Coming up for air at Keas

February 5, 2009

Building Keas has been more than a full time job for the last 9 months; exciting, rewarding, occasionally difficult, and overall enormously fun. Mostly, as we have hunkered down to build Keas, I have avoided giving speeches or anything else not required to get the product launched.

But I did agree to give a talk at TEPR and I gave it this week. I gave it because we’re at an extraordinary point in our history. We have a new administration who actually wants change and can see that the current health care system needs to change.  The basic thesis of the speech is that our health care system is broken and on track to get worse, and that the only way to fix this is to get truly participatory health care between the doctors and the patients and their other health coaches. Surprisingly, as I point out in the talk, we can make a major dent in our current $2.3 Trillion of costs by covering every single American who has health issues for $50 Billion or just over 2% of the cost. Of this money, only $3.6 billion would actually go to the people building the Health IT systems. The rest, as is called out in the talk, would go to provide incentives to consumers and health providers alike to work collaboratively on their health and, in particular, for consumers to be able to be the stewards of their own health with online and ongoing support from the health care community.

Other than that, this is an exciting moment at Keas. We raised a bunch of money in December so we’re well funded (although we’re carefully husbanding our cash). We are just about to launch our first pilots. We have an amazing team but we are still looking for 2 good programmers including one who is really gifted at user interface, Javascript, CSS, HTML, etc. In addition, we’re looking for one totally can-do doctor, passionate about improving the health system, collaborative health care, and online patient support and willing to do whatever it takes to make that happen at a startup’s salary.


Talking about Keas

December 22, 2007

I’ve started a new company, Keas Inc with a partner, George Kassabgi. Since a lot of people have asked about Keas and it is too early to be giving specifics, let me talk about the vision and the culture we’re dedicated to at Keas and the people we’re looking for.

What is the Keas vision? If you are one of the many at risk of losing your health, Keas will help you keep healthy. If you’re recovering from an illness Keas will help you to recover and stay well. If you suffer from a chronic disease Keas will help you be as well as you can be. Today no one helps you. You can’t assemble your health data to get the best care possible. Even if you can, your doctors rarely help because the system doesn’t pay them to keep you healthy. You don’t have tools that work online to help in these situations, partly because insurance doesn’t pay for them. Because of these problems people suffer both personal hardship and fear and economic deprivation, sometimes irreversibly. What is more we all pay enormous medical costs for this, and there are costs to society and to the competitiveness of our companies in lost productivity. It is our mission at Keas to fix this for you. Clearly it isn’t an easy mission or a short-term one. While we think we have some great ideas about how to make this possible, we have a lot to learn in the course of this adventure.

What is our culture? We are all focused on making a great service that the customers love and that truly helps them. We want to have fun and make a difference and get it right. We want to build the service with love and care. Every day, we want to make sure that our customer experience is as good as it can be. This doesn’t mean trying to get it perfect out of the gate. Heck you don’t know until people use it. See my talk on intelligent reaction. What this does mean is pouring resources into constant improvement once the service is out of the gate and steadily learning from the usage patterns to make sure that the service quickly and surely evolves in the right direction. This requires great listening skills and great empathy and great patience and data analysis skills and, oh yes, some creative design insight. It requires the humility to realize that it isn’t your vision for how the UI should look that matters, but what actually works for the customer.

What kind of people are we hiring? We are hiring people who are really good at what they do, relaxed, persistent, pragmatic and fearless. It is important that the people who come fit this profile because in a start up everything is uncertain. You have to roll with the punches. You have to expect that your plan will change as the data starts to come in. Success in most start-ups isn’t instant. If it were easy, it would already be done. You have to keep trying. Some ideas work. Some don’t. What we’re trying to do at Keas certainly is hard. We need great people who aren’t afraid to try hard things but are willing to also look at the facts, see when something isn’t working, chalk it up to experience, and try the next hard thing. If you want predictability go to a big company.

