Cubans overwhelmingly ratify new socialist constitution - <AUTHOR> https://www.reuters.com/article/us-cuba-constitution-referendum/cubans-overwhelmingly-ratify-new-socialist-constitution-idUSKCN1QE22Y <comment><USER2> Good discussion on reddit : [https://www.reddit.com/r/worldnews/comments/auv63j/cuba_rati...](https://www.reddit.com/r/worldnews/comments/auv63j/cuba_ratifies_a_new_constitution_that_creates/)

</comment><comment><USER3> I visited Cuba a year ago for a couple days on a cruise. I had a nice time, some great people, some great venues (REALLY great venues)... but won't be going back, and it's due to systematic deficiencies (trivial examples: garbage EVERYWHERE, many toilets have to ration toiled paper (!), not to mention, no incentive to clean the bathrooms, many restaurants had bland flavors due to the inability to order specialty food items and spices and only work with the bulk items the government gives you).

Also it's frankly weird how the last capitalist era there is basically enshrined in their culture (from the cars, to the fairly-well-preserved buildings dating from that era)

Odd observational note on the people: Many are into what I'd call cults but what most would call run-of-the-mill superstitious beliefs (voodoo, etc.)

<comment><USER4> I spent about 10 days in Cuba as part of a scientific research trip just before Obama eased the restrictions. What disturbed me the most was how many Cuban scientists I met who truly believed the Cubans would cure cancer for the entire world if it weren't for the American "blockade."

Aside from the government propaganda, a lot of South American & Caribbean countries have the same issues you've outlined. (Though the lack of toilet _seats_ has so far been pretty unique to Cuba in my travels most of the poorer countries are definitely BYOTP.)

One thing that really stood out to me about Cuba when I went was their odd transition to "private property" which this new constitution vaguely addresses. When I was there (in 2014 or 2015?) Cubans were allowed to "own" real estate but the government could force them to "sell" the property at any time, at the price specified by the government, and only to the seller selected or approved by the government. It didn't seem that "ownership" came with many rights or benefits.

As for the "voodoo" I think that's fairly common in the Caribbean/South America as well. There are "voodoo markets" in Haiti & Togo, for example. And the "witches market" in La Paz, Bolivia is... something if you're into being surrounded by dried llama fetuses.[1]

[1][https://www.dailymail.co.uk/travel/travel_news/article-52738...](https://www.dailymail.co.uk/travel/travel_news/article-5273869/Inside- bizarre-witches-market-Bolivia.html)

<comment><USER5> > What disturbed me the most was how many Cuban scientists I met who truly > believed the Cubans would cure cancer for the entire world if it weren't for > the American "blockade."

But don't these scientists know that they are way to lazy to cure cancer anyway because in socialism, people have no motivation to work?

> When I was there (in 2014 or 2015?) Cubans were allowed to "own" real estate > but the government could force them to "sell" the property at any time, at > the price specified by the government, and only to the seller selected or > approved by the government.

AKA eminent domain?

> > [https://www.dailymail.co.uk/travel/travel_news/article-52738...](https://www.dailymail.co.uk/travel/travel_news/article-52738..).

Seriously?

<comment><USER4> Cubans aren't lazy. By a long shot. I found them to be some of the most innovative and indeed they have quite the "hacker" culture given the very limited resources available to them.

And you're right, I didn't explain the property rights clearly. I commented in a rush and that was a mistake.

> Cubans were allowed to "own" real estate but the government could force them > to "sell" the property at any time, at the price specified by the > government, and only to the seller selected or approved by the government

What I meant by this (but did not clearly articulate) was that "homeowners" can not only be _forced_ by the government to sell at any time (similar to eminent domain) but also need _permission_ from the government if they want to sell. And even when they've been given permission to sell they don't list it on the open market or even have an assessment (as would happen with an eminent domain action). Instead, the government simply assigns a price to the property and then assigns a potential "buyer" for the predetermined price. If that "buyer" isn't interested, the government will assign another. I'm sure you can see how this system can easily be exploited by government administrators to obtain the most desirable property for themselves and their "friends" at an artificially low price.

And yes, I seriously linked to the Daily Mail. It certainly isn't always the best source of information but I was intending to share the photos and that link had the most variety. As I've been to the witches market, I found both the photos, and the information in the article, to be accurate and added to the conversation.

Your snarky attitude, on the other hand, adds little to HN. A quick look through your comment history makes me wonder whether you might benefit from a review of the Guidelines.

</comment></comment></comment></comment><comment><USER6> What exactly do they mean by "recognized the Internet"?

<comment><USER7> I think the "recognition of" only refers to the immediately following "private property", not the whole list in that sentence. I've often thought natural languages could benefit from a grouping operator :)

> There are references to {markets and {recognition of private property}, > foreign investment, small businesses, gender identity, the internet, {the > right to legal representation upon arrest} and habeas corpus}.

<comment><USER6> Question of what does the new constitution say about the Internet is still open.

</comment></comment></comment><comment><USER8> Seems like the people were offered a mixed bag: Have some direly needed reforms now in exchange for cementing the power of the party, which was already solid to begin with.

Honestly, let us just keep Cuba a toy socialist country as it is and not boycott it. Otherwise, where would we point to when we want to show real world socialism? Assuming that Maduro is on his way out, of course.</comment>


Pro-CISA Comcast trying to shutdown service for anti-CISA fax campaign - <AUTHOR> http://tumblr.fightforthefuture.org/post/126517363443/when-unlimited-is-not-unlimited-comcast-cisas

<comment><USER2> As far as cable companies go, they're kinda low on the telephony totem pole anyway. Probably best to ditch them and go with AT&T/Frontier/whoever your local phone company is.

</comment><comment><USER3> "The master's tools will never dismantle the master's house."</comment>


Ask HN: Must read non-programming computer science books? - <AUTHOR>

I'm not sure if title is correct but I'm seeking your recommendations for books on topics such as Machine Learning, Data Mining, Artificial Intelligence etc. Anything that can help me become better at programming and technology, anything that enables me do interesting things with data rather than creating regular CRUD web/mobile apps.
Topics that come to my mind are :
1) Machine Learning 2) Web Scraping/Crawlers 3) Artificial Intelligence 4) Data Mining <comment><USER2> [http://lesswrong.com/lw/3gu/the_best_textbooks_on_every_subj...](http://lesswrong.com/lw/3gu/the_best_textbooks_on_every_subject/)</comment>


What's Really Killing Digital Health Startups - <AUTHOR> http://techcrunch.com/2015/10/30/whats-really-killing-digital-health-startups/ <comment><USER4> I'm in the Health IT space but we took a different approach. Early on we realized most Health IT companies are really pharmaceuticals but they don't realize it. What I mean by this is, you need to have the budget of a pharmaceutical to play in this space: 1 - you need to spend millions to win over consumers and 2 - you need to have an existing network of connections into doctor's offices to convince them of your solution. Big Pharmas have both of those. They have reps that constantly visit doctors or hospitals to engage them and they have a well spent marketing budget to build awareness for their product. Most startups can't do either of those.

Then there is the long cycles. We signed some global Big Pharma brand (can't disclose). They actually approach us and were very eager to work with us. But even with that, it took exactly 2 years before we were able to roll out our pilot partnership.

Basically you need to go into this knowing it'll take 3-4 years before you can show any traction.

<comment><USER5> This comment and the OP mirror my own experience(s).

Additionally, data interchange between competitors is a non-starter. Possible solutions (work-arounds) will be single payer or continued market consolidation (hospitals merging and then implementing one of the big systems like EPIC).

Not mentioned is that continued churn like HL7 v3, ICD-10, meaningful use, etc. are hugely onerous while adding zero value. A cynic might wonder if its just make work for the consultants.

\---

Source: My team designed, implemented, and supported the backend of 5 exchanges. Like this one:

MedPlus to Implement Clinical Portal and Information Exchange for the Brooklyn Health Information Exchange (Jan 11, 2008) [http://newsroom.questdiagnostics.com/index.php?s=30649&item=...](http://newsroom.questdiagnostics.com/index.php?s=30649&item=94401)

<comment><USER6> You don't think HL7 v3 being somewhat of a markup language was an improvement?

<comment><USER5> It's a massive step backwards.

Bad has HL7 v2 is, it was a known evil.

With HL7 v3, there's so many more places to stuff data. And when it wasn't clear what goes where, partners created novel solutions. Just like with v2, but now with XML syntax.

We participated in an early NHIN competition (shoot out). The official WSDL only worked with one tool stack (Visual Studio?). I finally gave up and just screen scrapped the good bits. Used xpath to pull out the useful bits. Used SoupUI to create prototyped requests, manually massaged them to work, then turned them into Velocity templates.

We captured "official" requests and responses, stored them in source control. When something broke, we'd use diff to find the mutation. Turn-around was a few hours. Our two person team ran circles around our partner's teams with dozens.

I still use the fake it strategy for anything XML or web related.

<comment><USER7> As someone else who works in this space, this rings incredibly true.

I get the sense that the reality of any medical exchange format is 50% data structuring and 50% legal structuring.

Which is unfortunate... as lawyers aren't very good at commenting their code for non-legal professionals.

</comment></comment></comment></comment></comment><comment><USER8> Having done exactly this type of integration with legacy systems I think a point that gets glossed over is that it's the startups themselves who are full of engineers who think that the whole world has moved on to using NoSQL Node.js RESTful JSON APIs in the cloud (that buzzword soup was intentional) when the reality is that the majority of established businesses are using unsexy and what they would consider to be "legacy" technology.

