Big Tech Is Going After Health Care | Hacker News Reader

Big Tech Is Going After Health Care

nytimes.com

138 pointsSREinSF199 comments

There are some major hurdles for these SV companies to overcome if they want any level of success in this arena. EPIC and Cerner together hold over 50% market share of EHR systems in American hospitals. Their interoperability and patient facing applications are a joke. EPIC actively makes it difficult for third parties to build on top of their system.

Sure, these SV companies have figured out how to build great tech at scale but transitioning an entire hospital network to a new EMR is a massive undertaking -- both technically and organizationally. Many doctors had their world rocked by the forced transition to using EMR systems and they run the other way from those claiming a novel technology will solve all of their problems.

There are much greater issues at play here and IMO the organizational problems within hospitals are far greater than the technical ones. To be successful hospitals will have to become tech companies. They aren't exactly the hottest place for top tech talent to end up.

I think the patient first approach that Apple and Samsung have been taking are likely to win out. If they can build a system that captures an individual's personal health record doctors will want that data. Hospitals will have no choice but to begin integrating that data even if it lives outside of the walls of EPIC, Cerner, et al.

EPIC and Cerner are doing their best to, simultaneously:

1) Appear to be open, ready for innovation and playing fair (so hospitals don't replace them)

2) Maintain their position as gatekeepers, and use that position to extract as much revenue as possible. New startup wants to deploy tech at your hospital? Hospital probably will end up paying more to Cerner for the integration, than the new tech.

You hit the nail on the head.

Building anything on top of EPIC is unbelievably painful. You either pay EPIC engineers to access their "Dark API's" or pay $$ for their certifications.

Very few of these big medical device start-ups are actually integrating with patient records at a significant scale. Every instance of EPIC or Cerner is different and there is a lot of manual work needed to get up and running with live data in the patient record.

Sounds EXACTLY like an industry ripe for disruption

The EMR market for hospitals and large clinics really isn't ripe for disruption. This isn't an industry where a startup can quickly hack together an "80% solution" as an MVP and sell to some early adopters. Due to regulatory requirements and legitimate patient safety concerns any new entrant needs to be a 100% solution from the start. Otherwise they'll never make it past the first vendor down select.

There may be some limited opportunities for disruptive innovation in niche markets like smaller medical specialties with unique requirements, concierge medical practices, genetic counseling, etc.

>Sure, these SV companies have figured out how to build great tech at scale

Their tech is much disliked by most doctors. There's even a protest group LetDoctorsBeDoctors with a humorous song video (https://www.youtube.com/watch?v=xB_tSFJsjsw)

There is also a fully functional heavily tested free open source solution that most doctors prefer in surveys, called VistA or Openvista.

> Doctors at the VA really like VistA. In Medscape’s 2016 EHR Report, VistA was the top rated EHR overall and the most preferred solution for use as a clinical tool. http://hitconsultant.net/2017/05/10/reasons-not-to-replace-v...

I think that what Epic and Cerner have figured out is how to crack the corporate sales process. Doctors and patients don't choose the EHR system, managers do, and I guess Epic and Cerner are good at selling to them.

If any startups want to do a Red Hat type model building on top of VistA I hope they do well.

Both Epic and Cerner are making at least some strides toward opening up their platforms (Epic with App Orchard, and Cerner with Ignite, SMART on FHIR etc.) Athena has MDP ("More Disruption Please.") I get the feeling these organizations have at least come to the realization that they need to open up--granted their denial up to this point leaves them with a lot of catching up to do. But access to the data that exists in those systems is a pretty big carrot for integration partners to help push adoption.

Sorry, dude, but I think you fell for it. These entities try to make you think they're open, but really they are keeping entrants at bay.

Here's an interesting episode of the weeds podcast that gives some context by exploring why the fax machine is still so prevalent in US healthcare.

https://player.fm/series/voxs-the-weeds/fax-reform-bonus

You haven't addressed the point that jeremylee made about the SMART on FHIR platform now available in those EMRs. It's not a complete solution but it works today and people are building real applications on it. Take a look at the demos from the latest HL7 FHIR Applications Roundtable. https://www.hl7.org/events/fhirapps.cfm

But access to the data that exists in those systems is a pretty big carrot for integration partners to help push adoption.

The scary reality is, they don't even have access to the data in those systems. I had a friend contracted at cerner working on a FHIR api end point. Something as simple as answering the question "what medications have been administered to a patient" was extremely difficult to pull out of their system. One would think there'd be a simple report for that information, but they didn't have it. The domain/system knowledge wasn't there either. That one simple api endpoint drug on for months as new data was "found" in the 5000+ table schema. Oh, and they don't use foriegn key constraints in production either.

I can vouch for some of that as well, although I disagree with some of it. The domain/system knowledge is there, but there's likely a relatively small group of people that know all of the ins and outs. And the group that knows about inpatient medications likely isn't the the same that knows about outpatient medications. And maybe the ordering of meds is different from the administration of meds.

I think the point about FK constraints is perhaps a little too generalized. In a 5000+ table schema (which is entirely accurate!), I'm sure there are some tables which don't have FK constraints enabled. But I know for a fact that there are FK constraints on some of the tables (because I created them!)

You could say that about a LOT of organizations. Hospitals are perhaps another level though.

Apple and Samsung entering the healthcare space to compete with Epic (their name isn't all-caps) and Cerner, in reality, is going to be closer to this: https://xkcd.com/927/

Most of the employees at Epic and Cerner in the healthcare space are actually operations. Like, at least 60% of their workers are operations. Not only that, but they're not traditional IT workers who go out and get certs, they're really closer to devops professionals who are able to provide both IT support and have an intimate understanding of what they're working with. Last time I checked, Apple and Samsung don't really even have this tier of customer facing support. It's going to take organizational shifts for them to break into this sector, and it's not so sure a thing.

That said, I completely agree with your observation that hospitals need to become tech companies. My parents are medical professionals and I have also worked at a medical software company in the past, so I think I'm pretty well grounded when it comes to saying this: hospitals hate developers, and developers hate hospitals. From the perspective of the hospital worker, developers make overly confusing systems and as soon as the worker gets used to it, they completely change everything and make it even more complicated than before. From the perspective of developers, most hospital professionals are luddites who oppose all change and progress as a matter of principle. If the two roles were more closely integrated, these severe communication issues would be mitigated. Medicine needs to be redesigned form the ground up with these two fields learning each others' skills and understanding how and why the other field does what it does.

Fair points - I don't believe that Apple / Samsung are necessarily going to build out their own EMR systems. Rather I think the bottom up approach they are taking by creating an enormous amount of personal health data -- heart rate and exercise activity now with a growing ecosystem of third party devices -- that is up to FHIR specs is a step in the right direction.

Your second point really resonates with me. I have spent the last few months working within a large healthcare organization and it is extremely difficult to make necessary changes. There is a lot of distrust of our team to the point of hostility. Very frustrating

Good.

I spent a few years working in a medical IoT startup, and the current state of the "mainstream" medical monitoring technology is not inspiring.

During a brainstorming meeting, I asked one of our cofounders, a physician, to tell me about some of the problems he had seen in health. Don't try and solve it, just lets talk about problems.

He said that by far one of the most common causes for re-hospitalization is congestive heart failure. It's a super common problem, and it's actually really easy to catch (it has strong indicators). When your heart begins to fail, depending on what side of it fails, your body will retain fluid (in the form of blood) in either your heart or your organs. Regardless, you will bloat up, and gain weight quickly.

So if a patient is at risk for CHF, a nurse will monitor their weight every day (or multiple times a day) and watch for spikes. If their weight spikes, a doctor will intervene in whatever way is necessary.

Can you imagine my frustration at hearing this? It's this massive problem with an obvious (CHEAP!! SO FUCKING CHEAP!!) solution.

I spend $30 on a scale from amazon immediately, and about an hour after it arrived I had it connected to an android tablet and broadcasting its readings to a webservice.

We never went to market with that (long story). Please, if you have the means to take something like that and scale it, do so. You could save lives. I'm currently trying. More people should be trying. This stuff is so easy, and the impact that you could have is massive.

Also: please call your grandparents and just talk to them. Ask them how they are feeling. Social isolation (full disclosure: this is what my current project is trying to solve) is probably the area where we as software people could have the biggest impact.

Interesting you bring up heart failure readmissions. Not saying they aren't a problem, but here is a fascinating study in JAMA that argues that places with lower readmissions have higher (worse) mortality. https://jamanetwork.com/journals/jamacardiology/article-abst...

Not sure we (I'm a physician) understand even what the problems we need technology to solve are. But yes, we need technology to help (find and) solve some major problems that will improve lives.

Are there other examples of things you wish existed? Again, forget about if they could exist, just stuff you wish you had?

Loads. A functional EHR (UX). An easy way to keep track of what medications a patient is one and has been on (?blockchain). Better quality and cost measures (big data).

Couldn't this finding be explained by the fact that the hospitals with lower readmissions tend to be poorer (since poorer patients are less likely to be able to afford care)? I only took a quick look, but I didn't see how the paper accounts for this and other possible causality issues. On the other hand, it's certainly plausible to me that lower readmissions can cause higher mortality.

Sure. Or those hospitals gamed the system and didn't admit patients who should have been admitted. Or plenty of other explanations...

We call readmissions rate a Surrogate Marker. Something that isn't a hard outcome that we care about (that much), but rather an indicator of quality. We need surrogates to assess quality because hard outcomes are rarer. But this paper makes us think that maybe we need better markers.

