Legislating HIT: Pelosi's Got the Bit Between Her Teeth

Sometimes being prescient really sucks.

Forget yesterday's iceberg ahead warning.

You don't have 3 years to get a govt. affairs staffer, hire a lobbyist, and start calling the hell out of your congressional reps.

You have 3 months before Nancy really gets going on HIT legislation like HR 6898.

Happy holidays.


Health 2.0 Review - Smoke, Fires, and Companies to Watch

I'm breaking this review into two parts - the larger, more symbolic and conceptual overview (which will follow this post) and my list of companies (and teams) to watch (posted here).

For those of you I wanted to meet at Health 2.0 last week, my apologies.

I was quite literally running for three days straight and had little time onsite to powwow with friends and colleagues, old and new. It's not that I don't love you anymore - it is quite literally that Maarten den Braber and I (with a PHENOMENAL corps of volunteers - I can't name you all here but I will in a future post - again, THANK YOU) were putting out one fire after another for 72 consecutive hours.

That left very little opportunity for rational, critical, or creative thought, much less sparkling conversation, until the smoke cleared.

It has.

What's left behind is a warm, loose feeling, the kind you get after sitting a bit too close to the campfire, where your limbs are lax but the skin of your cheeks is bright and red and tight but somehow renewed.

This slightly toasted feeling is accompanied by a bit of an ashy taste at the roof of my mouth, and the smell of smoke lingering inside my nostrils, as with the last show - which reminds me how quickly fires both spread and flame out.

I'll share why there is room for both optimism and fear following Health 2.0 in my longer conceptual post, but can't resist some preaching from the pulpit here.

For lack of a more graceful way to put it - we're looking at this all a#$ backwards.

Two of my twitter comments sum up what I'm feeling:

1. really tired of co's selling consumers health data. Give it to us in a way that makes data useful to US and we'll pay to use the platform.

2. Health 2.0 is building the add-ons without a realistic, strong, user-friendly platform. We're the mushrooms. Where's the tree trunk?

We're building killer apps that are springing forth from fertile VC and ad revenue soil like mushrooms and other nutrient, dark-loving fungi.

But where's the tree trunk they can all grow on?

Instead of where's the beef, we should be asking ourselves where's the platform (or platforms)? I have yet to see a realistic platform-based approach similiar to Apple's iPhone development stance in HIT that provides grafting opportunities for many of the disparite apps shown last week in San Francisco.

The Robert Wood Johnson Foundation is doing the closest thing, but even they are still trying to save the Holy Health Record, rather than looking to professionals who want user-oriented, consumer/patient/human-to-human healthcare to survive and thrive.

In short: eHealth and HIT is the next newspaper industry.

Get ready for a sob story that's spun within an inch of its life as a rebirth. You'll hear it from hospitals. You'll hear it from the US government, who's now looking at really scary things like HR 6898.

We're at the point in healthcare IT where it's innovate or die, or, worse yet, innovate and get to market, pronto, or be legislated out of the US market.

Every. Single. Company. Dealing. With. eHealth, telehealth, mHealth, HIT, PHRs, PHAs, EHRs, EMRs. MUST pay attention to where this legislation is going NOW.

We've got probably 3 years until HR 6898, or something like it, passes.

You better have a govt. affairs person on your team. You better vet some lobbyists who are friendly with Starck and Pelosi NOW. Kennedy's staffers for health are frequent speakers at industry events. I'm just saying. Good place to start.

Mark my words. Congress will grasp onto 'saving' healthcare with tech via legislation like HEITA as a morsel to toss to the increasingly restive American public.

They can't fix a war, they can't fix the economy, but they can 'fix' healthcare by legislating national EMRs that your doctor controls, you betcha!


In that time, if we don't, as an industry, get out an effective, efficient, affordable consumer-facing health platform (or 20, and we're talking platforms that are quantum leaps above Google Health and HealthVault, no offense Goog and MS) we're done.

We'll all be contractors and any new tech will have to pass through the bowels of CMS before going to 'market' (imbue heavy skepticism here).

Preaching over, for now. But pay attention all. This is one of those posts where I'll look back 2 years from now and wish I'd had a larger megaphone to shout "Iceberg ahead."

Now quickly back to the business at hand.

There are many experiences doing demo rehearsal for the breakout panels (I didn't have the privilege of rehearsing with the vast majority of mainstage speakers, except for a few on the Privacy and International Panels), that I can't share. Professional and personal ethics prevent me from saying "this guy is an a*&hole," or "this company is all smoke and mirrors."

What I'll do instead is give a few of my favorites.

If you're interested in the good, the bad, and the ugly regarding Health 2.0, I highly recommend you set Google alerts for Health 2.0 and various iterations (Health 2.0 Conference, etc).

Here's my personal list of companies and teams that are close to becoming killer apps in their own right, especially if connected to a larger, more cohesive platform (the tree trunk) that enables 3 touch consumer access.

I'm not going to do long, lengthy reviews of what they showed onstage - for many of them I saw multiple demo rounds. Here's the deal - I'll pass along the companies. If they're of interest, check them out. Follow up. Do some digging.

To presenters: If I didn't include you after 7 rounds of demos, it doesn't mean I don't think you have great tech, an awesome team, a smart business model, or a nifty logo. It just means for some reason you didn't *QUITE* make my personal Best in Show. This is an opinion-based, not evidence-based review.

Out of more than 80 companies with whom I demoed, these guys stood out as the complete (or near complete) package. Biz model, team, design, functionality, real-world utility/relevance. Some are lacking in some areas and stunning in others - as noted.

My reviews also have nothing whatsoever to do with what the parent organization (Health 2.0 LLC) or the organizers of the conference (Matthew Holt and Indu Subaiya) think of you. I don't claim to speak for them in any capacity.

This is brief analysis for free. I don't hold paid positions with any of the companies below. Any other involvement is disclosed in full. I love doing this in more detail. If you want more, get in touch.

Without further ado, Health 2.0 "User-Generated Health" Best in Show (in no particular order):

1. HealthLibrarian. User interface, bad. Search capabilities, goooood. One to watch. These guys are brilliant and need a user-design friendly developer to slap some nice facepaint on this one. However, they do the backend design work for other companies/associations/clients, so pretty is as pretty does here.

2. Voxiva. International track record for mobile health applications that drive clinical results. Call CEO Paul and ask him to tell you about Mexico and Rwanda. Awesome. Lessons to be learned here abound.

