Employees who do not have high levels of education and technical skill will be continually insecure and will be displaced if they are not continually keeping ahead of the marketplace.  The most painful point the reporter makes is that anyone who starts his or her work career with major family or other responsibilities will have difficulty keeping current with the skills needed.  Maddie Parlier is 22 years old, has completed high school, but has not gone beyond it, is a single mother, and has no spare time or money to take courses and upgrade her skills.  She will be vulnerable to a future replacement by technology.

The problem with the increasing inequality of outcomes in our society in a time of global competition, continuous price pressure, and technology advancement is that continuous education and skill development are more important than ever.  However, achieving this goal is particularly difficult for those individuals who enter the workforce with the handicap of obligations that make continuous learning extremely difficult.

The story about Maddie Parlier begs two questions:

• Why did a woman who is obviously smart and a hard worker not continue her education beyond high school?
• How does someone like Parlier, with time-consuming family responsibilities, find the time to continue to upgrade her knowledge and skills outside of work hours?

When we consider these questions, we are inevitably led to a different way of defining the problem than is customarily used in analyses like these.

Why individuals like Maddie Parlier do not continue in school

My dad, who died in 2001, was a very intelligent person, with great wisdom and insight, and a continuous learner as an adult, but he dropped out of school after the 9^th grade.  My mom, also a person of great intelligence who was a continuous reader and learner all her adult life, dropped out of school after the 11^th grade during the early part of the Depression.  Why?

For them, going to school was an unpleasant and unproductive experience.  The classrooms experience did not engage either of my parents sufficiently to keep them in school, so they dropped out at the earliest possible opportunity.  While it is easy to say that we need better teachers and schools, the bigger problem is that schools do not teach people how to learn.  The educational paradigm is fundamentally flawed. Educators make the judgment that individuals have varying learning abilities, and assume that some people will learn, and others will fail to learn.

I can relate to my parents’ experience by what happened with subjects in which I did not do exceptionally well, like biology, chemistry and physics.

These subjects were taught in a standardized way.  I did not master them, but got good, although not exceptional, grades by sheer hard work and will power.  However, as an adult, I saw their value, and became genuinely excited to learn about the underlying principles of each subject. My daughter even gave me a brief chemistry tutorial on equation balancing recently.

Every one of us gets interested in a subject for different reasons, and we learn in different ways.  I think metaphorically and structurally, and recall information most effectively when I can engage multiple senses in learning the subject.

People have told me I have a photographic memory.  That is not true. I have a photographic memory on certain selective categories of information, but have a below-average memory on others.  My wife can remember the location of a house by a visual map of the color and style of the house and the houses around it.  She remembers foods she ate at a restaurant decades ago, and can even discern differences in the taste of an item from what she ate years ago. I cannot remember what I ate last Saturday night at the local tapas restaurant.

Why do I learn and retain information?

• The subject matter has to be important enough to want to retain it.  I tune out on information that will not matter to me, or that does not strike me as interesting.
• I take copious notes.  Contrary to popular belief, I do not file the notes, but review them once and discard them.
• When I take notes, my handwriting is highly legible, so that I can re-read what I have written.
• If a particular note is important, I underline it.  If it is exceptionally important, I place an asterisk next to it.
• After taking the notes, I re-read them, and I recite what I have written, so that I can hear from what I have written, in addition to seeing it.
• If the notetaking on a subject reveals a particular way of organizing and structuring the information, I create a visual structuring on the page of the notebook, either in the form of a graph, a flow diagram, or a chart.

The more of these tasks I perform, the more likely it is that I will remember what I have written.

My mother used to joke that the reason she dropped out of school was because she was required to do a paper on Sir Walter Scott’s Ivanhoe in her final semester as a junior in high school. I am sure that no one engaged with my mother in a way that helped her find meaning in the assignment.

Rather than trying to shoehorn every student into a one-size-fits-all educational system, let’s try to figure out the different ways in which to engage increasingly diverse populations in the art and the technique of learning.  The goal is “learning,” not “education.”

How do people with overwhelmingly complex lives carve out time for continuous learning, particularly of highly technical subjects?

How does someone like Maddie Parlier possibly carve out time to upgrade her skills?

• We have to create learning processes that provide more flexible self-learning opportunities.  It would be unfair to expect Parlier to attend a classroom course outside work hours, given her single-parent responsibilities, but she can learn online or in other ways.  If there are fees for such courses, she should be reimbursed under a company’s educational assistance program, just as she would if she were attending a class.  We need to make continuous learning as convenient and cost-free as possible.
• We have to teach people how to use small blocks of time as effectively as possible. A single mother holding down a job does not have big blocks of time for learning.  She might get a series of 5-minute blocks of spare time. We need to figure out how she can use them for learning exercises.
• We have to teach people how to multi-task more.

Alternative learning methodologies

Learning can happen anywhere, any time.  I love the text-to-speech feature of my Kindle, especially when I am in my car and can have the experience of listening to an audio book, even if it is in a computer-generated voice. I learn from online demonstrations of subjects.  I also have found that certain TV programs have presented subjects with far more impact than I have ever learned them in a classroom. My friends showed me about the many free tutorials on YouTube. I have even learned from a casual face-to-face encounter, such as a cooking demonstration at a supermarket or a restaurant.  We should test individuals to determine how they learn best, and should draw from their insights and experience, even at an early age, to figure out what is most likely to excite them. Courses should be created in ways that enable them to be delivered remotely and in a multiple ways.

What always amazes me about learning is what we discover about how people of all ages engage with the world.  Some people learn through video games and master complex subjects.  Others gain a great deal of insights from friends, work colleagues, peers, and even online communities.  Even today, I find that my best learning about potential applications for my I-Phone comes from other users.  One of my nephews told me about a new application called Soundhound, which enables my phone to pick up music sounds in a public place and identify the song and the artist.

In essence, everyone can learn, and we should figure out how to make that learning process happen.

How does learning fit into a busy schedule?

