The Takeaways: Week 42 of 2021

A periodic review of articles, newsletters, and podcasts that I found interesting, inspiring, or otherwise worth remembering.


Melinda Byerley (host), Stayin' Alive in Technology. Shireen Mitchell: "You Can't Stop the Girl" Part 1 of 2 (June 30, 2021) and Part 2 of 2 (July 21, 2021)

Tyler Cowen (host), Conversations with Tyler. Episode 134, Stanley McChrystal on the Military, Leadership, and Risk (October 20, 2021)

Melissa Perri (host), Product Thinking. Episode 38: Debating User Research, Experimentation, and the PM Role with Kent Beck (October 30, 2021)


Gordon Brander, Subconscious. Software scarcity (October 22, 2021)

There are natural scarcities in software.

Are scarce: names, trust, attention, labor. Have costs: hardware, the network.

[In addition to dealing with scarcity by creating centralization], there is [now] a second way to deal with scarcity in software: markets. Markets can be seen as an allocation mechanism that routes scarce supply to demand. This “function” is teleonomic. A market is an evolved system, not fully under our control, and capable of generating a wide range of emergent behaviors, good and bad. Yet markets do a remarkable amount of computation that is difficult to accomplish by other mechanisms. Markets embody a staggering amount of complexity.

John Cutler. The Beautiful Mess. TBM 43A/52: More Stories About the Mess (October 21, 2021)

We don't have enough stories about operationalizing any of this "at scale" (e.g. >10 teams). We don’t have enough stories about The Mess. Sure you have Spotify and those classic presentations and posts. And a couple of companies that have written "how we do _____" type posts. But beyond that there is very little to draw from.

There are very few examples to share with your team. Which is a big problem! Not every executive will be with it. They are right to distrust one company's blog post or one book.

Christina Farr, Second Opinion. Why investors are leaning into direct-to-consumer health (October 20, 2021)

The beauty of D2C health is that companies can’t hide behind a bad product that doesn’t engage its users. For years, too many businesses in digital health got contracts with payers that allowed them to sell on the basis of the total number of eligible members versus those who used it or benefited from it. In other words, companies can succeed when utilization remains low. Today, despite an increasing interest from payers in innovative per-outcomes models, Per Employee Per Month (PEPM) models still reign supreme.

With D2C health, teams are forced to build products that provide so much utility to the customer that they’re willing to pay for it. And ideally - although some solutions may be intended to be used only once or a few times - they’ll come back for more.

Nikhil Krishnan, Out-of-Pocket. How to integrate into an EMR with Brendan Keeler (October 12, 2021)

[Krishnan:] There's been a lot of debate and hope around the ONC's new interoperability rules. What's important about them and what new opportunities do you think it's opened up?

[Keeler]: What's absolutely terrifying people here is that it truly is open access for any app the patient chooses, bringing the data outside of the protections of HIPAA (metaphoric Gondor) and into the lightly guarded realm of the FTC (metaphoric Hobbiton). The main fear - All the problems of controversies like Tik Tok/China, Cambridge Analytica, and FaceApp/Russia, wrapped into one, except with health data. Data privacy wonks and certain EHR vendors fiercely combated this last spring (unclear why they waited throughout the entire comment period last year) citing this reason and asking for more vetting of applications. The final rule didn't change anything there, so non-profit industry groups like CARIN are doing their best to fill the gaps with a voluntary Code of Conduct for app developers. Ultimately, there's definitely risk, but the size of that risk depends on whether you think a patient is a rational buyer/tech user who can make truly informed choices of apps for themselves.

Web Smith, 2PM. No. 765: The Market Maker: Zillow, Opendoor, and the Housing Market (October 18, 2021)

Rather than a cash issue, Zillow is saying it experienced supply constraints having to do with on-the-ground workers and vendors. Leave it to a technology company to develop an algorithm to predict home values, but mismanage the human aspect of its business.