Do you have recommendations for any books or other resources that cover topics on healthcare quality measures? This is the first time I’ve heard of surrogate markers. I’ve been searching around for more info on the concept you’ve described but didn’t have a term for it.

Why do we need technology to help improve lives when so many diseases (type 2 diabetes, Crohn's, IBS, high blood pressure, arthritis, and dozens of others) can already be reversed and prevented by simply changing a person's diet and lifestyle habits? It's really quite insane that people would rather take pills for the rest of their lives to treat symptoms of a disease than actually getting rid of it altogether by giving up food habits.

Part of it is also due to traditional physicians being so dismissive of the role nutrition plays in a person's well being.

You broke the site guidelines by taking this thread into a flamewar and grossly overposting. We're trying for quality, not quantity, in discussion here—you went far in the other direction. You also broke the HN guidelines in other ways, like personal attacks and going on about comment voting.

All of this is really bad. Please don't abuse the site like this again.

https://news.ycombinator.com/newsguidelines.html

Before you become "so dismissive" of traditional physicians, you try getting someone to radically alter their lifestyle for the promise of potential benefit in 10-20 years. Even if you can point to a few people that have done it, I can point you to plenty of data that says it's really hard and most people can't. Even technology may not help: https://jamanetwork.com/journals/jama/fullarticle/2553448.

Edit: Also reversed is a pretty strong word. I haven't seen any compelling evidence that Crohn's can be cured with lifestyle change.

> try getting someone to radically alter their lifestyle for the promise of potential benefit in 10-20 years.

There is an incredible amount of confusion with regard to appropriate lifestyle interventions. Part of the problem is that your predecessors' predecessors (doctors in the 1950's and 1960's) came up with some simplistic and wrong advice that never got properly withdrawn: the hazard of butter and the superiority of refined vegetable oil, the hazard of salt (farmers and veterinarians give animals salt licks), estrogen as "the female hormone" -> DES babies && prescription horse urine (PREMARIN is PREgnant MARes' urIN), etc.

The American Heart Association still warns about saturated fat [0]. If science advances one funeral at a time, what can be done about organizations that insist on being wrong?

[0] https://recipes.heart.org/Articles/1013/Healthy-Cooking-Oils

Modern medicine does have some good advice, but it's very tough to separate the wheat from the chaff. I think medical professionals are just as confused as everyone else. On Christmas I heard someone (a physician's assistant) recommend an erection-killing intervention to help stop her sister's boyfriend's hair loss [1].

[1] https://www.webmd.com/sexual-conditions/news/20120413/propec... - this side effect might not be not universal, but is devastating to the men who suffer it.

"Palliative" drugs are commonly used. This is essentially Elisabeth Rosenthal M.D.'s rule #2 for American medicine: "A lifetime of treatment is preferable to a cure." [2]

[2] How Economic Incentives have Created our Dysfunctional US Medical Market - https://medium.com/@RosenthalHealth/how-economic-incentives-...

Dr. Brewer's pregnancy diet is supposedly quite helpful for dealing with common pregnancy problems. Iirc, the core pillars of this diet are adequate protein and "salt to taste". But conventional medicine never figured this out for itself - I've met lots of women who suffered from dangerously-high blood pressure during their pregnancies. One's diet consisted of saltine crackers - she was nauseous, and had to have labor induced before the baby killed her.

Appropriate lifestyle interventions start to benefit people right away. Coconut oil rapidly helps with alcohol cravings, for example. People can lose most of their excess weight over a period of 2-4 years. Pregnant women immediately benefit from adequate salt intake. Etc.

Doctors are doing much better today than 50 or 100 years ago. I think the industry would greatly benefit from a critical examination of common practices.

You haven't seen it because your traditional world of medicine does not include that group of people.

I have. About a dozen of them. In fact, each Crohn's patient that I've seen undergo a fast 2 weeks or longer has not had any flare ups since. And completely stopped taking all medications and undergoing their usual treatments.

(they do watch their diet after, mostly fruits and veggies).

Lifestyle change alone will not cure it. It must be preceded by a proper water fast.

Reversed IS a strong word, and very appropriate here.

Sad that you get down voted when you make so many valid and useful points. Galileo was in the same boat at one time!

I don't think you can blame traditional physicians. Most of them really didn't go to school for a decade to tell fat people to eat less. They want to solve medical problems, not play life coach.

Maybe there is a role for technology here. People accept statements from a machine that they'd take great offense to in person. Maybe Siri would be a better entity to tell you you're fat and need to lose weight.

Is this a new thing? When I was a kid, we still had what was called a "family doctor." I'm not sure these really exist anymore. He never hesitated to tell my mom she needed to lose weight or my dad he needed to stop smoking. Maybe the fact that he wasn't a specialist allowed him to be more practical with his advice.

From what I've seen, family doctors have been replaced by primary care physicians. There's still a place for generalists in the medical profession.

You've mixed up two separate concepts. Primary care physician is a role, not a specialty. Most PCPs specialize in family medicine, internal medicine, or pediatrics. The PCP acts as the patient's primary point of contact, leads the patient's care team, and makes referrals to specialists when necessary.

Could you clarify the distinction in the context of my parent's question? I think the same thing could be said of family doctor, but I'm not sure I understand what you're getting at. For what it's worth, my dictionary refers me to "general practitioner" when looking up "family doctor".

Effectively a PCP is a load balancer for the pharmaceutical industry, directing consumers to the appropriate pill pusher.

At this point you are trolling. Would you please stop?

Which part of my statement is inaccurate?

Family doctors (and specialists) still give their patients practical advice lose weight, drink less, eat better, exercise more, and stop smoking every day. Most patients ignore the advice. What more do you expect the doctors to do? If we want people to make better lifestyle choices it's going to take a new system of incentives separate from doctors.

I agree though, by the time a patient makes it to a traditional physician for advice it's pretty much too late in the game. What do you expect from doctors that accumulated a total ~20 hours of nutritional education in their many years in school?

And it stops there after a short suggestion. Maybe it's time for "behavioral medicine" a la behavioral finance. We already know people aren't going to listen (they statistically don't) so how else can we tell them in ways that they will listen.

Make it like life or car insurance. I don't pay as high of a premium as a person with DUI history. Why is my health insurance premium the same as a person with an unhealthy lifestyle that frequents the doctor far more than I do for ailments resulting from their poor dietary choices?

For many people the premium isn't the same. Under US law, medical insurance companies are allowed to offer premium discounts for members who meet certain wellness goals such as maintaining a normal weight or blood glucose level.

You know how in technology we like to say "no one got fired for buying Cisco?".

Well, for them it's no one got fired for selling Lipitor.

Exactly, and it's not an irrational decision either. There's a gap in the medical system. It's really really difficult to get people to change their behavior. It requires a completely different skill set from curing, preventing, or ameliorating clinical disease. Trying to get doctors do it is quite frankly a waste of everyone's time.

This dude posted up thread that Crohn’s can be cured by a 2 week water fast, so I don’t think he’s on the same page as you.

His views sound a little more extreme (and seem to ascribe malicious intent to what I would label as systemic biases), but I think there's a lot of truth in the principles behind what he says. It's accepted today to dismiss anything that hasn't been scientifically proven, which ironically does a disservice to science. I think if you asked most true experts in the field doing cutting edge research, they'd be the first to admit that they don't know if fasting could cure some cases of Crohn's.

You are being naive.

Who do you expect to do the "cutting edge" research to confirm fasting can cure Crohn's? Do you honestly not realize this is career suicide? There is zero benefit to researchers funded by the government or pharma to find out not eating for 10-30 days is the cure to something they are selling $200K/year treatment for. This is not a conspiracy theory - this is modern life facts 101.

http://www.crohnscolitisfoundation.org/about/sponsors/

Yeah - sure, every corporate sponsor on this list just wishes for the day that it is finally known that Crohn's is not actually a lifelong incurable disease - and not only there is a cure - it literally costs nothing. In fact, you SAVE money by not eating too! LOL. It's astonishing how otherwise very smart people (especially on HN) cannot see beyond what's in front of them. I actually think the more conventionally-educated someone is, the harder it is for them to admit solutions are far simpler than they "should" be.

I'm actually not disagreeing with you. Except that I think there is room to say that there are people working in this area who, like you say, are incentivized to research in other directions, not necessarily the one that most helps us. That doesn't make them evil or bad people. They're doing more to help than any of us trolling around on the internet.

I could see a computer calculated life expectency with weight loss as an option to increase it.

Being told you are fat is not a good reason to loose wight. People probably already know they are fat. Maybe there are other reasons that could be communicated...

Seems like one of those things where reason didn't get you to where you are, so reason won't get you out of it. People tend to have an emotional reaction to a person telling them to do something they already should be doing. Maybe tech can help. Here an example of what I'm talking about.

https://mobile.nytimes.com/2014/10/19/fashion/how-apples-sir...

Well as a physician, you can't really force your patient to exercise and eat better. The best you can do is prescribe a medication to treat the symptoms, tell your patient to exercise and eat better, and send them off.

Do you have an alternative to prescribing medication for type 2 diabetes and Crohn's? Do you think doctors should simply withhold care since it's their patients' faults that they have those conditions?

AFAIK, as a patient with Crohn’s, there is no evidence that any specific diet causes or cures Crohn’s disease. If you know of dietary restrictions which reduce risk of Crohn’s in the same manner as type 2 diabetes, please share it, as I know many people (both patients and physicians) that would be happy to help make lifestyle changes to cure their disease.