3. ZumeLife. A pager for health, essentially, with the Zuri. Disclosure: I am a beta tester of the Zuri. This is an unpaid gig. I like HIT toys and ZumeLife has been kind enough to connect me with one that daily monitors metrics I want to track. More on this later, but this kind of tech is up and coming. See also FitBit.

4. iMedix. The app, meh. Decent. The semantic search tech behind it - whoa. If you watch their demo you'll learn all you need to know to understand why semantic search is vital for the next generation of health 2.0 applications and networks. I won't go into gory details, but this team is patient, hard-working, and cuts through crap with a knife (including mine) to get things done under pressure. Ask to see the movie...Also watch the team. These guys are repeat entrepreneurs with sharp smarts and a great tech development team. Consider the package deal. A note on international Health 2.0 - watch the Netherlands for patient movements, innovation, and adoption of EHRs, but watch Israel's Silicon Valley for pure development power. Also irish eyes are smilin'. Check in with Enda Madden to learn about fascinating developments on the Emerald Isle.

5. ADAMs Health Navigator. For the iPhone. Drool. If you have an iPhone, it gets five out of five "buy it now what the hell are you waiting for" stars.

6. Rise of the Caregiver Sites: Careflash.com is looking like the pretty cousin of the poor relation it showed last show. Great updates, better UI, and really useful calendar function. Disclosure: I am considering an advisory board position (unpaid) with Careflash. Newcomer (to Health 2.0 Conferences anyway) ENURGI (pronounced energy) one to watch. Social network blah but searching for, corresponding with, and paying caregiver online is, finally, an app that makes sense and is useful TODAY in real-life scenarios that have highly relevant health meaning. CEO one to watch with deep experience in her industry, wit, and verve. Anyone who can rock a demo after a domestic comestible crisis rocks hardcore.

7. Change:Healthcare. Team. Rockin. Financial tools for managing and comparing healthcare expenses regionally is brilliant. Decision support, I likes it. A bit of design tweaking to come I hope, but this has potential to be online banking for health. A bit schizophrenic at the moment with where they want to go, and there are many roads yet to be considered. As with Organized Wisdom, another great team (sometimes these three swooping through the aisles remind me of the male Charlies Angels) with solid primary product and many miles to go before they sleep. Here's a cautionary note: Expand where it makes sense. Where can I print and share and take your recipe cards for health? Who are logical partners? Don't be Starbucks. Don't carry the puffy, bland, terrible tasting breakfast sandwiches. Stick to brewing great coffee before brand and identity dilution kills you. Are you the tree trunk or a mushroom? Disclosure: The Organized Wisdom crew gifted me with a great kelly green Organized Wisdom tee. I'm not worthy.

8. American Well. If they overcome issues with rollout in island paradise test case Hawaii look for even bigger things. One issue - where is their physician outreach program? How will they induce/incite docs to log on to the system and choose patients with whom they'd like to work? Nice setup with BCBS of Hawaii because docs they'll use are docs in network, who are compensated for using the system. Brilliant play within existing payor structure. See tons of work on other areas (visible in demo, Deep Dive), this portion of strategy not well illuminated. May be intentional knowing these guys, who have been go big or go home from the beginning. Repeat team with proven exits.

9. Disaboom. Pick for social networking site worth a damn. Seriously. Take a look. Amen to this being THE ONLY company who's paid attention to regulations for making websites accessible to those with hearing/visual impairments. Does what a social network does when it's working right - becomes integral part of daily life and ads value, connection, empathic support. Team rocks.

10. MyPacs.Net. YouTube of radiology. Awesome. Practical applications with expansion potential like whoa. Acquired by McKesson. Follow the founder.

11. Ozmosis.com. Social networking for docs. Invite only. Credentials checked. Team composed of practicing physicians, who MAINTAIN clinical practice. Plus 20. Functionality blows Sermo out of the water. And these guys tweet, thank the heavens.

12. EmphasisSearch. Navigating murky waters of specialist referral at academic medical centers, tertiary care centers. You're dxd with a zebra. Your PCP has no clue where to send you. Enter EmphasisSearch. Again, another service that isn't 'sexy' in terms of design but far more vital solves a REAL, current need. Another potential acquisition target.

13. FitBrains. Several faves on the Gaming for Health panel, moderated with verve (and interesting door prizes) by Doug Goldstein. This one's better than Scrabble or Yahoo!Chess. An online gaming site for the brain gain company with multiple games, ways to compete against coworkers, etc. And yes, I've, ahem, spent some time checking it out. Games based on five 'major muscle groups' for the brain designed around in-depth neuro-clinical studies. Surface AND substance - warms my heart. Warning - may be more addictive than Fantasy Football in group settings. Exec points here too. Michael, will you partner with AARP already?

14. Special Prize: HopeLab. This is a do good works, game well company. Disclosure: I participated in HopeLab's RuckusNation Challenge last year (online judge of plans submitted) - volunteer, unpaid activity. ReMission, a game HopeLab developed for kids with cancer distributed FREE and based on an amazing depth of medical and behavioral research, is THE ONLY APP I downloaded and continued to use at will when it was no longer strictly necessary for demo purposes. Being Roxy, the nanobot who zaps cancer, is quite simply addictive. As is the sense of victory that comes with 'adhering' to therapy and using chemo to outwit those nasty blobs of unruly cell growth. Get a presentation from Richard Tate, who, other presenters take note - ACTUALLY GAMED FOR MORE THAN A MINUTE while concurrently navigating his demo. Well worth your time.

15. HealthTalker. Fascinating model for social networking, activities, learning, activism that is condition centric, paid for by sponsors. Participants get sweet kit in the mail. Design-oriented and fantastically marketed; thank God for someone that gets the importance of UI. One to watch. Doing some VERY neat things. Acquisition target perhaps...

16. Limeade. CEO is a force of vertical nature at work. Henry could sell you a pet rock and make you feel shiny and happy laying out cash for the purchase. Employer wellness programs are nothing new, but employee-centric, fun, elegantly designed, and intensely private programs are. This company is begging for partnerships with innovative firms like Safeway (yeah, the grocery chain). Can't take plan with you if you change employers - YET. But feels trustworthy, like they're one of the only players in the space looking out for my interests a la regulations governing employer use of employee wellness info. I'd pay to get, pay to transfer, carry with me along my Brownian career path (thanks Carlos Rizo) like I do with my 401k vendor. Keep an eye out. This is a big mushroom that would only benefit from a Sequoia sized tree trunk.

