Category Archives: Culture

What’s new at HIMSS? Airbnb

A lot has changed since the last time I attended the Healthcare Information Management and Systems Society (HIMSS) meeting a few years back, but the biggest difference in my own experience at #HIMSS13 had nothing at all to do with health information technology. Rather, the big change was that even though I could only book 10 days ahead I was able to find low cost lodging close to the event, thanks to Airbnb, which describes itself as “a social website that connects people who have space with those who are looking for a place to stay.” Airbnb used information technology and social networking to completely transform my lodging experience from what it was only a couple years back. I’d love to see health IT transform health care to the same degree and as quickly. And although I do not believe health IT companies can just copy Airbnb’s model, perhaps some of the same principles can apply.

Here’s how things worked for me:

About 10 days before the conference I decided to go. But with 35,000 attendees –many coming from Boston– there were no flights whatsoever on Sunday, March 3, when I was available to leave, even if I had been willing to pay $1000 one-way. So instead I got creative and booked a flight from Providence, RI to Gulfport, MS. That wasn’t ideal, and it’s the same thing I would have done a year or two ago. I decided to stay in Gulfport, then drive or take a cab 80 miles to New Orleans on Monday morning. No rental cars were available for that trip so a cab it was.

Lodging was another story, with a happier ending. Hotels anywhere close to the convention center were sold out, although I did find a room at the Hilton for $900. No thanks. A couple years back I would have found a room 30 or 50 miles away or looked for a friend with a place there. But I remembering hearing about Airbnb and decided to give it a try. There were several listings for individual rooms and even whole apartments and houses within 3 or 4 miles of the conference. Many individual rooms were under $100. I signed up for an account, which took very little time, then followed a number of steps designed to increase trust and safety: I verified my phone number, connected via Facebook, Twitter and LinkedIn. I filled out a brief profile.

I looked through the listings, which included photos, bios of the hosts, and lots of reviews by people who had stayed at the specific properties, as verified by Airbnb. Most reviews were pretty positive, but hosts had replied to negative ones and gone into detail. I got a much better sense of what I was in for than anything I’ve encountered in health care. I selected a room for about $80 (< 1/10 of the Hilton price) and tried to book it. I sent a message to my host explaining why I was coming and letting him know I was a nice guy. This host had a policy, enforced through Airbnb, of approving prospective guests before accepting them. According to the site, most hosts reply within a couple hours, but they have up to 24. When I didn’t hear back within 2 hours I selected another spot, advertised as Street Car to Jazz Fest/French Quarter, which allowed instant bookings. This place was only $60 for a private room plus another $10 cleaning fee and $8 for Airbnb itself. The hosts’ extensive description gave me a good understanding of the place, mentioned free Internet, restaurants within walking distance, etc. Reviews were generally quite positive –and although it sounded much more like my hostel experiences from 20+ years ago rather than my more recent travel preferences– I decided to go for it. Information on Airbnb showed that the hosts, Robyn and Amanda responded to 100% of their listings, response time was quick, and that they updated their calendar frequently.

I was also reassured my Airbnb’s 24/7 phone support and various safety and security tips and guarantees.

I’m glad I went the Airbnb route. My hosts and I communicated over the Airbnb website but I also was given their phone number and email address. We coordinated my arrival time, they offered me a parking spot (which I didn’t need) and when I got there they recommended a close by restaurant that met my needs and suggested a cab company. (It was United Cab, which didn’t show up even after I confirmed and re-confirmed, but that’s not my h0sts’ fault).

I met a young French couple that was staying there for a month, and there were a bunch of law students staying there doing volunteer work. They were downstairs, though, so not bothering me. I had a good night’s sleep and was on my way.

Airbnb released my $100 security deposit within 24 hours and sent me a message asking for a review, which I provided and is now published. My hosts also reviewed me, so future hosts can see what I’m like (laid back, according to my hosts). And Airbnb let me communicate privately with the company if I had concerns I didn’t want shared or posted. (I didn’t.)

As I wrote, Airbnb’s innovations don’t translate directly into health care. There are some companies, including Castlight and ZocDoc that apply certain aspects of the model, including transparency of data and ease of booking appointments. Newer companies including Informedika and par8o are applying some of the principles to physician consultations and referrals. But there is room for a lot more and I’m hopeful Airbnb and other consumer Internet innovators will be inspirations. In particular I’m hopeful that new approaches will provide an alternative approach for providers that don’t want to be parts of big organizations.

In the meantime, Airbnb itself is making a contribution to health care by reducing expenses and increasing convenience of conference goers like me. No doubt it’s also being used by families who need to travel to other cities for medical visits.