There is some evidence that the low FODMAP diet that has proven very effective for managing IBS can also be effective for managing IBD such as Crohn's. Personally, it has been much more effective for me than any of the half dozen medications I have tried.

Of course, this is not actually a cure for Crohn's, just a treatment.

I agree, I was merely entertaining the parent's claim that Crohn's could be solved in that way. I'm sure he thinks Crohn's can be simply solved by going gluten/dairy free or by fasting.

Did you even see my reply? I don't "think" or speculate. I've seen it. 2 of them still take me out to lunch when I'm in town because I've changed their life with a simple suggestion which they took upon themselves to research further. It's all about a person's state of mind. If you want to be a slave to the systemic misinformation that's out there - sure, go ahead. If you want to explore alternative options that take away a physician's job security, all the power to you.

It's AFAYK because that's what you are being told currently.

Who do you expect to show you the evidence that a 2-week water fast will cure your Crohn's? The company that makes Remicade which brings them up to $200K a year per patient? A university that gets funded by the government that is lobbied heavily by the pharma companies?

Come on. Think about it.

I already shared it - now it's up to you to pick it up from here and do your own research if you are interested. I've seen many who have stopped and reversed diseases including Crohn's using water fasting followed by a diet of mostly fruits and veggies.

I’ve fasted for more than two weeks while suffering from a blockage large enough to prevent eating solid food. I still have Crohn’s. It’s possible and certainly important to manage inflammatory symptoms with diet, but unfortunately curing the disease through diet is just impossible. I’m glad it’s worked out for your friends. I just hope you aren’t preventing those with serious disease who need proper medical treatment from following through.

I don't, funny thing is I see it exactly the opposite, the traditional medical treatment and attitude towards alternative options is preventing those with serious disease from following through.

2 weeks is the minimum I've seen. Some need up to 30 and in rare, advanced cases even 40 days of fasting.

You come across very badly. Just based on how you engage, I was ready to shoot you down and I have pursued dietary and lifestyle changes for many years to manage my incurable condition. I also have recently concluded that fasting is beneficial for my condition, which flies in the face of everything I ever understood to be true.

A few thoughts:

1) Try to not overgeneralise. Even if you really know of people who were cured, that doesn't mean it is guaranteed to work every time for every case.

2) Try to develop a hypothesis as to why and how it works rather than merely asserting that it does.

3) Drop the conspiracy theory language and stance. It only hurts your case here.

I hope you really do know something useful. It might even benefit me if you do. But your presentation really needs work if you are going to get anywhere.

Best.

Thanks for your feedback. As I said elsewhere in this thread, my presentation does appear a bit harsh when done in a comment section such as this one vs. how I am in real life.

I don't know if it makes sense to change it. It may seem counter intuitive, however it's been my experience that the harsh tone and somewhat trolling-like language IS what sparks some people to PM me and make initial contact, or at least open a new tab and start googling.

I used to not be like this online, and I definitely see better response from my current style. (better in the sense that I think it results in more people taking it upon themselves to research this further). Yes, it has its drawbacks and my responses are usually at the bottom of any health-related thread on HN, but even this thread already got a few people to find my email (it's not hard) and send a quick note.

The downvotes here and general negativity towards fasting does not paint the real picture. There are many silent voices out there who will not engage here fearing backlash from other users or even employers or potential customers.

I'm always happy to and offer to jump on the phone with anyone who wants to talk and hear from a live anecdote or just be pointed in the right direction research-wise.

Getting rate limited or banned may not serve your goal too well.

And one would do well to set their ego aside and try to first do no harm. Getting converts to your fasting religion may feel like a rush, but you may wind up harming someone. It does not sound to me like you really want to look at the possibility that your cure may not be all that and a bag of chips, which just sets off alarm bells for me.

I am a potential ally. I have done similar things. You choose to not engage those facts while justifying your admittedly trollish behavior. I don't think this speaks well of your motives.

If you want to make the world a better place, the best place to start is with the man in the mirror.

Your last statement makes no sense. I already started with the man in the mirror. That man is arthritis-free since day 20 of a water fast 6 years ago. That man plays soccer every weekend, after not being able to for many years.

I made my own world a better place. Friends and loved ones who listened to my real-life non-troll opinion are better off today. Every single one. A coworker who dismissed it 2 years ago came around a few months ago and said he's no longer diabetic. Nope - the doctors did not find a special pill just for him. No new injection discovered. He checked himself in to a fasting clinic and walked out a new man.

I'll consider toning it down in the future. It will still be downvoted and the only difference will be less discussion, which will result in less attention from those who need it most. Me? I don't actually enjoy this. I spent a couple hours refreshing HN today just for this when I could have been doing something else. I choose what threads to comment on very carefully because I know HN is very science-oriented, but people will die waiting for the pharma companies to admit this.

Me? I don't actually enjoy this

Then you are free to stop, no?

I have one and only one person listening to what I have to say about my condition and getting better.

I was you a few years ago. I have been doing this 17 years, not 6.

Anyway. Probably just wasting your time and mine both.

Ciao.

I'm curious if you don't mind sharing, how long was your longest water fast?

I do mind sharing. You clearly have an agenda. You are desperate for validation. You found a thing that works for you, you want to think it will work for everyone and ... Sigh. I have barely engaged you and I feel tired.

Think on this: I am a potential ally, doing similar things. You are actively picking a fight with me and driving me away.

Ask yourself: Why is that?

It's not about getting converts. That's the first problem here - that getting someone interested in a water fast as remedy to a disease is considered "cultish", some crazy conspiracy or religion. Seriously, have the pharmaceutical companies infected our minds this badly? That radiation seems normal and applauded as a great suggestion, but a water fast, simply the act of just resting and not eating.. is.. dangerous or some wild crazy tinfoil hat idea?

No, the first problem here is you are certain you have a cure. You will listen to nothing to the contrary. Anyone who has evidence or experience that contradicts yours is dismissed as not having fasted long enough.

Your behavior is egomaniacal and casually callous.

I have cystic fibrosis. I am getting well when doctors claim it cannot be done. I have been in your shoes in arguments. I am trying to give you the benefit of the doubt and be constructive.

But, sorry I engaged. Carry on with your knowingly and intentionally trollish goal of getting converts to your totally not a cult.

Also - why shouldn't I be certain that water fasting IS helpful and likely to cure many diseases? All the evidence I have and been exposed to shows precisely that. I'm not saying people should start it tomorrow. All I say is - research it, you will be introduced to an entirely different world of medicine.

Yet you have no issue with people who have never even heard of this concept coming here and making definitive statements that this is all non-sense?

I have not seen or heard today of any evidence that says water fasting is either (a) harmful or (b) not useful. Do you have any sources?

It is well known that fasts need to be from a few days to 40 days. I'm sure you've come across that 40-day number before if you're not entirely new to fasting.

I am pretty new to fasting. I don't know of the evidence you are pressing me for. The request tells me you don't actually understand what I am saying.

So maybe take some time to digest it and if you ever want to really talk, my contact info is easy to find.

If you want anyone to believe you then I would expect to see evidence from a large scale, double-blind clinical study published in a respectable medical journal. Find some researchers yourself and help put it together. Since there's no expense for medicine or food it ought to be fairly cheap to run. Despite your ridiculous conspiracy theory, hospitals and universities frequently conduct studies that aren't funded by pharma companies. Just pick up some medical journals and start reading to see how totally off base you are.

Look into research and patient treatment results by the likes of Dr Herbert Shelton. There is quite a bit of literature to support caloric restriction and in particular water fasting as ideal treatment option for many diseases once you filter out MSM sources that tell you it's a lie (and in the same page push you ads by Pfizer.. yep, clearly unbiased!)

It's not about who funds the research - there is literally no benefit to confirming that water fasting cures diseases. Nobody in the medical industrial complex would benefit from this. Not even food companies! (because you won't be eating for up to 30 days and then change your consumption habits drastically against mass produced factory food).

Are you referring to this one?

Shelton, Herbert M. Fasting Can Save Your Life: How Christians Can Change World Events Through the Simple, Yet Powerful Tools of Prayer and Fasting. Natural Hygiene Press, 1964.

Please.

Seriously - why would someone like you be so opposed to water fasting?

Think about it for one minute - patients go through extreme treatments like chemo, radiation, Remicade, whatever - anything to get better, right? Why is exposing your body to crazy treatments so accepted, but this isn't? Nobody is telling you to expose yourself to chemicals, eat crazy things, drink concoctions.. really. What's your issue with water fasting? Such a pure process.

So why not give this a shot? Type 2 diabetes people in fact see results in a matter of few days. What do they have to lose? I'm sure you're intelligent enough to realize water fasting for extended but still short enough of timeframe is not starvation, right?

If you could make an effort for 5 days for the chance of never having to suffer from Type 2 diabetes - why the heck not give the patient the information? This is sick, truly sick, and people like you are keeping it so.

On the contrary. I am not at all opposed to fasting, although extended fasts do carry certain health risks. You have presented a plausible hypothesis. Now do the hard work to validate your hypothesis by following the scientific method instead of wasting our time with unverifiable anecdotes.

Can you please point to the study that shows extended water fasts carry certain health risks?

Posted some more links for you in another comment.

Please what?

Do you have proof that you know of someone who water fasted for extended period of time and was not cured or was harmed?

Because I DO have the opposite proof.

So your empty statements and insinuations is just trolling.