Who are we still looking for? Engineers. We intend to keep Keas small until the ideas are proven (we’re self-funded). There is room, however, for a few engineers and for a proven development lead. In general people need to be able to get to San Francisco (we’re by Mission street and 1st Street close to everything), but we could use an engineer or two in the east coast as well or one or two willing to be there for significant periods of time. What kind of an engineer do you need to be? Well, in a word, excellent. More generally, productive, fun to work with, willing to tackle any problem, willing to work in Java or PHP or RubyOnRails, use machine learning or whatever language makes sense for the job, careful to avoid Not-Invented-Here when possible, good-humored, and burning to do something that really matters. It will be a small elite engineering team and we need it to really rock.

Why would you join? If we get this right, literally 100’s of millions of people who currently are on track to get ill or have chronic diseases and are at risk of getting still sicker will live longer and better lives because of you. In addition the ideas are genuinely interesting, hard, require thought, insight, and creativity. There is almost nothing easy in what we need to do. That means almost all of it is challenging and fun. You get to come in at the beginning of this adventure and that is always a blast. You’re going to get to work with wonderful people who care and want to make a difference. Ever since I moved into helping out in the health arena, I’ve met people I’m in awe of, people who are brilliant, caring, somehow hold down 4 jobs at once each of which would be full time for many of us, and still have happy personal lives. These people are going to love you because if this works, you’re going to be letting them run like no one else has. All you’ll have to do is work with them, listen carefully to them, and then be brilliant and quick. What more could you ask?

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Health and the Aspen Institute

November 26, 2007

A few weeks ago, I went to the Aspen Institute which just held an astonishingly good symposium on health. Special thanks to Michelle McMurry. It was particularly amazing and interesting to hear the talks of Peter Agre and Michael Bishop whose stories about winning the Nobel prizes were fascinating because both started in many ways as outsiders to the world of biology and without the relentless pre-professionalism of today’s kids and perhaps because of this initial distance changed science and medicine as we know it.

The obvious focus at the conference was on the train wreck that is US health care today. It became clear at the conference that if things continue as they are right now, we will manage to be spending $4.4 trillion dollars by 2015 or almost the entire Federal budget and still be delivering less than high quality health care and probably not solving the new epidemics of obesity and diabetes in this country. Clearly, this can’t go on. We are currently spending over 16% of our GDP on healthcare whereas France is around 8% and our overall health is worse. To go to the projected 30% would be a disaster and it was telling that not one but two heads of the congressional budget office (one past and one present) were attending the conference. One of the moments I found most unintentionally ironic was Bill Frist saying that of course we needed universal insurance as an obviously frustrated Elizabeth Teisberg pointed out with her usual lapidary clarity that insuring all would actually be cheaper because we would have preventative medicine rather than disaster handling, clinic care rather than ER care, and much less money spent by insurers trying to duck covering people since all would be guaranteed coverage. Where were the Republicans on this during the last eight years? But there was a thoughtful discussion about how this, all by itself, isn’t a solution, and we need to alter the system to actually reward people for good overall care and wellness of patients and good outcomes rather than paying doctors for procedures. It short we need the system to help keep people well rather than only treat them (at best) when they are sick.

There was an interesting talk given at the conference where it was claimed that of the four things you want from insurance:

  • Access for all
  • Affordable by all
  • Quality care
  • Constant innovation

you can only get two. The European system was held up as one that delivers on access and price, but not quality. Frankly, while I’m aware of some of the long and even unacceptable waits in the UK and the limited access of cancer patients there to new drugs, it isn’t clear to me that Europe isn’t in general getting three out of four while we get only one (innovation).

The most striking and shocking graphs at the conference were about type II diabetes and its rise in this country from a rare occurrence to a national epidemic in just 16 years due to an epidemic of obesity. Watching the time lapse graphs of this spreading across the US is like watching some terrifying science fiction movie about aliens taking over the country except that this is real and has happened. The terrible cost of this disease will dwarf that of cigarette smoking which, even now, kills 440,000 US citizens a year or ten times as many as breast cancer for example and compared to all coronary disease killing about 2,400,000 a year including those due to cigarettes. As it is, we cannot afford Medicare and as I said above, within eight years the cost of the current health system is projected to approach the total cost of the entire Federal government and we haven’t saved any money for this. Furthermore, incredibly, despite these crushing expenditures we are getting worse outcomes and longevity than countries spending half of what we do such as France and Japan.