Bionic eye: seeing the future

FDA just approved an implant for certain people with severely limited vision. This “bionic eye” does not restore sight but it does help “detect light and dark and help [people] identify the location and movement of objects.” So it could be a big help from a functional standpoint for certain individuals, even though it’s far from perfect and may not be completely safe.

Fast forward a decade or two or three and imagine a time when implants (or some other approach) can restore vision to normal. That will be pretty cool for the many people whose vision is relatively poor and there will likely be a lot of demand for such treatments/devices, even from people that we would not consider visually impaired today.

But then imagine that the technology keeps advancing and gets to the point where technology can improve on natural vision, so that someone with a bionic eye becomes more like the Six Million Dollar Man, especially if they get enhancements not just to the eye but to other body parts as well. I’m in my mid-40s and have a reasonable expectation of living to the time when this moves from science fiction to reality.

If you think about it, we are already starting to get there in limited cases.  Oscar Pistorius, now infamous for other reasons, shows that a double amputee can be as fast or faster as Olympic runners. How soon until other Olympians –who already commit their lives and bodies to the pursuit of excellence– will want body modifications to improve competitiveness?

Obviously the path of medical technology will raise all kinds of ethical issues. It’s time to start the discussion.

If nurses were lawyers

It’s interesting to contrast the markets for new lawyers and new nurses and how those markets are portrayed in the popular press. Casual observers and reporters are willing to take it for granted that there is a shortage of nurses and a need to train a lot more of them. Students are responding by applying to nursing schools en masse and nursing schools are boosting enrollments. Reports that 43 percent of new nurses are unable to obtain jobs in the profession are explained away as recession related or irrelevant to the “looming” long-term shortage.

Lawyers are different. When it’s reported that only a little more than half of new law graduates get a job as a lawyer within 9 months of graduation, the Wall Street Journal rightly refers to a “lawyer glut.” Prospective applicants are getting the message and law school applications are down 30 percent since peaking a decade ago. On the other hand, those in the law school business are not giving up so easily. Nineteen law schools have been accredited since 2000 and several more startups are in the works. If these schools were smart they would take a page from the playbook of the nursing schools and support research to show why more lawyers are needed.

I’m not saying that the prospects for nursing jobs are as bleak as that for lawyers. But I do advise prospective students for any professional school to take a good hard look at job prospects before taking on a pile of debt and devoting several years to further schooling.

Call it a health insurance store or market instead of an exchange

I’m a health care expert who follows health reform closely, so when I’m confused about something I know most people are. When Massachusetts passed the universal coverage law in 2006 I didn’t understand exactly what the Connector was supposed to do. If they had called it a health insurance store or marketplace or comparison site I would have grasped the concept better. Once it’s explained it’s obvious, but why use the word “connector” in the first place?

The federal Affordable Care Act makes matters even worse. It calls these things health insurance “exchanges.” That word has the wrong connotations. When I hear the word “exchange” I think of a stock exchange. That’s not somewhere I go to buy or compare products or services to use. Others think of “exchange” as what they do when they made a purchase that was the wrong size or received a gift they didn’t like.

Even for health wonks that fully grasp the concept, the word “exchange” is confusing, because the term is also used in the context of health information exchanges, which are used to exchange clinical data. I often hear people asking about the impact of the “exchange” –without specifying “insurance exchange” or “information exchange,” and I have to ask them which they mean.

There’s a simple solution to this: let’s dump the word “exchange” and use a term that’s more understandable and appropriate. How about:

  • Store
  • Marketplace
  • Comparison site
  • Supermarket

The nursing shortage myth

For years we’ve read that the US faces a looming shortage of nurses. Shortfalls in the hundreds of thousands of nurses are routinely predicted. These predictions have been good for nursing schools, which have used the promise of ample employment opportunities to more than double the number of nursing students over the last 10 years, according to CNN.

Yet somehow 43 percent of newly-licensed RNs can’t find jobs within 18 months. Some hospitals and other employers openly discourage new RNs from applying for jobs. That doesn’t sound like a huge shortage, does it?

But the purveyors of the nursing shortage message have an answer for that. Actually two answers: one for the short term and another for the long term. The near term explanation is that nurses come back into the workforce when the economy is down. Nurses are female and tend to be married to blue collar men who lose their jobs or see their hours reduced when the economy sours, we’re told. Nurses bolster the family finances by going back to work –or they stay working when they were planning on quitting. There’s something to that argument even if it’s a bit simplistic.