Agree. My dad, also a physician, blames himself for being overweight. But if "everyone" is overweight, can it really be their fault? Surely "the system" has as much or more blame to share.

Your dad, Big Food, Big Pharma, MSM, his parents. The blame is in that order.

Sure, most physicians nowadays will mention to the patient that diet and exercise are beneficial, but at the same time will outright dismiss the critical role that diet specifically plays in curing the disease.

Yes, the alternative is a 10 to 30 day water fast for both of those. I know several people that successfully cured both. Especially Crohn's, the amount of misinformation given by physicians is stunning and borderline criminal. $200K a year Remicade treatments GONE after 2 weeks of water fasting. Why would Big Pharma have any incentive to get this message out there?

High blood pressure for example can be reversed entirely after 5 days of water fasting. Completely gone. I don't know how else to say it. I have first hand knowledge of many successful water fasts, but the medical world has brainwashed everyone to the point that I get shut down immediately in any social setting by even mentioning this. But that's okay. Not forcing anyone to do anything they don't believe in. All I can do is share my knowledge and point people in the right direction when they're ready.

Prove it. In a randomized, placebo-controlled, double-blinded trial.

There are plenty of quality and health savings organizations that would fund such a trial if there were any hint of benefit. But there isn't.

I'm glad to hear that pseudo-science still gets shut down in social circumstances.

It is slowly trickling in.

http://www.telegraph.co.uk/science/2016/03/12/fasting-for-th...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4684131/

I personally know multiple people that did listen to me and others who told them about the healing powers of a water fast, and cured their illnesses by doing it. There's really no downside. You are not "starving" yourself. That is such an insane myth.

I myself did too - got rid of a bad arthritis in the knee that I've suffered from for years - just 20 days into a fast (this was 6 years ago, no inflammation of any kind since).

So, no studies linked, just a quote collection and an interview?

I am not aware of any study (that has been made public, remember they always have that option at the end) by a pharmaceutical company or university that was set out to test whether water fasting for 5+ days is beneficial in treating or curing disease.

Several reasons:

1. They conducted one, but didn't like the results.

2. "Don't ask what you don't want to know the answer to" applies here - there is ZERO benefit in discovering that water fasting indeed reverses diseases to which these entities have vested interest in keeping their symptoms a lifelong struggle to patients. Nothing good would come out of it for them. The entire modern medical business model would collapse.

Tin foil hat? Sure, label me that. All I can do is drop tidbits that may be helpful to someone now or in the future. I already know that I've helped a couple dozen people personally in the last few years, myself included.

Those people would still be in a very bad shape if they waited for government or pharma company to endorse what has already been proven to be used successfully for hundreds of years as a primary healing treatment.

Sorry for being so dismissive, but with so much noise out there, it feels like a waste of everyone's time when such a claim is made without the science to back it up.

For sure, there are seemingly endless possibilities that are not being thoroughly explored by the many scientific bodies, but I can understand why that is.

Thanks for taking the time to reply with more information/research.

Here some more links for you to dismiss:

http://www.sciencedirect.com/science/article/pii/S1934590914...

https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-...

http://www.sciencedirect.com/science/article/pii/S1550413115...

I think there's a lot to be said for sleep, diet, and exercise for combating many what are often termed lifestyle illnesses. That said, I think there's a lot of use for tech (which is really just applied science) in monitoring, diagnosing, and researching illnesses and treatments, as well. And not all maladies can be treated by sleep, diet, and exercise alone.

I can easily imagine anecdotal evidence like that you mention while dismissing the rest of the medical establishment (with loaded phrases like Big Pharma) is likely to get you dismissed as well. Perhaps that's not how you intend to come across, so perhaps you might look at tempering your arguments to make them more palatable to those you believe are brainwashed.

The way I comment here is not really how I relay this information to people IRL, especially because I'm very aware and sensitive to their health situation at the time. Here I know I'm going to get downvoted instantly, so I don't bother as much. Mostly threads like this frustrate me, because I know so many people can be helped but online communities shut down these types of discussions and people barely scroll all the way to the bottom to read the truth.

So anyway, I hear your feedback and agree with it. Offline I'm much more patient and I do make it a point to take my time and only slowly break the news to them that traditional medicine has been lying to them for so many years, coupled with real evidence and pointers as to the direction they should be looking at in evaluating what I just shared with them.

> "The way I comment here is not really how I relay this information to people IRL"

> "Offline I'm much more patient"

I encourage you to behave more like you do in real life here on HN. Much of what has unfortunately become accepted as discourse on many forums does serious damage to actual meaningful discussion. If that's not what you're interested in, please just refrain from commenting. Many on HN, for all it's faults, are trying for something better than average, even if we don't always succeed. People are still people, regardless of where you're encountering them.

Well, IRL people would give some verbal feedback before they dismiss my suggestion. In HN, they just downvote and walk away.

And I have, so far I answered every comment, including the physician who wanted links to "proof", whatever that may be. After all, who really benefits from finding proof that water fast cures illnesses that otherwise require a lifelong regimen of medication and doctor visits?

Perhaps there's some chicken/egg going on here? On HN, members will downvote based on tone as well as message because many do value civil discourse and recognize that regardless of the value of the substance, the manner in which a member communicates that substance can drag HN down. And deciding not to couch your comments as constructively as possible is much more likely to result in downvotes, if that's what you're concerned about. You've gotten plenty of feedback in this thread.

If you have a message you want to convey, it's in your best interested to also convey it in a manner that has the best possible chance of being accepted. If you've already decided that's not worth the effort, it's probably not worth the effort to comment at all.

I agree, I may come off as a troll. I get your point. It's too bad if I do though, my intention is to point people in a direction that will help them and one that they've likely never come across before because no one in the traditional medical world will ever suggest this as a viable option.

I will make it a point to phrase my comments differently in the next health-related thread.

> "I will make it a point to phrase my comments differently in the next health-related thread."

Why wait? Why not start now?

Unfortunately water fasting is not effective in treating chronic procrastination.

I've worked in healthcare tech before and one thing we didn't need was more people claiming you could solve every problem with some random FOTM untested medical method that doesn't hold up to scientific scrutiny. No need to make yourself out to be some sort of scientific martyr. If you can't do people here the justice of backing up your comments, don't comment and then complain about getting down voted

I did back it up. Again, remember, there is not much "science" to back it up - because universities and pharmas have such little incentive to studying what may prove to render the medical world useless. Think about it. Why would they study it? If it doesn't work - anyway no one believed it. If it does - all their patented work becomes unncessary for many diseases.

So you are left with real life people who have seen success. And there are plenty once you open your eyes.

Accusing physicians of being dismissive of nutrition by being dismissive of technology is sort of ironic, no?

The reason many physicians are dismissive of nutrition is because they only get about 20 hours of total education on the subject.

Well you can do both. There are apps to improve food habits as well as the other stuff.

I'll throw in a slightly contrary opinion.

I work for a health-insurance startup. And many of the people we cover are on extremely low fixed incomes. It's not unusual for them to be in situations where they have to choose which bill to pay this month and thus which utility will get shut off next month for non-payment. Their premiums are heavily subsidized and they only have insurance at all because of government programs, sometimes only because they're eligible for multiple programs which combine to help them out (and which are also constantly on the chopping block). So any kind of cellular phone, let alone a multi-hundred-dollar smartphone with service contract, is simply an unaffordable luxury for them.

And that's why I worry about these kinds of efforts. More affluent people can benefit from smartphone-centric approaches, but a huge percentage of the US slips through the cracks when you do that.

So solving America's health-care problem is not going to happen by focusing on people who have smartphones. That will just heighten the divide; the people who are already in a position to get good care will continue to get it, and the people who aren't will continue to get worse. If you want to avoid the grim-meathook-future problem, smartphone-centric (and, really, most tech-centric) approaches are unlikely to work.

There are plenty of indicators that could be monitored in various patients for various diseases, but a lot of them may require doing things that are beyond the ability of someone who is not medically trained. Some of them require intravenous blood samples, for example. But others are like example you mention (which only requires that the patient weigh themselves at a given time each day).

It would be nice if we could make it simpler for people to measure things like their own hemoglobin A1C, blood urea nitrogen/creatinine, blood flow around organs/extremities, etc. and send the data to a service that can be used to alert medical staff if something looks like it's getting worse.

> Can you imagine my frustration at hearing this? It's this massive problem with an obvious (CHEAP!! SO FUCKING CHEAP!!) solution.

I suspect the nurse is there to perform the “getting the patient on the scale” function, not the “reading out the weight and tracking it” function.

Perhaps the scales could be built into the bed somehow?

Modern hospital beds do have scales built in.

Thanks - I did not know that.

Full-automation should be possible then - no need for the nurse to get the patient on the scales.

That's probably what #rayiner meant when he wrote that the solution is obvious.

It seems like the real (meta)problem is that the system’s incentives don’t reward this. If a doctor’s take home pay increased as these things were avoided, you wouldn’t need some risk-tolerant startup to dive in with some innovative protocol; someone would have figured out a fix a long time ago.

(Edit: to adapt the old saying: if life-saving were profitable, common sense would make us all saints. But alas, we live in a world where regulatory arbitrage pays more.)

I think we should ask how we got to the point that the incentives are so incompatible and how we got to that point and how to realign them.

Both doctors and hospitals are financially incentivized to avoid rehospitilization. It is actively tracked and directly impacts billing. Check out the "Hospital Readmissions Reduction Program" that Obamacare introduced.

I’m sick of people spreading FUD about medical billing based simply on the ridiculous “the man is out to get me” narrative.