So you have companies like one I was recently a part of integrating a Node web app and API with SOAP and SAML end points and suddenly it's everyone else's fault that things are hard when really you probably should have thought through those tech stack choices before you started.

I'm not saying the article is wrong. I agree with it wholeheartedly but there's a lot to be said for not researching the market you're about to jump into thoroughly enough before you begin.

<comment><USER9> Heh.. you hit the nail on the head here. I've been in health integration for the past five years. By restful nosql whizbang node standards, healthcare is full of really weird old shit, and if you want to interoperate, you have to be ready to party like it's 1999, because a lot of these systems were legacy even then.

It is rather frustrating to see some of the API designs that are finally getting shipped in healthcare now, though. Right now, I'm interfacing with a market leading EMR vendor's web services API. They advertise it as "REST" with a straight face, but it's the lake wobegon of REST APIs, where all of the responses are "HTTP/1.1 201 Created" (even the GETs) and all of the response times are horrible.

Personally, I'm rooting for startups like Redox Engine ([https://www.redoxengine.com/](https://www.redoxengine.com/)) to bring some sanity to this world, because I don't think the EMR vendors are going to do it on their own.

<comment><USER8> They won't do it on their own because there's really no incentive to make this information easily accessible. Healthcare is like Microsoft and Oracle in the 90's. Everyone wants you locked in to their platforms and services. Add to that the fact that you're constantly dealing with incredibly sensitive information on the level of financial data (arguably even more sensitive) and it gets worse. In finance you have PCI compliance to deal with. It's tough but not as crazy as $50k fines for every instance of leaked data with HIPAA.

<comment><USER10> It may not be deliberate attempt to lock customers in, but just the first part of what you said: there is no incentive to make this any easier. It basically works, so hospitals/clinics that need to make a few simple customizations can do so with REST API calls but it isn't easy enough for third-parties to quickly and easily build large applications. There's so much going on in healthcare that it is hard for big vendors to justify cleaning up their web services over doing other things. Especially when the "interoperability" buzz fits in better with supporting FHIR, CommonWell, Healtheway, HL7, etc.

</comment></comment></comment></comment><comment><USER11> I'm in the digital health space (CEO of Omada Health).

Agree completely on the IT & product integration barriers highlighted in the article. This (& more) make health care a nuanced place to build a business.

There are simply more stakeholders to manage:

       - Employers (Google, etc; those w/ >500 emps usually carry financial health care risk)

       - Plans (United, etc; both carry risk and administer employer plans)

       - Providers (Sutter, etc; deliver care, can carry some risk, contract with plans, and sometimes contract directly w/ employers)

       - Benefits Consultants (Mercer, etc; guide employers, more)

       - Societies (AMA, etc; build guidelines, unify provider voices, more)

       - Patients (you; remain frustrated w/ system complexity)

       - Consolidators (McKesson (Rx logistics & channel), Express-scripts (pharmacy benefit manager); add leverage and efficiency)

       - Regulators (HHS (HIPAA), FTC, FDA, etc; define ground rules for all these players)

       - Suppliers (Pharma, device, digital health; sell value into this space)

This # of important stakeholders makes it difficult to "trace a dollar" and figure how who is your buyer. It's important to understand the basics of the financial, contractual, and regulatory relationships between all of these.

But it's also very, very fascinating. And once you suffer through some of the learning curves can get quite fun. There are enormous financial _and_ impact opportunities to be had. The wall can be a little high.

I'm always still learning, but if you need help on your idea and how it'd fit in, email me at email@example.com.

<comment><USER12> This is a GREAT post. It is a giant puzzle, not for the faint of heart but very fun. Provider motivations vary widely based broadly on their economics and interests. There's 316 distinct U.S. markets alone! Cheers, Sherri (CEO@Medigram)

</comment></comment><comment><USER13> Based on this article whats killing digital health startups is they dont understand they are fundamentally in the integration business.

I worked for a company in a total different sector that eventually ended up being acquired for a significant amount of money.

More or less the company 'succeeded' because almost everything 'product' wise was window dress. the actual value of the company was the fact that we had done the legwork to integrate with dozens and dozens of difficult legacy systems and was able to expose them in a single unified API that our 'product' used. The purchasers didnt really value the 'product' or the companies 'brand' they valued the integration and the business relationships with the integration partners that were necessary to keep these integrations working...

Seems like what the article is really saying is that in this particular market the money is in the integration not the 'product' over the integration.

<comment><USER14> Certainly you can make money at integration, vast amounts of money are made. But as one friend in the business really did tell me once "your job is taking one piece of crap and another piece of crap, get them to talk to each other and so turn them into a third larger piece of crap". Integration "works" but overall often makes the problem worse or at best allows you to run place. Imagine when something else has to talk to your "talks to ten things thing".

For good or ill, The _start-up ideal_ is generally to solve problems broadly, to disrupt an entire industry rather than build one more extension to that industry.

The problem of integration, of conforming to byzantine standards and to the mess that overall existing health IT, is itself _still_ just a detail in the overall problem of health and technology.

The fundamental problem is the messiness and unpredictability of physical human bodies/human health.

The reason that health records are a mess is that there is no easy to way to universally classify "what is going on" with a given person in a cut-and-dried fashion. For any field of a health record, there is significant gray areas once you get to a large scale (including "basic" things like "male" and "female").

Just as much, health procedures often don't benefit from automation because what one person does to care for another person is subtle and not easily codified.

<comment><USER15> > For good or ill, The start-up ideal is generally to solve problems broadly, > to disrupt an entire industry rather than build one more extension to that > industry.

But which start-up has ever done that?

Not even Google or Facebook did disrupt an entire industry – they just built one more extension to an existing industry.

<comment><USER14> Meh,

Come-on, look at my context. Of course, disruption is never a fundamental up- end, just a streamlining towards a simpler and more productive approach - <USER2> and airBnB being the classics (whatever their social value or lack there-of).

The start-up approach (or disruption, the most archetypical part of it) is aiming for more streamlining at the end of the process - rather than aiming to be one more orifice slurping up money from one of the vast streams of money that already exist. Contrast AirBnB with a company that might "let you reserve rooms with ten of the largest hotel chains in the world" \- sure, both change things, neither absolutely change the world but AirBnB is still a more fundamental change (again, in values-free terms).

<comment><USER15> Well, many successful startups are just that, though.

"let you reserve rooms with the 1000 largest hotel chains in the world" is quite a fundamental change, as you get direct price comparison, info in which weeks it will be cheapest, etc. (And, unsurprisingly, there are dozens of startups doing exactly that).

</comment></comment></comment></comment></comment><comment><USER16> Saying these companies could just open their APIs is probably wrong. None of the legacy EMRs has a good underlying data model and what they have tends to be customized per site. There might be some minor functionality you could get to work consistently across sites with such an open API but chances are it wouldn't cover everything your innovative startup needs.

In summary I don't think it's only lack of willingness; bad design was baked in from the beginning and piled up over the years.

As an aside, speaking as doc and programmer whose been in this field for more than a decade, I repeatedly find hilarious the hubris from developers coming from outside the field who think they are gonna fix healthcare with their amazing new perspective. Poor bastards. I feel sorry for the ones who aren't being arrogant dicks about it.

I recently reconnected with a guy who had a super high profile successful startup (like, success level=my mom even uses it) who tried to start his next company in healthcare. Fast forward a few years (i.e. a few weeks ago) and he sounds like he has PTSD

<comment><USER5> What you say is true. I solved the problem by flipping it around.

I'm going to give away the secret sauce I created for our backend.

"Traditional" EMRs imagine an idealized data model and then write ETLs to import to that model. The jargon we used was "adjudicating the single best record (SBR)" or "source of truth".

My system slurped up all data, stored mostly as-is, and then used information retrieval strategies (think Lucene) instead of querying (think SQL).

This solution was wicked fast. We showed our customers data back to them, so validation was simple. And we were super nimble when they changed their minds (what is a "visitation", how to displays scripts, updating lab results).

Sad story short: our group was acquired, my strategy made the reigning CTO's head explode, he attempted a rewrite, failed, then the execs killed the product.

<comment><USER16> Better search is definitely needed and seems like something the EPICs and Cerners of the world could easily do if they just assigned a couple smart people and left them alone. Instead they'll probably form vast teams of search stakeholders.

But search is only one need. You say EMRs imagine an idealized model. Maybe. They certainly never develop one. And that's what you need to reach the potential of medical data analytics. The software needs to "understand" what the data means without constant human intervention

<comment><USER5> Perhaps my effort was informed by my prior experiences with ERP/CRM systems and the semantic web.

I'm firmly in the folksonomy (vs taxonomy) camp.

We just showed our customers data back to them. In most cases, it was the first time they'd ever seen it. Hence the churn on "what is a visit", resolving scripts, etc.

I don't know anything about medical data analytics, but if we captured the data, then its there to be mined. It was just HL7 (or whatever), as is.

<comment><USER17> Honest question: who wants to read raw HL7? To whom is the ability to access HL7 on-demand a killer feature?

</comment></comment></comment></comment></comment><comment><USER18> Also something less talked about is how hospital administrators don't want to share their data for competitive advantages. So, they're more than happy letting the EMR vendors taking the blame for the lack of interoperability while in fact that said lack of interoperability is exactly what they're looking for when partnering up with an EMR.

So, when trying to sell a third-party product to a hospital, administrators forward you to the EMR vendor, while EMR vendor forwards you to the administrators :) Each of those "forwarding" takes a few months.

