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	<title>Coss Effective &#187; Technology</title>
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	<description>Discussions in Improving Efficiency in Health Care</description>
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		<title>Medical Practice and 20% of Income from Cash</title>
		<link>http://tomcoss.com/2010/04/03/medical-practice-and-20-of-income-from-cash/</link>
		<comments>http://tomcoss.com/2010/04/03/medical-practice-and-20-of-income-from-cash/#comments</comments>
		<pubDate>Sat, 03 Apr 2010 18:22:24 +0000</pubDate>
		<dc:creator>Tom</dc:creator>
				<category><![CDATA[Efficiency]]></category>
		<category><![CDATA[Healthcare]]></category>
		<category><![CDATA[Information]]></category>
		<category><![CDATA[Technology]]></category>
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		<guid isPermaLink="false">http://tomcoss.com/?p=412</guid>
		<description><![CDATA[<p>In regard to portability and ease-of-use, competing with a pen and piece of paper is difficult.  We all know how a pen works, paper is lite and is easily moved about &#8211; there is no &#8220;down time&#8221; or &#8220;learning curve&#8221;; in addition, pharmaceutical and medical device companies will gladly give you all the pen&#8217;s you might <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2010/04/03/medical-practice-and-20-of-income-from-cash/">Medical Practice and 20% of Income from Cash</a></span>]]></description>
			<content:encoded><![CDATA[<p>In regard to portability and ease-of-use, competing with a pen and piece of paper is difficult.  We all know how a pen works, paper is lite and is easily moved about &#8211; there is no &#8220;down time&#8221; or &#8220;learning curve&#8221;; in addition, pharmaceutical and medical device companies will gladly give you all the pen&#8217;s you might desire.</p>
<p>The downside of pen and paper is that the information contained on paper doesn&#8217;t aggregate well.  You can&#8217;t look back through it easily to assess what works and what does not.  In earlier days when a family physician took care of you from cradle to grave, it wasn&#8217;t a problem; as long as the physician stayed alive, he or she was a biologic historical database of what went on in a patients life.  Today, however, with highly specialized and fictionalized care, it&#8217;s a problem.  So why not the sluggish acceptance of EHR&#8217;s in the private sector.</p>
<p>To the casual observer the perception is that costs are real, and benefits vague.  These excuses are self-damaging and weak minded.  Time to get busy.</p>
<p>In this piece regarding<strong> <a title="Electronic Health Records and Clinical Trials: An Incentive to Integrate" href="http://www.softwareadvice.com/articles/medical/medical-news/electronic-health-records-and-clinical-trials-an-incentive-to-integrate-1031910/">Electronic Health Records and Clinical Trials</a></strong> from Chris Thorman of <a title="Softwareadvice.com" href="http://www.softwareadvice.com/medical/electronic-medical-record-software-comparison/">Software Advice </a>speaks to one legitimate benefit often talked about, but seldom realized.  True, the use of practice data in clinical trials is limited, but it&#8217;s not zero, and it grows over time.   Identifying subtle changes in treatments over time, or simply identifying patients for whom detailed clinical studies are appropriate, will contribute to improving efficiency of bringing new drugs and treatments to market.  In so doing, a faster path to market results in a longer period under patent protection, and higher product lifetime valuation with lower costs.</p>
<p><strong>In the end it looks like this</strong>: the medical practice of the future needs to begin now to design itself toward increasing  its efficient and percent of total annual revenue from cash.  This means providing services for which patients will pay cash along with discovering new means by which practices can contribute value and receive compensation outside the existing constraints of third party payment.  This includes EHR&#8217;s, but also means a way patients can<strong> <a title="AppointYou Inc." href="http://www.appointyou.com">create appointments on their own schedule 24/7</a></strong>, along with a means by which medical practices can keep in closer communication with their patients.</p>
<p>There is no stability or efficiency in health care without successful and vibrant medical practices.  It&#8217;s time for every practice to find an EHR that works for them and put it to use, along with systems and processesto build and manage closer relationships with their patients.</p>
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		<title>Repricing in America</title>
		<link>http://tomcoss.com/2009/10/03/repricing-in-america/</link>
		<comments>http://tomcoss.com/2009/10/03/repricing-in-america/#comments</comments>
		<pubDate>Sat, 03 Oct 2009 22:31:16 +0000</pubDate>
		<dc:creator>Tom</dc:creator>
				<category><![CDATA[Efficiency]]></category>
		<category><![CDATA[Information]]></category>