Fair enough -- I was severely understating the extent to which there are financial incentives. But I think you're making a similar error in the opposite direction, coming from the approach of of "that problem is solved because we have a law for it." Imagine in any other context:

"Everyone makes a living wage, because we have minimum wage laws." -> No, cost of living can eat it up in some areas, and some people are forced to go contractor, where take-home can get arbitrarily low.

"Taxis provide vital, universal service because they're obligated to take you anywhere." -> Yeah, but in practice they can flout this with impunity.

In this case, yes, the most obvious cases of hospital failure will be undercompensated, getting some incentives right. But is that the same thing as saying that actual, effective measures to avoid screwing up will translate into higher profits, and the people capable of identifying these will benefit from pointing them out? I think that's a stretch.

Why do you think such a simple measure, as proposed by this startup, has to drag them kicking and screaming into implementation? Isn't this something a hundred doctors might have noticed and suggested? Something system level isn't working. Either the feedback loop between hospitals and doctors is broken, or it's too easy to relabel a readmission as being a new issue, or something like that.

If startups have that kind of resistance to something so simple, that suggests a lot of easy improvements are still being held up by misaligned incentives, and supports my original point that system level fixes are a bigger target for health outcome returns.

Is there any chance you would be up for talking about where one could go about working in tech on problems like these? Every time I've looked, I usually just find hospitals maintaining poor IT infrastructure and CRM-type systems. I would love to work in this space.

Strangely, I've been able to find startups in the education space, but not in healthcare. I imagine 90% of the problem would be integration into the behemoth that is medical administration, but that's something I also have the skillset for.

Hacker news has a limit on replying to responses with less than a few votes, but my email is in my profile

The tech is the easy part. Integrating into a 24/7 high turn-over environment where all employees, IT included, are stretched to the max, is the real issue.

And pumping the data in to their myriad EHR systems, getting those records associated correctly across those systems+, the unintuitive UI/UX problems you'll inevitably face, as well as training issues. And God help you if it's a place where they home brew their own solutions instead of going with a vendor. My company is in the health care space, as well, and a lot of the problems _do_ look easy ("that's just a CRUD app, right?" easy) until it comes time to get them adopted in the health care space.

Wifi-enabled scales that connect to webservices already exist on amazon - I assume the hard part is getting some certification so doctors/nurses can 'prescribe' it to patients when they leave hospital or while they're in hospital and getting the webservice to talk to $hospitalSoftware, etc?

Failure to market an IoT product is unfortunately my experience as well. I hope the medical industry gets better, re-hospitalization sounds ridiculous for something easy to detect.

The monitoring devices are the real problem, not the people. Do you think all weight spikes simply equate to having CHF? You can't just rely on such a basic measurement when dealing with an incredibly complex system such as the human body. A lot more specialist equipment is going to be needed to come to a final conclusion (Questioning from experts, MRIs, XRays, even Microsurgery with cameras).

What consumers can currently access are weighing scales, and heartbeat monitors. Maybe even temperature monitors. Do you think this stuff is useful for diagnosing medical conditions? There is a whole lot going on under the surface that we simply can't see at all, that's the real problem.

Your comment is a great example of the disconnect between people in this space and people not in this space. Do you actually think anyone in this space would believe that weight spikes are tied to CHF in all cases? You don't diagnose CHF by weight. It's something you trend in known patients.

Comments like this are one reason why doctors give zero shits about the potential of computing. Explaining even the basics of a narrow area of human physiology to some overly arrogant IT guy is maddening (arrogant is fine, for Pete's sake, it's not like doctors aren't arrogant). Yes, the doctors can be blamed for conflating computer scientists with the IT guy who came to replace their mouse. But the IT guy and the CS guy (always a guy) can both equally be blamed for their unholy arrogance. How many lives did you save today? Zero? Ok, at least I didn't spill any data (that I know of).

This can go round, and round, and round.

You have no idea how far down the problem goes. I know this because no one knows how far the problem goes. We sequence hundreds of thousands if not millions of genomes, and still we don't know. Do you really think we spend a decade in training and come out thinking everything is simple?!

Now, on the flip side, doctors also don't even know how to frame their problems, in no small part because they're only required to take 2 semesters of calculus. And then most of them punch out of math as fast as possible.

Computer scientists should be going to biology conferences. Go to ASCO. Pick a medical specialty, they have multiple conferences a year, I garauntee it. There's one or 10 in your city. If you want middle ground, look at microbiology, immunology, molecular biology. They use a fair number of quantitative methods (sequencing, mass spec, flow cytometry, etc).

I'm a software guy in the healthcare space, albeit not medical devices. We see this problem all the time. Despite the fact that most of the people involved have degrees, often Phd level, in CS, Math, and Physics we see no end of other software folks from typical tech companies coming in and describing how we just don't know what we're doing and that we need big tech to come in and disrupt us.

There's a reason we do things the way we do them and it's not because we're stupid and/or ignorant.

I agree that his comment was not in good taste, but I think he must have simply misread or skimmed the parent comment, or misunderstood.

Your comment is a great example of unnecessary escalation. He made a mistake, no need to pin all this angst about the disconnect between doctors and engineers on one mistaken comment on the internet. While I think the parent commenter should apologize, I think ideally you should too, this is blowing things out of proportions and that's not the kind of dialogue I like to see on HN, or anywhere on the internet.

Fair enough, happy to go first. I hearby apologize for escalating, although the disconnect and it sources stand. What is sufficient remedy? Shall I delete my comments?

chill. I personally don't think you really escalated all that much, and outside of the casual misandry (hehe, couldn't resist piling on with another complaint) I got genuine value from reading your comment.

Why on earth do you think you can generalize your anecdotal experience to conclude tech people are any more arrogant than doctors or staff in whatever field?

We can agree there is a massive disconnect, but there is plenty of arrogance to go around and I’ve seen it on both sides in these situations. Moreover, whoever’s arrogance it is, is only one part of the problem, and I think not the largest one.

Just the legal and regulatory hurdles alone pour molasses all over what would normally be a fast moving startup effort. Worse, some products or services have to worry about the reasons the bureaucracy exists in the first place: What level of risk mitigation is sufficient to keep from killing people? Here’s a hint, it’s a level that doesn’t speed up your time to market.

There can also be a lot of time wasted by people who may be very talelented within their specialties, but require lots of hand holding to ramp up on the medical issues, technologies, product design and user experience (which still always exist), and business strategies depending on their background. Ideally you have at least one person with great expertise in one, and training and/or a knack for the others, who can see the big picture, and everyone else must make honest assesments of where they can really add the most value.

We always talk around here about how ideas are cheap and the team and execution are what matter. Based on some time I’ve spent with doctors and entrepreneurs in these scenarios, my impression is that maxim is even more apt in this space.

I have been working with some extremely smart, hard working computer scientists on a real, hard problem in this space, a problem I've been working on for 6 years. Easily 20 years of work left. I have a great deal of respect for what you are capable of.

The white hot fury was directed at the sophmoric response of hacker_9 which I then used as an exemplar of a few trends in behavior I have watched for over a decade.

I understand your frustration, I believe your experience, no personal attack was intended.

I only hope we can agree that generalizations about good and bad character traits is tricky business, even if all this was not anecdotal. I hope there can be more agreement because there truly is life changing work that needs to be done, but as with so many things in life, it sometimes requires effort to remember our previos experiences may not always predict our future ones.

What an ironic comment - I tell a software developer that medical science isn't as easy as measuring weight changes, supporting the point that doctors need to do a lot more than that to come to a diagnosis, and then a doctor (I assume) tells me to STFU because.. oh, of what I originally said in the first place. What was your point here? I hope you don't make these kind of mistakes with actual patients.

This is what I was responding to:

> Do you think all weight spikes simply equate to having CHF? You can't just rely on such a basic measurement when dealing with an incredibly complex system such as the human body.

Considering you were knowingly addressing someone who worked in the space and blew right past something you obviously knew within seconds (not all weight spikes equate to CHF), thinking there was even a remote possiblity they hadn't thought of that, despite having a physician on staff to discuss with.

Your response here (as quoted) is exactly why doctors throw their hands in the air and wait for someone else to come along. You actually thought you had an insight and despite remonstration, you persist in thinking you outwitted everyone on this thread. That's the point.

You're lack of humility coupled with your snowflake sensitivity is why we don't want to work with a lot of computer people. The sad fact that a lot of doctors also equate computer science with IT is another problem.

You would think OP would know that, but the original comment basically tells us all to measure our weight simply to check for CHF. If it were that simple we'd all do it I presume, but of course weight change can be a range of things. Many of which are not problematic. Hence why I pointed out that better measurement devices are needed. I've also got a feeling that it may just be you in particular that 'IT' don't like dealing with.

You're still missing killjoywashere's point.

Their point was that _of course_ everyone involved (including the person you were originally replying to) knows that a weight-measurement is not sufficient to diagnose CHF. Literally everyone in the conversation has already presupposed that point.

However, blhack working with a physician learned that it would be a super useful medical tool to have an automated mechanism for taking those weight measurements because it's a useful early indicator.

Your response was exceptionally dismissive, given that there were people in that space who knew what they were doing and knew it was useful. Yet, you came by and in 10 seconds decided it wasn't useful and wasn't worth doing.

So, what makes you more qualified to make that decision that blhack and the physician they were working with? Why are you so arrogant to assume that the physician who stated that would be useful was just wrong?