It is easy to criticize people who do not take time to improve their skills.  However, in the real world, people have multiple jobs, are juggling time-consuming family responsibilities, and often have challenging commutes to and from work.  Moreover, many jobs are physically and mentally draining. For many people, the ability to take time to learn simply does not appear to be there.  How can we help people carve out the time to learn?

• We need to show people how to simplify their lives, reduce the wear-and-tear of daily activity, and create learning time.  Too many people drive to work alone every day.  Even when public transportation is unavailable, there are many underutilized carpooling, vanpooling, and ride-matching services available to people.  I gained an extra 90 minutes a day of reading time when I commuted by train between New York and Connecticut. When shuttle services between the train station and the office were unavailable, many people gave me rides to and from the train, and I learned a great deal from them.
• Buying hot, healthy pre-prepared food virtually eliminates cooking time, and frees up time for other activities.
• If I were a young parent today, I would be looking for tools to order groceries, clothing, supplies, hardware and other items online for home delivery to save on shopping time.

If large blocks of time cannot be created, then we have to coach people how to use smaller time blocks more effectively.  I always felt that one of my advantages over other people was the use of 1-5 minute time blocks.  When I watch live television, I put the set on mute during commercials, set an alarm for 3 minutes, and do something productive. More and more, I record programs to reduce the watching time from the original running time by fast-forwarding through commercials. I recapture that time for other purposes.

How do I use 5-minute drives to and from the coffee shop? I turn my Kindle into an audio book and listen to a few pages while driving.  The Kindle also can be read outside while I am walking and even while I am waiting in line at the grocery store or some other retail outlet.  I have done a lot of reading in the security lines at airports, while I watch other people stare into space.  I also remember doing work during the many times I waited with my children at the pediatrician’s offices as they were growing up.  I took my own materials, rather than relying on what the doctor’s office had available.

Everyone has spare time. The only question is how to take advantage of it.

We need to teach people how to multi-task more.

When my children were young, I used to take them to the local doughnut shop, get a cup of coffee, browse the newspaper, and talk with them.  It was a great bonding experience for us, and I typically read to them and talked about whatever I was doing.  I also used to take them to museums on Saturdays and Sundays and learn as they were learning.

Today, the shoe is on the other foot.  When I am with my adult children, I ask them about what they are learning, what books they are reading, what movies or videos they have seen, and what places they would like to visit, and why.  My daughter is great in the sciences, so she continually directs me to good resources.

Also, as I noted above, we have a lot of waiting time in our lives that can be usefully deployed. Today, many people use their cell phones to talk or do text messages while they are waiting for someone, but it is easy to convert some of that time to learning time.

We have to change the paradigm from schooling to learning.  We have to change the paradigm from learning as a highly standardized activity to a highly customized one. We have to change the paradigm from learning as a process that takes place within specific certified courses to one that can occur anywhere.  I have no problem with testing people to see what they have learned, and rewarding them for having achieved a certain level of competence, but we need to make it as easy for them as possible.

This skill and knowledge gap is solvable. We can help the Maddie Parliers of the world compete in the global economy and support their families.

In this case, the employer is the Port Authority of New York and New Jersey, an entity created by a contract between New York and New Jersey and jointly owned by the two states.  This entity is not accountable to elected officers or voters, except for the indirect influence that elected officials from the two states sitting on its board of directors have on the entity’s operations.  Oddly enough, entities like the Port Authority were created over several decades in the 20^th century because elected officials believed that they would operate in a more business-like fashion and not be subject to the corrupting influences of elected officials trying to “buy” votes by bestowing favors on constituents. However, the lack of public accountability means that the customers of the Port Authority, namely those who travel in the New York Metropolitan area, will bear the brunt of the abuses of the pension system.

In one sense, it should be easy to solve this problem: abolish this “pension spiking” scheme in the next collective bargaining session.  However, we get a hint of why these kinds of schemes are so hard to uproot. A toll collector named Princesella Smith is quoted as saying: “I’m blessed. I have a great job, and, in this economy, it’s great that I can cover everything with my eight hours a day and overs.”

Executives and union leaders who both know that paying a toll collector like Ms. Smith $89,599 per year is absurdly excessive also have to confront the fact that, but for her oversized compensation package, she probably would be living in a much more difficult economic situation.  She is a human face to the problem of reducing the government budget deficit.  I found that, at Pitney Bowes and at other large organizations, no matter how well these organizations were managed and how tightly costs were controlled, it was difficult to bring pay into line with what made sense for customers.

The overpaid employee is a real person, often well liked and appreciated for his or her organizational commitment.  While I do not know how good an employee Ms. Smith might be, she is clearly doing a job, collecting tolls on the George Washington Bridge, that few people would choose to do if they had other choices.

Not only are overpaid employees often liked and appreciated, but senior executives often know the families of these employees and the tragedies and challenges the employees face.  At Pitney Bowes’ Connecticut operations, there really are no executives living in enclaves that totally separate them from coming into contact with ordinary employees.  I was highly likely to interact with company employees outside the office. When my second son was younger, the president of the Little League baseball program was a product manager at the company. Our housekeeper’s husband worked at the company. When we went to school events, we would meet parents who were company employees and whose children were friends of our children.

It is easy to blame militant labor unions for fighting to preserve the jobs of overpaid and under-skilled employees.  However, my experience is that these problems would exist in any organization in which executives, voluntarily or otherwise, build close personal relationships with people up and down the organization.

Over time, I developed the skill of confronting people I knew and liked, but who had to leave the company.  I had to convince them that it was not only in our best interest, but in theirs, that we were taking them out of a job, reducing their pay, or in some other way taking an adverse employment action.  I operated on the simple principle that if I could not look them in the eye across a table and justify what we were doing, the action was indefensible.  Thankfully, I never had to make the judgment that an adverse employment action was indefensible when I used that test.

When we teach senior executives to care about employees as individuals, then we create a different problem.  It becomes challenging to look those overpaid and under-skilled employees in the eye, meet them in the coffee shop and deli, see their families in the school events, or run into them on the street, and tell them that you either have to eliminate their job or reduce their pay to bring it into line with what the market pay should be for their job.