		<category><![CDATA[Technology]]></category>
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		<guid isPermaLink="false">http://tomcoss.com/?p=318</guid>
		<description><![CDATA[<p>I&#8217;ve been bothered in the best possible way by a comment made by Richard Davis, President and Chief Executive Officer of U.S. Bancorp.  In almost a throw away fashion Richard told an audience of business executives in Orange County California, that the economy is going through a process of &#8220;repricing &#8221; downward.</p>
<p>Clearly we know this <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2009/10/03/repricing-in-america/">Repricing in America</a></span>]]></description>
			<content:encoded><![CDATA[<p>I&#8217;ve been bothered in the best possible way by a comment made by Richard Davis, President and Chief Executive Officer of U.S. Bancorp.  In almost a throw away fashion Richard told an audience of business executives in Orange County California, that the economy is going through a process of &#8220;repricing &#8221; downward.</p>
<p>Clearly we know this to be the case in the housing industry, as those of us with houses have seen about 25% or more of the assessed value of the house disappear.  As troublesome as this has been for many people, it has not stopped there.  Just look around and you&#8217;re seeing it in the automotive business, grocery stores, and restaurants offering significant discounts. In the labor market, those getting new jobs are doing so at often dramatically lower salaries.  Everything it seems is ratcheting down, finding a new market clearing level.</p>
<p>This deflation, or to be more positive, repricing, has consequences which favor highly efficient, low fixed overhead companies over those with large superstructures of bureaucracies.  As we&#8217;ve seen, some companies can relieve some pressure by laying off labor, but those companies (I&#8217;m thinking GM) with lots of large buildings and large fixed expenses, can&#8217;t adjust sufficiently and quickly enough.  For these large companies, it is exceptionally difficult to accommodate to downward price adjustments, hence they fail.</p>
<p>Companies which do succeed in these environments are new ones.  These companies benefit by being new and not around so long as to have large fixed expenses, these are the entrepreneurs.  The best way to grow our economy is for the US to have a brisk entrepreneurial bias in its policy decisions.   In this Economy, as serial entrepreneur Ken Forbes, CEO of <a title="AppointYou Inc." href="http://www.appointyou.com" target="_blank">AppointYou</a> in Aliso Viejo, California told me, it is easier to create a job than get one.  This is the best time for the creative among us to leverage their comparative advantage of being lean, to get their products and services into the economy and make wonderful things happen for us all.</p>
<p>Thomas A. Coss</p>
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		<title>Texting and Everything Else You Do In Life</title>
		<link>http://tomcoss.com/2009/08/17/texting-and-everything-else-you-do-in-life/</link>
		<comments>http://tomcoss.com/2009/08/17/texting-and-everything-else-you-do-in-life/#comments</comments>
		<pubDate>Mon, 17 Aug 2009 20:25:48 +0000</pubDate>
		<dc:creator>Tom</dc:creator>
				<category><![CDATA[Information]]></category>
		<category><![CDATA[Technology]]></category>
		<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://tomcoss.com/?p=232</guid>
		<description><![CDATA[<p>Last June, the Senate Judiciary Committee began hearings on texting. Included in the discussion were executives from AT&#38;T, Verizon along with othere the focus of which was the nature of charging for text messages. Though the hearings were interesting, the real headline is in the data surrounding texting itself</p>
<p>In 2008 over one trillion text messages were <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2009/08/17/texting-and-everything-else-you-do-in-life/">Texting and Everything Else You Do In Life</a></span>]]></description>
			<content:encoded><![CDATA[<p>Last June, the <a title="Senate Hearing Site" href="http://judiciary.senate.gov/hearings/hearing.cfm?id=3917" target="_blank">Senate Judiciary Committee </a>began hearings on texting. Included in the discussion were executives from AT&amp;T, Verizon along with othere the focus of which was the nature of charging for text messages. Though the hearings were interesting, the real headline is in the data surrounding texting itself</p>
<p>In 2008 over one trillion text messages were sent in the US.  According to AT&amp;T, texting grew from 2.4 billion in January of 2007 to over 31.1 billion in January of this year.  The direct costs per text were estimated at approximately three tenths of one cent each, with an average charge to the telephone subscriber of 1 cent per text message.  Approximately 420 text messages can fit the bandwith it takes to have a one  minute conversation.</p>