Your insight wasn't particularly insightful, and you presented it in a way that was condescending and dismissive of others in the space.

OP said that CHF always causes sudden weight gain; they never said that sudden weight gain always indicates CHF. You're the only person here who implied that.

A doctor accusing other professions of being arrogant? That's rich.

You mean where I said

> I didn't spill any data (that I know of)

> doctors also don't even know how to frame their problems,

> most of them punch out of math as fast as possible.

How about the part where you said:

> How many lives did you save today? Zero? Ok, STFU

Last time I was at the hospital they seriously asked if I wanted Reiki. If you can get through med school and still believe in that, sorry If I don't have much respect for your education.

Doctors and IT people are the two most arrogant professions I've ever come across, and I even work in finance.

Thank you, point partially taken. I deleted the expletives. Have an upvote.

This isn't about diagnosis, it's about monitoring already at-risk patients. He clearly stated nurses take this sort of measurement manually for at-risk patients, it's a simple solution to automate an existing workflow that involves an unnecessary amount of manual labor.

It is possible that some of the noise (non-medically relevant changes) could be filtered algorithmically, and conversely conditions might be able to be picked up that might not be noticed by a normal provider. Physicians use those tools to diagnose disease all the time, that's why there is a thermometer, scale, and stethoscope in every doctor's office in the world, I don't understand how these tools aren't useful.

They can tell you something is different, or out of the normal range, they don't give you the real cause of the problem though. This is left to the doctor who will take into account age, gender, medical history, as well as the fuzzy description of the problem from the patient. Then they'll give you some medication and hope that it heals in a few days, if not, then re-assess and do more trial and error diagnostics and medications (which can go on for months, even years).

If we had technology that could monitor internal changes on a real time basis though, then the face of medicine would change forever.

If you're going to monitor every aspect of a person's life, you're going to generate so much data that you'll generate almost nothing but false positives. None the less, I don't see why you couldn't just scale your level of significance way up and be a useful screening device. Obviously any diagnosis must be made by a doctor, but that doesn't mean your biometric information wouldn't be useful.

I think they only use weight to screen people specifically at risk to determine if they need to take a closer look.

An easy, fast, cheap test which usually means a more expensive test or exam doesn’t need to take place.

As someone who most recently worked in product at a healthcare startup I found the most difficult thing about innovation in the space is the cost of compliance/regulation.

When you work in an industry that is so highly regulated, and assuming you are working at a company that follows the rule of law, how do you actually "disrupt" a set of problems in this industry when there is so little wiggle room for doing things differently? Following legal guidelines in healthcare means reenforcing bad norms rather than disrupting them.

One of the biggest WTF moments I had when I first started was realizing that fax communication is HIPAA-compliant whereas email/SMS are not, even though in theory anyone could walk by a fax machine at any time and take medically sensitive information sent over.

I work in medical devices. The regulation can be unnecessarily prohibitive, but more often than not I see it used as a cop-out.

Where one entrepreneur says "the status quo in this space is so behind the times I can't work there," another says "there are enhancements waiting to be back-ported into this tightly controlled space from domains that have already been proven it to be a good idea." Only one of those people knows how to make money.

That's just the low-hanging fruit. And there's so much of it. Foot-stomping about having a formal quality system instead of "move fast and break things" is letting the perfect be the enemy of good.

> One of the biggest WTF moments I had when I first started was realizing that fax communication is HIPAA-compliant whereas email/SMS are not

That's not exactly the case; fax communication can easily violate HIPAA and email, appropriately secured, can be compliant, even for PHI (SMS is more problematic because it's unsecurable).

The issue is specifically that there is precedent (or, at least, a widely held interpretation, not sure there is actually directly applicable case law) that fax is not an electronic communication mechanism for the purposes of HIPAA law and regulation, so while general rules on disclosure and communication apply to it.

> even though in theory anyone could walk by a fax machine at any time and take medically sensitive information sent over.

Not having appropriate safeguards to prevent that at a HIPAA covered entity is, itself, a violation of HIPAA.

It could be your mindset. When I worked in drug development (wet chemistry and lots of animal studies) the regulation, while everpresent, just didn’t seem like any kind of burden when compared to everything else we had to deal with.

I'm pretty sure email can be HIPAA compliant as long as you implement the system using the established guidelines.

Re email: Because you don't know if the destination server is encrypted (you send emails from your server and it finds the destination), any email must be intercepted at your server and a hyperlink to a secure site inserted in place of the email body. The email becomes just a notification via SMTP. The recipient then goes to the site and logs in to view the email. The PHI is what you care about (and it's, very, very strict). No PHI in the subject either.

I suspect the reason faxes are compliant is a few:

1. Grandfathered in. 2. The number of unauthorized people that can see them is very limited (to whomever has access to the fax machine). 3. Modern fax machines print face down. 4. Data is in hard copy format which is more difficult to copy.

As an aside, modern fax machines are probably less secure than the old ones. Fax machines using digi-boards and databases and whatnot. The vast majority of US healthcare use faxes though.

> Re email: Because you don't know if the destination server is encrypted (you send emails from your server and it finds the destination), any email must be intercepted at your server and a hyperlink to a secure site inserted in place of the email body

Couldn't this be solved by just encrypting the email itself? Even the headers could be encrypted along with the body.

On the subject of fax machines, would they still be compliant if they're connected to a VOIP system?

>Couldn't this be solved by just encrypting the email itself? Even the headers could be encrypted along with the body.

Yes, but that's typically more cumbersome as you have to trade keys with everybody that needs an email. I wrote an emailer for a medium sized company and it sent about 500K emails and 500K faxes a month. That's a lot of key management.

You could use symmetric encryption, but then you give out the shared key to so many people, it tends to lose value, especially when you don't control how your recipient organizations protect the key. (it could be in a file on a shared folder named Email-EncryptionKey.txt).

On top of all that, each client will have to be taught how to decrypt (and encrypt) emails, either at the employee level or at the network admin level. Most provider organizations are small. Typically a doctor or two with a nurse and a couple people working the schedule and regulatory. In summary, it would achieve the objective but it's not ideal.

>On the subject of fax machines, would they still be compliant if they're connected to a VOIP system?

Yes, as long as no PHI went over an unencrypted channel and all servers are secured (physical and computational) and logged.

> but that's typically more cumbersome as you have to trade keys with everybody that needs an email.

What would be needed is a public key infrastructure. If organizations like the state board of medicine could serve as a certificate authority for physicians licensed in that state (or maybe the DEA since they issue id numbers to physicians that are needed for controlled substance prescriptions), then the key management would not be as much of an issue. In other words, it shouldn't be handled by individual organizations; it should be handled by the authorities who are responsible for licensing doctors, nurses, pharmacists, hospitals, etc.

> On top of all that, each client will have to be taught how to decrypt (and encrypt) emails

This is certainly something that can be automated and shouldn't have to be a manual process. A plug-in for a program like Outlook should work in the vast majority of cases. That is, if the email is sent to the wrong address, then the recipient would only see encrypted text, but it would automatically be decrypted for the correct recipient.

That sounds fine in theory and if implemented well it would work, but I'm not sure how well it would work in reality. I just refer to my small business tax return every year to get an idea of how many forms would need to be filled out to just send email. How would that work for offices that send non PHI emails? Would it go through that system too, or would it have to key on recipient email addresses? How hard would it be to shut down and create a new email for each employee that left, etc. Would you have to have a special email server just for PHI and another for regular? How many times would employees accidentally send PHI over a non-secured channel on accident?

Also, physicians themselves rarely send emails, they have office assistants do it. They are busy providing care. How would that work? The office assistant position doesn't have any direct regulation (that I know of) so you'd either have to have the physicians send out emails (ya right), have an assistant use the physician's account (oh no), or add a bunch of regulation to office assistants (to the tune of doctors and nurses) which would make them more expensive and make office visits more expensive (etc).

It sounds good as a technologist, but if you look for unintended consequences (costs), I'll bet there are a bunch I didn't even think of.

Also, organizations are highly motivated to get this right because the fines have teeth. Up to $50K per incident capped at $1.5 million per annum.

https://www.truevault.com/blog/what-is-the-penalty-for-a-hip...

> How would that work for offices that send non PHI emails?

They could encrypt those emails as well. While sending a non-encrypted email that contains PHI is a problem, sending an encrypted email that doens't contain PHI shouldn't be an issue (as long as the intended recipient can decrypt it, which they should).

> How hard would it be to shut down and create a new email for each employee that left, etc.

That comes down to revoking the certificate or using shorter intervals for the duration where the certificate is considered valid. For example, if the organization requires that one changes their password every 60 days, then a certificate should not have more than a 60 day period where it's valid.

> Would you have to have a special email server just for PHI and another for regular?

This wouldn't be server dependent. This would be dependent on the email client handling the encryption and decryption. The more that's automated, the less chance that there's a mistake with regards to email containing PHI.

> Also, physicians themselves rarely send emails, they have office assistants do it. They are busy providing care.

Physicians have to do all sorts of things like writing progress notes, dictating admission and discharge summaries, calling in prescriptions, writing orders, etc. The system they use could also be used to securely send PHI containing email to other physicians, pharmacists, or hospital systems.

But regulation could be a good incentive against physicians allowing others to use their account credentials to do things like sending PHI information to other organizations. No physician would like to be summoned by the board of medicine of the state they're licensed in over something like that.

But I think that a lot of the problems could be addressed by those who have cross-domain knowledge about technology and health-care (speaking as someone who went through medical school and subsequently changed fields to computer science/software development).