So the focus was largely on why do we have this catastrophe and how do we do better? I’ll talk more about this later. While sitting at this conference it was depressing to watch the Republicans fighting and Bush vetoing the proposed extensions to SCHIP where the states are trying to extend to just guarantee medical coverage to poor kids who otherwise aren’t getting it where again the alternatives are ER room, much more severe problems, years of illness (these are kids!), or families going deeply into debt to keep their kids healthy.

It was fascinating to learn about how much genetics is now able to play a role in diagnosing illnesses and in even predicting high risk, but my overall take was that while it is amazing what we do now know, it is still a very very long step from here to actual drugs which take advantage of what we know to cure the diseases in question. What genetics clearly can do for us, even today, is start to inform us about when we need to live our lives with particular care because of an unusually high risk of diabetes or breast cancer or ventricular fibrillation.

Overall, I was struck by two very basic points:

  1. We need to work much harder to help people stay healthy. The epidemic we face is largely avoidable. If we could reach out to the huge number of people currently at risk of type II diabetes or in the early stages and just get them to eat better and slightly less and exercise 30 minutes a day, we’d literally save this country hundreds of billions of dollars or thousands of dollars for every man, woman, and child in this country not even counting the terrible costs in lost productivity and illness and poor quality of life for those who suffer.
  2. If we can just agree that the job of medical care is to keep people well or get them better and reward people for doing this well rather than paying insurers and middlemen and doctors for procedures, we would save even more not even counting again the terrible costs in lost productivity and the damage to our overall competitiveness.

I was asked in some comments since I restarted blogging to discuss what I learned while running Google Health at Google. It is a delicate subject because I’ve publicly blogged about a fair amount of what I learned and some of the rest I think is now Google’s business. So, I’ve added a sidebar listing the talks I did give publicly on health while I was still at Google. This is a starting point for learning what I learned while working on health during the last two years.

Lastly, while I was at the conference, Microsoft launched HealthVault. I want to commend Microsoft for launching HealthVault in Beta. The web desperately needs an ATM networks for health records so that we can find and connect to the expertise we need online with our health data as context be it interpreting our labs or warning us about medicine issues or helping us recover from an illness. I read a snarky blog complaining that they were copying Google Health. I don’t see it that way. They launched. They are doing a good thing. Consumers need to be able to take charge or their health data and control it. Not the federal government. Not the hospitals. Not the insurers. Us. Even if Google does launch something similar, competition is a good thing for all of us. That being said I certainly hope that Microsoft follows the principle that our health data is our data for us to control and allows those of us who put data into the health vault to easily take it out of the health vault or copy from it electronically if we so choose and provides an open doorway to those who have programs to help us make sense of our health data. But I bet they will and if so, congratulations to them.


Blogging again and Building again

October 2, 2007

Well, as some seem to know, I’ve left Google. And now that I’ve left, that old entrepreneurial fever has struck me again and I’m off working on a startup. Google is a wonderful company and I had a great time there and had a lot of fun building something I really believe in, Google Health, which I think has a great potential to change the way consumers manage their health when it launches. Still, for me, it is time to start a new company and I’m off and running.

I’ve been dusting off extremely rusty engineering habits and writing code. Not elegant code to be frank. Just enough to think through my ideas. Some extremely clear-headed and smart people can work out everything abstractly in their heads and then just go and implement it. I’m not one of them. Watching me write code is like watching an indecisive sculptor work with clay. I shape it. I look. I wince. I reshape it. I play with it. I wince some more. I ask my friends, nurse my wounds, and then reshape it yet again. And so on. Constant iterative development. It takes three tries before it is even close to the way it should be, best case. I think it is totally worth it. The arguments and design decisions are just way more concrete and tested.

