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Craig Stoltz from the Health Care Blog writes:

There are many good reasons to deplore Wikipedia, not the least of which is its authors’ cultish smuggery about the righteousness of their cause and the rightness of their content.

Of course there is also its internecine complexity of processes. The documentation tracing the petty bitchery about an entry is often longer than the entry that is produced. The international collectivist negotiation over matters of “fact” is beginning to remind me of the United Nations, but without the fancy New York headquarters.

A brief diversion from usual topics, but I too have been listening to the “wisdom of crowds” nonsense for long enough.

Wikipedia is great, but it has a limited ability to do a few things well: reign in pop culture to a reasonable degree and make anyone with an iPhone at a cocktail party the final arbiter on any topic.  (Full admission: I am an iPhone user.)

But even their model has broken down.  To wit, there is a long and extensive series of gatekeepers who review articles and decide if they are worth keeping.  As Craig writes, much of this reasoning is circumspect, and now, Wikipedia is going to make it even harder to publish on their site.

What you talking ’bout, Wikipedia?

As much as they might downplay it, there is still a chain of human command laboring behind the curtains of Wiki.   The crowd wisdom has little to do with the success of wikipedia; what’s truly amazing thing is that by appealing to basic emotions of all humankind — the need for fame, the need to judge others — most of these writers and editors do work for free.

You could get the same results if you dumped a series of photos, videos, ancient texts, etc. that were all authored by a small group and set the wiki admins loose on organizing it.   See Amazon.com and their wishlist series – it’s a neat way for me to bring order to a disordered set of data; Amazon provides an incentive for me to do so –small amounts of fame and the hope that someone might buy me a gift. 

I’m curious, didn’t we use to call this job “being a librarian?”

What I find increasingly strange about the Wiki-universe is how distrustful it is of its own fans.   There is now a sniff-sniff, Wikipedia is too good for that kind of attitude regarding certain types of content.   Articles that are not “relevant” or “news-worthy” — again, decided by the overly-invested, unpaid admins – are deleted.  So what if the article on historical Christian hairstyles wasn’t good enough to make the grade, isn’t the point that Wikipedia has no limits — that because it is the very antithesis of an encyclopedia set, which once bound and printed is limited — so it should be able to encompass all kinds of knowledge, however random?

But here’s the last laugh.  Wikipedia is now authoring an encyclopedia.  (One wonders, Will they e-mail out updates?  Will digital ink self-correct?) 

Such a move is proof that the printed word — the book that you can hold in your warm, Kindle-less hand — is still something the crowd aspires to, whether ’tis wise for the Wiki franchise or not.

Of my last post about open source food, Jeff Jarvis commented:

I wasn’t suggesting that the kitchen should be turned over. I’m exploring the ideas of openness even in restaurants. For example, I’d like to know which dishes get ordered more so I can use that in my decision. Or perhaps diners can suggest improvements in recipes. And so on.

Next I’m tackling health. Since that’s your expertise, how do you think Googlethink could come to health care? Could it? Can doctors and health institutions be more transparent? What would we learn from aggregated and open data? Would there be value in a social relationship among patients? And so on. I have some ideas but I’d love to hear your thoughts.

From my point of view, the biggest challenge in healthcare institutions is the institutional thinking that goes on behind the scenes. Many good hospitals are trying to keep it all together, given the unfair hand they’ve been dealt: price-setting from insurance payors, even lower price-setting from the government, and the legal responsibility to treat anyone sick enoug to walk through their ER doors. Add in overall costs of service delivery increasing at a time when the costs of insurance are biting Joe Q. American’s pocketbook and Michael Moore’s Sicko… well, it’s a rough time right now in healthcare.

This leads to institutional thinking: how do we keep this boat together? And the simplest answer is command and control leadership. Don’t take risks, don’t innovate, trim costs wherever possible, etc. That’s not a critique — I’m sympathetic to the challenges here — but it does mean that providing patient access to data inside of a hospital is risky because it opens the hospital up to more risk.  Patient benefits be hanged!