Good discussion, but I think you are solving a problem that has already been solved, but you are proposing a much more cumbersome and complex way.

The current method is for insurance companies to install software on their SMTP server and that's about it. Much less overhead, much less chance of mistakes, much less cost to the physician's office, much cheaper overall and just as good for protecting PHI (since it's automated, no accidents).

Also, the vast majority of communication containing PHI is with insurance companies and the government, so your solution moves the onus of protecting PHI from the insurance companies to the small physicians, which I don't think is overly helpful.

Of course there is no way to really tell unless we complete vet it out and put cost associations with everything and do PHI leak risk assessments. I'm perfectly happy leaving this as a thought experiment though. :)

> The current method is for insurance companies to install software on their SMTP server and that's about it.

I would hope that they require TLS encryption for any connection to their SMTP server. Otherwise, any communication containing PHI could easily be intercepted. This also doesn't address the issue of securing the IMAP or Exchange and MTA server(s) that the sender uses to send the email to the insurance company.

> much less chance of mistakes

Unless the sender CCs a copy to another address where the MTA doesn't require TLS encrypted connections and doesn't have any such software installed on the MTA. That's why the solution I proposed (having the client program automatically encrypt the email before sending it and relying on PKI to handle decryption on the other end) would be more fool-proof since, even if the email was CC'd to another address, it couldn't be decrypted by the unintended recipient.

As for the cost argument, I think it could be implemented as a nominal cost on top of the costs that the physician already incurs in the process of applying/renewing their license, the practice license, etc (e.g. name, mailing address, telephone number, fax number, email address along with your PKI state board signed certificate).

> Also, the vast majority of communication containing PHI is with insurance companies and the government

Doctors have to communicate with other physicians outside of their group practice, hospitals they may not be affiliated with, and pharmacies. How is PHI communication in this context currently handled?

> Of course there is no way to really tell unless we complete vet it out and put cost associations with everything and do PHI leak risk assessments.

That is true. But I think that the technology we currently have to secure communication between clients and webservers (that allows us to do things like buy things online, interact with the bank, file taxes, etc along with client side certificates) should work perfectly well with PHI containing information. The problem is setting up the PKI for that type of communication.

Since governments, universities, and private companies have already done this, there's no reason why hospitals (especially university affiliated hospitals), state boards, and health care providers can't also do this.

Based on that response, I don't think you are understanding how it works (or I didn't explain it well). This is for emails originating from insurance companies.

Software intercepts any queued or targeted outbound email, then:

  1. Replaces the body with a hyperlink to a web site and instructions, removing all PHI.
  2. Hyperlink instructs recipient to login create account / login to view mail over SMTP.
  3. Recipient logs into website (with TLS obviously) and reads email with PHI over secured channel.
  4. Recipient can now read and reply using the website.

Pretty simple. As far as physicians communicating with each other and pharmacies, they typically use faxes and phone calls.

> This is for emails originating from insurance companies.

That was the part I misunderstood. I thought it was for physician offices sending information to the insurance company.

> Pretty simple. As far as physicians communicating with each other and pharmacies, they typically use faxes and phone calls.

And that's an issue that could be addressed if all entities had a PKI set up such that they could communicate online regardless of application protocol used while maintaining compliance with HIPAA).

Yes, if you wanted to extend a nationwide system for any and all PHI communications, your idea would be a good approach.

In a more wonderful world than what we live in today, the US government would have setup a simple, unreadable (even by them) secure channel for everyday citizens to be able to transfer sensitive data to verified businesses and other citizens. They can't see past the criminals using it to subvert the police though.

> In a more wonderful world than what we live in today, the US government would have setup a simple, unreadable (even by them) secure channel for everyday citizens to be able to transfer sensitive data to verified businesses and other citizens.

We pretty much already have that with the PKI system that web browsers (and other programs) check when verifying certificates for various websites we connect to (including this one). It doesn't require government intervention. It does require configuring servers that doctors, pharmacists, hospitals, labs, insurance companies, etc use to authenticate themselves with each other and a number of authorities to verify their identities (like the CA bundle that your web browser uses to verify that the server you connect to is indeed Hackernews and not some rogue entity).

PKI is a powerful tool which certainly can be used in a healthcare setting. Unfortunately, because of organization inertia, it's probably not going to happen (despite the fact that the technology behind it has been around for decades).

>We pretty much already have that with the PKI system that web browsers (and other programs) check when verifying certificates for various websites we connect to (including this one).

As an aside, it took a seismic event (the confirmation of mass government spying) to actually get it implemented properly, and the US government did file a few lawsuits about being able to openly break encryption with a back door. We're fortunate to still have it fully intact.

>It doesn't require government intervention. It does require configuring servers that doctors, pharmacists, hospitals, labs, insurance companies, etc use to authenticate themselves with each other and a number of authorities to verify their identities (like the CA bundle that your web browser uses to verify that the server you connect to is indeed Hackernews and not some rogue entity).

Yes, that's more in line with the solution that we implemented (well paid to have implemented) with the outbound email interception and website redirection. All PHI goes through TLS via the website.

>PKI is a powerful tool which certainly can be used in a healthcare setting. Unfortunately, because of organization inertia, it's probably not going to happen (despite the fact that the technology behind it has been around for decades).

Ironically, they use it heavily in integration from third parties. Their SFTP/FTPS was locked down. They use a login whitelist and PGP signatures for login, everything must be encrypted with asymmetric PGP keys, folders were locked down, the works.

Many of our larger clients requested that all email and fax correspondence go exclusively through those SFTP/FTPS channels. Smaller clients had difficulty handling that on their own and usually had to call in a local support guy eventually.

It certainly happens in the bigger companies. They don't mess around. It's the smaller companies that struggle with it because they don't readily have the expertise.

Indeed it is as long as you’ve configured your email system to use TLS and not downgrade to no encryption if the handshake fails for mail systems where HIPAA-governed information is departing to.

Source: Not a lawyer, not your lawyer. Sign off provided by non profit bio research orgs lawyer before I set it up.

This is my understanding as well. Additionally, I believe you can send encrypted attachments over an unencrypted connection. Furthermore, https://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.p... suggests that it's acceptable to send patients unencrypted PHI if they've explicitly agreed to accept the risks associated with that (although I'd be extremely cautious in those situations)

That’s more for B2B use cases. Like between a medical practice and hospital.

The unreliability of delivery to destinations that don’t support TLS will create customer service issues in B2C scenarios.

The Direct Project has an SMTP implementation which allows for emailing medical data in a secure, HIPAA compliant way. http://wiki.directproject.org/SMTP+Implementation+Developmen...

> fax communication is HIPAA-compliant whereas email/SMS are not

I thought that HIPAA had the provision that stated that encrypted communication is compliant. That is, if the email or SMS was encrypted, then it would be in compliance with the act.

FWIW, healthcare compliance is a solved problem (disclaimer: I work for the company that solved it - Datica.com).

The larger problem is that young companies don't understand what it takes to be compliant, nor the resources to do it themselves. Remember, compliance is all about proving what you say you do. If you can prove it, you're golden.

So it's not that SMS or email isn't HIPAA compliant, it's that the work, controls, and monitoring you'd need to put in place to prove compliance is a massive burden. This is where risk management comes into play. If risk isn't a core tenant of your offering, you're better off building the preferred UX (like using email over fax) and assuming no risk.

so ELI5 why we shouldn't just get rid of HIPAA? from the way people talk, all HIPAA does is guarantee that things will always be awful(?) how does HIPAA help if it just keeps us in the past?

It’s also the law that prevents doctors from telling their friends about your hilarious medical conditions, or selling information about you to pharmaceutical companies to market to you directly.

It’s a very thorny law, but it’s like that for a reason.

For the same reason you won't call Uber to take you to the hospital if you cut off your arm.

Aerospace also has high compliance hurdles. But rockets are extremely phallic. Even urology can't beat aerospace on that axis.

And yes, having been in this space for a while, the fax is a great example, a loophole for lawyers, who still do lots of paperwork by fax, because there's case law to support the practice (not the security mind you, just the practice).

Neither the lawyers nor the doctors understand math. Between the two, the lawyers at least took a formal logic course.

Doctors think most of the software they use is just magic, if they think of it at all. The only other association with computers that they have is the IT guy who comes to replace their tower every other year.

Physician here. SV Tech will win because it is customer centric. Traditional Healthcare tech is enterprise centric - the precept on which they base their strategies is 'economies of scale'. People are not widgets. Economies of scale (aka corporate controlled healthcare) do not apply. As institutions grow larger, eddy currents of dominance develop - fiefdoms that compete for control, power and share of the budget. There are so many layers of middle management that the most popular complaint is that everyone is a manager. Our hospital actually has 5x as many employees as there are patients in it. I know of no other industry where this skewed statistic exists. Can you imagine an airliner with twice as many stewards as passengers? Perhaps the legal profession is an exception, where you have so many bodies tending to a trial. In healthcare, patients are lost in this machine and the cacophony of voices speaking to them is a disservice. Perhaps tho in this era of the consumer age, some patients conflate quantity with quality and might actually feel 'more is better'. If healthcare is delivered through a watch on your wrist instead of an army of servants, the layperson might be able to focus his/her understanding on the single voice their device has.