However, I don’t delude myself that the code I’m writing is anything but prototype code. Prototype code is really sneaky. It sort of works and it is easy to kid oneself and that it is just a step from this code to the working product. Especially today with Amazon’s EC2 and DreamHost and frameworks and LAMP and Ruby on Rails where it seems that as soon as it works, you can scale it. In point of fact, I think the usual facts apply and it is still a long hard slog to get from prototype to product, but it is useful to get agreement about what needs to be done when, which kinds of people are required and when, and as a tool to chat with partners and potential employees and potential customers before the real thing is done. All that being said, Smart engineers welcome!! 🙂

Oh yeah, what am I building? Actually, I’m going to keep that to myself for a bit. Come work with me and you can find out, but otherwise, you’ll need to wait.

And why am I blogging again? Well, when at Google I noticed a strange thing. If I wrote a controversial post (and if you look at my sidebar on old posts you’ll see a few) people assumed I spoke for Google and got really annoyed at Google which wasn’t fair and was embarrassing since Google was treating me really well. So I desisted. But now, it is my company and I’m willing to take some of those risks. It is the great thing about it being your company. I’m always fascinated by what I learn. I should say that not all my posts will be about XML and databases or even AJAX. I do still care about technology and will write about it when the mood hits me, but I’m equally likely to write a review of a great book I’ve read or a complaint about the way the health system in this country works and what problems we’re running into building this startup.

And why did I switch URL’s from http://www.adambosworth.net? Sheer laziness. WordPress just makes it so easy and I liked some of the features.

Glad to be back in more ways than one.


Sad Commentary

November 27, 2005

This latest article in the BBC highlights why I no longer vote Republican since the Republican Party has become the creature of irrational know nothings who, if we had always listened to their ilk, would have us all still living in caves without fire. It is sad because I’m not a big believer in big government and government’s innate ability to solve problems (compare Walmart to the Federal Government in Katrina) nor in government’s good judgement or common sense and it would be nice to have a choice. But right now the Republican party is catering to a group that no one who believes in the canons of western civilization should countenance.


October 19, 2005

I finally posted an entry that I’ve been sitting on for 3 months. I should have posted it 3 months ago.


Salesforce.com

September 28, 2005

It has been a long time since I posted. I find that most of what I want to post these days would rile a fair number of people and then Google would get the blame even though these are my personal opinions, so I chose to keep my thoughts to myself. The last thing I want to do is hurt a company that has been very good to me and fun to work at. However, I gave a public speech at the latest Salesforce conference where 3,000 of the faithful were there to celebrate and chat about ideas. Salesforce recorded it and kindly let me link to it so here it is and my thanks to Marc Benioff for letting me give it and generally being a good friend.


Sidekick II rocks

July 18, 2005

As usual these days, let me preface this post by reminding people that I’m speaking for me, not for Google, in this post. As some of the readers of this blog know, I’ve been a die-hard Blackberry user for a very long time (I actually talked to a TV station about how cool Blackberry was in early 2001). I strongly suggested to Nokia that they could learn from the Blackberry in 2002/3. I’ll never switch. Until last week that is. I bought a SideKick to use for my month off (August) and became an instant addict. First of all, it is fun! The graphics are engaging, the camera works well enough for trivial shots and then it is totally easy to email the shots to someone or make them the default picture for a contact meaning that if that contact calls you, the picture shows up on your screen. The IM to both AOL and Yahoo work really well and they let you change your status easily. It is amazing to be walking down the street and using IM with your friends. The SMS is really well built in as is the email so you can see from the main screen if you have new SMS or mail messages from people as well as if your friends are logged onto IM. The tasks UI is so intuitive that my daughter is instantly becoming organized. The phone is so cleverly managed that you can call call people you usually talk to without ever using the keyboad and like a cell phone it has a green phone icon on the spinner to connect and a red one to hang up. The browser is the best browser I’ve seen on a mobile device. It is well organized. It is reasonably fast. Multitasking is a breeze. There is a key on the lowerleft called the jumpkey which will instantly bring you from any app to anyother without stopping the call you’re making or the mail you’re writing or the chat session or the page you’re browsing. You can completely customize the rings when people call you to play the music appropriate to each one and the sound is OK. This is the social version of the Blackberry. It is the Blackberry for the rest of us (well it would be if the price went down a bit). All the keys you really need for email addresses are separate non-shift keys at the bottom of the keyboard! It is the Mac of mobile devices. I gave one to my daughter for her graduation and she loves it.