The longer term argument is that many nurses are old and will retire soon, just when the wave of baby boomers hits retirement age themselves and needs more nursing care. Don’t worry, the story goes, there will be tons of jobs for nurses in the not-too-distant future. This logic comes through again in today’s CNN story:

Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage [emphasis mine] will reemerge in the United States.

“We’ve been really worried about the future workforce because we’ve got almost 900,000 nurses over the age of 50 who will probably retire this decade, and we’ll have to replace them,” [economist and nurse Peter] Buerhaus said.

I don’t buy this logic. And I stand by what I wrote almost a year ago in Nursing shortage cheerleaders: There you go again:

My issue with the workforce projections is that they don’t take into account long-term technological change, but simply assume that nurses will be used as they are today. I’ve taken  heat for writing that robots will replace a lot of nurse functions over time. People seem to be offended by that notion and have accused me of not having sufficient appreciation for the skills nurses bring.

So let me try a different tack. Think about some of the job categories where demand is being tempered by the availability of substitutes. Here are a few I have in mind that have similar levels of education to nurses:

  • Flight engineers. Remember when commercial jets, like the Boeing 727 used to fly with two pilots and a flight engineer? Those planes were replaced by 737s and 757s that use two-member flight crews instead
  • Junior lawyers and paralegals. Legal discovery used to take up many billable hours for large cases. Now much of it is being automated
  • Actuaries. Insurance companies used to hire tons of them, but their work can be done much more efficiently with computers

I don’t know exactly how the nursing profession is going to evolve but I do notice that the advocates for training more nurses are typically those who run nursing schools rather than prospective employers of nurses, such as hospitals.

If you want to be a nurse, go for it. But if you’re choosing nursing because you think it’s a path to guaranteed employment, think again.

Mental health access is no substitute for gun control

I’ve been surprised at the upswell of support for increasing access to mental health services as an antidote to gun violence like we witnessed in Newton on Friday. I’m a big advocate of mental health care but just don’t see how anything we do in that arena would have prevented either of the last two mass shootings.

Accused Colorado killer James Holmes seemed to have plenty of access to mental health. According to Reuters he had been “under the care of a psychiatrist who was part of a campus threat-assessment team.” Meanwhile, Newtown shooter Adam Lanza lived in an affluent community, where a high percentage of residents have commercial health insurance that includes straightforward access to mental health services.

Access to mental health care did nothing to stop Holmes or Lanza, but access to high-powered weaponry enabled mass killings. It seems the case for reducing access to such arms is therefore a lot stronger.

Advocates of increasing access to mental health services would be wise to back away from using the Newtown tragedy as a springboard for their cause, especially when there are so many other sound reasons to  back mental health. Instead I would highlight how offering mental health services to people with depression can free up needed capacity in primary care and lower overall medical costs, and how improving mental health treatment can boost productivity and economic growth. There are also plenty of compelling arguments to make about the opportunity to improve quality of life for mentally ill patients and their families even if they are not as dramatic as preventing a massacre.

Why Massachusetts can afford universal health insurance

Health insurance in Massachusetts is more expensive than anywhere else in the country and yet the state is able to afford universal coverage. How can that be? An important part of the explanation is that the state values education, and a well educated population yields a highly skilled labor force with high incomes. Those high incomes can support health insurance coverage.

While the US as a whole is a laggard in education –scoring 25th among 34 countries in math, for example– Massachusetts students are world class. In science, Massachusetts is right up there with Singapore, and it does well in math, too where our students rank right below Japan and above Russia. This bodes well for future Massachusetts performance in technology and science fields, which are likely to be major drivers of the economy in the next generation (unless finance takes over everything). There’s no international comparison that I’m aware of for creativity, but I’m willing to bet Massachusetts would come out well there, too.

Achieving meaningful health care reform and universal coverage require more than just passing health care laws. Enlightened policy in multiple fields –especially education– is a critical enabler.

Like taking candy from a baby

A New England Journal of Medicine Perspective (Candy at the Cash Register — A Risk Factor for Obesity and Chronic Disease) argues that, “the prominent placement of foods associated with chronic diseases should be treated as a risk factor for those diseases. And in light of the public health implications, steps should be taken to mitigate that risk.”

In other words, the authors would like to see the concept of New York City’s ban on large, sugary drinks taken a step further: restricting where within a store potentially harmful products are placed. A decade or two ago the tobacco industry unsuccessfully tried to defend itself from smoking bans by claiming that this line of reasoning would lead us down the path toward restricting unhealthy foods, like cheeseburgers.