The other secret weapon of SV is that it promises to get people to open up their pocketbooks to actually pay for their own healthcare. Government will adore them for that. If you think that will never happen, just stop and think for a minute. People shell out hundreds of dollars a year for the privilege of being tracked and being advertising targets. All because the mobile device caters to their impulse for 'connectedness'. Imagine if this device promised a longer life, better sex, better sleep, less disease. And it showed you with colorful cartoon graphs how much better you were every time you asked it. Forget the fact that many of these parameters are only relevant to the big picture. Statistics apply to populations and any attempt to assign characteristics from population studies to a given individual carry uncertainty. They never tell you how big the error bars are, do they? Certainly a better diet and more exercise confer health benefits. But trying to 'gamify' this data will just add a cognitive burden and most likely will lead to more popular misconceptions and misinterpretations. Or perhaps it will be a new social nexus?When I am in a Starbux or Panera, there are always a few conversations my ears cannot avoid as people share their health problems over a sandwich and a coffee. And I cannot help laughing at how ironic the whole HIPAA thing is.

Ultimately I fear that tech will foster the return of snake oil salesmen, on a massive scale. We are in a deregulation mania now and I think healthcare will soon fall under Trump's razor and he will encourage SVTech to make their move.

Yeah, nothing's going to happen. Compliance costs are too high for any of Silicon Valley's business models to work.

I'm with you on that. For reference I pulled up Google's announcement that "Google Health" is being shutdown.

https://googleblog.blogspot.com/2011/06/update-on-google-hea...

I could see Big Tech enter in other areas (Apple Watch and and their research app are promising)

The post doesn't say that they shut it down due to compliance costs. It says they shut it down because almost nobody found it useful.

I think the argument is that the problems are too challenging for the management culture common at places like Google. Getting a product developed, certified, and deployed is likely be longer than it takes for them to get bored, forget what they were doing, and move on to something else.

The companies mentioned in the article "Apple, Google, Microsoft and other tech giants" have quite a bit of money for costs. Though for hospital they may need more of an IBM/Oracle corporate type model rather than apps.

Obviously that's false. There have been many successful Silicon Valley healthcare companies creating software, drugs, biotech, medical devices, etc. Just drive around and look at the names on some buildings.

The way you fix the existing system, is by not trying to change it. You replace it instead. You build new, lighter, more nimble approaches to old problems, rather than trying to convince existing power structures to change. That's where any gains will come from by big tech entering the fray, if there end up being any.

Trying to change something like the hyper regulated, hyper stagnant, special-interest dominated US healthcare system, is a folly of an idea. You kill it instead by routing around it with new solutions wherever possible.

Simple example: the rapidly growing market for direct primary care subscription services [1]. Pair that up with guaranteed catastrophic coverage for all by the US Govt or state governments, and the US healthcare system as we know it is dead due to a simple route around that would dramatically lower costs. It's far easier to implode a failed bureacracy by replacing it in that manner, than by trying to change the existing bureacracy. You see that in everything from old media (which held a cartel stranglehold on broadcast access, the Internet routed around them), to the taxi medallion cartels (which Uber & Lyft murdered by routing around them instead of trying to convince them to change).

[1] http://www.businessinsider.com/direct-primary-care-a-no-insu...

As the MOOCs found out, you can't just "replace" certain societal services - especially those beset with volumes of regulation and numerous groups of powerful stakeholders happy to reach out to politicians and the public (AARP, Insurance, numerous govt entities, drs groups, nurses groups).

2/3 of healthcare is paper pushing, the easiest thing the tech community can automate is boring old CRUD paper pushing. I hope one day we as consumers have the chance to get a USB stick to store and retain our own medical records. Walk into dr's office / hospital, hand over device, boom their is your whole history including previous surgeries, allergies, etc. Whatever is done gets imprinted on device, walk out with an updated history. That is some seriously productive low-hanging fruit.

There'd need to be a lot of work making sure that it's safe in that:

a) Losing it should not expose your entire medical history to whoever picks it up

b) Losing it should not mean losing your data forever. Giving the consumer the responsibility for backups is not a solution either, since those can be lost or stolen as well.

c) It has to be tied to the person's identity, so you can't borrow/steal your friend's to get meds

d) Can't be tampered with or forged to fake conditions or clear conditions

e) Records who edits it, when, and a diff of changes.

f) Records who reads it, and when

g) Resistant to physical damage or water. I should be able to go swimming with this device or have it go through the wash without worrying about its safety.

These are all pretty hard problems on their own, and together, you'd have to design pretty much the world's safest storage device. If it existed, I'd put my SSH keys on it too!

actually, most of my patients were not interested in reimbursing me for the cost of the usb stick, although they would gladly accept it for free. I was willing to provide their ENTIRE medical record, but they were not interested. I think people are just as happy to be spoon fed and not knowing what they are eating as long as its free.

If there is one industry that needs to be disrupted, that is US's health care industry, it is too expensive.

I don't think tech disruption is necessary to reduce costs, a multidisciplinary approach could do something similar.

Edit: apparently my comment never finished, lol. What I meant to say is that disruption could work, but I think that optimization and regulations with the tools we have today would also alleviate many problems we have.

They are going after health care because they either ran out of customers or people to advertise to.

Hopefully they can make some progress but so far I don't see much.

It's an immensely lucrative and recession proof industry.

I wonder if this will prove to be an opportunity for cities outside of SV to grab a bigger piece of tech. Nashville?

https://www.bizjournals.com/nashville/news/2017/09/22/health...

Interesting to see the big players like Apple, Google and Amazon making significant investments in this area.

The big problem though still lies in the maze of regulatory bodies with which all these innovative solutions have to navigate before they even get mainstream. Small players who does not have enough financial leeway ends up burying what could be a groundbreaking solution. Of course, governments need to do their due diligence as public health is the one at stake but there needs to have a certain compromise where the end result is the good of the public and humanity.

This article is pretty devoid of content, and really only mentions that the Apple watch can be used as a constant heart monitor. Big deal, you aren't going to get much information from measuring just your heart beat and knowing next to nothing else of whats going on in the rest of your body too.

The real technological breakthrough will come when we have the ability to measure in real time what is going on in our various organs, such as enzyme production and transportation of molecules, but that's a long way out yet.

Toto, the producer of fancy toilets in Japan, is believed to be developing some kind of back-end analytic system.

Would love to get some insight into the work at Verily or DeepMind Health for a software developer interested in working in healthcare.

Why hasn't Big Tech made a bigger dent in the insurance industry?

Insurance has quite a lot of specialist knowledge that isn't really tech.

I am all for it if someone can make the doctors use emails instead of faxes.

The problem is that we don't have a key server for doctors. I really wish someone would lobby the HHS to provide a key server that maps to providers' NPI. Then setting up PGP for email can be streamlined.

As it stands now, everything is fragmented because companies want to lock practitioners and health care orgs in. I'd love to see them start issuing "HIPAA compliant" seals for the implementation of open and secure standards that make it easier for health care systems to communicate and transfer data easily. That way all these closed solutions will have an incentive to actually make communication between practitioners easy and secure.

The biggest joke is secure messaging. There are all these apps for secure messaging between practitioners. Of course, you have to be using the same app to open a communication channel. I know at least one of these companies is using XMPP on their backend, so it's likely others are as well. They are literally using open source solutions to make a problem that the open source solution was supposed to solve! There's no reason why $SecureMessenger can not communicate with $MessageSecure. They just don't want that to happen because they think it will cause them to lose business.

I don't want "big tech" anywhere near my doctor's office or anything else having to do with my health.

Too late. HIS is Health Information Systems and have been around for decades.

Also, thanks to the patriot act, doctors and hospitals share your health information to the federal authorities without a warrant. So there's that.

https://cdt.org/insight/law-enforcement-national-security-ac...

And it's going to throw your medical privacy out of the window in the process.

I suppose we'll also see some major deregulation similar to the net neutrality repeal in the healthcare industry before long.

Maybe, but in this case there's an entrenched interest (health care companies) that might want to use medical privacy as a way to keep themselves from being Uber-ized.

Not necessarily. You can still provide decent services collecting anonymized data.

I am a big believer that we have already discovered a safe, free, plentiful lever against some of the most high profile diseases (cancer, Alzheimer’s, some mental illnesses) out there in fasting/calorie restriction/keto.

I highly doubt it will ever become mainstream for the simple reason that no healthcare or big tech co can make money from telling people to eat in a way that induces ketosis.

Science of Fasting doc: https://www.amazon.com/Science-Fasting-Sylvie-Gilman/dp/B075...

Insane how we both get downvoted isn't it? Oh well. Another decade or two before people wake up.

Agree with you, so much of our economy and social structure is built on the fact that people get sick - and either stay sick or get medicated for the foreseeable future. Sad. All we can do is mention it, even though we get shut down quickly be it online or IRL.

Mandatory anecdote: I cured severe arthritis in the knee 6 years ago through a 30-day water fast. It was gone by day 20 or so, and stayed gone for 6 years now. It's sad that so many people suffer needlessly.

Step one is getting to consensus on sugar = toxic, then refined carbs = bad, then getting people to stop believing we were evolved to eat consistently throughout the day everyday

It’s amazing that “you are what you eat” has become so controversial

The old "a calorie is a calorie" that Reddit/HN geeks like to point out wearing their science hat. LOL. Oh man... Sometimes I think we've gone too far. My kids have a hard time finding classmates to play tag with because most of them are overweight and prefer to sit in the shade and eat their Costco bought school lunch. It's really sad what's happening.

It's unfortunate that people think "tech" is what health care needs, when in reality society would benefit tremendously if something as simple as a 5-10 day water fast became mainstream [again], as it used to be, before modern medicine took over.

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