<comment><USER19> This. Interoperability is great when it lets data into the system, but a huge threat when it allows data out.

</comment></comment><comment><USER20> _As any engineer knows, most software applications have APIs; it's simply a business choice whether to publish them or not._

This makes it sound like opening an API up to the public is akin to flipping on a light switch, which as we all know is rather misleading. There are significant investments and expenditures (documentation, support, etc.) to make if you want to properly serve up a public API and no, not every company does those things as a side effect of developing a product.

<comment><USER21> Totally agree.

And I'm not sure it is safe to say that "most" software applications have APIs in the sense the author means.

<comment><USER22> In enterprise, unless it's been written in the last 5 years, the odds are good that it doesn't have APIs. Or, if it does have APIs and was written in the past 10 years, those APIs are only intended for internal (within the app itself) consumption and could never, ever be used externally.

<comment><USER21> Yeah. From my experience, public API's are only opened up when there is enough money generated from them to fund someone dedicated to managing/implementing them.

</comment></comment></comment></comment><comment><USER23> Digital health is difficult since:

1\. [B2B] Providers/enterprises aren't willing (or able) to integrate into legacy systems

2\. [B2C] Consumers see their futures selves as strangers [1], and most aren't willing to put in time now to prevent something that may or may not happen in the future (e.g. sickness)

Which is sad, because this is a huge area for tech to have a meaningful impact on lives.

There are definitely some interesting companies in the space. For example, Omada Health [2] sells to companies. Companies like them because their employees' health increases (meaning more time spent working) and insurance companies like them because their loss ratio decreases.

[1] [http://www.vox.com/2014/12/18/7414105/procrastination- future...](http://www.vox.com/2014/12/18/7414105/procrastination-future- planning) [2] [https://omadahealth.com/](https://omadahealth.com/)

<comment><USER24> I wonder if part of the B2C difficulty is that insurance pays for most healthcare but (with a few exceptions) not for the lifestyle choices that would reduce healthcare costs.

If there was more of an emphasis on preventative measures that insurance paid for, I wonder if it would be different.

<comment><USER25> What lifestyle changes would an insurer pay for--at least without very intrusive lifestyle monitoring? (Which will increasingly be possible to do whether it's done or not.) There are often discounts for gym memberships and the like. And annual physicals are typically paid for.

<comment><USER24> I'm genuinely not sure. Paying for gym memberships, FitBits, and things to get people exercising could be one option. Or maybe insurers could use extra incentives to encourage people to get flu shots or regular checkups?

<comment><USER26> One thing ACA did which at least is plausibly useful (though whether it'll move any statistics remains to be seen) is to include an annual physical plus all CDC-recommended vaccines with $0 billed-to-patient cost. So even if you otherwise have a high-deductible plan, you don't pay a copay or deductible for those services. This isn't quite an active incentive, but it's an attempt to remove the price disincentive, with the hope that'll result in higher vaccination rates (the flu vaccine is included).

</comment></comment></comment></comment></comment><comment><USER27> I think it's interesting that this article is being written in a time when more Digital Health startups are surviving than ever before. It doesn't take being an insider to succeed in healthcare anymore; there's better options for hosting and information is no longer hidden or sold on how to integrate with EHRs and payors.

As someone who has spent the majority of my career working in Digital Health (née Health IT) and helping people get data in and out of EHRs, I think any assertions that we're about to enter a new era of magical integration efforts are usually off base. There's no magic bullet to solve digital health integrations. It takes:

\- Defining the value proposition of integrations for your market (Meets regulatory concerns, reduces double documentation, saves time and money)

\- Knowing what the playbook for integrations looks like for your industry. What does it mean to be an integrated telehealth vendor? An integrated cancer analytics platform?

\- Having a team that know how to operate in the space. EHR and HL7 vets are hard to find, recruit and retain. I think this is particularly true in the Bay Area. Expertise here is crucial.

I know alot about this and this is what our team at Catalyze has focused on solving NOW, not whenever the magic solution arrives. Looking for help on keeping your Digital Health startup alive? Let me know. I'd love to help you out. Email me -> mark <at> catalyze.io

</comment><comment><USER28> Lot of interesting comments about difficulty of IT integration. However, there is a much more fundamental problem with Healthcare IT. That has to with a lack of a functioning market. Thanks to HITECH subsidies, a bunch of money has flowed into EHR and related systems. It gives the impression of a customer paying for these systems, but once that fades a lot of these HIT companies are going to find that they are not in a market. People who think another 3-4 years will fix the issue are in denial.

Look, there are lot of industries that work in IT integration. If you take manufacturing, retail, finance, telecom etc. there hundreds of systems from the '60s and integration (and all the pain) is probably 80% of the work. 100's of billions of dollars are spent on IT integration. There is no magic 'one true IT system' but lot of hard work and slog. Nothing very special about healthcare. But, there is functioning market in these industries. Consumers of these systems have a very clear idea of how IT is going to help them run their business, it is sustaining system. They pay money, IT people build systems.

Not so in healthcare IT. Healthcare consists of bunch of fragmented and tiny providers interspersed with some large players. As such very few are managed as a business (as a retailer would for ex.), instead it is managed almost like a bazaar style haggling model. Try to squeeze out as much as possible from the insurance company, reduce the cycle time of payment, negotiate some extra tests, enter the correct ICD code etc. No standard business metrics that everyone can agree upon. If the value pitch is "we will help you get paid", then you have failed. My view is that this state of affairs will continue until there is some large scale integration and verticalization. Until we have these fragmented healthcare system in place I don't see a good future of healthcare IT.

I mean sure there will always be some people doing this, but people have working on healthcare IT since the '60s. Having super clean one true data model is fanciful at best but it actually will not solve anything. The $40 Billion of HITECH subsidies have managed to create a half assed EHR ecosystem with Epic taking a chunk of the market share. It will be interesting to see how the industry will manage to get the customers to pony up the next $40 Billion and the next and the next. In a fragmented system, the only IT system that can work is some sort of Slack type system (or communication tool) for patient/providers or between providers.

</comment><comment><USER29> Give me a fucking break. HIPAA compliance is actually an issue. Published APIs may have benefits to businesses, but what is the benefit to the patients? He claims this hurts patients when his only evidence is his company couldn't cut it. HIPAA was written in the interest of patients who don't want the entire world to know they are HIV positive or have had 5000 sex partners because they are a sex worker or whatever. Lives can be ruined by leaving that kind of info flapping in the wind. Furthermore, federal fines for not complying can be painfully high.

If you don't want to deal with HIPAA and take it very seriously, then stay out of this space. You aren't worthy.

<comment><USER30> Just because the APIs are published doesn't mean that the data is out there for any unauthenticated client to access. Of course HIPAA is important, but it is not a serious problem for interoperability.

I work on a SOA team for a large healthcare organization, so I'm well aware of the issues. The problem comes down to the usual case of entrenched vendors working to protect and expand their turf. EHR vendors are notorious for being terrible for interop—some are better than others, but they all see integrations as competing with their own offerings. Non-trendy methods of exposing data—SOAP, custom MUMPS code, direct SQL access—are the norm. That's not a problem, except that documentation is often incorrect or nonexistent (while being restricted to direct customers, of course), and the vendors really don't care about APIs. They see interop as a necessary bullet point on a sales sheet, but they'd rather not have those APIs be used in place of their (usually crappy) complementary apps that they're trying to upsell.

Interop is a HUGE win for patients. Without it, we lose one of the main advantages of EHRs—the ability to access our own information when we need it, and allowing the information to be fluidly shared between providers. Of course, privacy is paramount—but in my experience, interop is not the attack vector I'm most concerned about.

<comment><USER29> Well thank you for those remarks. It really doesn't change my assessment of the piece. He is basically arguing that his competitors aren't graciously handing over the reins so he can make bank. How shocking. Like him, other people want to protect their income stream.

He dismisses the presumed "cheap excuse" of HIPAA compliance given by someone who did not want to work with him. This does not give me confidence he takes HIPAA seriously. I had annual HIPAA training (as well as Gramm-Leach-Bliley) when I worked for a major insurance company for a few years. So I am not unfamiliar with HIPAA.

</comment></comment></comment><comment><USER10> BTW, while I would love to improve the healthcare industry and I wish you the best of luck, I don't think software is the primary problem. Sure, it is very expensive and always 10 years out of date. But the real problem is government and the payer model.

I'm excited to see where retail clinic initiatives like CVS's go, since that's actually a real change to how I, the patient, get care. Instead of consulting my insurer's website to find out what clinics they accept then calling up to make an appointment in a busy doctor's schedule, if I could instead just walk into the store and get what I need like I could any other product that would increase the convenience by enough that I might use it to keep healthy rather than to fix myself when I'm very sick.

We need ways for companies to compete in giving the most convenient service at the best prices. We need full price transparency. We need the prices to be things people could actually pay. (Insurance was originally for catastrophic care where the cost for a major illness or surgery would get too high.) Having prices so high that only insurers can pay them means only insurers DO pay them and since hospitals and clinics know this they can charge whatever they want.

(I once went to a dentist who advertised cheap wisdom tooth removal. I found out the way he did it was send a huge bill to the insurance and whatever the insurer declined to pay he would just forgive. Basically he is kinda willing to work for free but take as much as he can possibly get from the entity that has the deep pockets.)

<comment><USER31> > (Insurance was originally for catastrophic care where the cost for a major > illness or surgery would get too high.)

Agreed 110%.

> Having prices so high that only insurers can pay them means only insurers DO > pay them and since hospitals and clinics know this they can charge whatever > they want.