17. Hello Health/Myca. Jay Parkinson was off rockin' the audience at Pop!Tech, but Doc Sean Khozin was onsite doing what he does best, caring for patients (myself included after some tachycardia on the morning of day II - scary but inconsequential - thank you Sean, send me a bill!) and talking about the platform Myca has built that lets him do that. Key words: caring, lets, platform. What it's all about people. Size, scalability, future competition in the space are biggest issues here, but oh, yes, keep watching.

18. MedicalPlexus. Design, UI icky but neat FaceBook for doc groups. Team is young, well-educated. Sermo group fools if they don't buy this company and these guys while they're still accessible. Ozmosis team take a look too.

19. KwikMed. "Only" for a lot of online pharmacy stuff, including licensed to prescribe online (betcha didn't know that was out there, did ya? Join the club). Ask founder/CEO to tell you the story of how and why he started company. Hint: It involves the little blue pill. Again, exec team huge plus. Got their stuff together. Going after existing market. If I was Target or Safeway I'd buy them, roll them in, become part of 2 prong strategy including onsite minute/retail clinic partner.

18. Plus3Network. The fitness user's friend. Huge growth potential with Outside-reading, urban-biking, occasional 5k running crowd. Right now more 'serious' fitness users (triathletes, people who bike to work, etc) than weekend warriors, but an awesome site with a do-good be-well model. Can organize group activities, see what other people around the world are setting up (great to set up, say, international health group meeting to be conducted during a bike tour of The Netherlands...rubbing chin....). You choose a corporate sponsor, work towards nifty prizes, and help them raise funds. Awesome model. Talk to the CEO. Great guy, got his head on straight.

19. ZocDoc.com. 3M in funding from Khosla Ventures. Former McKinsey team that picks their people carefully. Wore orange scrubs at previous demo gig. Verve for presenting, and substantive bedrock of kick-ass, specialist doc and dentist booking software beneath it all. Wish they'd been on mainstage. They need to expand outside the Big Apple, and Ted Eytan we better hope they pick DC next. Put it this way. If they called, and I was on the other line with someone, I'd hang up to talk to them. Pronto.

20. QTrait. Opposites attract, genetic profile dating. Craziness. Actually some nifty genetic stuff (a la carte genotyping?) I'll probably buy this year, or ask to receive for Christmas. Founder bench strength and background like whoa. One to watch. Best of breed for consumer-friendly design. Others take note. Lose the circa 1999 interfaces. Probably will be all over press/media this year. If you're interested in the genetics stuff (and with Sarah Palin's assertion this week about pet projects like 'fruit fly testing in Paris France, I kid you not!' being a waste of funds, you should be) - take a look that the discussion on this beta tester's blog: http://bustermcleod.livejournal.com/196345.html.

21. PrivateAccess: Most complete trial platform I've seen. Helps take what is a VERY acutely subjective phase of healthcare decision making for consumer and provider and put it into objective steps, easy to follow and understand terminology. Team worked like dervishes to pull this off in time and is drum tight. A top 5 must-follow for next year.

22. USPreventiveMedicine. Wellness and disease management platform. Bigger, sexier, better designed DM. For a 'Health 2.0 company' really deep founder, exec team, and advisory board strength. Also tiptoeing towards policy recs and advocacy.

There are also plenty of companies I wish had been represented onstage, but I didn't have ultimate veto power to choose 'em, I just rehearses 'em.

These include Sugarstats and CureTogether, Polka.com (which appeared at the Launch breakout) among others.

More importantly, notable audience segments that many tweets (myself included) think would be valuable to include at the next show (or any other of its kind):
  • medical librarians
  • medical educators
  • med students
  • nurses (of all stripes -starting with you NurseDan)
  • other provider segments (PAs, NPs, etc)
  • 'academics'
  • practicing physicians
  • hospital execs
  • medical writers/journalists (academic and 'popular')
  • patients

By the way...a healthy forest is made of many tree trunks of various diameters.

There's plenty of room here for multiple platforms to pave the way. But someone's gotta go first. We need a spark before the bonfire can really get going.


Health 2.0 Demo Tips - By Popular Request, Republished from Twitter

Over the past 2 months, I've worked with 70+ speakers presenting during Breakout Panels at this week's Health 2.0 Conference.

The goal was to schedule 3 rounds of calls and online meetings before Health 2.0, and to have a 3.5 minute presentation gift-wrapped and ready to go, with all presentation info (speaker bios, demo URLs, media, etc.) submitted by September 30th.

Ha. Ha I say!

Of course I had a beautiful Google Calendar set up and prepopulated, a tracking spreadsheet, and a highly idealized vision of how this would all go.

The reality was over 300 hours of calls, emails, panicked last minute changes, time zone errors, missed opportunities, miscommunications, and heartache as some companies put in work for presentations that didn't fit formatting requirements and had to go back to the drawing board.

But the reality was also amazing serendipitious moments of joy when a founder illuminated a product so skillfully I was ready to weep with gratitude. Moments when a personal health narrative was an integral part of a company's founding. Moments when the semantic search engines behind some next-gen social networks finally traded coin in common sense design.

This gig has been, without doubt, one of the most challenging I've ever undertaken.

It has also been a privilege the likes of which I'll probably never experience again - personalized front row tours with some of the most innovative HIT firms in the country? Straight from their executive teams? And I'm supposed to suggest potential improvements? What planet did I wake up on this morning? Who pimped my work life?

(Blogger's Note: That would be a big shout-out to Matthew Holt and Indu Subaiya, who handed me the sweetest assignment in the history of Health 2.0, except for the Great Surfboard Search Robin Smiley got, but more on that at the show...)

Seriously, after doing over 300 of these calls, some underlying patterns start to emerge.

First, you're there to help them practice, ask relevant questions, suggest 'wow' wording, and then end the call. Finite. It was tough for me to realize each practice wasn't a consulting gig.

You can't change a company, or a product, during demo practice. And that's not your job. Your job is to make sure that 3.5 minutes is as clear as they can make it. Start with the expectation "You have 3.5 minutes to NOT suck" and work up from there (sometimes slowly).

As we tried to pack 30 mins worth (average presentation time of a demoer 'before' we started our work) of demo into a masochistic 3.5 minute slot, some interesting things happened.

1. I've learned the value of brevity.

Shocking, concise, cut to the quick brevity.

We're not talking about a breath of fresh air here - we're talking about comments delivered with the gust of a glacial wind.