<p>Why is text messaging growing so much?  Well simply because it is efficient.  The text message forces the sendor to be succinct (you have only 160 characters in which to get your point across) and it can be very quickly consumed.  Over the weekend, by oldest daughter told me that she just heard a voice mail left by her sister 4 days ago.  This isn&#8217;t to say that she&#8217;s disengaged, just that voice mail is not the preferred mean of communication.  She went on to say that occassionally she&#8217;ll get text messages from her friends telling her to check her voice mail.  Texting is simple, succinct, fast, and it&#8217;s semi-perminant.  You can save a text message to refer to later on, not as easy in voicemail.</p>
<p>In a world in which information flows so effortlessly and at near zero cost, texting speaks more of the future than the past.  Who know that email would become &#8220;so yesterday&#8221; so soon.</p>
<p>Tom</p>
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		<title>Texting and Efficiency &#8211; This is Just The Beginning</title>
		<link>http://tomcoss.com/2009/07/08/texting-and-efficiency-this-is-just-the-beginning/</link>
		<comments>http://tomcoss.com/2009/07/08/texting-and-efficiency-this-is-just-the-beginning/#comments</comments>
		<pubDate>Thu, 09 Jul 2009 02:14:51 +0000</pubDate>
		<dc:creator>Tom</dc:creator>
				<category><![CDATA[Efficiency]]></category>
		<category><![CDATA[Technology]]></category>

		<guid isPermaLink="false">http://tomcoss.com/?p=235</guid>
		<description><![CDATA[<p>&#8220;This message of twenty four words and 138 total characters takes you less than five seconds to consume, that is why texting is popular.&#8221;</p>
<p>According to a University of Pennsylvania study, the speed with which we consume information from our eyes to the visual cortex in the brain is approximately 10 megabytes per second, we hear at roughly one <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2009/07/08/texting-and-efficiency-this-is-just-the-beginning/">Texting and Efficiency &#8211; This is Just The Beginning</a></span>]]></description>
			<content:encoded><![CDATA[<p><span style="WIDOWS: 2; TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: 16px 'Times New Roman'; WHITE-SPACE: normal; ORPHANS: 2; LETTER-SPACING: normal; COLOR: #000000; WORD-SPACING: 0px; -webkit-border-horizontal-spacing: 0px; -webkit-border-vertical-spacing: 0px; -webkit-text-decorations-in-effect: none; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px"><span style="TEXT-ALIGN: left; LINE-HEIGHT: 21px; FONT-FAMILY: 'Lucida Grande'; COLOR: #333333; FONT-SIZE: 25px">&#8220;This message of twenty four words and 138 total characters takes you less than five seconds to consume, that is why texting is popular.&#8221;</span></span></p>
<p>According to a University of Pennsylvania study, the speed with which we consume information from our eyes to the visual cortex in the brain is approximately 10 megabytes per second, we hear at roughly one tenth that speed or a rate of about 102 kilobytes per second. </p>
<p>Just think how drastically communication has changed over the past 35 years.  The first email went out in 1971, still it would take nearly 30 years before email became pervasive in society.  In the mid 1990&#8242;s business still depended heavily upon voice mail, a slow and often annoying means of sharing information with colleagues in a time shifted manner.  The annoying part came when people, seeking to gain favor with superiors, would copy everyone on the message.  That copying continues today in email but in that there is hope.  </p>
<p>In December of 1992 the first text message was sent via SMS or Simple Messaging Services. During the second quarter of 2008, AT&amp;T reported that more text messages were sent from cell phones than actual calls.  Texting is becoming a preferred means of communicating short messages from person to person. On June 9 of this year the US Senate held hearings from the major telephone operators in regard to pricing of texting services offered customers, and it is from those hearings that this story unfolds.</p>
<p>Though providers charge 20 cents per text when the individual has not chosen a texting plan, those people represent less than 1% of users.  The average price per text is around a penny.  The cost of providing that text is estimated to be about 0.0325 cents per text, providing the carriers with a very handsome gross margin of nearly 70%.  Still, what really matters is that texting is growing at a rate approaching 50% per month and that texting is seen as fast and efficient.</p>
<p>This past 4th of July weekend I spent some valuable time with my daughter (16) and five of her friends.  For a few minutes I was able to discuss with them their texting behavior, preferences and general insights into text messaging.  Texting, it turns out, has a lot of benefits besides being efficient or quick to consume.  It&#8217;s <strong>private</strong> for one, often more priviate than email, and it can be <strong>consumed discretely</strong> &#8220;even during church&#8221; according to one of the girls I interviewed. Texting has <strong>perseverence</strong>, it stays on ones handset and can be accessed at a later time.  This is an added value to texting not commonly considered and from a marketing perspective, holds great promise.</p>