I've explained this in more detail on another recent HN thread, but basically: prices are 'so high that only insurers can pay them' by design, but it's not for the reason most people think.

It is generally illegal for providers (hospitals/doctors/etc.) to charge different rates to different patients based on their insurance status[0]. However, it is not illegal for providers to negotiate standard rates for specific payers. Combine this with the fact that providers lose money on their publicly-insured patients[1], and it becomes clear that they have to overcharge the rest in order to end up in the black.

So what they do is set absurdly high sticker prices, knowing that the private insurers will negotiate those down (usually this is done in multiples of what Medicare pays - e.g., Aetna will say, 'We'll pay you 150% of the Medicare price for billing code 99481 this year'.

Uninsured patients are stuck with huge bills as a result, though this is basically an unintentional side-effect of the fact that hospitals _can 't_ give them lower bills initially. It's also the reason that hospitals are almost always willing to negotiate with uninsured patients. If they know to ask, they can almost _always_ get that down to 10% of the original rate. That bill isn't meant for individuals, they don't really expect individuals to pay, and they'd much rather negotiate a discount and have it paid in full immediately than have a patient default, which has negative repercussions for their bad debt ratio.

Privately insured patients end up having higher premiums as a result, because their insurers are paying higher rates to subsidize other patients who are not paying any premiums at all (publicly insured patients)[2].

[0] There's a little nuance to this, but that's the general idea.

[1] Medicare reimburses less than the actual costs of services provided per- patient, before accounting for any overhead

[2] This subsidy happens at the claims level, so it counts towards the insurer's requisite MLR.

<comment><USER32> _[1] Medicare reimburses less than the actual costs of services provided per- patient, before accounting for any overhead_

Hospitals don't even know what a given service costs, so this statement seems to need a little more equivocation around it.

<comment><USER31> > Hospitals don't even know what a given service costs,

That's not really true. We're talking about the costs of goods sold, which means it's pretty easy to place a lower bound on the marginal costs. For example, if the lab supplies for running a certain test cost $100/unit from the vendor and Medicare pays $93, you know that the hospital is losing money off of it. We're not taking into account the overhead, infrastructure, or any of that stuff, since it doesn't factor into COGS.

Anyway, this number comes straight from Medicare's own figures, astonishingly. I can't dig it up right now, but it's in the public record, somewhere within a ~100 page PDF. I have the PDF at home and have linked to it on HN before. Medicare literally acknowledges that they reimburse less than 100% of the direct costs that they incur (in 2012 it was 93%, IIRC.)

<comment><USER32> I don't see it here:

[https://hn.algolia.com/?query=by:chimeracoder%20medicare&sor...](https://hn.algolia.com/?query=by:chimeracoder%20medicare&sort=byDate&prefix=false&page=0&dateRange=all&type=comment)

I don't think you would have linked it in a comment where you didn't mention medicare.

I'm honestly curious about it, I certainly believe that Medicaid reimbursements are not matching costs, but I think for Medicare they often are.

<comment><USER31> Not the PDF I'm thinking of, but just googling the numbers I remembered, here one example:

[https://www.floridahospital.com/sites/default/files/finance_...](https://www.floridahospital.com/sites/default/files/finance_part_i_revenue_hib_november_20131.pdf)

> In 2012, beneficiaries of Medicare and Medicaid received nearly 60% of the > clinical services provided by Florida Hospital (as measured by charges)vi. > However, payments from these government programs represented just 40% of > Florida Hospital's total net revenuevi . In comparison, private payers > received 30% of the care provided by Florida Hospital and represented 56% of > its total net revenuevi

And the next paragraph:

> hospitals such as Florida Hospital have no ability to negotiate the payments > from the public payers – Medicare and Medicaid – that pay for the majority > of the clinical services provided. This poses a tremendous financial > challenge for hospitals because these payments do not cover costs. In order > to overcome these shortfalls, hospitals negotiate higher rates from private > insurance groups. For this reason, continuing cuts to Medicare and Medicaid > payments create an unsustainable business environment and put undue > financial pressure on private payers

(The common response to this is that we need to increase funding to Medicare. While it's true that Medicare happens to be underfunded, that doesn't actually address the structural problem. Because Medicare has the ability to change their reimbursement unilaterally[0] while it has to request additional funding from Congress, these two will _always_ be out of sync).

[0] the word 'negotiate' is often used here, but since hospitals are essentially legally required to accept Medicare patients, it's no more a fair negotiation than the negotiation you have with Comcast over your bill. You can squeeze a few extra dollars out of them if you fight, but at the end of the day, Comcast has all the power, so they can - and do! - price-gouge.

</comment></comment></comment></comment></comment></comment><comment><USER33> One way this industry may get nudged significantly (disruption is too strong a word and not exactly a great thing when dealing with peoples health) is to approach it from the outside the system and come at it from the consumer health angle. Yes, it is far more limited in many ways as you can't build a system a hospital can integrate but there is still a lot that can be done.

20-30 years ago, if you had a problem, you went to a doctor and that was about it. Now, people are more likely to choose to (or forced to by cost) seek alternative practitioners or at least partially take matters into their own hands (independent research, dietary and lifestyle changes, etc). These will usually be people who are not really getting helped by the system and are probably facing issues where lifestyle is a big factor (autoimmune issues, diabetes, obesity, etc). If you can successfully help that group of people where the system has failed to, then you may start to see some real changes as most people ultimately will (eventually) gravitate to what actually works (yes, I am an optimist).

Of course, as another commenter mentioned, we tend to be terrible at doing things now to benefit our future selves, but I still believe technology could play a big role in helping with that and the current options, like wearing a fitbit, are barely scratching the surface, mainly in that they aren't yet doing much to prove their benefit to the consumer or obviously help them day- to-day. That is a really hard task when health changes occur over long timespans but at least it is just hard-hard, not EMR/politics-hard.

<comment><USER34> Maybe something like this? [https://www.patientslikeme.com/](https://www.patientslikeme.com/)

<comment><USER33> I have used them and they are definitely on the right path but they haven't yet got past the point of just showing a lot of graphs and comparative statistics, etc. As always, it comes down to translating data to useable knowledge, which we as an industry are obviously trying to figure out across pretty much all verticals

<comment><USER35> My understanding is that PLM very much translates to useable knowledge - <USER3> for the pharma and PHM folks who mine the backend (which is how they make money). Notably, this is all quite above-board: it's not a "secretly mine people's private medical details" situation, it's "overtly mine people's private medical details in order to help find treatments for their rare disease"...

<comment><USER33> You are right about that - and I think they are doing something really good (and props to them for being really up-front about how they operate) but unless they can really do something to help patients day-to-day, is seems the participation rate will probably always be small and inconsistent, which means a smaller, less-complete data set that will yield less accurate and useful results.

Again, I like the goal and I did try them but it is not a good user experience or particularly helpful on the individual level so even doing it altruistically really didn't last. To get that kind of rich dataset, you need the user to be highly engaged which means they are really getting something out of it and using it for the primarily selfish reason that it helps them.

Having now had a lot of experience dealing with the medical system as related to complex and chronic diseases, I still find myself really surprised by how little the "consumerization of x" movement has impacted it. Per point of the original article, I shouldn't be. The massive bureaucracy, the regulatory capture, and the general politics of the industry are so all-consuming that there is little time or energy left over for the patients. (disclaimer: yes, there are a ton of amazing individuals working in the industry but even they are, unfortunately, really handicapped by the system itself)

</comment></comment></comment></comment></comment><comment><USER36> To think that your startup can "disrupt" an industry that has the spending equivalent to that of the GDP of an entire country is a fool's game. Most need to focus on longevity versus strategizing a quick exit.

Also, I worked for one, been part of the contract negotiations and have seen at first hand the difficulty many face trying to deal with providers and payors.

Shameless plug, I'm available for HIPAA consulting in San Francisco. I'm a former InfoSec officer.

<comment><USER24> Could I talk to you about a project I'm developing? It's marketing solutions for healthcare practices, ideally connected to EMR and IT systems. Would love to hear your thoughts and advice.

Email is in my bio.

</comment></comment><comment><USER37> The biggest issues I've seen haven't been legacy/technological challenges, but almost completely political/incentive/motivation reasons on the part of hospitals wanting to build interfaces for many practices. On the part of vendors, many systems Nextgen/Allscripts/GE etc, can often charge an exorbitant amount to build and maintain the interfaces.

Even if a practice/vendor is savvy and deep pocketed enough to get past the politics and expenses, then you're at the whim of the competence of the interface teams which can range from incompetent to good, with the average being on the lower end. I've often seen something that should literally take a couple hours, take a year to get completed, if ever.

There are bigger initiatives taking place to try address some of these interoperatibilty issues, namely Health Information Exchanges (HIEs), although their economics remain unproven.

It's not all gloomy, I can honestly say that in the last 5 years, anecdotally, the hurdle to building interfaces feels like it's getting less and their sophistication and capabilities are getting higher.

</comment><comment><USER10> No discussion about APIs in health care EMRs would be complete without mentioning HL7's new FHIR protocols: REST-ful web service endpoints for HL7 health data. It makes developing applications with these standards much easier.

But that's only one piece. You need business relationships to even connect to the EMR in the first place. I think the problem with breaking into this industry is: (1) Huge incumbents with tons of cash who have shown they will spend a lot of money to smear each other, buy out smaller companies, or just implement the new feature in their own system. (2) Excessive government regulation which makes it hard to play in this area legally and makes everyone afraid to work with you.