I have been point-blank told, at more than one hospital, how much they’d like to get rid of system X or software Y, but they can’t. Even though it doesn’t work and there are better products available, they just can’t. It would be too costly — politically or capital-wise.

From an infrastructure standpoint, most hospital software is cumbersome, expensive, and (let’s face it) old. The sales cycle for a hospital engagement is often 18-24 months — contrast that to a Google service: free, immediately available, updates whenever you want! As good as the technology is, each hospital technology infrastructure is a jigsaw puzzle that barely fits together as is, never mind inviting a behemoth like Google into the mix.

A typical patient experience, from a hospital standpoint, goes as follows:

1. I’m healthy.
2. I’m worried I’m sick and go online to get health information.
3. I see a doctor/RN for diagnosis.
4. I go to a hospital for treatment.
5. I am discharged.

Being a patient in a hospital is a terminal experience: it ends in discharge or death! The medical systems were created long before Starbucks convinced every industry that consumer relationships were what mattered (thank you, SB, for getting the stinky breakfast sandwiches out; here’s a to a $30 stock price again.)

Google Health might end up being a great tool for diagnosis but hospitals can’t embrace it… unless so many the physicians demand it for their patients.

The churn and noise about hospital transparency is basically saying, “Here’s proof we don’t kill that many people.” Transparency = quality of outcomes for a hospital. But in 5 years, that won’t matter. Once the measures of quality are open to the public, the payors and Medicaid/Medicare will use it as an excuse to stop paying hospitals with lousy outcomes. So, overall, the healthcare experience should get better. But that doesn’t mean we’ll know any more or less about the process.

I place much more faith in the power of patients to self-organize in a way that wasn’t possible even two years ago. With sites like PatientsLikeMe, patients in recovery — discharged, perhaps from a hospital — are about to connect about their quality of treatment in a real-time, clinic study fashion. Sites that provide disease/condition/treatment communities will be where hospitals can knock it out of the park. Imagine if every cancer patient in your town heard that XYZ Hospital was the best — from the site moderator!

That’s where the openness will come from: empowering patients who had great experiences to market the hospital with a level of authenticity not possible any other way. We just ran a few webinars on this topic — so popular, agencies and competitors showed up in droves to hear what we had to say. That tells me we’re striking a chord.

But, as I always say, the nice thing about talking about the future is that it’s difficult to be proven wrong.

And by way of continuing the conversation from yesterday, Jeff Jarvis wonders if Google ran a restaurant, who would do the cooking?

Besides the silliness of open source restaurants as a concept — technique matters far more than recipe — the NY Times contrasted that notion with the need for efficiency in dining, noting that too many choices killed the Manhattan diner.

But art demands risk and taking a step forward into the unknown.   Asking your customers to make all the choices — which, one might argue, is an artistic choice in and of itself — is not the same thing as crowdsourcing.  For example, Threadless.com has plenty of folks vote on the best designs, but still maintains final creative control on which t-shirts to send into production. 

Even Wikipedia, famed for its “wisdom of crowds,” has become more bookish and patroling than in the past.  Giving an example at a client site, we created a page for their hospital… and then they got banned.   For copyright infringement. 

I think the point of the restaurant was “Can we imagine Google mashups working in a world outside of technology?” 

Sure, go to any jam band or jazz pickup group.  The improvisational talent is found plenty of places.   But if you don’t share a common level of expertise, you can’t play along.

I read an excellent post on Mashable today,  about how less is more and how to unlock the web.   Much of the post concerns Twitter, an application so sublime, it’s hard to put into words what it does for you.   (But you can follow MedTouch on Twitter here.)

The power of simplicity can’t be understated.  By example, I had a microwave/toaster oven for a brief period of time.  It was left by the previous residents of the house.  Wonder why?   Because I’m sure they found it difficult - as I did - to determine how long to cook something (no numerical keys; just dials) and to take items out when it was a toaster (you needed tongs) and why you couldn’t leave things on top of it (much surface area hotter than a microwave).

In short it was a “time saving” device, but only if I could adapt to it. I couldn’t.  I had a solid understanding of a Platonic microwave and toaster oven ideal.