<p>The point of all this is that texting is more than the electronic version of sending notes among young kids in high school.  Texting is important because it is succinct and so very quickly consumed.   Character length constrictions force a succinctness that is greatly needed in communication, while also improving upon the speed by which the message is consumed. That same message above could be re-written:</p>
<p>&#8220;<strong>This msg of 24 wds &amp; 138 characters takes u less than 5 secs to consume, thats y txtng is popular</strong>&#8221;</p>
<p>This version is now down to 21 words and 95 characters, a character reduction of 32%, while still clearly conveying the same message, only instead of taking you 5 seconds to consume, you consumed it in about 3.  With the abundance of information thrown at us on a daily basis, anything that eases its consumption is good news indeed.</p>
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		<title>Risky Thinking Surrounded by Hubris</title>
		<link>http://tomcoss.com/2009/05/08/risky-thinking-surrounded-by-hubris/</link>
		<comments>http://tomcoss.com/2009/05/08/risky-thinking-surrounded-by-hubris/#comments</comments>
		<pubDate>Fri, 08 May 2009 17:13:13 +0000</pubDate>
		<dc:creator>Tom</dc:creator>
				<category><![CDATA[Information]]></category>
		<category><![CDATA[Technology]]></category>
		<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://tomcoss.com/?p=193</guid>
		<description><![CDATA[<p>The banking and finance industries were among the first to make extensive investments in information technology.  Perhaps no other industry has done more with detailed information technology. You can see that in your own experience of ATM&#8217;s and now web access to your accounts.  Checks clear in a matter of hours and personal credit cards are <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2009/05/08/risky-thinking-surrounded-by-hubris/">Risky Thinking Surrounded by Hubris</a></span>]]></description>
			<content:encoded><![CDATA[<p>The banking and finance industries were among the first to make extensive investments in information technology.  Perhaps no other industry has done more with detailed information technology. You can see that in your own experience of ATM&#8217;s and now web access to your accounts.  Checks clear in a matter of hours and personal credit cards are accepted virtually everywhere in the world.  If you were to think of industries in which there is an abundance of information from which sound decisions can be made, the finance industry would likely rank among the top, yet after all the detailed information across decades, the finance industry did not forsee the problems in which we now find ourself.</p>
<p>In the book the Black Swan, Nassim Taleb points to many failures of financial decisionmakers in their paying attention to details, in particular their propensity to depend upon exotic financial equations in providing them guidance in their decissions.  The challenge we have in Dr. Taleb&#8217;s book, is that it was first published 2 years ago and described with great clarity what we are experiencing today.  So what are we to make of this?  What does the lessons of the current financial crisis have for those seeking similar metrics for the future of healthcare, namely Comparative Effectiveness measurements.</p>
<p>First, this is not to suggest that we shouldn&#8217;t look into the effectiveness of new products and procedures, but it is a warning to those that place such great hope that such analysis will save money.  It may, but it very well may not.  Truth be known, medicine isn&#8217;t much better than the financial industry at predicting the future, and we don&#8217;t have nearly the data that the financial industry has.  Healthcare is arguably 20 to 30 years behind the banking and finance industry in regard to their information systems and the information they produce.  Imagine the leap of faith required to think that medicine can do better than the financial industry with less experience, less information and an eminently more complex biologic processes.  Just how are we to believe that?</p>
<p>Medicine profits heavily from surprise and we benefit by capitalizing on the unexpected.  I think of small and powerful things like Folic Acid during pregnancy that lowers the incidents of neuro tube defects.  Or a failed antihypertensive drug that later became Viagra and is now used with great success in the treatment of patients with pulmonary hypertension.  In what possible way could these beneifits be discovered ex ante?  In the end, it is the hight of hubrice to begin to think that we have all the data we require along with the ability to analize it, and in so doing apply Comparative Effectiveness metrics to lower costs while improving outcomes.  This, ladys and gentlemen, is what they call in Basketball a &#8220;head fake&#8221;.</p>
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		<title>Healthcare Reform and the Coss Conundrum</title>