To you guys who built the Sidekick II, first thanks and kudos. I love this machine.

Secondly some suggestions. I should be able to use pictures anywhere meaning what if I receive one in email, I can add it to my gallery and I can send them over IM and I can set my status profile in IM to show them and make them a background to the main screen. Alt and the spinner for editing text within text needs to be more clearly explained since fixing typos is a common need. Blackberry’s editing has two features you really need, holding a key down should shift it, not repeat it, and the spinner should go through the international versions of it. Also two spaces should put a period after the prior word. You need to beef up your spell correction. “youl” ought to become you’ll without me having to tell the machine. When looking at long pages or messages, “t” should take me to the top and “b” to the bottom. There should be some trivial way to add entries to the address book over email. These days, storage space is really cheap. I have 1gb on my Canon camera for $80. Let me do this here and store ALL my mail and a lot more photos and some MP3’s please. 100 mail messages isn’t enough. Build a decent calculator for school kids with sin and cos and so on. This can be the killer phone for the IM generation. And again, take advantage of pictures. Let me put the pictures people mail me into my gallery and, with 2 clicks add to a person or to my IM status or as the background for the home screen or send to someone over IM. Give me a replaceable battery and a way to charge from Firewire or USB.


Speaking up

July 10, 2005

I’ve been sitting on this post for 3 months because I didn’t want to hurt Google. But Google has given me permission to post this, and in any case, it speaks for me and not Google.

Unlike many of my peers in the computer industry, I was a history major in college and have loved and read history ever since. I studied, in particular, the progressive era in history, an era when the industrial revolution evolved from the grim satanic mills of England into the modern industrial world. But the understanding I always had was that none of this would or could have been possible without the renaisaance and without the slow but sure rise of secular humanism and the spirit of scientific and intellectual inquiry that started at that time. After the fall of the Roman empire, in many ways the lights went out and, in the 14th century particularly, life in Europe hit a new low stroke the the terrible plague, the start of the mini ice age, and the wars between France and England. In the 15th century we saw the Spanish inquisition and the reconquista, but really, it was the last gasp of intolerant religious fanaticism and the spirit of inquiry and discovery from art to music to science was everywhere. The lights had been turned back on. As a child, growing up in New York City, I took for granted that mankind had learned these lessons. I assumed that mankind understood that freedom to think, to reason, and to experiment were paramount and that any irrational intolerant irrational beliefs that threatened these freedoms or, even worse, abused or injured people in the name of some mystical or fanatic cause were horrific reminders of the past.

I fear now for my children growing up into a world where the leaders turn their backs on the spirit of reason and inquiry. Where the new cardinals of the church deny evolution not on any grounds of empirical reason or evidence, but rather like children having a temper tantrum because they want it not to be so. Where the leaders of this country try to take Terry Shiavo’s husband to court not because of any evidence, but because they are angry to have been proven wrong by science. Where cowardly murderers kill innocent men, women, and children and claim to do it in the name of a religion, meaning something that no one can possibly argue with from a rational point of view. Where the education board of Kansas makes the state a mockery by demanding that irrationality be held to be as valid as science. Where 1.2 billion people consider it acceptable for some man with a vision to utter a Fatwa ordering some person killed simply because he doesn’t like what the other person chooses to believe in or even just disapproves of his line of inquiry. Where political correctness means that if some lines of inquiry are pursued, others feel free to harass and abuse and even threaten the people trying to find out the facts. Where people believe that they have the right to tell others what to believe, what to wear, what to eat, what to say, and what to think.