With one to three 15-30 minute phone calls and two to three (if we're lucky) online demo rehearsals, there's no time for mutual b^&-kissing and becoming best friends (leave that for the cocktail parties onsite).

I've also learned brevity is not my delivery duration vehicle of choice, which is why I was an English major not an engineer. And why some of you had hour-long calls. Sorry.

By the end round of demo practice (as in, it ended yesterday), I was delivering not 15 second elevator pitch examples, but TWO SECOND elevator pitch examples (ok, maybe 5, but as I said, I'm not so strong on brevity).

2. My hatred of the telephone as a communication tool is confirmed.

I can't get any feedback through the damn thing other than vocal intonation, which conveys even less than the words you choose to type in an email or Tweet.

I had to let suggestions drop into the void and then wait painfully for the presenter to respond. Had the reason for the suggestion come across? Did the importance of focusing on the issue telegraph through the wires?

Sometimes I just couldn't tell, and that's annoying as hell when you want things to be as tight as possible.

That said, webcam is creepy for demos, especially if I haven't met you in person beforehand. And every meeting software under the sun crashes and has its pitfalls. More on that later.

3. If you're a presenter, it is excruciatingly difficult to remove yourself from the lead role, but this is what you MUST do.

I am not making this up. Don't let ego force your product, cringing, from the stage. You're there to pump it up, not beat it to a bloody, submissive pulp.

The audience can tell when this happens, and it's as embarrassing as hearing an unhappy couple argue loudly and viciously in a crowded restaurant.

Audience members remember really good presenters like a great dance; we're following along without feeling led - the steps are just easy and smooth.

It takes a hell of a lot of work, and a prodigious talent, or both, to be a presentation impresario. But they are out there.

They're the ones you don't want to stop talking. They're the ones that choose words with a ruthlessness during the prep phase that belies their casual presentation during the final talk.

They're the ones who choose phrases that build consensus and convey commitment, layering potential so skillfully that after they finish, you're tempted to ask them to cosign a mortgage on your next house.

3. Presenters, past, present, and future - remember this....If anything, your demo is a duet, not a solo.

It really is all about the demo, the product.

As a presenter, you are a narrator, the conductor of a highly complex orchestra.

Be quiet. WALK SOFTLY. Let the band work its magic.

If you overnarrate, all we hear instead of sweet music is a lot of discordant noise.

4. Focus on the Big Picture.

Surprisingly, presenters, even REALLY good needed some prompting to elucidate meta issues.

I'm guessing it's a case of not being able to see the forest for the trees, or being so intimately tied to the product that you forget newcomers need to grasp these things in under 4 minutes.

But I don't really know. Maybe no one had ever asked them these questions (and thus again I espouse the value of a user-centric design model).

To ALL PRESENTERS for Health 2.0 - your demos should include vital stats like:

  • How does the user find you? (Google search, WOM, physician referral, etc.)
  • Who pays vs. who uses? Are they the same or different (Ex. health social networking site where 'payers' are purchasers of ad space but users are consumers living with diabetes)
  • Where do you live in the Health 2.0 ecosystem?
  • What privacy/security safeguards are in place? Do you use Verisign, https signin, etc.?
  • Do you allow users to participate anonymously? Why or why not?
  • How much do you cost or are you free to users? (shocking how often this came up)
  • Community strength? Users per month? User growth Y/Y? M/M? Not asking you to share the black box here, but for each general example you give me ("thousands of users last week") I will push you to illuminate this in quant fashion ("7,568 new registered users joined last week").

In between doing demos with presenters, I was on Twitter (as usual) keeping up with the world revolving outside Health 2.0 prep.

In sharing experiences, I'd make up (or slightly exaggerate) some things that occurred.

No presenters were harmed in the making of these tweets, as I didn't actually post any of them in real time during a demo, about a demoer with which I was practicing.

A few, however, are real examples from Health 2.0 companies that were doing something REALLY RIGHT during their demos (commendations). If you're at Health 2.0, listen for user 'Dana Scully' for instance.

I posted these on Twitter as "Demo Tips:" They were both cathartic and, I heard later, potentially useful.

Here's the whole list - enjoy.

And to any presenters reading this, first, thank you for your time, your effort, and your willingness to share yourselves and your companies. It will pay off in short order, and it's been my pleasure working with you.

And second, I wasn't talking about you in that bikini wax tweet. Probably.

See you at the show...and remember, YOU ARE READY!


Never Underestimate the Power of Unexpected, Minute Beneficence

From @alexismadrigal's tweet stream today:

"Virgin america guy just ran a gate game, giving away a free stuff to the person who brought up the oldest penny. Dozens digging for change."

Nice contest, sweet metaphor. Even if all you give away is an extra cookie on the plane you've just scored +20 for consumer engagement.

Can you imagine if the patient advocate/registrar running pre-op or the ED triage process pulled a similar stunt?

Hospitals - would someone suggesting this be hired or fired?

Think hard before you answer.

Never underestimate the power of unexpected beneficence, especially in healthcare.


HR 6898 - Your Call to Get the #$%^ Off The Proverbial Couch

Two days ago I posted about HR 6898, the Health e-Information Technology Act (HEITA) of 2008.

Bob Coffield wrote an excellent post here at the Health Care Law Blog calling attention to the bill and providing further vital details (the bill is currently in committee, a link to Congressman Stark's webpage, etc).

A new e-colleague Steve Ambrose emailed me the following comments after reading. Thanks Steve, for allowing me to share. I hope other medical pros will follow your example and read the bill:

"I read the proposed bill ad nauseum.
This looks like it could get mighty cumbersome and extremely bureaucratic. I really can't wait to see how long it takes to agree on a uniform data set. Also, don't be surprised if that $10 million in grant monies for HIT in academia is spoken and secured even before the bill passes. And the little guy seems to get the little print.

I don't like it. My innate sense is that things are going to get a bit more sticky in the next few years, with more health systems growing out and capturing more market share. I feel as though the small practices will be purchased or simply lose so much share of business that they will be forced to sell or close. I just feel like this bill probably started off with good intentions and is heading in the wrong direction.

Where are the days of the good ol' country doctor, the home visit and Sunday being a day of rest?"

It's particularly ironic timing for me to have read a bill about eHealth from start to finish, as I'm spending close to 14 hours a day preparing eHealth, mHealth and HIT companies to present at Health 2.0 next week.

As the team works with execs to refine, refine, refine presentation language and tweak formats to ensure maximum message download packaged into minimum duration (they have 3.5 mins to impart their messages), I'm wishing Stark would throw an open Health 2.0 on the Hill day.