Julie Appleby, KHN. Insurance Focused on Virtual Visits? The Pros and Cons of a New Twist in Health Plans (October 15, 2021)

The virtual-first concept was so new that Priority Health [in Michigan] called those enrolling this year to ensure they understood how it worked. “If people were more comfortable with brick-and-mortar, they should choose other options,” [Vice President of Individual Markets Carrie] Kincaid said, adding that the plans have drawn 5,000 enrollees since January, a number she hopes will double next year.

Alicia Donager, CNBC. Google is still ‘all in’ on health care: Chief health officer Karen DeSalvo (October 21, 2021)

In Google’s new strategy, [Google Chief Health Officer Karen] DeSalvo said it will continue to focus on the three areas that it believes it can make a difference in users and their communities: through its search capabilities, access to cloud tools for caregivers, and providing community context around social determinants of health “that drive health almost 80%.”

Matthew Herper, STAT. The new vision for the now-merged Doctor on Demand and Grand Rounds begins to take shape (October 18, 2021)

For a lot of people, not to mention health care experts, this does beg a question: is this the fix we really want? In talking about creating an environment for better health care, experts often talk about the concept of a “medical home” — a place where the patient can always go. Few, probably, imagine that home would be purely digital. What most of us probably want is our own doctor, who knows us. We want telemedicine appointments with our own doctor. Don’t we want to develop a relationship that goes beyond the entries in even the best electronic medical record?

But [CEO of Included Health and the founder of Grand Rounds Owen] Tripp argued that that world is mostly gone. A large number of consumers don’t have a doctor. They simply don’t have an easy way to access the system at all, he said. That doesn’t exist, he said, “for the vast majority of people.” There needs to be another way, he argued, to keep the health care system from dealing with people’s problems one symptom at a time, ignoring the health of the person as a whole.

Rachel Kroll, Writing. Big company tale: six months for a list and a button (August 28, 2021)

I'm going to use dates here to give some idea of how long a single task can drag on. We'll start from January 1st to make it easy: dates are correct relative to each other here.

Date of the final step: June 17.

Molly Mielke, Future from a16z. Why We Crave Software With Style Over “Branding” (October 8, 2021)

Evaluating software by its style — and how it makes us feel — signifies a shift to recognizing tech as a part of our society and identity, as opposed to an inanimate tool without an opinion. Software has become so integrated into our lives that it is no longer simply a utility. Within this new state of the world, style communicates the software’s values and signals the type of person for whom it is intended — something that many tech brands today consistently fail to do.

Katie Palmer, STAT. Buoyed by its popular weight loss app, Noom enters digital mental health (October 14, 2021)

Noom, a New York-based company founded in 2008, is wading into an exploding field of apps for mental health, dozens of which are based on the same CBT tools that aim to change the way people think and behave. Users can download simple mindfulness reminder apps for free, or pay for more built-out programs like Bloom, Youper, and UnitedHealth Group’s Sanvello. And CBT is used in over half of prescription-based digital therapeutics with FDA market authorization — for everything from insomnia to PTSD to irritable bowel syndrome — according to an IQVIA report on digital therapeutics.

For digital health and wellness companies, CBT is low-hanging fruit not just because of its strong evidence base in clinical settings, but because it’s relatively easy to express in digital formats. “On the surface, it can be easy to implement on an app,” said John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center. “But it’s unclear how well app-based CBT works and what parts don’t translate well.”

Katie Palmer, STAT. ‘My jaw dropped’: Basic security flaws in third-party apps leave millions of patient records at risk (October 18, 2021)

But the continued adoption of the FHIR standard, along with the general trend toward remote patient care and data sharing, has accelerated the number of apps and APIs facing sensitive health care data, building a far more expansive clinical app economy. Consider how cybersecurity threats for cars have evolved. “Historically, with cars there was no attack surface; before 2001 they weren’t connected to anything. Now they’re basically computer networks on wheels,” said [hacker and cybersecurity analyst Alissa] Knight. “It’s the same thing with FHIR. It’s not that we’re getting vulnerabilities because of FHIR; what’s happening is FHIR is allowing this connectivity and portability of data and it gives people a platform.”