I had a couple friends pitch me a medical-related startup idea a few years ago and I declined. They didn't last long before some bigger player came and implemented their idea thus stealing their customers.

Also, the article mentions reinventing the wheel of integration libraries. Having open APIs will not magically solve all problems. It mentions Kareo and says they are building out their own EHR. THAT is reinventing the wheel. An EHR is mega-huge. It has tons of modules and for the main vendors takes 18 months to 2 years or so to configure it to the satisfaction of all parties. It sounds like the advocated world is to have lots of small "open platform" companies re-invent the wheel by making a new EHR module-by-module but with different startups inter-operating instead of locking each other out. You realize that all the major vendors today started like that? They were all first one module and gradually added more. Why do you think hospitals tend to buy the integrated software to replace myriads of independent legacy systems? If you can't fully understand that and articulate why your "open platform" would be better then you're going to fail.

<comment><USER38> FHIR is probably the best hope that we've got. I am biased of course, but I've bet a few years of my life on it. :)

Happy to help anyone learn more about the spec @medhacker

[1] [http://www.annemergmed.com/article/S0196-0644(15)00226-7/ful...](http://www.annemergmed.com/article/S0196-0644\(15\)00226-7/fulltext)

<comment><USER39> FHIR is gross and overdesigned, like everything else in this moribund industry.

<comment><USER40> Instead of complaining, feel free to propose a better alternative. The HL7 standards development process is very open.

However usually the complaints about health IT complexity come from people with a lack of domain knowledge. The industry is irreducibly complex. Attempts to drastically simplify the IT systems and standards are doomed to failure since they lose the ability to cope with many common real world situations.

<comment><USER39> The industry's _irreducible complexity_ is killing people every day, and bankrupting the survivors.

The fact of the matter is that the gatekeepers blocking improvement (which really only is attainable through simplification and standardization) are going to keep doing so until they die or are payed off.

We've spent 30 years building up a morass of incompatible and tailored systems and then training all the administrators that this is somehow normal and acceptable.

</comment></comment></comment></comment></comment><comment><USER41> I'm a grant writer and have worked for numerous Federally Qualified Health Centers (FQHCs) and a smaller number of hospitals. From their perspective, EMR and related systems have tended to cost at least as much as they've saved. Some of them have seen the vendor jousting Sung describes and have experienced all sorts of vendor fatigue and vendor lock-in.

At the same time, FQHCs and hospitals are facing CMS requirements that dictate increasing EMR usage. This effort has had... some setbacks, let's just say. And what Executive Directors are willing to say off the record is not pretty: [http://seliger.com/2015/10/25/meaningful-use-regulations- cms...](http://seliger.com/2015/10/25/meaningful-use-regulations-cms-hrsa- fqhcs-and-the-stalled-push-to-electronic-medical-records-emrs).

<comment><USER42> Why doesn't the federal government build an EMR system and require its use as a condition of accepting Medicare payments?

Sure, I'd expect a terrible process and result previously (such as the mess healthcare.gov was when rolled out), but I have a lot more faith with the USDS and 18F in place.

<comment><USER43> They did. VA pioneered emr...

OpenVista by medsphere is based on Vista, the gov emr...

All emr companies are walled gardens.

In 2009 I built the first mobile HL7 compliant client for the iPhone which was emr agnostic and could work with any emr -across an esb... But all emr companies shunned us because they wanted to protect their walled gardens. At the time hospitals shunned us because they didn't believe the iPhone was a good enough device (big enough screen) to be usable...

We built integrations into a number of systems... But couldn't get traction at that early stage. So we open sourced it through medsphere...

Dr chrono came along and took different tack which was to make an actual emr...

After working with so many hospitals and these systems I basically gave up... The system is pretty broken and the artificial barriers to entry are pretty lame.

<comment><USER44> > HL7 compliant client... which was emr agnostic

In my experience, there's no such thing. HL7 is a spec in only the loosest sense of the word. Half the time you had an 80-character console output dumped into the "freetext" fields. Then there's all the codes used for different drugs, tests, admission/discharge (plus differentiating when they're standardized or user-entered with appropriate typos).

Point is, all the costs were really in the integration. Getting access to the HL7 streams wasn't bad once you got far enough in the sales cycle. Once you had it, it was a one-off project to parse the specifics of the messages. And that was just for a read-only analytics system... trying to generate compatible messages to feed back to the EHR is a whole other beast.

That's the challenge getting into this space if you're a web or cloud engineer... you come in with the mindset that "oh, HL7 is a messaging standard, I'll just read the spec and use it." In practice, there's an infinite amount of variability. You really need to treat each hospital as it's own one-off integration, plus all the politics needed to get access to the messages in the first place.

<comment><USER42> That's exactly why I'd want to tie a nationwide EHR/EMR system to Medicare reimbursements. In this case, not only must you drag the horse to water, you must force it to drink.

<comment><USER44> Obligatory xkcd: [https://xkcd.com/927/](https://xkcd.com/927/)

<comment><USER42> Touché.

</comment></comment></comment></comment></comment></comment></comment><comment><USER45> It's not just the lack of API's that makes it hard for digital health startups, a big hurdle is the perceived lack of security of a cloud based solution in regards to health care data.

A friend of mine works for a digital health startup, and the majority of the RFP's they receive automatically disqualify them if they have anything hosted in the "cloud", so they are forced to buy and maintain all of their own servers.

In addition to these costs (which could already be considered prohibitively expensive) they have to use enterprise versions of proven ETL and BI tools for the perceived added security benefits (i.e. they can't use open source).

<comment><USER46> I believe this is out-of-date. Our healthcare startup has passed in-depth security reviews from multiple huge carriers, and we operate in the cloud and use tons of open source. (We're hiring Rails devs!)

It is a meaningful effort to be HIPAA-compliant, that prevent us, for example, from using lots of cool SaaS services. The bigger issue for us is that each integration still has customizations associated with it, because of a lack of agreement about what fields mean.

</comment></comment><comment><USER47> At drchrono (#1 iPad EHR on the Market, YC W'2011) we are building a very open API that has an open door policy to our customers and other digital health startups.

If anyone is working in the digital healthcare space we'd love to work with you. You can get access to and build on our JSON API in 1-2 days. Sign up here: [https://drchrono.com/api](https://drchrono.com/api)

Here is a youtube video we shot with a startup that built on our API: [https://www.youtube.com/watch?v=HBCIzuXEH44](https://www.youtube.com/watch?v=HBCIzuXEH44)

<comment><USER48> My dad's practice uses drchrono. It looks like the API usage is still in it's infancy. Can't wait to see more companies take advantage of it!

</comment></comment><comment><USER12> I respectfully do not agree with John's statements.

1) You can do an easy light integration with the right IT shops just using for example on EPIC: Wellconnect, Oauth, and whitelisting servers on both sides. This takes three days and provides much of what most providers require.

2) Like stated at the recent Healthtech conference, no one should try to come into digital health without a decade of healthcare experience at least to understand the challenges, drivers, political, regulatory, clinical, technical, and macro financial.

Just my respectful but diverging opinion.

Best,

Sherri (CEO at Medigram)

<comment><USER12> Weconnect

</comment></comment><comment><USER49> Regulations, Big Pharma and Legacy Software will all take years to change, changing the behavior of an industry is usually pioneered by a few and in medicine that's pretty tough.

All is not lost though, startups that make software for healthcare are slowly taking hold of the market, but all those startups that have been killed off in the process have made a change for the newer ones to get this far.

</comment><comment><USER50> "This kind of behavior by incumbent vendors leaves a lot of young digital health startups at risk of not being able to scale fast enough before their seed rounds dry up."

And the incumbent vendor would say ... "so what?" Why would they care that young startups can't gain traction? What's in it for them? Pretty much nothing, from what I can see.

</comment><comment> c-slice EHRs are starting to open up more. EPIC (largest EHR vendor in the US by market share) just opened an API for some types of medical data. AllScripts and Athena also have open-ish APIs. 5 years ago none, and I mean literally zero, of the EHRs had APIs.

<comment><USER51> Practices on EPIC are still fundamentally non-networked, so even with an "API", you can't scale your product from one practice to all of them without some amount of non-trivial integration.

I work at athena and we're dogfooding our API for an increasing number of products/components as it's an easy way to both decouple internal services and improve the API for our partners. From my lowly, uninformed position as a developer, we're growing the number of partners as fast as our team can support at this point.

<comment><USER27> That's true on the one hand. On the other hand, Athena wants a significant chunk of your profits to connect to their API. At least HL7v2 interface were one-time, scale everywhere from a cost model.

</comment></comment></comment><comment><USER52> When the cost of adopting your technology is vastly higher than the price you charge, you're usually screwed.

</comment><comment><USER53> _" Another well-established vendor created a partner program under the guise of wanting to disrupt the EHR market (one in which they had significant market share), then later rejected our application because, they said, it was competitive with one of their modules."_

Now, where have we heard that before, in the mobile device space?

</comment><comment><USER54> Yes, the old buying closed source software being shit for companies eh. Surprising.

</comment><comment><USER55> Articles like this make me wonder about Oscar Health.

<comment><USER23> Oscar Health is actually an insurer. They're trying to win by (a) better marketing and (b) using tech (like free fitness tracker) to reduce their loss ratio.

I've heard their innovation was also in pre-paying facilities for services. The collection rate for facilities from insurers is abysmal, so Oscar can negotiate a substantial discount by paying up front. Same idea as if you go to an MRI facility and offer them cash up front - they sometimes give discounts up to 75%. (Note: not 100% sure Oscar does this, I heard from investor and don't have time to research.)