Hell. I'm thinking Matthew Holt and Indu Subaiya should present a call to arms at Health 2.0, and suggest this. Double hell. I'm thinking if they don't, I will.

If I could march onto the Hill and show Congress what I want eHealth to be, it would look suspiciously like Ted Eytan's crowdsourced definition of Health 2.0, or the Nexthealth vision (complete semantic interoperability of health = healthcare goods and services will be available to consumers, online and offline, at will).

It would look like efficient, empathic care. It would look like conversations between physicians, patients, caregivers, and providers.

It would be enabled by incentives that pay docs to talk with me about my healthcare and wellness goals. It would be enabled by tech that fits into my palm. Tools that seamlessly integrate into my life, like my new Zuri (beta tester!) that would beep and remind me to exercise and take my glucosamine chondroitin.

I don't have time to march to the Hill. Like most of you, I'm too busy trying to save healthcare by waving my little white flag over here at Health Management Rx, and at Nexthealth.

Neither do you, right? I don't have the time to lobby, you might be thinking (or the money). And I can't afford the 2 hours to read that bill and form my own opinion...

Bollux. It's not all about PACS. Sometimes it's about conversations. Determination. Reading the bill draft, from first sentence to last. Sit down with a glass of red wine. A cup of tea. Rediscover what it feels like to have a cause, because if the blogosphere doesn't, no one else will.

In this case, dear healthcare readers, you can't afford NOT to lobby. That is, unless you believe consumer-centric PHR development should be killed in the cradle.

There is so much of value in this coming show in San Francisco that it's hard to know where to begin. It's not all fairies and snowflakes and puppy dog tails, but it does gather a unique crowd of entrepreneurs, docs, bloggers, and assorted sundry healthcare types.

As a result, it's like bootcamp for the industry sector. Come as a groundling (for all you Shakespeare fans) to throw jeers, or come to cheer the efforts of companies like Organized Wisdom, Hello Health, and Change Healthcare.

I'd like to issue a challenge, an open call, and invite members of Congress and staffers working on this bill to show up at Health 2.0 next week.

Tomorrow, I will be calling the offices of my Congressional representatives (the ones that represent me when I'm stateside at home in St. Mary's County, Maryland) and extending the invitation personally.

We'll put you to work on the volunteer staff. You can trade labor and some time in the trenches at the conference.

Nothing's free at Health 2.0. Trade your time for our knowledge. I bet you'll learn more listening in on hallway conversations than you would reading 500 pages of white papers back in DC.

Plus, there will be press.

And don't you want to talk about something besides Main Street versus Wall Street?!


Radio Silence: Preparing for Health 2.0

Dear Readers -

Today GruntDoc declared Health Management Rx "dead" and removed it from his blogrollls.

This means:
1. Posts have been slow, and;
2. Posts have had little value to readers whom I respect and admire.

GruntDoc, my apologies.

This was an excellent reminder to get back in the saddle, despite other commitments (and a love affair with new channels, especially Twitter), and blog, blog, blog.

I'm currently working with more than 80 speakers and 55 volunteers to prepare for Health 2.0 - User-Generated Health.

The above photo is from a live demo I did this Friday with Rex Jacobovits for MyPACS.net (McKesson), the "YouTube" of radiology - one of the companies I'm helping prepare to present October 22-23rd.

This means Monday's calendar is packed with 14 (yes 14) demos, not counting calls, emails, etc.

Health Management Rx content has suffered as a result, and many thanks to GruntDoc for throwing down the gauntlet.

A desire to connect online and offline worlds, and provide a healthy dose of pessimism and optimism when viewing the diverse (and often disjointed) world of health management was the impetus behind my entry to blogging last April.

That commitment, despite what's happening with my career, has not changed.

Blogging is not a hobby. Connecting people, online and offline, interested in improving healthcare management and delivery the world over, is most definitely a career.

But more than that. It's probably a calling.

I'm still too idealistic to have the enthusiasm and passion for change beaten out of me.

I'm still excited by new tech I believe has healthcare applications (hello, new friends at Mingle360). I still want to connect those interested in being innovators, interrogators, and implementors.

Offline, I've been working on Medical Education Evolution things and getting a new thing off the ground - starting a "geeky" Tech Brunch series in DC (with now comfy collaborator Ted Eytan). Look for a time/place for the first "geek" brunch after Health 2.0.

Online, I've been advising friends who are starting new businesses and working on longer-term commitments like the Innovation Challenge, which, for the first time this year, has a health component sponsored by the Robert Wood Johnson Foundation.

That sounds suspiciously like I'm making excuses.

I'm not. I want Health Management Rx to be a continual reflection of this myriad of possibility, this maelstrom of recombinent communication, a place readers come for first looks, innovation soundbites, and sometimes smarmy commentary, despite how much sleep I'm getting or what big hairy audacious goal is stealing my hours.

Or, as @alexismadrigal said recently on Twitter, it's probably what I've dedicated my life to.

GruntDoc, every once in awhile you don't need platitudes, you need a kick in the ass. Thanks for mine. Consider HMRx back from the dead.


Breaking News: Congress Wants to Create National eHealth Network, Legislate Who "Owns" Health Data

Clue - it ain't patients. Google. Microsoft. I hope someone in your healthcare organizations reads this brief. Look especially to the latter 1/3rd.

Browsing Twitter this afternoon, I learned about a House bill draft (HR ____) nicknamed "Health e-Information Technology Act of 2008" from @jesran.

It has not yet been assigned a number, but the draft copy is available here. It looks to be in pre-committee.

Sponsors: Mr. STARK (for himself, Ms. SCHWARTZ, Mr. MCDERMOTT, Mr. MCNULTY, Mr. LEVIN, Mr. EMANUEL, Mr. NEAL of Massachusetts, Mr. PASCRELL, and Mr. LEWIS of Georgia).