Think about the job of a postal worker who manages mail sorting machines.  At Pitney Bowes, we were able to employ and retain people who would do this work at about 1/3 the rate that the Postal Service was paying for the same work.  We were consistent in our pay practices with the real market for this job.  The Postal Service’s pay rates were artificially high, both because of a collective bargaining agreement, and because of the political pressure that postal union workers could bring to bear on elected officials.

The concept of a “living wage” is that people must earn enough in any job to be able to afford a standard of living above the federal poverty line.  However, what “living wage” advocates forget is that the “living wage” movement would result in fewer jobs and more expensive products.  As I look across our economy, I see many candidates for job eliminations if wages for that job get too high, not the least of which is the toll collector job.

When I go to large retail grocery stores and pharmacies, I am increasing seeing self-service stations, including some at the checkout counter.  When I go into bathrooms, I see electrical hand driers, which clearly replace the job of transporting and stocking paper hand towels. Postal sorting machines have replaced most postal clerks who sort mail.  Automated banking kiosks replace tellers, as other vending machines provide 24×7 service in place of retail clerks.

The largest job elimination trend, which particularly comes into play at this time of year, is the substitution of online shopping for retail purchases.  In past years, my wife frantically traveled from store to store to buy Christmas gifts.  Today, she sits with her computer and orders everything online.  While the merchants that deliver in response to online orders certainly employ people, fewer people are needed for online transactions, compared with their retail counterparts.

In essence, the labor union and “living wage” movements, whether they want to admit this or not, are hastening the elimination of the jobs they are trying to protect and enhance. They will win for a few years, but eventually the desire for consumers to get the highest level of convenience and value at the lowest cost will override the desire to protect someone else’s overpaid job.

“High consumption of care is driven by the crowd of academic medical centers, specialists, and equipment needed to perform tests. The Bay State has one doctor for every 267 citizens — versus one doctor for every 425 people in the nation as a whole. Supply drives demand. “

Supply-driven demand happens for two reasons, often overlapping:

• Healthcare providers believe in a particular treatment or therapy, and try to maximize the number of people who access it.  This is often reduced to the saying that “If you have a hammer, every problem is a nail.”  Supply-driven demand occurs when people who should not be customers for a particular service become customers because the provider of that service force it beyond its natural market.
• Healthcare providers have excess capacity, and try to get that capacity in use.  This happens with expensive diagnostic imaging equipment, hospitals, and outpatient centers.  It is even arguable that physicians react to reduced usage of their services by patients who become healthier by increasing the frequency with which they see other patients.

The other reason hospital capacity drives demand is that, even when it makes sense to close or shrink a hospital, there is a strong reluctance to shrink or close a facility that appears to be a strong job preservation engine in a community.  However, we must confront the issues associated with repurposing healthcare facility and provider assets, because our current healthcare architecture is unsustainable.  Too many Americans, probably now in excess of 15 million, are employed in healthcare, and too much of our GDP, now around 17%, is devoted to healthcare spending.  We need to redeploy a significant percentage of healthcare assets toward alternative uses.

Closing a hospital can be done in the situation in which there are other hospitals that can absorb the patient population the closed hospital used to serve.  In Stamford, Connecticut, St. Joseph’s Hospital was closed and most of its patient population migrated to the Stamford Hospital in the late 1990’s.  The Stamford Health System, which owns the Stamford Hospital, created a new wellness, outpatient diagnostic, and outpatient surgery center on the old St. Joseph’s Hospital site.

However, there are less drastic alternatives to closing a hospital, especially when there is one hospital in a community and closing it completely is not a viable option for the served population.  Repurposing big chunks of hospital campuses is an option that healthcare policy makers have to consider, and for which they need to develop an expertise. Although the examples I have found around North America all relate to redeploying complete hospital sites, as opposed to partial redeployment, they are instructive on what could be done with separable parts of hospitals.

In Vancouver, British Columbia, the unused hospital space became an Arts Center.  In Rogers, Arkansas, the closed St. Mary’s Hospital became a Center for Nonprofits.  At Virginia Commonwealth University, a former hospital was converted to student housing.  At the Tufts Medical Campus, unused hospital space became a café and fitness center.

The repurposing of hospital space that is no longer needed for patient care can also take into account the needs of medical residents, who could live in the space, which, in some cases, has been converted to residential and retail space.  Given the exorbitant cost of medical school and medical residency programs, subsidized housing could be a great alternative to more hospital beds.

I could also envision an innovation incubator, in which there are small offices for entrepreneurs of start-up businesses.  In downtown Stamford, Connecticut, there is an attempt to use an old government building as an incubation center.

While hospitals will lose revenue potential by shrinking, the overall healthcare system needs to look at what benefits society as a whole, as opposed to what will maximize an individual hospital’s revenue and jobs.

What happens to those no longer working at the hospital?

• Those working as healthcare professionals, doctors, nurse-practitioners, nurses, physician’s assistants and nurse’s aides can be redeployed to the remote or the onsite care of patients in their homes.
• Those working in clerical and administrative jobs could also be redeployed in organizations that provide care, but in a less capital intensive organization.
• Those who provide facilities related services can provide those services to whatever uses are substituted on the site.  There are some facilities services, such as hazardous medical waste management, that will go away completely, but food service, maintenance and repair, and delivery services will survive.

Who loses when a hospital is repurposed?

• Providers of expensive diagnostic technology will see a significant volume drop.  Eventually, Medicare and other payers will create payment systems that reduce payments to a level at which unconstrained use of diagnostic imaging tests will not be able to be reimbursed.
• Doctors who rely on scheduled surgeries will lose opportunity because the hospital will do fewer surgeries.  However, one alternative to a portion of a hospital is an outpatient surgical center, which can absorb a portion of the supply.
• Providers of ambulance and emergency medical technician services will see a volume drop only if there is not alternative hospital to which to take patients, so emergency departments will not be automatically reduced to handle real emergencies.  However, there are emergency department transactions for non—urgent care that can be taken out of the hospital altogether, and can be managed through remote care.
• Labor unions which represent certain groups of employees that will be scattered when redeployed among a number of employees will lose, to the degree that their collective bargaining agreement is narrowly targeted at a specific employer.