<comment><USER56> _What Oscar Is Up Against_ ([http://go.theinformation.com/152dc2](http://go.theinformation.com/152dc2))

> After two years in operation, the financial trajectory is becoming clear, > both in terms of the growth and the costs. In New York, the company > projected a sevenfold increase in premium revenue next year to $399 million > from 2014. But it also projects a loss of 12% of premiums, equivalent to $47 > million, according to regulatory filings.

...

> Oscar's losses stem from two sources: higher medical costs as a percentage > of premiums than rivals, and higher administrative costs, both of which are > traditionally problems of scale in the industry.

> In New York, it projected that 91.5 percent of premium revenues would be > eaten up next year by medical claims costs, among the highest projected > ratios in the state. That leaves little left over to pay for administrative > costs, estimated to be 17 percent of premiums next year, or taxes and fees. > Included in administrative costs are the company's engineering and marketing > costs.

> History says insurance companies need at least 200,000 to 300,000 members in > a state to be viable, according to Ash Shehata, a partner in KPMG's health > care practice; Oscar had 38,000 members in New York and New Jersey as of > June 30, with plans to expand to Texas and California this year.

...

> But Oscar believes it can succeed as a sustainable and profitable business > with only 80,000 to 100,000 members per state, according to a person > familiar with the company. Though scale is important to contain > administrative costs, the person said, Oscar's plan is to avoid playing the > big insurance company game of using size to negotiate lower claims costs > with providers. Instead, it will curb claims costs by partnering closely > with select providers to exchange data.

'Partnering closely with select providers' is probably the same thing you're referring to - pre-paying facilities for services.

<comment><USER29> Why did they start in New York? In order to do business in New York, an insurance company has to be headquartered (incorporated) there. (Edit: No other state requires this.) And New York is expensive.

This sounds dumb to me.

<comment><USER56> They probably started in NY because most of the founding team is living in/near NYC, according to a document filed with the NY DFS ([http://www.dfs.ny.gov/insurance/exam_rpt/x9475o13.pdf](http://www.dfs.ny.gov/insurance/exam_rpt/x9475o13.pdf)). It also states that "The Company is a wholly-owned subsidiary of Mulberry Health Inc. ("Mulberry"), a Delaware Corporation."

Perhaps they thought that the administrative costs stemming from operating in NY wouldn't make/break the company - it's whether they can substantially reduce the claims costs that will really determine the outcome. And if they're from NYC, the founding team probably had preexisting contacts in the local medical institutions, which made it easier to form the partnerships that are key to making Oscar's business model work. One of the founders is Joshua Kushner ([https://en.wikipedia.org/wiki/Joshua_Kushner](https://en.wikipedia.org/wiki/Joshua_Kushner)), whose family is well-connected in NYC (for example, his brother's father-in- law is Donald Trump).

<comment><USER29> The insurance giant I once worked for also has a wholly-owned subsidiary in New York. This is probably a common tactic for coping with the ...quirky New York law concerning "No insurance company can sell insurance in our state unless you incorporate in our state."

I know something about the history of the insurance giant I worked for. I know that their success has a lot to do with one of the founders having been a lawyer by trade and making strategic choices concerning things like where to found their headquarters.

I have trouble fathoming doing something less strategic while hoping to break into such a highly regulated industry, basically.

Anyway, thank you for replying. Have an upvote.</comment></comment></comment></comment></comment></comment>


Student Loans, Gateway Drug To Debt Slavery - <AUTHOR> http://consumerist.com/2010/09/student-loans-gateway-drug-to-debt-slavery.html

<comment><USER2> The Bill Gates quote at the bottom is quite significant. I get more out of Yale's recorded Physics II lectures on iTunes U than I do out of the lectures at my current college, even with the added interaction with the instructor. It's amazing how much you can learn or aid your learning using just free resources on the Internet.

<comment><USER3> I believe my understanding of programming was many times multiplied from what it was when I watched SICP lectures which are, yay, available on MIT web-site :)</comment></comment>


Ask HN: How to create gated static HTML page? - <AUTHOR> I do have a static HTML site that I want to make accessible via user/password authentification. I have at least 500 private users. Which options do I have apart from Netlify Pro's Identification (99$+/month), using Lamba on S3 (0) or fiddling with NGINX/Apache Basic HTTP Auth?<p>Setting up a full Laravel seems to be overkill as well. Hosted solution with custom HTML would be best, but any framework (PHP, Python, JS) would work too.<p>(0) (https://hackernoon.com/serverless-password-protecting-a-static-website-in-an-aws-s3-bucket-bfaaa01b8666) <comment><USER2> Perhaps consider moving the site to Firebase and put Firebase Authentication in front of it (believe the author piece is free based on [https://stackoverflow.com/questions/44161195/which- pricing-t...](https://stackoverflow.com/questions/44161195/which-pricing-tier- mentions-firebase-authentication)) ? Firebase services also have a general free tier (although may not be suitable to your use case if course), and many paid pricing levels.

</comment><comment><USER3> For $15 p/mth, you have a couple of options with Aerobatic [0].

Option 1 is using the Auth0 plugin [1, 2] Option 2 is using the Password Protect plugin [3]

Disclaimer: I work for Aerobatic.

[0] [https://www.aerobatic.com/](https://www.aerobatic.com/)

[1] [https://www.aerobatic.com/blog/announcing- auth0-plugin/](https://www.aerobatic.com/blog/announcing-auth0-plugin/)

[2] [https://www.aerobatic.com/docs/plugins/auth0/](https://www.aerobatic.com/docs/plugins/auth0/)

[3] [https://www.aerobatic.com/docs/plugins/password- protect/](https://www.aerobatic.com/docs/plugins/password-protect/)

</comment><comment><USER4> Looks like the only way to do this is to proxy all request to the static server through an authentication server, and you could write the authentication server in any language.

[authentication server] -> [static server]

Unfortunately, this kind of defeats the purpose of having a static server.

<comment><USER4> Just found this [http://www.htaccesstools.com/articles/password- protection/](http://www.htaccesstools.com/articles/password-protection/) and it reminded me of this post.

</comment></comment><comment><USER5> I would use Wordpress</comment>


JavaScript Summary for beginners - <AUTHOR> http://slowwaker.work/javascript-summary-for-beginners <comment><USER2> Never use innerHTML! user innerText instead! And btw slice, substr, and substring, just pick one and stick with it!</comment>


Ask HN: Can local online news be disrupted? - <AUTHOR>

I don't think online local news and communities are as developed as they could be. I think a new unique site can be developed for individual cities that offering something other than the usual what's on/guides/local deals. Ways I feel it can be improved:<p>- A Youtube channel that produces short form documentaries (similar to Vice) to compete with local news, aimed at a younger audience.<p>- Work with brands through promoted content (similar to Buzzfeed) rather than banner ads and blatant advertising.<p>- Partner with tech companies solving local problems such as Homejoy, Uber and Blue Apron.<p>- Develop a community of people (similar to Product Hunt) that are passionate about the town/city.<p>- Push this content out through dedicated and effective social media channels. @DiscoverLA on Instagram is a great example.<p>Can local news be disrupted? What would you like to see on a website for your local area? What would keep you coming back? <comment><USER2> Local new likely can't be disrupted because its existence tailors primarily to those who shun modern technologies. Therefore using new tech to "disrupt it" fundamentally fails to understand your target audience.

For example the "Average" viewer of local news only watches for ~6-12 minutes if you throw out the 60+ demographic which will watch 70min+. On top of that viewer engagement is typically 50-60%, once gain if you throw out the 60+ demo which reaches the 90-95% engagement local news likes to brag about.

The 18-29 and 29-39 demo's only have high >70%/90% engagement for traffic/weather. Most other categories are <50-60%

The "core" audience local news is tailored too are people who watch news not to gain news, but to be entertained by news. This is also shown by most 18-29 demo believes that news doesn't report in-depth enough, while the 60+ demo feels there aren't enough stories in a given time block.

Young crowd wants journalism, old crowd wants to be entertained.

<comment><AUTHOR> Thanks for the feedback, really interesting points.

I'd be specifically talking about online local news.

With that being said, could a Youtube channel producing short-documentaries similar to Vice's highly successful format engage the 18-29 demographic on local issues? As this news would be more in-depth and as you said this appeals to a younger demographic.

What about online websites for local news too? Do you think they can be improved? Currently the local websites near my city (Manchester, UK) only publish restaurant deals, reviews and unimaginative news.

<comment><USER2> The problem is, at least the western world. The local news isn't news. Nothing actually happens in our back yards, restaurants open/close, local man gets divorced, local elections, local women fights telephone pole placement, etc.

As you limit your content to ~50km you limit what you can report on, and most of it, surprisingly isn't that interesting. CNN airs news 24/7 from around the world, and even they have to greatly hype stories to fill all their air time.

And on top of all of this political partisanship with news. You will easily lose 50% of your audience for reporting on a story "wrong" or in disagreement with somebodies political opinions.

</comment></comment></comment><comment><USER3> Yes, I think it can be. I feel the reason no one has yet been successful is that the cost to do so is likely very high, even using local volunteers. Many people try to solve local news, local events type problems. Even Google and Yahoo want to solve this as it really is something that can drive user engagement.