Why is the bill important? Take a look:

  • It defines an EHR, and places control of an EHR strictly and SOLELY in the hands of providers and staff (numbers to the left are lines in the bill), p.4:
18 ‘electronic health record’ means an electronic record
19 of health-related information on an individual that is
20 created, managed, and consulted by authorized
21 health care clinicians and staff of one or more orga
22 nizations, that conforms to standards adopted under
23 section 3003(a), and is made accessible electronically
24 to other health care organizations and other author
25 ized users."
  • On p.5, it defines providers as the following, but adds "any other category...determined appropriate by the Secretary":
2 ‘health care provider’ means a hospital, skilled nurs
3 ing facility, nursing facility, home health entity,
4 health care clinic, Federally qualified health center,
5 group practice (as defined in section 1877(h)(4) of
6 the Social Security Act), a pharmacist, a pharmacy,
7 a laboratory, a physician (as defined in section
8 1861(r)) of the Social Security Act), a practitioner
9 (as described in section 1842(b)(18)(C) of the Social
10 Security Act), a provider operated by, or under con
11 tract with, the Indian Health Service or by an In
12 dian tribe (as defined in the Indian Self-Determina
13 tion and Education Assistance Act), tribal organiza
14 tion, or urban Indian organization (as defined in
15 section 4 of the Indian Health Care Improvement
16 Act), a rural health clinic, and any other category of
17 facility or clinician determined appropriate by the
18 Secretary.

  • Pages 5-6 define HIT (line 1 denotes jump to p. 6):
23 The term ‘health information technology’ means
24 hardware, software, integrated technologies and re
25 lated licenses, intellectual property, upgrades, and
1 packaged solutions sold as services that are specifi
2 cally designed for use by health care entities for the
3 electronic creation, maintenance, or exchange of
4 health information. "

WAIT A MINUTE: HIT is "specifically designed for use by health care entities?" Are patients/consumers considered healthcare entities? I'm getting a sick feeling in the pit of my stomach here.

  • A new post is born:
"There is established within
8 the Department of Health and Human Services an Office
9 of the National Coordinator for Health Information Tech
10 nology (referred to in this section as the ‘Office’). The Of
11 fice shall be headed by a National Coordinator who shall
12 be appointed by the Secretary and shall report directly to
13 the Secretary."

  • Part of his/her job? To pave the way for a "nationwide health information technology infrastructure" that:
  1. allows for the electronic use and exchange of information
  2. ensures each patient's health info is secure under 'applicable law' (Hello HIPAA)
  3. improves quality
  4. reduces medical errors
  5. advances delivery of patient-centered medical care
  6. reduces costs resulting from inefficiency, errors, inappropriate care (say what?) duplicative care and incomplete information
  7. ensures appropriate information to help guide decisions is availble at the time and place of care (that one's a doozy - cost? quality data transparency requirements at a national level?)
  8. ensures inclusion of meaningful public input (how defined?) in development
  9. improves public health reporting
  10. facilitates research
  11. (another doozy) "promotes a more effective marketplace, greater competition, greater systems analysis, increased consumer choice, and improved outcomes in healthcare services" AKA CONSUMER CENTRIC CARE
  12. improves efforts to reduce health disparities (wait, healthCARE delivery disparities or HEALTH disparities?)

  • Every 2 years, the National Coordinator and HIT Advisory Commitee must update/make new recommendations. This is a VERY big job. Ted Eytan could take it.
  • When developing recommendations, the National Coordinator must initially refer to DOD and VA, which are cited as models of interoperability for EHRs (GAO report 08-954 p.6-8 specifically cited in the bill) p. 12.
  • The poor National Coordinator must ensure that information is collected and transmitted in "a manner that is reliable, accurate, unambiguous and (wait for it...) based on a uniform provider data set (who defines this Uniform Provider Data Set?)." The coordinator's FIRST TRIP should be to Health 2.0. Next trip to New Zealand. Third trip to Medicine 2.0.
  • Sensitive health information may be "segmented" ie broken up into little pieces and scattered into the wind to protect our privacy. Great. Good luck putting that broken picture back together, p. 14.
  • Shocker: To the "maximum extent appropriate" coordinator must incorporate CCHIT ambulatory and inpatient certification criteria.
  • National Coordinator will solicit public input via open public meetings and comment periods, p. 16.
  • She will also develop a program "(either directly or by contract)" -ummmm, SOMEONE's getting paid...-for the voluntary certification and periodic recertification of HIT systems and components.
  • The National Coordinator needs to be an open-source guru too, using definition of 'open source' as defined by the Open Source Initiative.
  • She will have to "provide for coordinating the development, routine updating, and provision of an open-source health information technology system that is either new" or based on an existing system. This system must be made "publicly available for use" 9 months after adoption of initial standards by Secretary (laughing, wiping eyes), p.17-18.
  • National Coordinator shall establish a consortium of tech, legal, clinical geeks familiar with open-source. Hello - patients? I'd give my right arm to be on this consortium. Probably literally.
  • OH MY GOODNESS. National Coordinator = Merchant of Venice. She may charge "a nominal fee" for the adoption "by a healthcare provider of the health information technology system" p. 19.
Wait a minute.

So not only are we not INCENTIVIZING doctors' use of EHRs, we're going to CHARGE THEM TO USE THE NATIONAL EHR SYSTEM?

But wait. It's all ok. If I'm a smaller provider or in a rural area I may get a price break - there is a "significant hardship exception" available to those working in areas with no Internet access (p.53). Also, hospitals may get paid a million bucks to implement (p.59), PLUS discharge volume incentives. Thanks Uncle Sam.

Also, later (p. 44-45) the bill seems to say (I could be wrong on this quick+dirty read) that IF you successfully implement and become a "meaningful user" by 2014 you get $15k. By 2015, you get 12k, 2016, 8k, 2017, 4k, and by 2018 only 2k to line your pocket.

How do they determine 'meaningful use?' Maybe by looking at drug claims submitted via the system.

Oh, and by the way, the National Coordinator has TWELVE MONTHS to develop a strategic plan detailing how to achieve the above objectives. After which case a straightjacket or lobotomy may be necessary.

The plan must also include timeframes.

The National Coordinator has to publish the strategic plan, and then subsequent implementation reports every 12 months. She can create and use task forces and work groups, in addition to the HIT Advisory Committee, for help here.

Of course, the coordinator also has to do a website, which includes grant information for HIT implementation, and appoint personnel. Staff will be funded by appropriated monies from 2009-2013.

Also, the office gains revenues from an "open source product licensing fee" (p. 26).