The bigger challenge in closing or repurposing a hospital is political.  Elected officials intervene on behalf of any group, which believes it will be disadvantaged.  This is especially the case if the apparently disadvantaged group is organized to effect powerful political advocacy, such as a labor union, or if there is a high proportion of people of color in the groups affected by the decision.

The biggest skill set required in repurposing healthcare assets is the ability to envision a future that is better for the community, better for the community patient population, and not unduly disruptive to the various stakeholders, which benefit from having the hospital remain intact.

Having leaders who can think through and implement a game plan to transition elected officials and the communities they represent toward an alternative future that reduces the footprint of the healthcare system is our biggest challenge.

Unlike Walt Mossberg, whom I quoted the other day, or the many other commentators who celebrated Jobs’ successes, Schulz focused on the fact that Jobs had many major failures along the way, including the Apple I computer, the Lisa computer and the NeXt computer.  He was asked to leave Apple in 1985 and did not return until 1997.  Steven Jobs failed repeatedly and publicly, and he paid in the short run.  However, today, the Apple employees and shareholders are more secure and richer than they ever could have imagined.  He invested repeatedly for the longer term.

That article and the reflections on Steven Jobs’ failures caused me to think about other transformative individuals are their repeated failures, as well as the many failures that have occurred in my life.  Two individuals who have talked, present and past, about their failures were Thomas Edison and J.K. Rowling, the author of the Harry Potter novels.  Edison celebrated his unsuccessful attempts to solve problems through innovation because, as he said, he learned what did not work and it helped him figure out better what did.

More interesting than Edison has been the life story of J.K. Rowling, who, after college, failed at marriage and an early attempt at writing before she finally began to succeed in her late 20’s with the Harry Potter novels.  Rowling gave a commencement speech at Harvard in 2008 at which she spoke about the many benefits of failure, among them, the focus it gave future efforts, the self-confidence and inner security it generated, the wisdom it helped her developed, and the fact that it helped her separate real from “fair weather” friends.

As I have gone on many journeys in my life, I have had both mistakes and colossal failures.  I failed at my first two jobs out of law school, both with reputable law firms.  I made mistakes along the way as a business executive.  I made investment decisions that failed.  Since retirement, I have had many failed attempts to raise money for both Dossia and my film From the Rough, and, although I am more confident about success in both cases, I have actually been propelled forward by the failures.

Each failure requires careful study to understand its lessons.  Oddly enough, my failure to secure traditional major studio financing for the film has taught me that the film very likely has a large underserved market that the traditional studios have ignored, the market for films directed at women and people of color.  The film The Help appears to be supporting my assumption that there is a market for intelligent content directed at audiences Hollywood has left behind.

I have been told that I was stupid and naïve by people experienced in the market spaces in which I initially failed, only to find that I was getting that feedback more because I threatened an established order than that my initiatives were flawed.  My health care vision has been proven right over the last 20 years, despite the fact that I was not taken seriously by industry experts when I first articulated it 20 years ago.

My unsuccessful attempts to accomplish something had the effect Rowling discussed in her commencement speech:

• They increased my determination and will to succeed;
• They helped me sort out real friends from pretenders;
• They helped me seek out help and build support systems I would not have needed if I succeeded immediately; and
• They helped me focus my life on what mattered most.

What particularly resonated with me about Rowling’s remarks was her comment about those who refuse to take the risks of failure.  She referred to them as the “willfully unimaginative.”  She said that they become imprisoned in a psychological world in which their fears and even their nightmares get more frequent and more intense, because they get more removed from the messy real world in which failure is an everyday occurrence.

As I call on large corporations today for Dossia, I see these people every day.  I see them also in government and even sometimes in the not-for-profit sector.  They experience huge stress and expend significant energy worrying about low probability events.  In so doing, they increase the odds that something very bad will eventually happen to their organization, and, perhaps, to them.  When someone worries about low probability risks and tries to avoid them, they usually take their eye off the ball relative to higher probability risks and end up not being able to avoid them.

It’s sad, but I see large corporations inadvertently engender risk-averse behaviors by stupidly conceived downsizings and restructurings.  They announce a big layoff, take a long time to execute on it, and make everyone progressively more insecure, not just during the period of the layoff, but well beyond it.  Survivors learn the wrong lesson from avoiding a layoff.  They become more cautious and put their organizations at much longer-term risk.

I spent a lot of time talking about failures when I led Pitney Bowes, and getting people comfortable with the idea that, if they failed, it would not be the end of the world.  I met with many people we had asked to leave the company, and I deliberately told them that there was life after Pitney Bowes.  I shared my experience with failing at two successive law firm jobs, and being asked to leave the second firm.

This is a time unlike any in my lifetime, although every time period looks more stable and placid in hindsight than it was when people were living through it.  The good news about a turbulent time is that failures happen more often to more people, and there is less of a stigma attached to failure.  Individuals can experiment more, fail faster and more often, and find the right future path sooner and more painlessly than they could at a time when everyone is expected to succeed and failure stands out more.

We should be celebrating the intelligent and determined unsuccessful efforts of people, perhaps as much as we celebrate successes.  That is why, while I commented on Steven Jobs success a few days ago, I want to make sure that I give equal time to his failures.

These theories are certainly part of the explanation, but I would offer another explanation: that we are in the midst of a long-term redefinition of the skills and capabilities our economy needs, as well as the way we govern ourselves as a society, and that, as a result, there is a serious mismatch between the skills our economy needs and the skills and capabilities available within our country.

Our economy, our labor-management relations, our government tax collection systems, our communities, and our social relationships are build upon an economy based on regular full-time jobs with well-defined and relatively stable definitions of job responsibilities.  However, the world we are entering makes our ways of organizing work, labor-management relations, tax collections, communities, and social relationships obsolete.

When young people ask me about how they can have successful careers, I tell them that there are three ways of defining their career objectives: around a job or a profession, around working for a particular organization or industry, or around a mission or cause.