The problem is it takes significant man hours to make local news, events relevant daily. If you just look at your local news, cut out all the sensationalizing around each crime/victim, the news boils down to about 6-10 minutes of real news, 3-5 of which is your local weather, the other few minutes is usually something the local station is doing in the community or highlighting, like a local teacher etc. They repeat the same news cycle about every ~6 hours, usually 6am, noon, 6pm and 11pm. I believe they use this formula in part because the can centralize research and collection of news stories around the local police, jail and city/county daily publishings, and then hammer it home for a 24 hr cycle. The formula works too because a lot of people will watch that type of content and they are hitting different demographics with each time slot.

So IMO to properly solve this problem, it would take significant local presence to collect, and organize the happenings around the city/area, assuming you wanted to differentiate some from local news. Then you have to get it published in some meaningful way where people can search it, use it and receive value so they will return again. This takes significant production in a short window.

Also, as I think a lot of sites/people have found out, the build it and they will come just doesn't work. Volunteers just won't start adding their content to a site because it exists, there has to already be a following or there is no benefit. Same for companies willing to sponsor a persons time to do this, if there is no audience to sell to, why would they dedicate the dollars to do it. So it is up to a central group/company to create the local following first then it can expand with the aid of others, but initially it would require significant labor, time and money. Multiply this by the number of local areas and you start to see that while doable it is definitely a large problem to tackle.

</comment><comment><USER4> Patch.com nextdoor.com</comment>


Ask HN: Books/Resources on Product Development? - <AUTHOR>

Looking for some books and resources on product development.  Especially geared towards a tech company/startup with a software/web app product.
Our product has been in development for years and the perpetual cycle of growth => new features => bloat may be getting out of hand.  Need help!
Any suggestions?! <comment><USER2> One of my favorites is Lean Analytics. Goes over all aspects of product growth metrics.</comment>


Ask HN: how do you know if you have a secret, just wrong?  (from Thiel lectures) - <AUTHOR>

there was a previous HN discussion on the secrets lecture http://news.ycombinator.com/item?id=3962129
from the next lecture Reid Hoffman says -
A side note on invention and innovation: when you have an idea for a startup" consult your network. Ask people what they think. Don't look for flattery. If most people get it right away and call you a genius, you're probably screwed; it likely means your idea is obvious and won't work. What you're looking for is a genuinely thoughtful response. Fully two thirds of people in my network thought LinkedIn was stupid idea. These are very smart people. They understood that there is zero value in a social network until you have a million users on it. But they didn't know the secret plans that led us to believe we could pull it off. And getting to the first million users took us about 460 days. Now we grow at over 2 users per second.
so if the nature of having a secret is that people disagree with you, how do you know if they disagree with you because its a good secret, or if they disagree with you because you have a shitty idea? <comment><USER2> _How do you know if they disagree with you because its a good secret, or if they disagree with you because you have a shitty idea?_

This is a great question. So simple yet so difficult to answer.

If we were to go about this systematically, the best way would be to write out the reasons behind your belief in this secret, and then compare your reasoning to smart people's. Human brains don't always get it right; sometimes (oftentimes) we possess incorrect or incomplete models of reality and are simply unable to or too slow to adapt. Listing out your reasoning is a way to expose these flaws whether in your logic or in theirs.

Either the people who disagree or you yourself are missing some key information or insight. Maybe they are jaded or scared or risk-averse or never really took the time to fully think about the idea.

That is probably the only systematic way. But, we must account for the importance of courage as well. It's impossible to be 100% sure of any society- changing secret, so also important is the guts to stick with your secret. Everyone could see through the emperor's new clothes but only one person dared to trust himself and risk saying something. Same as in life, many people have known secrets but they didn't risk following through with it.

Again, it's impossible to be 100% sure of anything and we must account for luck. So say some people disagree with your secret and they peg the chance of success at 5%. Well, if you have some insight that they lack, maybe that quintuples your chance of success to 25%. It's not 100% but now your secret could be worth pursuing, even if you fail in the end!

<comment><AUTHOR> thanks, yeah I guess that's what I figured, try and give people's objections as much consideration as you can, and if you still believe it, I guess you got something

</comment></comment><comment><USER3> I think the biggest thing here is, "What you're looking for is a genuinely thoughtful response." If you are holding back a secret on how you'll solve the problem, and do get such responses; you'll hopefully know which it is.

If you are given that genuinely thoughtful response, it will come with the problems with your idea and the reasons that they think there are problems. You can then compare this information to your secret information. If the problems they present match up, and you have plans to solve them, that's great; if they come up with something you had missed, either a different reason or a widely different problem, you may need to rethink the idea.

Of course, this process isn't going to be 100%, and you're still going to have to some faith in that what you believe is correct, but it's a decent process to go through.

I also don't believe you always have to take the non-obvious route, it is just likely to have less direct competition and a higher risk/reward vs an obvious problem.

<comment><USER2> Yep, its the classic road less traveled idea. Greater risk that you'll get eaten or find nothing at all, but also greater chance you'll strike it big.

Its interesting how many different kinds of startup strategies there are. Some take the unexplored route and flail about trying to find a business model or concept that sticks. Others just copy what others are doing and attempt to out-execute / outcompete. The correct strategy probably has a lot to do with the strengths of your founding team. If you are all execution monsters then choosing a well-traveled space and out-executing everyone is a play that could work well. If you have a founder with unique vision, then following him into the Blue Ocean could prove extremely lucrative.

</comment></comment><comment><USER4> Lets wait until LinkedIn is actually reasonably profitable before taking advice from LinkedIn founders.</comment>


74,476 Reasons You Should Always Get the Bigger Pizza - <AUTHOR> http://www.npr.org/sections/money/2014/02/26/282132576/74-476-reasons-you-should-always-get-the-bigger-pizza <comment><USER2> "One 14-inch pizza has roughly the same area as 1 14-inch pizza..."

How enlightening!

</comment><comment><USER3> Reason number 74,477: You Won't Become Obese Unless You Always Get the Bigger Pizza.

<comment><USER4> Moderation is key.</comment></comment>


One-Quarter of Working Americans Have Zero Retirement Savings - <AUTHOR> https://www.wsj.com/articles/american-households-remain-financially-fragile-fed-survey-shows-11558627721 <comment><USER2> Also, a quarter of working Americans are early in a career, and people generally earn most of their retirement wealth later in a career.

Here's [1] a interesting set of data that demonstrates this. Here's an age breakdown of the worforce [2].

Since about a quarter of the workforce is under 25, I'd not expect them to have much retirement at all. Sure some older people also have too little, but this article makes it sound much worse than it probably is by treating wealth as static.

So since younger workers generally (and historically) have had little net worth but ended up with decent net worth, I wish articles like this would point this effect out and explain the nuance better.

[1] [https://dqydj.com/net-worth-by-age-calculator-united- states/](https://dqydj.com/net-worth-by-age-calculator-united-states/)

[2] [https://dqydj.com/workforce-by-age-calculator-united- states/](https://dqydj.com/workforce-by-age-calculator-united-states/)

<comment><USER3> > Since about a quarter of the workforce is under 25

Your [2] source shows 12.18% under 25 in 2015.

<comment><USER2> You're right. But the overall point still stands when comparing with net worth by age graphs. People have median low net worth till later in their careers. And early on much of that worth is equity, not retirement savings.

</comment></comment></comment><comment><USER4> This is kind of an unhelpful statistic. Thanks to extended adolescence and over education many Americans don't really start working until their mid to late 20s. So the fact that younger workers have no savings doesn't say much about the economy. It also ignores social security. Even if you earn $15,000 a year, so long as you work 35 years, social security will keep you around the poverty level. It also ignores pensions, which 13% of workers (and almost a quarter of baby boomers) are entitled to receive.

<comment><USER5> Oh Lord, it says a lot about the economy. People aren't entering extended adolecense because they love Mom's spaghetti.

</comment></comment><comment><USER6> The data cited in this article comes from the Federal Reserve's _Survey of Household Economics and Decisionmaking_. Their website[1] has the full 2018 report[2] as well as CSV of the data going back to 2013 when it started.

The headline comes from the _Retirement_ section of the PDF, which begins on page 55 of the PDF.

As mentioned by others, this "None" category isn't nearly so interesting as some of the other data in the report. Notably:

> _When asked about their finances, 75 percent of adults say they are either > doing okay or living comfortably. This result in 2018 is similar to 2017 and > is 12 percentage points higher than 2013._

[1] [https://www.federalreserve.gov/consumerscommunities/shed.htm](https://www.federalreserve.gov/consumerscommunities/shed.htm) [2] [https://www.federalreserve.gov/consumerscommunities/files/20...](https://www.federalreserve.gov/consumerscommunities/files/2018-report- economic-well-being-us-households-201905.pdf)

<comment><USER7> _75 percent of adults say they are either doing okay or living comfortably_

That percentage would go up if people's expectations of what "doing okay" means goes down. If society is telling millennials that they're doing well if they can afford a room in a shared house and a new iPhone then they will report that they're "doing okay", especially if they have peers who can't afford those things. That doesn't make it true compared to a generation before them who could afford to buy a house and a new car at the same age and strata of society.

It's a measure of perception rather than anything objectively useful.

<comment><USER8> As an early 'Millennial' I'm quite surprised by how much those about a decade or younger than myself are okay with things being much worse for them than they were for me.

It was easier for me to find housing, study without massive student loans, and receive health care without high costs and/or navigating complicated options.

While I can't tell for sure, it also seems like it was easier for me to get a job out of college that paid acceptably, and that offered decent prospects for the future.