So, who are the National Coordinator's Knights of the Round Table? The HIT Advisory Committee. Who's on the Commitee?
  1. DHS appointees from AHRQ, CDC, CMS, HRSA, IHS.
  2. 1 member pick from Senate majority leader.
  3. 1 member pick from Senate minority leader.
  4. 1 member pick from Speaker of the House.
  5. 1 member pick from House minority leader.
  6. Presidential appointees from Veterans Affairs, NIST, and DOD. Yep. DOD!
In addition, the HIT Advisory Committee contains a very interesting dozen appointees chosen by the Comptroller General of the US. These '12 disciples' include:
  • 1 advocate for healthcare patients and consumers (!)
  • 2 healthcare provider reps (1 a doc)
  • 1 from labor union (uh oh SEIU, make sure we don't get a doc from BIDMC on here too)
  • 1 member with expertise in privacy/security
  • 1 w/experience improving health of vulnerable populations
  • 1 member from health research
  • 1 health plans/3rd party payors
  • 1 HIT vendor rep
  • 1 shall represent purchasers or employers
  • 1 w/expertise in healthcare quality measurement and reporting
  • 1 w/expertise in open source HIT systems
The HIT Advisory Committee will have 1 Chair, 1 Vice Chair, one of whom must be from public sphere, one of whom must be from private sphere. Members are paid a per diem rate and are reimbursed for travel expenses. Members serve 3 yr terms, and 10 constitute a quorum.


But adoption by "private entities" seems to be voluntary (p.34).

The National Coordinator will develop an HIT Resource Center to develop best practices, provide tech support, and accelerate the aims of the bill.

Now let's move on to carrots and sticks.

CMS and other federal agencies "relating to promoting quality and efficient healthcare in Federal government administered or other sponsored healthcare programs" may require providers to implement the system (play or we don't pay, p.40).

Medicare Advantage plans (MAs) get a variety of special incentives described with a rules schedule that's dizzying - check out pages in the 70s.

Also, there's a $115M pot of grants and loans available from 2009-2013.

Grant and loan programs may also be funded by agencies such as AHRQ available for providers and also for states and Indian tribes. Read pages in the 80s and 90s. Grant and loan recipient must demonstrate sustainability of quality improvements and cost decreases.

Medical Education Evolution folks take note - Special grants and efforts to develop academic curricula that incorporate HIT use and adoption in clinical education are proposed on page 99. Requirements are spelled out on pages 100-103. 10M bucks is available for these initiatives from 2009 -2011.

I can hear the contractors salivating now. In fact, I should start a contracting firm. It'd qualify for minority owned discounts and incentives and I'd be competing in a protected space as a female owner/exec for the duration of these funds (2009-2013). How's that for a Health 2.0 business model?

How will Joe Six Pack and Alaskan Hockey Mom learn about this initiative?

No later than a year after this bill passes (and may God have mercy on our souls), the Office for Civil Rights within DHHS will "develop and maintain a multi-faceted national education initiative" (read - poorly designed website with long, counterintiutive URL where they slap up patronizing information and quizzes) to "enhance public transparency regarding uses of their protected health information, the effects of such uses, and the rights of indivuduals."

This office will spend 10M dollars to implement this campaign. Give me 10k and I'll start a bloggers campaign that would reach more people and generate more buzz.

Big Picture Issue? Great. The government will now have access to my EHR. In fact, the government will OWN my EHR, and pay docs to keep it out of my hands.

Or so it seems at first read. On page 125, however, the bill authors tell me patronizingly that I can "obtain from such covered entity a copy of such information in an electronic format," AND that the provider can't charge me for that copy.

Well, at least they ARE saying the data can't be sold without my permission (page 125).

And on page 128 they say that providers can't use this information for marketing purposes, or to send a communication that "encourages recipients of the communication to purchase or use the product or service." In legal language, they're not considering that a qualified "health care operation."

What Happens if Your Data Gets Out?

Breaches and other privacy and security issues are covered in pages from 103-118; Google, Microsoft, and other PHR vendors will want to read p. 110 closely:

2 RECORDS.—The term ‘‘vendor of personal health
3 records’’ means an entity that offers or maintains a
4 personal health record. Such term does not include
5 an entity that is a covered entity for purposes of of
fering or maintaining such personal health record.

Big Govt. is also going to take on Google and Microsoft. Read page 131 guys. Read it again. And again.

You heard it here first: 1 year after this Act, the Secretary and the FTC will do a study on privacy+security requirements "to entities that are not considered covered entities" (see page 132, line 7, where the gauntlet is thrown, and your advertisers should you allow any, on line 8, and your partners - perhaps even patients and users, line 15). See also "business associate contracts" page 137.

And little PHR vendors, you're not out of the woods either. The government will investigate clients using your site as a cobranded app or customized PHR portal. See page 132, line 19.

Why you should read this bill draft again, and again, and again:
  1. It's a mountain of legislation that makes HIPAA look like a molehill.
  2. It also systematically reinforces the position of patient as 'other.'
  3. Consumers will not have control over personal health narratives. Our input to PHRs is trivial, 'outside' the system and relevant only for our personal use.
  4. This bill would ensure that PHRs and EHRs will forever remain disjointed halves of information necessary to improve care.
  5. It does not provide adequate time for the government to develop or acquire such a system.
  6. It does not provide adequate incentives or support for docs to implement such a system.

But, if you aren't using PHRs by 2018 anyway, I'm betting you're out of business sometime in the next 10 years.

Now, what are you going to do about it?

PS - I nominate Dr. Richard Reece for National Coordinator position. I nominate Dr. Stanley Feld to be the next Secretary of DHHS.


Welkom en Dutch Grand Rounds, Grote Visit - 4th Edition!

Health Management Rx has the unique privilege to host the first US-based Dutch Grand Rounds today!

Due to the language barrier (ours, not theirs!), the format of this Grand Rounds will be text heavy - some posts are in English, some in Dutch.

Our Dutch colleagues have kindly translated many Dutch links to English text for us, so content of those posts is included below en total.

Since we have so much great 'imported' material to cover, I'll keep the intro short and sweet.

It's a privilege to provide inside perspectives from my adopted homeland. This is a rare chance for the American health and medical blogosphere to hear what's really going on over there in the Netherlands, and how Dutch bloggers view international healthcare fumblings.

Or, as e-Patient Dave and Susannah Fox put it recently: "What's with the Dutch?"

What's amazing is we don't often hear about Holland over here in the insular US of A, unless you're a tech and/or design addict (check out Dwell, Wired, Fast Company, etc. to read about the latest, including Dutch design superstars like Tord Boontje). Or a windmill enthusiast.

These are my friends who reclaimed a homeland from the sea, create beautiful art, pottery, food, families and literature, and bought New York before anybody else across the pond could sense future value.

Point: The Dutch are at the forefront of what's new and what's next, in tech, in architecture, in health.

We're building a global network of healthcare firestarters, connecting with new friends in Israel, Canada, Hungary, and of course the USA.