Career objectives organized around jobs or professions

In the past several decades, we have heavily emphasized training people for specific job categories and causing them to define themselves around a particular job category.  People get jobs as teachers, lawyers, accountants, consultants, general managers, IT professionals, auditors, engineers, or HR managers or professionals.

In fact, I think we have gone overboard in rigidly defining jobs and professions by creating state and local licensing requirements that have significantly raised entry barriers and lowered employment in many professions.  For example, to get a license to cut hair at a barbershop in Connecticut requires a one-year course of study that costs a person $20,000.  While there are good reasons to require education, training, and certification for hair cutters, since they handle sensitive and potentially toxic chemicals, I find it hard to believe that the certification process should cost an applicant $20,000.

Colleges, universities and training schools, as well as governments, like the idea of slotting people into job categories.  It is easier to organize curricula around job categories, and, as noted above, it can be highly profitable to train people for specific, licensed job categories.  It is easier for government regulation and reporting to attach people to specific jobs.  Unions can more easily organize around particular crafts and job categories.

The problem with this form of career organization is that, from time to time, particular types of jobs or professions become very attractive and end up creating surpluses of people with job-specific skills.  This happened with aerospace engineers in the 1960’s after the space program was phased out, with journalists after the Internet obsoleted traditional print journalism, with IT professionals after the hiring surge caused by Y2K ended, and with lawyers after companies found ways to automate what lawyers used to do.

Over a much longer period of time, productivity improvements will obsolete any particular narrow job description that pays a high salary or that, even at a low salary, employs a lot of people.  Agriculture has employed progressively fewer people, as has manufacturing, and we are seeing a similar reduction in call center workers as we move more toward self-service.  In the next decade, I predict that retail cashiers in large stores will decline as technology moves us more toward self-checkout systems.

Today, we have many people trapped in jobs or professions for which the supply far exceeds the demand.  Creating more specific jobs in specific categories is not a good way of managing and sustaining an economic recovery.

Organizing careers around companies or industries

This was a popular way of building a career after World War II and into the 1980’s and still remains as a way of thinking about career planning.  In the 1940’s through the 1970’s, people entered the automobile industry because it seemed large and stable.  Today, the U.S. automobile industry has probably shrunk permanently because we have declined from purchasing 17 million new passenger cars a year to about 11-12 million, as cars become more reliable and their replacement cycles lengthen.

Large companies relentlessly shrink their workforces over time, even in good economic environments, especially as they seek more productive and lower cost work environments, so the notion of attaching oneself to particular companies is obsolete.  When I was growing up in Rochester, New York, cousins and friends urged me to seek safer employment in companies like Eastman Kodak and Xerox Corporation, companies that have a fraction of the jobs they had 40 years ago.

Government and health care jobs have increased significantly in the last decade, but government jobs are already shrinking, and I predict that health care jobs will as well.  We will find ways to get more health care tasks done offshore or through technological means.  For example, the task of drawing blood will move from being a high-skilled task in a laboratory to a self-administered task for many applications.  We will still need nurses trained in drawing blood intravenously, but the occasions when intravenous blood draws will be needed will decline over time.

Careers organized around missions, causes, or problem areas

To me, the most sustainable careers are those organized around a mission or a cause that will take decades to address.  We are blessed or cursed, depending on one’s perspective, with societal issues that are going to take years, if not decades, to address.  Those who can identify recurring work responsibilities needed in the addressing of those missions, causes, or problems can secure long term employment.

For example, America will have a long-term need to rebuild its crumbling infrastructure. It will be several decades, if ever, before we complete this process. Those with skills deployable on the process of rebuilding America will be employable for a long time.

We have a shortage of civil engineers and systems engineers to do the work on the major capital projects required for this rebuilding process Relative to other professionals, such as attorneys, those who can help manage environmental, land-use, and financing issues will be employed for a very long time.

Funding may ebb and flow, but we do not have the luxury of stopping work on these projects.  Moreover, even if a specific type of professional work declines, there will be adjacent spaces in which work will be needed.

We have big, long-term societal problems, such as the rebuilding of our crumbling infrastructure, the sustainability of our environment, the need for energy conservation and efficiency, and the reskilling of our workforces.  We also need to deliver services to turn our least productive citizens into more productive members of our society.  Those who focus on societal needs and then work backward to what tasks are required to meet those needs are most likely to figure out what skills are needed and then to develop those skills.

We have to get away from rigidly defining jobs and certifying people into those jobs, and to move toward defining broad societal needs and deploying people toward meeting those needs.  Government can facilitate these processes by organizing stakeholders to address them, but it is a hopelessly inefficient and slow stakeholder in creating jobs and filling them with people that can meet complex and often fast-changing needs.  Government also has to get out of the business of creating large and inflexible entry barriers for jobs and professions.  To the degree that licensing requirements exist today, government needs to have a process of revisiting those requirements every few years to insure that they still make sense.

It is a tragedy that we have so many potentially productive Americans on the sidelines, either collecting unemployment benefits, or, in some instances, having exhausted their benefits when there are so many compelling societal needs that remain unaddressed.

The Old Paradigm: Healthy people subsidize those who get sick or injured through no fault of their own.

Throughout the history of U.S. health insurance, the prevailing paradigm was that everyone paid for health insurance, with the healthy people paying higher premiums to subsidize those who became sick through no fault of their own.  State insurance regulators authorized the issuance of health insurance policies with three rating frameworks:

• Community rating: everyone paid the same premiums;
• Adjusted community rating: differences in premiums are allowed, based on population demographic factors like gender, age, and geographic differences in health care delivery costs; and
• Experience rating: those with pre-existing conditions either were denied coverage, paid more, or had coverage exclusions.

All these systems assumed that insured people had no control over their health.  Therefore, adjusting premiums based on individual behavioral risk factors, such as smokers’ penalties, allowed in life insurance policies, or premiums based on taking a drivers’ education course, part of automobile insurance ratings, were not allowed in health insurance policies.