Perhaps I shouldn't be surprised, because what I've heard from those a decade or so _older_ than me is the same story. Among them, things like being a 'long-term student' or getting a job with a straight track to various promotions, seemed much more common, and rent was cheaper. And they've expressed being surprised that I seemed so okay with things getting a bit worse than it was for them.

</comment></comment></comment><comment><USER9> And of the ones that do there is a lot of leakage with people taking loans or cashing out accounts when they change employers.

This is specifically what I am working on but taking the angle of helping people break the paycheck-to-paycheck cycle and make some progress towards their goals. If someone can save up enough to establish a small emergency fund then they are less likely to raid their retirement savings when their car breaks down or they get a medical bill they cannot afford. Further, when one feels like they have their financial life in order they are more willing to make 401(k) contributions beyond their matching amount.

It is difficult though. The default action for people and their personal finances is inaction. Working through some ideas to help that but there is no silver bullet.

<comment><USER10> In order to even consider the problem in terms of savings though, we first have to get to a place where 78% of American workers are not living paycheck to paycheck.

[https://www.forbes.com/sites/zackfriedman/2019/01/11/live- pa...](https://www.forbes.com/sites/zackfriedman/2019/01/11/live-paycheck-to- paycheck-government-shutdown/#18a39dc84f10)

<comment><USER9> Yup, budgeting really is step one in building up enough of a cushion to break that cycle. And budgeting is a change of mindset that is hard for people to adopt. Going from looking at "how much is in my account" to "how much do I have left in my grocery budget" takes time but, when fully bought into, is a powerful way to take charge of your finances and drive the changes needed to build an emergency fund, get out of debt, save for retirement, etc.

Of course a budget doesn't always work. Sometimes one can only reduce their spending so much but still not reach a balanced budget let alone save a few dollars. In those cases the income side of the equation needs to be focused on. I suspect, but don't have data to back this up, that the job market isn't as strong as the official numbers would lead us to believe so there might not be a higher paying opportunity waiting down the street. Certainly wage growth is lagging. There is definitely a disconnect between the macro economy and Main St. in a lot of towns.

This is a huge problem that is only getting bigger as health care costs continue to rise, particularly for people stuck in the Medigap in retirement. But there are no easy answers or short cuts. I think we continue to do what we can to chip away at the problem and, like with budgeting, small improvements can have outsized results over the long term.

</comment></comment></comment><comment><USER11> This is the direct result of failure in the educational system.

With a little bit of financial knowledge (applied), nearly every American should have something to fall back on.

Financial education should be mandatory.

</comment><comment><USER12> With the baby boomers planning for retirement, housing over-valued, and land likely in a similar over-valuation (anywhere that's actually useful)...

Where exactly should I be stashing my retirement to last past when the baby boomers?

I guess maybe that's why people buy so many guns and such, they have a valuation and will be worth something come revolution or as collectors items...

<comment><USER13> A percentage equal to your age in long term bonds and the rest in index funds, I strongly recommend Vanguard. It is my opinion that investing in rental property is the best thing you can do. If the the economy tanks, that just means people who had money have to sell their house and rent.

<comment><USER14> Your first and second sentence seem to contradict each other.

<comment><USER13> I think that's fair to say. If you wish to incur risk and put some of your savings to work, then I would recommend the rental property game. I think it is the most effective way for a white collar worker to amass wealth in a single working lifetime. You must also take advantage of compounding savings in the market.

The mix of these 2 is dependent on the risk the person/couple is willing to incur.

</comment></comment></comment></comment><comment><USER15> I'm actually surprised the number is that low, tbh.</comment>


Spoils of Nature on Instagram - <AUTHOR> https://beside.media/dossier/spoils-of-nature-on-instagram <comment><USER2> I was in Bali last year and I saw several spots like rice fields marketed for Instagram pics. Locals had put up swings, coconut shaped canopy etc.. I was surprised to find out that there was huge queue for 'The Bali Swing' and one girl I spoke to, had spent the entire morning getting dressed up so she can take the perfect insta pic.

I have completely stopped posting travel pics on social media.</comment>


Ask HN: Monitor size - <AUTHOR>

What size is/are the monitor(s) for your machine at home? What size would you prefer? <comment><USER2> I have a 24 inch samsung and the size is perfect as a single monitor. I, like many, don't like looking at two or more different screens. The only thing I would be aware of is that unfortunately with my macbook pro the quality of the samsung just doesnt compare to an apple display and i fiddled with the settings for ages. Adjustable height and rotation was really important for me, and the quality is good enough for the cost.

</comment><comment><USER3> single 27-inch apple display at home. i hate switching between dual screens so this is a perfect setup for me

</comment><comment><USER4> I use three monitors, all 22" 1920x1200. The centre monitor is in the landscape orientation, while the other two are in portrait orientation.

I am not sure what to think of the wide screen aspect ratio. In some cases it can be good, though sometimes I think it's just a bit extreme.

</comment><comment><USER5> I have 3 monitors.

Left 22" (landscape) 1680x1050 Center 23" (portrait) 1152x2048 Right 22" (landscape) 1680x1050

Pretty happy with my current setup. I have them on monitor arms which is the best thing... ultimate control over placement.

</comment><comment><USER6> 1280x1024 17" monitor. I'd prefer something larger, at least 1080p resolution. I've tried using multiple monitors before, though. Doesn't do much for me, but then I mainly used them for playing video games and chatting on IRC...

</comment><comment><USER7> 22" - 27" with anything larger I seem to only see the corners with one eye or I have to move my head to focus on something which is really annoying, 24" is probably the sweet spot for display to price ratio right now.

</comment><comment><USER8> 15" Laptop (MBP) + 21" LDC @ 1600x1200dpi. I like the 15 inch for the laptop and 19-23 for the external monitor though I don't mind a smaller monitor as long as it can run at 1600x1200 or above.

</comment><comment><AUTHOR> It seems that the screen resolution is just as important (if not more important) than the monitor size. Is this a fair statement?

</comment><comment><USER9> @ home: 23" 1680x1050 attached to my 13" MacBookPro @ office: 21" && 23" both 1680x1050 attached to my desktop

</comment><comment><USER10> 2x1920x1080 at home (21" iMac plus 21" external). I'd prefer 1920x1200, maybe even 1600x1200.

</comment><comment><USER11> 3x 30" cinema displays (2560x1600)

<comment><AUTHOR> Good lord, where do you put them?

<comment><USER11> My "desk" is a fire-door atop two heavy-duty sawhorses.</comment></comment></comment>


Show HN: CartoChrono, a mapping tool – useful to anyone else? - <AUTHOR> http://www.cartochrono.com <comment><AUTHOR> I'm considering spending some more time on this to refactor the code and add a couple of new features. I want to find out whether such a tool is of use to anyone else, before spending further hours. I am open to feature requests.

</comment><comment><USER2> Hey, This is a great idea but the way I see it its more of a demo tool but without any way to export the map (as embedded map or even GIF). May be I didn't completely get the point or it might be a good add.

Anyways, great work and hope to see new features.

<comment><AUTHOR> Thanks, I like the idea of making an embeddable playback widget for other people's web sites. The point was to be able to visualise chunks of CSV time/position data - being able to publish those visualisations may be a useful feature.</comment></comment>


The necktie paradox - <AUTHOR> http://mindyourdecisions.com/blog/2009/12/15/the-necktie-paradox/

<comment><USER2> The explanation confuses _Price_ and _Value_. The scenario that's laid out for us is that initially the men are unsure which tie is more expensive. If neither of them believes that one tie is more expensive, then neither of them value their own tie above the other.

Thus, each man has two outcomes: either he will acquire a second tie of the same value to him, or he will be left with no ties. Ignoring the diminished marginal utility of the second tie over the first, it really is 50/50 -- but to an economist, it's not for the reasons explained.

<comment><USER3> No, the reasons explained are perfectly valid.

Another way to think about it is: you are risking losing the more expensive tie (50%) and your potential gain is a more expensive tie (50%). Those are obviously of equal and opposite value.

<comment><USER2> The prices of the ties are irrelevant. The only thing that matters is how much each party to the transaction _values_ those ties.

Imagine that instead of ties, the other guy has a share of GM stock that he bought two years ago for $40. And I've got my wedding ring, which cost roughly the same. By your logic, getting the GM stock would double my aggregate value, and I should be able to shrug off the loss of my ring.

But in the real world, the GM stock has little to no value (due to its depreciation), while the ring has huge value to me (sentimental or not, it's still value).

The same things that make that true, also make things that had widely differing purchase prices provide equal value (what economists call utility) to someone.

<comment><USER4> Wow, you are really nitpicking here.

For the paradox, its assumed that value = price. Yes, in reality, thats not true, but thats not the point. If you don't like ties as an example, feel free to use the original envelope with money or think of some other item where value = price (or is directly proportional to it). In fact, as long as I can say each person might value the other person's tie more than his own, the paradox holds.

</comment></comment></comment></comment><comment><USER5> How is misapplied probability theory a paradox?

<comment><USER6> As much as I hate to wave the dictionary around in a comment, a paradox is an _apparent_ contradiction that may not actually be one, and usually isn't. You don't need an _actual_ contradiction to have a "paradox". (I'd argue an _actual_ contradiction is simply a contradiction and not a paradox at all, but the dictionary I consulted disagrees.)

</comment></comment><comment><USER7> not really a paradox. learn to play poker.

</comment><comment><USER8> If they really enjoy ties or collect them, they would probably be able to tell if their wives gave them cheap ones. If they don't, their wives probably don't really love them.

So, given their suspicion, I'd say the most likely outcome is divorce.</comment>