At the time I thought the tobacco campaign was disingenuous and the fears were ridiculous. Second hand cigarette smoke was annoying and dangerous to bystanders, whereas people who eat unhealthy food mainly harm themselves. It seemed implausible to me that we would actually get to food bans. Looking back, I can see that Philip Morris et al. were actually on to something. I’ve even gotten to the point where I can see the logic of rules that restrict the sale of soda in schools, for example.

But that’s as far as I think we should go. While it’s undoubtedly true, as the authors argue, that “food choices are often automatic and made without full conscious awareness,” I don’t agree that this provides sufficient cause to take regulatory action. Instead it would be better to educate people about how their choices may not be as autonomous as they think. Once they understand that, marketing and placement of products may still be effective, but I’m more confident leaving choices in the hands of the consumer.

This education about marketing should be extended further, and I’d particularly like to see physicians have a better understanding of how they are affected by industry marketing and how patients are influenced by drug company ads.

Time to talk about constipation

The New York Times advertising column (In a Forthright Campaign, More Unmentionables Mentioned) highlights a new campaign by Purdue Pharma’s Senokot laxative that asks, “Does your prescription medication give you the burden of constipation?” As the headline suggests, the Times’ focus is on the relaxing of taboos in advertising, but I think they’ve missed a more significant point.

Sure, advertisers used to avoid mentioning bodily functions, only hinting discreetly at them when promoting tampons, toilet paper and the like. But after many years of ads for Viagra and its “ED” competitors, and the mainstreaming of pornography and rap, is it really a shock that a company uses the term constipation?

The bigger story is that the market is now ready for a more grownup conversation about drug side effects. “Minor” side effects such as constipation are a widespread consequence of drug therapy, yet they can have a serious impact on patients’ quality of life. Often doctors don’t realize how serious such side effects can be, and patients are either embarrassed to bring up the topic or worried their doctor won’t take them seriously. But it turns out patients will discuss the topic with other patients on sites such as PatientsLikeMe.

Drug ads are required to mention side effects, but the information is generally conveyed in a compliance-oriented style that does not contribute to consumer understanding. I wouldn’t expect anything more from the drug ads, but there is an opening for products such as laxatives that can provide relief.

As a final point it should be noted that Purdue Products has plenty of experience with this side effect. The company’s cash cow, oxycontin is a leading cause of the very constipation that Senokot is designed to relieve!



Rerun: Analyzing infant formula marketing

The Health Business Blog is taking a break and re-running some posts from 2008. If you’d like to comment, please do so on the original post.

I’ve posted before about the marketing of infant formula through hospitals and about the practice of sending formula samples to expectant mothers.

Today I glanced through Nurture (Volume 08-1), a promotional magazine from Enfamil baby formula’s maker, Mead Johnson Nutritionals. The publication includes clearly marked advertisements for Enfamil products along with some articles on nursing and other typical new-mom questions, like whether babies can recognize colors and how to involve dads and grandparents in their care.

The formula companies go to some lengths these days to be seen as supportive of breast feeding. The first two-thirds of the relatively long article on returning to work focus on buying a breast pump, stockpiling milk at home and pumping at work. Only in the last third does the discussion turn to baby formula. That should satisfy most critics.
But the most interesting marketing pitches for formula are subtle ones, contained in pieces that are ostensibly medical or parenting advice. Here are two examples:


[Question] My 3-month-old is eating like a champ. Is she ready for solids?

[Answer] Not quite. The American Academy of Pediatrics recommends waiting until your baby is 4 to 6 months before introducing solids. Before then, she won’t have enough control over her tongue and mouth muscles to swallow food, and it may increase her risk of developing allergies. But there’s no need to wait beyond 6 months either, even if you’re worried about allergies…

Subtle marketing message: As baby grows and starts drinking more and more, you may be worried about whether you are producing enough breast milk. Don’t give solid food, but definitely supplement with formula!

Here’s another example:

Make Room for Daddy

Want to get in on a little secret about the daddy-baby bond? Well, you can start by putting Dad on diaper duty. (We though you’d like that!)… The more Dad is involved in day-to-day caregiving tasks, the stronger the bond will be… So have Dad take the night-feeding shift, stroll with baby in a carrier, or just enjoy playtime…

Subtle marketing message: Tired moms definitely deserve a break on the night shift. Of course Mom could pump extra breast milk during the day or just before bedtime, and let Dad give it to Baby, but who has the energy? Just let Dad mix up the formula and feed it to Baby. After Dad does that job a few times the nightly formula routine will become well-established. And while he’s at it can’t Dad just take along a bottle of formula with him for that “stroll with baby in a carrier,” too?