Twitter is an excellent example of an application that is so simple, you know we are still working to understand and appreciate its value.   In that sense, adding more features to something we are still in the process of discovering, robs that experience of joy.

Now, not everything can be Twitter, but this certainly explains why we prefer a conversation rather than an RFP.  There’s a joy to the creative process that comes out in conversations in way over-processing never quite gets at.

If you saw the movie, the Pursuit of Happyness, you’ll be aware of GLIDE, the Bay-area center for humanitarian programs.   Somehow or other, they’ve got Warren Buffet involved and if you bid quickly, you can have lunch with him for a mere $80,000.

I do like that the “Free Shipping” tag.   Nice to know you won’t need to fly Mr. Buffet, who owns his own jet company, out for a snack at Au Bon Pain.

It’s that time of year again: time for the RFPs.

Every time June rolls around it seems as though the website project that’s been shelved comes around again for its due and to sum up the hopes and dreams of said project, we receive an RFP.

What perfect way to begin a relationship – with lots and lots of paperwork.

Let me share with you the sad truths about RFPs and why we reject 90% of the ones we get: a good vendor can tell a bad RFP within about three pages.  You may think, “But we worked so hard on it, why won’t you respond?” or conversely, “If you don’t want our money, fine!”

These arguments don’t really work on me: as we’re in the enviable position to have many really awesome clients and no bad clients, I am determined to keep it that way and see no reason to change.

There are three kinds of really bad RFPs:

1. The Kitchen Sink RFP whereby a hospital gets together and makes an unprioritized wish list of “stuff” they wish they had and seeks a “ballpark” quote.

The underlying theory: if we put it all down, we can see what we can get in under budget.

How to recognize one: you make a bulleted or numbered list of 20+ items.

The results: all you’ll get back are lies, lies, and more lies.   Why?  Well, you’re lying in the first place.   Building a site with a real CMS is far more important than including a gift shop for your volunteers.  And becuase you can’t decide on that, communicate it effectively, and disappoint people at the beginning of the process, you’re counting on a vendor to come in and take the heat.   Does that sound like a project you’d want?

2. The Consultant RFP whereby a hospital hires a consultant to help them build the point-by-point items that are most important to them and susses out functionality before cost.

The underlying theory: a consultant will help us stay focused, provide us an industry-standard RFP template, and manage the vendor responses so we don’t have to.

How to recognize one: your pocketbook feels lighter after every conversation.

The results: you’ll get back responses which conform to the consultant’s own opinions of how things should be done and then, once you pick a vendor, the consultant leaves.  It’s an arranged marriage of sorts.  Except that instead of spending quality time with the vendor, you spend all that time with a consultant… who then leaves.   The problem for a vendor in this relationship is that we’re never sure if the consultant is speaking for themselves or for the client.  And, we note, many consultants mysteriously end up recommending the same vendors.

3. The Checkbox RFP whereby all features and requirements for the project are reduced to Yes/No questions and then priority ranked, ordered, sorted, and priced.

The underlying theory: Excel can make our decisions for us.

How to recognize one: it’s unreadable to human beings and is often over 1″ thick when printed.

The results: you will get back shockingly few respondents and even though you went through all the trouble, you will end up with canned results nonetheless.  Then your Excel genius will be ticked off and you’ll pick the vendor who got within a mile of filling out the paperwork properly, which often is the one who is most desperate for your business… because they had the time to put into filling out this immense paperwork.  Mmmm — a recipe for success!

Look, there’s about three companies in the United States who are qualified to do this work at all and another four or five who have some overlapping experience in the market.   The main reason you don’t need an RFP is that the world of folks willing to provide services to healthcare is incredibly small.  (And the world of talented folks is even smaller…)

You could spend a single day hearing 1 hour pitches from everyone, cut your list to three, and then go chat up their references.   Your success, in any multi-disciplinary web projects, is not going to rest on features but on selecting a partner you can trust will deliver.

Bad RFPs scare away good vendors and appeal only to those who are desperate for cash.  The point of an RFP is to de-personalize a purchasing experience but with a web project, you need a partner, not a dealer.