The old paradigm made more sense in the early 20^th century because most health care costs arose from life-threatening infectious diseases or catastrophic injuries, believed to be beyond individual control. There were fewer treatment options for major diseases, and they did not have huge cost differences. Therefore, rewarding patients with lower premiums, deductibles, or co-pays for intelligent, discretionary treatment decisions made less sense.

The New Paradigm: Health insurance premiums, co-pays and deductibles are adjusted based on patient behaviors.

Recent decades have seen a radical shift in health care cost drivers.  Preventable and controllable diseases, such as Type II diabetes, heart disease, many cancers, and behavioral health and substance abuse conditions, comprise the vast majority of our health care costs.

Additionally, there are huge differences in the intensity of care provided to individuals, based on their providers selections and decisions they make among discretionary treatments.  Differences among end-of-life treatment options are hundreds of thousands of dollars.  Prostate cancer or back pain options can vary by tens of thousands of dollars. More health care costs are controllable.

Health insurance regulations and plan designs have not recognized these realities. Self-insured employers have the best chance to design health plans with the new paradigm because they feel the most pain and have the most plan design flexibility.

Value-based health insurance plan design is the new paradigm for self-insured employers.

Principles

Value-based health insurance plan design for self-insured employers is the new paradigm.  It is based on the following principles:

• Plan members are rewarded for behaviors reducing the risk of incurring preventable medical conditions.
• Plan members are rewarded for making intelligent choices of high value providers.
• Plan members are rewarded for intelligently evaluating treatment options.
• Plan members that adhere to treatment protocols get rewarded.  Those refusing to adhere to treatment protocols get penalized.
• Providers delivering better care at lower cost are rewarded with higher reimbursement rates.

Evolution of value-based health insurance plan design

Employers like Pitney Bowes adopted relatively simple versions of value-based health insurance, and obtained excellent results:

• They made preventive care free to plan participants, while charging participants for accessing the health care system.
• They supported health plans by making preventive care such as immunizations, health screenings, and health risk appraisals conveniently available, and paid participants for health-promoting behaviors.
• They enabled individuals to adhere to chronic disease treatment plans by making maintenance medications free of charge.
• They steered participants to treatment paths that increased their intelligence in making treatment decisions:
  • Pitney Bowes provided higher mental health reimbursement rates to participants accessing eight free behavioral health counselor visits before selecting their treatment path.
  • Pitney Bowes introduced a multi-stage treatment path for treating morbid obesity, with bariatric surgery as a last-stage, as opposed to first-line, treatment.
  • They created higher charges for emergency department use for non-urgent care, or for excessive diagnostic imaging test use.

These plan design implementations were successful, but the patient-controlled, portable, personal health management system, with a core personal health record, takes value-based health plan design to a new level.

The newest paradigm: value-based health insurance plan design rewards the right behaviors more precisely, faster, continuously, and more powerfully through a personal health management system.

Large self-insured employers understood that employees needed help navigating complex health care systems.  They purchased disease, care, and large case management programs, often from third-party insurance administrators to improve engagement. They also provided health-promoting behavior incentives, either within health plans or in separate employer-sponsored wellness programs.

The 2011 Towers-Watson Survey of employee benefits executives indicates that large employers are dissatisfied with these programs.  These programs achieve about 10% engagement from the target population, and have not produced hoped-for health outcomes.

Employers are also dissatisfied with prevention and wellness programs, because they believe that they are not securing additional participants.

How do personal, portable, patient-controlled health management systems solve these problems?

Personal health management systems allow data collection more frequently, more precisely, and in real time.

Daily tracking of biometric data increases the likelihood of controlling the disease being managed. For example, tracking blood pressure for a person with hypertension increases the likelihood of controlling hypertension by over 50%, based on a 2009 Kaiser-Permanente study.  This supports Peter Drucker’s observation that “what gets measured gets managed.”

A new value-based health plan design application would reward an individual partially for tracking key biometrics and partially for controlling them.

Personal health management systems create new and more effective ways of delivering health care coaching that an employer can reward.

Rewarding someone for engaging in a wellness program or for engaging with a health coach, nurse, or physician to manage a medical condition has produced disappointing results.  Wellness program providers routinely get only between 10-15% of the target population engaged in these programs.

Tailoring communications to consumer preferences will improve consumer engagement. The ability to supplement face-to-face and telephonic communications with text messages, or online web site, e-mail, and live chat tools makes these programs more effective, especially if the consumer receives rewards for every contact, not just the initial contact.

The value-based health plan could vary the co-pays and deductibles for an individual who engages frequently with health coaches or nurses in managing a chronic condition.

Personal health management systems are more effective at monitoring adherence with chronic disease treatment plans and other necessary medical practices.

One inherent frustration of self-insured employers is that high health care expenses come from individuals who fail to adhere to their chronic disease medication regimens, thereby ending up receiving expensive acute care.  A personal health record will receive information as to whether a prescription is filled within minutes after it is filled. The Vitality Glowcap device also enables monitoring of whether users are taking their medications.

In addition to making maintenance medications free of charge, the value-based health plan could provide incentives for filling a prescription within a specified period, for taking medications on schedule and for getting timely refills.

Personal health management systems can provide exceptional patient decision support tools for health care treatment decisions on conditions for which a variety of imperfect treatment options are available, such as back pain, obesity, mental health, prostate cancer, and end-of-life care.

Treatment differences manifest themselves in such discretionary decisions as:

• caesarian surgeries,
• surgery as a first-line option for relieving back pain,
• prostate cancer victims using either the most expensive laser treatment technology instead of watchful waiting,
• administering chemotherapy extending life a few weeks, but resulted in shortening life for many patients, and
• using bariatric surgery for morbid obesity.

The personal health management system can provide tools for patients to understand the strength and weakness of all treatment options.  Requiring patients to study these options does not automatically nudge them toward the least expensive option, but helps them control the decision, as opposed to having it imposed on them by their physician. It also makes them more active partners in managing their health.

The value-based health plan gives strong financial incentives for patients to engage in a careful, interactive decision process before making a choice among discretionary, imperfect treatment options.