I fear because today, so many seem to fear to speak out. So many seem to fear to say that any “faith” which presumes to dictate to others not because there is some clear fair process that led to the dictates (laws voted on by people whose individual rights are protected by a constitution) or because they are clearly preventing bodily harm to others (preventing rape, robbery, murder, or abuse), but rather simply because people of that faith believe that they have the “right” to dictate to others is wrong. Those who believe otherwise are trying to drag us back to the 14th century because they fear and hate a world in which the facts trump irrational belief and where, therefore, inquiry may always show that their “obvious truths” are just obsolete shiboleths.

It is wrong. The belief that some imam has that he has the right to snuff out someone’s life through a Fatwa because of their apostasy or heresy is wrong. The belief that terrorists have that they have the right to kill and maim and burn innocent people because they are angry at injustice is wrong. The belief that some governments have that they have the right to kill and wound their own citizens when they protest peaceably is wrong. The belief that some Catholic prelates have that they can dictate what people believe about science is wrong.

It is all akin to letting a child’s tantrum dictate the judgement of an adult. It promotes irrationality over reason and faith over facts. The reason that homicidal madmen are so frightening is that one cannot reason with them. No more can one reason with the people who rule on the school boards in Kansas, the people who bomb innocent people in buildings and subways, the people who shoot their own citizens for protesting, or the prelates who presume to tells others how to live rather than simply choosing that way for themselves and hoping it acts as an example for others.

It is time to speak up. It is time to say that facts are what matter, not faith, that human progress is accomplished through unfettered use of reason and inquiry and tolerance and discussion and debate, not through intolerant and irrational acts of terror or edicts. For all of our children and for the future, speak up against this wave of intolerance and irrationalism washing over the world.


In response to comments

June 3, 2005

Several people have commented on my most recent post arguing that what is really required is more fundamental than Ajax and needs to be XML based. Despite having been part of XML pretty much since the beginning (late 96) I have a very pragmatic point of view about this. Engineers should use the best tool for the job. For example, sometimes the best way to send data from the server to a running page isn’t XML. It is a Javascript fragment that when “eval’ed” on the client turns into a set of js arrays or values which can then be used within the page. This can be faster and easier to program. If so, why not use it? More generally, I actually agree that Ajax is somewhat transitional, as I hinted at the end of my last post. It makes pages richer and more interactive which is a good thing when appropriate (again the right tool for the job), but it doesn’t solve the issue of creating content for mobile devices or many other issues. That being said, this idea that XML is the “answer” arouses my skepticism. I think it can be a useful tool and it can be a religious mistake. For example, in the early days, Xpaths weren’t expressed as they are now, e.g. as expressions. Instead they were expressed as big chunks of XML, a sort of XML infix parse tree for the expression. It was awful and we fixed it. Similarly, XML turns out to be a very cumbersome way to encode procedural logic compared to, say, script. What is really useful about XML is that the parsing/tokenization comes for free and that it can represent a very rich set of data models and it is relatively self-describing and that, at this point, it is standard. So when the problem calls for a tool which requires sharing data between applications or encoding state of an application (e.g. the new Office announcements from Microsoft) it seems reasonable. But when describing the procedural logic within an application or even the expressions, in my experience, it usually is not.

One clear limitation of XML is that there isn’t an easy way to update it. If you already have some XML and want to alter it in some way, there is simply no standard right now for doing this and the DOM code is usally both hideous to write and relatively fragile since there are no guaranteed ID’s on elements or checksums. Another obvious limitation is moving binary data about. One of the XML founders tells a hair-raising story of a company telling him how they plan to move video around by encoding it and including it in the XML itself. Because of all this, I’ve recently been spending a lot more time working with ATOM and RSS 2.0. These are XML, but they are more. They have the idea of sets which means that one can understand how to insert or replace items and ATOM has a protocol for this. It also means that some very low tech ways can be described to get subsets out of them. They support the idea of LastUpdated and ID so that replacing an item within the document can make sense. And they have explicit and very sensible ways to point to binary data which describes where it is, what type it is, and how big it is and then leaves it to the client to use normal ways to subsequently fetch in this data.

Anyway, I don’t mean to argue to strongly with the thoughtful comments on the previous post, but to caution that this is all engineering, not religion, and pragmatism should rule.