What you need to know about Holland:

1. Yes, we ride bikes. Alot. Ask us about 'oma fiets.'
2. No, we don't wear clogs. Usually.
3. Ignore us at your peril. We are all on Twitter. Are you?

You might say we're a nation where being a maverick is the norm. No wonder I feel so at home...Lekker!

Why pay attention to the Dutch healthcare ecosystem and blogosphere?

1. They are further along in PHR development.
And they let people who are patients 'own' medical and health data.

Why does this matter? Because there isn't a snowball's chance in hell we'll reach agreement on who 'owns' data until someone builds a killer app that let both patients and providers have access and sharing/privacy rights.

As John Sharp said on Twitter yesterday:
JohnSharp Icon_red_lock @jenmccabegorman As Health 2.0 epatients, we can take charge of our health info but the docs still write the scripts


From Robert (@hout): PHR-On-A-Stick (Netherlands)

Two doctors at Maastricht University Medical Centre, in cooporation with Cinsol corp., have developed a cardiologic Personal Health Record, on a Flash memory stick, called Cardiostick.

Cardiostick contains personal data, insurance data, and medical info about pacemakers, operations, heart rhythms, x-rays, ECGs and scans.

When plugged into the computer, an emergency page appears with all important medical information in four languages.

The patient owns the Cardiostick and is able to add and edit password protected information. He also can grant access to others (doctors).

Cardiostick is currently being used by apprx. 500 people.


Good luck ;-)

2. They are paying attention to genomics. Again, watching where the puck is going, not where it is (thanks @gapingvoid).

From Laika's MedLibLog, an excellent analysis of DTC (direct-to-consumer) genetics firm 23andme's recent price cut in "23andMe: 23andMe, not yet."

Can't believe I missed the "celebrity spit party" - @unitystoakes can you tell us more about it at Stoaked?

And check out the comments in Laika's blog entry, where Dr. Steven Murphy tells us about a new group, HelixGene, dedicated to "better genomic medicine."

3. They've agreed they need a NATIONAL EHR/EMR SYSTEM.

Lodewijk Bos, @icmcc, Founder of the International Council on Medical and Care Compunetics (ICMCC), has an excellent commentary here.

His main point? A tethered EMR will never live happily ever after with an untethered PHR. We need a comprehensive design, or a system to link the two interfaces - and buena suerte with building that one.

Or, as Lodewijk puts it: "The concept of a separate EHR and PHR is fundamentally wrong."

The first article to which Lodewijk refers, by Martijn Hulst, is published in Dutch, but Martijn has been kind enough to translate it for us Dutch n00bs.

From Martijn Hulst comes a translated summary his blog-article about electronic health records (http://www.martijnhulst.nl/weblog/pivot/entry.php?id=472) in Holland.

The post, in Dutch (via the link above) gives an overview of the EHR-debate in the Netherlands.

What you need to know about systemic, national EHR implementation in Holland (per Martijn):

1. The government is trying to get a law through our Parliament.

2. In this law they demand that on September 2009, every caregiver is connected to the main EHR-application, so that the exchange of health data between caregivers is possible.

3. When they made the initial law there were many reactions:
  • The Council for Public Health and Health Care said in an article that the whole idea of the EHR and the law isn't looking at what is possible with the web.
  • A general practitioner published an article and wrote that the EHR of the government is nothing more than an 'air castle' (castle in the clouds) and that it won't work in such a short period.
  • The society of general practicioners aren't willing to help, because they don't believe in the EHR and because there's another discussion between them and the government about payment. (It's always about the incentives eh Martijn?!)
  • A lawyer, who studied privacy-questions about EHR, said the EHR is not good for the privacy of patients, because caregivers wouldn't have the approval from the patients to look in the health records of their or others patients.
  • A consultant about EHR's wrote an opinion-article and said some things about who is owner of the EHR (patient versus physician, another recurring theme).
  • The insurance companies and the dutch association of patient-consumers (NPCF) said that regardless of the critics we must go on with the law, because patients are waiting on a main EHR-exchange and that it lead to some prevention and less mistakes in healthcare.

4. They believe in consumer-centric, human t0 human care.

From Martijn Hulst:

"In my posting I give another view and write about the world patients live in (the 'health2.0-world'). In this world patients are already exchanging information, meeting each other, monitors online his / her health, and so on. This world is far from the world of the law. And, well, you know already, this is not a technical problem, but an organizational and culture problem. This is also studied in the model of Bettine Pluut (from Zenc). I put a diagram of this model in my posting.

In my conclusion I write that the whole implementation of EHR's must not be a question for IT-companies, but must be a question for organizational-(change)-consultants. You can't force caregivers to work in a short period with a nationwide EHR, you can't force caregivers to exchange their information and you can't force healthconsumers ('im-patients') to choose for an old idea of EHR's, when they already explored online a world of possibilities."

And from Jacqueline, @fackeldeyfinds, a look at putting human-to-human healthcare into practice here.

An Energizer Bunny who outsparks even yours truly, Jacqueline has an overview of the intersection of people and tech (or lack thereof) in healthcare here (in Dutch but check out the images on the slideshow - you'll get the drift).

5. They are connectors extraordinaire who will give anyone a chance. They live well but move around, a lot.

They are statespeople, diplomats and are not shy about taking risks, like including somone blogging about getting rid of a pot belly in Dutch Grand Rounds.

How can you NOT want to make healthier eating choices, in Holland, the US, and abroad, after reading DietBlueBook's description of, ahem, an apple shaped appreciation for good living?

"Hidden under my shirt is a jiggly treasure trove of human belly fat - perfect for some fun loving squeezing and a show of wealth perhaps in some poorer countries, but to me, it’s a sad reminder that I’m out of shape and have been hitting the ice cream cartons and Asian carryout meals a bit too hard."

Yeah, really I just couldn't figure out how to fit this one in there (no pun intended).

But eat too much pie in Holland and you too will be dealing with Dutch double belly.

AdmirableIndia's post, has, on the other hand, nothing specifically to do with healthcare, or Holland, but DOES have some very nice therapeautic photos of sunflowers.

AND since Van Gough was particularly fond of this flora, you made it in by a hair AI.

Thanks for brightening our day.

Tomorrow a quick followup and announcement of the next gathering place for Dutch Grand Rounds.

Until then, be well, do good work, and think seriously about booking a trip to Holland.

Tulip fields are lovely in the spring, and I know a little place we can brainstorm.

Tot ziens all!