Personal health management systems are great vehicles for helping patients, those making care decisions for them, and those working with them to improve their health to determine their life goals and values, as well as their sources of well being in their daily lives. Armed with such information, physicians and other health care professionals can help patients and those making care decisions for them make the best decisions on how to optimize health and well being.

Many flawed health promotion strategies assume that, if we educate individuals on healthy behaviors, they will engage in those behaviors.

Optimal health does not generally drive individual behavior.  Otherwise, no one would smoke, abuse alcohol, overeat, play inherently dangerous sports, or drive recklessly.  Many factors influence health-related decisions, such as peer and family acceptance, the pleasure derived from unhealthy behaviors, the perception that unhealthy foods cost less than healthy counterparts, and the belief that the unhealthy behavior has healthy side effects (smoking suppresses appetite and keeps smokers thinner.)

We need to understand life goals and values before changing them.  The personal health management system is wonderful for engaging in a dialogue to determine life goals, and figuring out what motivates both healthy and unhealthy behaviors.  The Mayo Clinic has a wonderful tool called “motivational interviewing,” which is great for this purpose.

These life goals are particularly critical to understand when the individual is unable to make healthcare decisions.  End-of-life decisions lend themselves to decision processes tested against life goals and values.

Value-based health plans, combined with personal health management systems, would be a major step forward in helping us produce better health care at lower cost.

Whole industries and marketplaces, and often political and social paradigms, depend on people willfully denying reality.  In health care, the stubborn myth is that more care is always better care.  This myth enables health care providers to make more money, not have to make tough end-of-life decisions, and appear to be giving the patient what he or she wants.

Excessive care often puts the patient in worse position than if no care were given.  Many drugs are ineffective and have negative side effects. In certain cases, aggressive cancer treatments shorten life. Surgeries not only do not correct the problem for which the surgery is done, but create other complications.  The Dartmouth Atlas Survey, which was created by Dr. John Wennberg, has demonstrated over several decades that there is no relationship between the intensity and cost of health care across regions and the health outcomes.  It often happens that we spend more and get less for our money.

We willfully deny this self-evident truth, because, if we acknowledged it, we would have a health care system with different winners and losers.  Many high-cost health care regions would lose revenues and jobs.  More painful end-of-life conversations would have to take place. Society as a whole would be far better off, but many individuals would have painful readjustments.

Similarly, in the film industry, there is a deeply imbedded view that commercial success for films is totally random.  It is best reflected in how many people have interpreted a famous quote by William Goldman, an author and Academy-Award winning screenplay writer: “In the end, nobody knows anything.” Goldman meant to point out that making commercially successful films is an art, rather than a science, and that there are no guarantees of success.

His thoughtful observation has been distorted into a view that commercial success is totally random.  This view of success as being random is insidious because it denigrates the value of intelligent planning and execution, as opposed to the seat-of-the-pants decision-making many people make.  It turns every filmmaking endeavor into the equivalent of playing the exceptionally low-odds Powerball lottery. It also justifies making no significant changes to what intelligent film industry executives know is an unsustainable business model.

The unpredictability myth enables some to resist any changes in business practices that would increase predictability and likelihood of success.  Companies like Epigogix, which offers predictive modeling on film screenplays, and Opera Solutions, for which I am an advisor, which provides data analytic solutions for increasing the yield on film recommendations to customers, prove that, while results can never be guaranteed, the odds of success can be significantly improved.  There are many film industry executives who have developed extremely workable and intelligent business models, but what has made them successful has not been universally understood or copied.

Among politicians, a similar, deeply imbedded paradigm is that success is a result of luck.  Politicians, many of them far left Democrats, refer to taxes that redistribute wealth as “progressive” and as “ways to help the less fortunate.”  To them, the difference between success and failure is a function of how lucky breaks are distributed.

Success is a combination of smart decisionmaking and luck.  Malcolm Gladwell, in his book Outliers, argues that Bill Gates’ success was heavily influenced by computer access he had at his prep school.  He also gives many other examples of people who had similarly privileged access to resources needed for future success.  Bill Gates clearly had an opportunity not available to many Americans in the 1970’s.  However, Gates was not the only student at that school.  Others had the same access, but he was the only one who took full advantage of it.

In my life, becoming the CEO of Pitney Bowes involved a great deal of luck.  However, my work, and the assistance I received from family and friends over a lifetime, enabled me to benefit from the lucky breaks when they came.  I worked hard, deferred many gratifications, and experienced a lot of resentment from those who chose not to work as hard.

Other than lottery winners, there are no instant successes.  Many so-called “overnight successes” are really cases of people who have labored for years to be ready to take advantage of the one big break.  I wrote about this in a blog some time back about the difference between the way Bill Wyman accurately chronicled the Rolling Stones’ success, compared with how popular media described it.  Popular accounts of the Rolling Stones’ origins focus on the early partnership between Mick Jagger and Keith Richards and imply that there was instant chemistry and genius yielding early success.

Wyman, a founding band member, told a different story.  The individual band members toiled for years as solo performers and members of other bands.  They experimented with different musical styles, inspired by artists like Lonnie Donegan who led the way with musical pieces that combined multiple musical genres. The Rolling Stones did not achieve instant success, but built the foundation for what appeared to be instant success after the Beatles led the way in the U.S. in 1964.

Even those cases of performers “discovered” decades ago in various Los Angeles area soda shops, such as Lana Turner at Schwab’s drug store, often leave out the foundational processes that led to the “discovery” or that followed it.  Turner grew up under very difficult circumstances, being born in Idaho and moved to San Francisco as a child, and worked hard to be ready for her break.  She made a number of gutsy decisions, including a decision to leave one studio and join another as a teenager.

With the exception of lotteries and those smart enough to take their casino winnings and save them, there are relatively few cases of lucky, overnight sustainable successes.  When people get lucky and win lotteries, they often are unprepared to deal with the consequences of success and either lose their money over time or experience huge disruptions in their lives. A great TV show in the 1950’s The Millionaire, depicted people presented with a tax-free million dollar check (comparable to $10 million today) from an anonymous donor, who often struggled to live with their newly-found wealth.

