For the Week of September 8, 2003

Except for the fact that her husband is running for President, Dr. Judith Steinberg Dean of Shelburne, Vermont is a lot like my doctor in Decatur, Georgia.

She has 4,000 patients in her practice and can't take any more. She shares an office and staff with another physician, and spends her day rushing from examining room to examining room.

Behind her, chaos reigns. The staff is constantly juggling the shifting demands of patients, tied to someone else's technology platform. When someone calls the phone rings and (if they can even take the call) the caller may then go right on hold. When someone comes in they may or may not be seen near the appointed time. Even long-time patients may find themselves facing paper forms which must be hand-input. Leaving is a dance of more paper - which insurance, what's the co-pay rate - resulting in receipts out the ying-yang.

Most medical professionals are drowning in paper. Worse they are at the mercy of others to keep up. When you spend your day using skills gained over a lifetime, even thinking about the office computing environment is a major distraction, a grossly sub-optimal use of your time.

Yet many doctors are spending a lot of time on just that. Government, insurers, hospitals and drug companies constantly push new incompatible systems on them. Maintaining a steady income forces a doctor onto a treadmill whose speed is constantly accelerating.

No wonder Dr. Dean's husband left the business. Next to her day the Presidency is easy work. Doctors only stay at it because they love it, as she evidently does.

There are two contradictory forces beating down our nation's physicians. On the one hand is their need to be efficient, with time and money, which keeps going up. On the other their ability to control their technology environment keeps going down.

The result is a big problem for the rest of us. The easiest way to keep your health costs down is to have a good, personal relationship with your family doctor. They are the gatekeeper to the rest of the medical community. They can tell you, and your family, when expensive care is wasted care and make you believe it.

There are also some great new technologies coming along to increase doctors' efficiency without adding strain to their lives. Our therapist now has a Windows Laptop with a screen she folds back over the keyboard and writes in, like her old paper notebook. Her notes become typewritten pages in a database with a few pen-clicks, and her prescriptions are (for the first time) readable by any pharmacy. New "presence" technology from Sun Microsystems, based on Instant Messenger, can let staff know when a doctor can take a call, and route each call to a doctor who can pay attention to it. PDAs linked to wireless networks can eliminate the need to run back for patient records, and they're easy to update. The HIPAA law, with its requirements for controlling which employees get specific access to which records, is trivial to comply with when the office's automation is up-to-date.

Yet there are no standards in medical office technology. Each hospital group makes its own decisions and pushes those down to all doctors practicing with it. Each insurance company has its own systems that all doctors must comply with. These standards are often contradictory. When they change, a doctor's staff may have to re-key their entire database, off paper forms from people (like me) with bad handwriting and bad attitudes.

You can't expect a doctor to handle these questions on her own, any more than you can expect a rap group to run its own concerts.

The time is past for all this to be rationalized. So here is a cunning plan to do just that:

• Hospital chains and insurance providers need to get together on a common platform for moving data around. Medical XML tags need to be standardized. Internet broadband needs to be standard.
• Hospitals should hire "efficiency experts" who will go into doctors' offices, make specific recommendations, stick around to implement them, and assure that upgrades can be paid-for in real dollar savings down the road. (If a change can't pay for itself in a year, doc, don't make it.)
• As much as possible the "detail men" from drug companies, who clutter these doctors' offices, need to make their pitches over that Internet broadband connection, and come by the office only when they are expected.
• We need a Smart Card standard for medical payments, compatible among insurance companies, with biometric features, patient pictures and readers in every office.
• The insurance computers connected to these readers should be able to handle all back-end billing and deliver to the clerk the amount of co-pay required within 15 seconds - the same time it takes to clear a credit card transaction.
• Every doctor should have a Web site, and an e-mail address, through which patients can get questions answered and request appointments.
• The goal of everyone in the channel (yes, medicine is run through a sales channel) must be to eliminate all paper from all offices by a date certain. Patients should be able to hand over their insurance cards, which would allow new doctors to download everything they need to give treatment.
• When patients lose their cards or have them stolen, all doctor offices should be equipped with retinal scans and fingerprint readers that can identify an individual and bring up the necessary data from a secure online store.

None of this is science fiction. All of this can be done without resort to the government, except (in some cases) as a facilitator. I know this because I just took my daughter to a hospital for some tests and we were in-and-out of there in under 30 minutes. The savings in time (and money) from all this can be huge. And if Dr. Judy's husband does (by some chance) lose the Presidency, he should not mind at all coming back to the office.

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Takes on the News

A Meme For Technology

Infoplease defines the word meme as "a cultural item that is transmitted by repetition in a manner analogous to the biological transmission of genes."

The heaviest use of the word today, surprisingly, is in the world of politics. Politicians look for "memes" to get their candidates elected. Movements look for "memes" to bring people around to their point of view.

A meme, like a brand, has to be short, punchy, preferably one-word. It has to sum up what's right about you, or wrong about them, clearly and unambiguously.

Technology needs a meme to explain the route out of its doldrums, and so I've come up with one.

Competition.

There is, simply, a shortage of competition in today's technology world. Our policymakers should be looking to create more competition.

How is competition limited by public policy today?

