the Gaucher Disease recognition CDS bibliographic citation is listed, the developer is Practice Fusion, and the funding source is Genzyme. Connect the dots. Did they have the funding sources listed for all of these CDS interventions? We don’t know.
Interesting:
*On April 8, 2019 the following Pain Management CDS advisories were removed from the EHR:
Patient should be assessed for pain. Document pain scale in the flowsheets section of the encounter.
Patient has chronic pain and should be assessed. Follow the link to complete the Brief Pain Inventory (BPI) short form assessment.
Patient has pain documented and should have a pain care plan.
I do remember that I was aware of the sponsored CDS in ~ 2014, as I recall speaking with the PF Chief Medical Officer about a program that was sponsored to remind providers to immunize patients. I think it may have been influenza and/or HPV. The program was evidence-based, and it was successful: more patients got the immunizations they needed. I remember asking about compliance with the ONC certification requirements (yes), if they had an objective “approval board” like the one we had created at Allscripts (no).
The company’s drive for revenue overshadowed their legal and ethical commitments. I know that there are many people at the company who were not involved in this activity. Good people who work hard and are proud of the product they have build over > 10 years. The company is now a subsidiary of Allscripts (a fact that was oddly missing from the DOJ announcement) and I know that the Allscripts team is providing the maturity and oversight that Practice Fusion simply never had. Full disclosure: my son worked as an engineer at Practice Fusion from August 2014 until April 2018.
Lesson Learned?
Is this happening elsewhere? Has it happened to other companies? I don’t know. But if it is – I suspect they’re on notice now and I sure hope they’ll stop. I applaud the ONC and DOJ team that worked on this (and other) efforts to protect us from companies who have lost their way. Thank you!
Dan used to say to me that we needed to motivate our teams to pull the rope. 
Here’s a photo of the hole in the bottom. The lower right corner is gone (due to the collision with the garage door frame) and in the upper right you can see some of my practice cuts. More on that shortly. This hole needs to be precise, so the camera housing fits in properly. Misalignment of the camera is bad: it will mess up the collision avoidance system and the images that the parking assist monitor won’t work. The other hole isn’t as important: just need to have a hole there so the cable can be attached/detached. 
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