		<link>http://tomcoss.com/2009/03/07/healthcare-reform-and-the-coss-conundrum/</link>
		<comments>http://tomcoss.com/2009/03/07/healthcare-reform-and-the-coss-conundrum/#comments</comments>
		<pubDate>Sat, 07 Mar 2009 19:51:14 +0000</pubDate>
		<dc:creator>garrett</dc:creator>
				<category><![CDATA[Healthcare]]></category>
		<category><![CDATA[Technology]]></category>

		<guid isPermaLink="false">http://tomcoss.com/?p=145</guid>
		<description><![CDATA[<p>There are a lot of hopes placed upon the role of healthcare IT to address the ills of the healthcare industry, some are legitimate, many are not.  One such limitation I call the Coss Conundrum which goes like this.</p>
<p>Suppose for a moment that you and I are in a business arrangement in which your responsibility is <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2009/03/07/healthcare-reform-and-the-coss-conundrum/">Healthcare Reform and the Coss Conundrum</a></span>]]></description>
			<content:encoded><![CDATA[<p>There are a lot of hopes placed upon the role of healthcare IT to address the ills of the healthcare industry, some are legitimate, many are not.  One such limitation I call the Coss Conundrum which goes like this.</p>
<p>Suppose for a moment that you and I are in a business arrangement in which your responsibility is to beat me unmercifully about the head and shoulders with a stick; my responsibility is to provide you with a stick.  Just how big a stick would you expect?  If you&#8217;re thinking anything bigger than a standard yellow pencil, you&#8217;re likely to optimistic.</p>
<p>Here in lies the conundrum.  The stick, in this case, is healthcare provider information, and it is here where the government&#8217;s efforts run up against the pragmatics of broad based implementation.  Why would any private practicing physician pay money for an information system if, like the conundrum suggests, the practitioner feels that the information may be used like a stick with which to later be beaten?  Few will speak of this out loud, but the issue is real and legitimate.  Any mishandling of patient clinical data, either to violate the privacy of the patient, or even to punish the choices of the practitioner, results in the same limitation.</p>
<p>Using information needs it&#8217;s own sets of ethics and guidelines.  The technology, thought considerable, for the EMR is not sufficient to understand, there remains the evolutionary psychology and professional ethics to provide the assurances required for adoption.</p>
<p>Tom</p>
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		<title>American Recovery and Reinvestment Act of 2009</title>
		<link>http://tomcoss.com/2009/02/10/american-recovery-and-reinvestment-act-of-2009/</link>
		<comments>http://tomcoss.com/2009/02/10/american-recovery-and-reinvestment-act-of-2009/#comments</comments>
		<pubDate>Tue, 10 Feb 2009 21:04:03 +0000</pubDate>
		<dc:creator>Tom Coss</dc:creator>
				<category><![CDATA[Healthcare]]></category>
		<category><![CDATA[Technology]]></category>
		<category><![CDATA[Congress]]></category>

		<guid isPermaLink="false">http://tomcoss.com/?p=115</guid>
		<description><![CDATA[<p>Farmers have known for centuries that if you want to harvest wheat in October, you need to be planting in the spring.  If one is otherwise preoccupied and doesn&#8217;t get around to it until August, the wheat doesn&#8217;t care.  It won&#8217;t all of a sudden work extra hard to meet an October deadline.  In effect, you&#8217;re <span style="color:#777"> . . . &#8594; Read More: <a href="http://tomcoss.com/2009/02/10/american-recovery-and-reinvestment-act-of-2009/">American Recovery and Reinvestment Act of 2009</a></span>]]></description>
			<content:encoded><![CDATA[<p>Farmers have known for centuries that if you want to harvest wheat in October, you need to be planting in the spring.  If one is otherwise preoccupied and doesn&#8217;t get around to it until August, the wheat doesn&#8217;t care.  It won&#8217;t all of a sudden work extra hard to meet an October deadline.  In effect, you&#8217;re stuck.  Planning to late, the error is on the throw, not the catch.</p>
<p><a title="H.B 1" href="http://thomas.loc.gov/home/gpoxmlc111/h1_ih.xml#toc-H9CF6734CF120469F91C4164B90AF3E00" target="_blank">House Bill 1</a>, now working it&#8217;s way through congress has highly specific provisions for the promotion and adoption of Electronic Health Records.  Included in this package (Sec. 3412) are direct subsidies to hospitals who implement qualified EHR&#8217;s for their facilities.  According to the House version of the bill, these subsidies range from $2 million to about $6.37 million with payments beginning in 2011.  This is where the harvesting story comes to play, it takes time to get these initiatives under way, and the time to start is now.</p>
<p>There are a great deal of challenges in rolling out an EHR, regardless of the size of the organization, still this train is leaving the station.  No time to waste.</p>
<p>Thomas A. Coss</p>
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