And please note next time you visit: the Mayo Clinic does not have cheer cards.

One of the funny things about running a web company in the healthcare space is that there’s a lot of interest from the venture capital community.   And about once a month, someone from a VC firm will call me up, ask me a few questions about the space, and conclude that yes, we don’t need their money.  (Admittedly, I start the conversations with, “I’m happy to talk to you, but we’re not looking for your money…” so this idea has been well-planted in their minds.)

Yesterday it was Michael Segal, from Bessemer Venture Partners, whose name I mention as I promised him I would: he subscribes to a Google Alert for such name dropping events such as these.  Bessemer is a fine fund — one of two family-run VC firms that I know of which has thrived — Venrock, from the Rockefeller family ventures, being the other. 

I always enjoy these conversations since they follow a predictable pattern: the caller has attended Harvard, is learning about the healthcare space, inquires about competitors, asks about our products, asks about the market, concludes with a vague interest and I suggest if they ever have questions about the space, they should feel free to call.  

I never hear from them again.

I’m not knocking VCs — in fact, someday I think it’d be fun to join the ranks – but their job is increasingly hard given the stock market, decreasing talent who can run large companies, and a shrinking need for their services.   Thanks to web technology becoming less expensive every day, the need for $10m or $20m has been cut to a few hundred grand.   That’s actually tough for VC firms since they want to put the most amount of money in the most likely winners and focus their portfolio on what they need to manage.  If you had a choice between putting $10m to work in one company or $1m in 10 companies, which would you pick?

I’d go for the latter, but that’s my outlook as a passive investor.  When you’re managing a $350m fund, you pick the former, believe it or not.

So why the ramblings about VCs other than to tweak my new acquaintance?  Nearly every HIT vendor needs to take outside capital to get a company going because of the sales cycle in healthcare.   If one were to custom build an application for a specific hospital and then try and roll it out globally, you will fail. 

The sales/marketing cycle for healthcare is easily 18 months, often much, much longer.   HIT companies need to capitalize accordingly.  In other words, hosptials are loathe to make decisions quickly and that drives up their costs, which requires outside capital to fund the sales cycle, and that drives up the costs.   And when the companies are big enough and need to pay back the VCs?  They go public… which drives up the costs.  So anytime you see large amounts of outside funding flowing into a healthcare company, especially when they are profitable, you can be sure prices will rise within 18 to 24 months.

All that said, I don’t see any other way for HIT vendors to get into the business except if you’re lucky or very, very good coming out of the gate.

In the (admittedly small) market that we are in, MedTouch is known for delivering results at a considerably higher quality and at a very fair price, still less than what others charge.  I think that’s such a competitive advantage, I’m not sure we’d trade that for a few million in funding we wouldn’t need anyway.  Maybe someday, we’ll have the Starbucks-sized idea, but for now, we’re content to get smarter with each new client – and boy, do we have some exciting announcements coming out regarding new clients — as the industry moves away from e-health and towards Health 2.0

More about that change, later this week…

UPDATE: A had some complaints from VCs about a comparison I made to the banking industry, which I thought was a fair critique given it wasn’t the point of this article.  Hence, rescinded. 

I’m back from the AMA Houston SIG meeting on healthcare and technology, presented by:

Plus Katie Laird, from Schipul, moderated the panel.  

We had about two hours to present, take questions, and wrap it up.  I felt the Q&A could have gone on for another two hours, the audience was so engaged.   The most helpful aspect was that each presentation built on the previous.  Ours was focused on why healthcare was changing due to social media and then Chris and Jennifer followed up with the successes and challenges of from an inside the hospital point-of-view.  (Chris does it because it’s a clear passion, in the midst of other jobs; Jennifer is fortunate enough to have this be her full-time position.)  Jay, from CareFlash, finished up with a demo of sorts to show the benefits of social networks to the caregiving community.