• When phone companies are given monopolies on Internet broadband using their lines, that's a monopoly, not competition.
• When cable companies are given the same thing, that creates at best a duopoly, not competition.
• When those who create software operating systems are able to dominate and devour the application markets they create, that's monopoly, not competition.
• When content owners also own the distribution networks necessary for anyone to reach the market, that's a monopoly, not competition.
• When copyright is extended to death plus 75 years, that's a monopoly, not competition.
• When patents are extended into things as simple as business models, or into software algorithms, that's monopoly and not competition.
• When unexploited copyrights and patents are used to hold-up people who are profiting on similar ideas, that's monopoly and not competition.

The purpose of patents and copyrights is to encourage the production of more stuff, not to prevent it. Yet that's just what patents and copyrights are doing right now, preventing new innovation from coming to market. They're becoming property rights used to snuff out competition, keeping prices high, weakening our international competitiveness.

The great thing about this meme is that embracing it, and using it, won't cost you a dime. Much of what needs to be done can be done through regulation or executive order. The rest can easily be done by Congress.

The Federal Communications Commission has the power to restore competition to Internet broadband. The Justice Department, through the antitrust laws, has the power to force ownership of operating systems and applications apart. The separation of content from distribution was in fact the law for decades, starting in the 1950s and ending in the 1990s. It's time to admit the experiment with monopoly has turned out badly in this area.

A single court case can re-direct the patent laws. The copyright laws can easily be revised by Congress.

There will be enormous resistance from monopolists to all these changes. There should be. The aim of this entire program is to weaken the biggest companies, and force them to become competitive again, by encouraging the creation and growth of entrepreneurial competitors. Does anyone doubt that we would be better off with 1 million start-ups and 100 tech giants than 100 tech giants alone?

What political meme can be used to create new competition?

It has already been used. It was used 100 years ago, by a Republican, Theodore Roosevelt. The meme consisted of one word - Trust.

Bust the trusts, said Roosevelt, and so we must. We need to bust the Telephone Trust. We need to bust the Cable Trust. We need to bust the Software Trust, and the Media Trust, and the Copyright Trust, and the Patent Trust.

The word Trust is important because, as in Roosevelt's time, we aren't always talking about obvious monopolies. We are often talking about shared monopolies, oligopolies, companies that secretly work together to defy the market and siphon off monopoly profits.

Anyone who wants the technology industry to grow needs to remember this one old saw. Speak softly and carry a big stick.

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Minnesota Becomes Panama

It was inevitable that the backlash against Voice Over IP (VOIP)services, which started in the developing world, then extended to countries like Panama would come to the U.S.

The same conditions exist. Governments are addicted to an unsustainable form of tax revenue. Incumbent monopolists with huge lobbying budgets are crying foul. Current employees, threatened with lay-offs, and retirees - threatened with loss of benefits - can be thrown into the mix.

The problem is, it's just as difficult for Minnesota to do anything about this as it is for Panama. Bits are bits .

Minnesota is not alone in its stupidity. Jeff Pulver has a complete list of state actions in this area and this should give you a Clue. How in the world can states (let alone countries) regulate what people do with the Internet connections within their jurisdictions?

The road these states are taking is the Napster road. It's the road the RIAA chose some years ago when it attacked Napster in court, rather than even trying to negotiate a customer-friendly pricing scheme. Napster had a server, and could be shut down, but Kazaa does not. So the RIAA is now stuck with trying to sue customers and force these services off the Net.

VOIP won't even be that easy to attack. There are no "big sources" in the customer space, just individuals with software and broadband connections. There's not even a telltale "signature" regulators can look for, since voice is a low-bandwidth application.

Plus, those companies whose bidding the states seek to do are also in on the game. Why do you think you're being offered all these "all in one" packages for local and long distance service at one low rate? It's because the calls are being routed over the Internet using VOIP.

All this was predictable six years ago, when the first VOIP applications such as Net2Phone appeared. But no one did anything about it.

What must be done? States need to wean themselves off voice call taxes. Per-line monthly taxes on broadband (and cell phone) users are the only alternative. And they're going to have to fight for those "tax increases." Meanwhile, it is time to admit that the voice network as we knew it in the 20th century is dead. Stick a fork in it, it's done. Everything is Internet now, and for the Internet to flourish it must be a competitive market, not a duopoly with two players in each state, a phone and cable giant.

We laughed at the "Third World" when they were forced to wean themselves off $2/minute voice call taxes, right after VOIP was born. It's time for the Panamanians to share a cackle at our expense. Bottom rail on top now.

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The Blogging Meme

Macromedia has a new version of its Contribute software that lets Macintosh and Windows users cooperate on the creation and maintenance of Web sites.

This is, in fact, the first appearance of the "blogging meme" in a standard application. Just as anyone can create a Word document or an Excel spreadsheet without some "gatekeeper" to make it available on the network, so it should be easy to maintain an entire Web site with a Webmaster acting only to create and implement the basic design and features.

What this means is that "Webmasters," so-called, will go into one of three directions. They could head for pure design - creating and updating templates. They could head into the business of programming - creating and coding new features. Or they could become pure managers, setting and enforcing rules across the Intranet for all personnel. But their days of standing between the creation of content and its "posting" to the Web are ending.

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Clued-in, Clueless

Clued-in is the warning given the U.S. government about its over-reliance on Microsoft software . The company right now is in a world of hurt (http://www.corante.com/mooreslore/20030801.shtml#50224).

Clueless is paying anyone $140 million to run the New York Stock Exchange . Even though Richard Grasso has done a pretty good job he is not unique. Too many CEOs today are like Alex Rodriguez - no one is worth that much money.

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