My favorite thing about speaking at conferences — aside from my desire to one day be a talking head over a blue screened city backdrop on CNN – is that it’s a rare time when I can be completely honest with my opinions since the room is not full of clients at varying stages of engagement with what we’re doing.   That resulted in a neat exchange with an attendee (Richard Laurence Baron) on his blog over his concerns that I predicted the death of the written word (I didn’t, but you could take some comments that way) and what it meant for his life as a freelancer (hopefully, more work for more innovative.)

Most of all, this conference forced me to examine our embrace of social media for the company — we now have a MedTouch Twitter page; thank you Jennifer — and our clients.   For example, I’ve had this blog sitting outside our main site because I wanted to make sure that I’d write enough to keep it up (it’s been a year!) and also, I wasn’t sure our point of view would warrant exposing it to every visitor to our site.  Thanks to this conference, I’ve figured it out, so in a few weeks, we’re going to tear this down and rebuild it stronger.

Until then, feel free to talk to us about your hospital’s social media needs.

From the Boston Globe, Walgreens looks to open retail clinics in Mass:

A Take Care spokeswoman, Lauren Tierney, said yesterday that the company expects to open the first of its Bay State clinics in the fall. The company currently operates 173 clinics in 14 states and intends to have 400 running nationwide by the end of the year.

Tierney said the company was attracted to Massachusetts, in part, because of the state’s drive toward near-universal health coverage.

“We applaud the progressive efforts Massachusetts has taken to cover more lives in the state,” Tierney said. “And we hope that Take Care health clinics can provide more access points to get patients into the system.”

This is the quote that has me scratching my head. Why is universal health coverage good for a retail clinic outfit? Shouldn’t it be the opposite — that, as previously posted, 50%+ of the walk-in care has no insurance, thus you’d go where no other alternatives exist? Take Care was acquired last year after building about 100 stores and, I think, Walgreens was right to see the opportunity.

I suspect the play here is less the coverage for healthcare, but more the pharmacy, for which any health plan can provide legitimate, cost-savings benefits. After all, Walgreens (and CVS) are in the pharmacy business. This after Walgreens targets 7,000 stores nationwide and Rite-Aid buys up Brooks. If you’re in the Northeast, you know that the CVS store is as ubiquitous as Starbucks, but that won’t even match the super-chains:

Although the drugstore chains can’t beat Wal-Mart Stores Inc. or Target Corp. on price for health and beauty aids or other items, they are superior on convenience, Mr. Hertel said. “Consumers get choices, pricing, hours, and a lot of the benefits that go with 24-hour access nationwide to a prescription system,” he said.

Ah, it’s store placement — that’s how the drugstores will compete.

UPDATED:

So this tells me that Walgreens’ or CVS’ or Rite-Aid’s comparative advantage lies in:

1. Being open after hours to suggest they are “always open”
2. Locating themselves fractionally closer to you than the big box (Wal-mart, Target) retailers

Therefore, population density and socio-economic makeup is critical to the drugstore chain’s survival as they aren’t as efficient as the big boxes at logistics. Since they have to charge higher prices for that inefficiency, they can make it up on smaller, more profitable sales.  (Instead of the CostCo size tube of… well, never mind.)

Hmmm. If I owned a drugstore chain, I’d try opening a store next to an ER in a well-heeled zip code to see if it out-performed one with a clinic in it…

Remember when Cerner dissed Google Health?  This news came out today in the Globe about Google Health and BCBS of Mass:

Come this fall, members of Blue Cross and Blue Shield of Massachusetts will be able to go online to look up their healthcare claims and some medical records, which the insurer says will help patients manage their medical care and have more productive discussions with doctors.

The feature is being offered through Google Health, the new healthcare Web portal recently opened by the Internet search giant based in Mountain View, Calif. Blue Cross-Blue Shield said it is the first health insurer to sign on to the service.

Since Cerner sells its goods to hospitals and hospitals are reimbursed by health plans and those health plans are demanding more up-to-date, quality information on patient outcomes…  Hmmm.  Seems like those patients are going to want to use their Google Health accounts — backed by their health plans — when they show up for a doctor’s visit.

And kudos again to the great state of Massachusetts, the right in the center of healthcare innovation.  (Did we mention we had an office here?)