Adherence to myth is unaffected by one’s level of education and wealth.  Many educators with advanced degrees adhere to the myth that, if only we gave teachers and schools more money, the quality of education would improve.  Clearly, good educators would benefit from having more resources.  However, giving a poor or mediocre teacher a higher salary and smaller classes with more equipment and supplies in a nicer facility will not turn that individual into a better teacher.  Moreover, someone ill-equipped to teach does not get better with experience.  Teachers’ unions and other advocates of more education funding would be much more credible if they acknowledged that many members of their profession do not belong in it.

What do we do about these persistent myths?  First, acknowledge them in a non-judgmental way. Second, recognize that, if there is economic dislocation from changing a paradigm, such as the amount of health care we deliver, the way we evaluate potential feature films, and the way we fund education, we need to anticipate and address that economic dislocation.  Unfortunately, people rely on the rules of a marketplace, a business, a government, or a system, and we need to transition them to some degree to a new system. In the transformation of electric utility service, we call these obsolete systems “stranded costs” and we develop plans to pay for phasing them out. All this obsolete health care, education, and government infrastructure is a “stranded cost.”

Most important, we need to recognize that every myth or paradigm is a temporary way of thinking about the world.  We must stop reinforcing the notion that there is a fixed way of thinking about the world that, once learned, will give someone a permanent advantage.  Experience is valuable, but the most important lesson that we need to recognize is that, sometimes, experience gets in the way of insight.  The art of being successful is knowing when experience is useful and when it must be discarded.

Life is inherently uncomfortable and insecure.  We should not teach our children to seek security and certainty, but to build resilience, continuous learning skills, and the capability to address the widest range of life’s challenges.

What makes this article insightful is that it takes apart batches of job tasks and looks at the skills required for each one, and their replaceability by technology or self-service solutions.  Beyond the obvious example of toll takers, which, thankfully for all drivers, are rapidly disappearing, he points out that jobs which exist because of the need to move physical items or information, jobs which exist solely because supply is artificially limited or restricted, or which exist because of artificial or gimmicky price and value differentiations, or because of government-conferred monopolies will disappear over time.

We can think of many examples of these jobs.  Many other jobs we believe to be relatively secure and resistant to changing conditions will decline in number:

• Jobs that help people get from one place to another for work tasks and meetings may decline over time.  The simplest solution to traffic congestion is a reduction in travel of all kinds.  We can do more work on computers where we live, including meetings, webinars, and telephone conversations, that obviate the need for as many people to travel to a single place every day to fulfill their work responsibilities.
• Things we used to acquire through face-to-face retail transactions are rapidly being replaced by home deliveries or video downloading.  For example, every video rental store in our community has gone out of business in the last 18 months.  Video on demand or home delivery of Netflix movies has replaced what those stores used to do.
• Self-service machines are replacing humans in many tasks.  For example, in many cities, particularly in Los Angeles, I almost never seeing parking garage attendants in public parking lots.  We pay for parking at a machine and exit by placing our parking receipt into a machine at the exit.

However, even more interesting than these examples are the cases in which traditional professional tasks are being either replaced or downsized, done by people outside the United States, or done by people with lower level skills.  For example, in the health care field, many state laws still require laboratory tests to be ordered by physicians, which requires an individuals to visit a doctor’s office to get a reading on vital metrics like cholesterol, glucose, or triglycerides.  However, other states now recognize that the individual is capable of going to a lab, getting a test, reading the interpretive results, and then consulting the doctor, if needed.  These gatekeeper functions for physicians have to disappear because they are not good uses of the physician’s time.

Lawyers have begun to lose work to self-service functions for a generation.  Many people can draw up a variety of legal documents with a little help from the Internet, and can do more of the work on contractual documents that used to be done by lawyers.  The jobs that require professional credentials, such as lawyers and doctors have many tasks that truly require their credentials and experience, but there are many tasks that the client or patient can perform, and others that a less-skilled professional can perform as well.

This is significant because it suggests that, as Kessler points out, we will have many longer-term unemployed people from occupations that did not used to produce them.  The best solution for those people is to reinvent themselves, not to beat their head against a wall trying to find another job like the one they lost.  Generally, when a major newspaper, magazine, or TV show profiles someone who has been unemployed for a long time, that individual has trapped himself or herself in too narrow of field of vision in a job search process.

We have to teach those who find themselves unemployed to redefine their assets and their aspirations to look at opportunities where the economy is growing, not where it is shrinking.  The biggest challenge for unemployment is in those communities in which the entire community is depressed, in some instances, the entire country.  In a recent set of stories about Ireland, articles have commented on the fact that, at the peak of Ireland’s financial bubble, 25% of the population was employed in the construction industry.  This is similar to Las Vegas and Arizona.

People trapped in these communities who cannot leave need to create an export opportunity, in which they sell goods and services to people outside the community and bring wealth into it.  The most difficult challenge is figuring out what people somewhere else might need that an economically depressed community can create and export.  To perform this analytic process, depressed communities often need to bring in individuals to think more expansively about the communities’ potential than the people living in the communities can do on their own.

No job is secure because its requirements will change.  Some tasks will disappear and others will emerge.  Those who recognize this reality will do just fine.  Those who deny or fight it will be highly stressed out.

In early 2009, the Obama Administration included significant funding in the ARRA stimulus legislation for the upgrading of medical records in physician offices, and directed the U.S. Department of Health and Human Services and the Federal Trade Commission to issue regulations, which would implement a transition process over a multi-year period.  Those regulations are largely in place and the legislation and regulations have enabled Dossia and the other players in the market, including Microsoft and Google, to get anchored in a relatively stable, coherent regulatory environment.

When many members of the public do not understand is the difference between electronic medical records, which a physician or hospital might maintain on their patients or a pharmacy, or insurance company might maintain on its customers, and a personal health record, which the patient or customer maintains on his or her own.  Even the Executive Branch of the federal government and members of Congress did not understand the difference when we started four years ago.

Many people ask us: why should a patient maintain a record separate from the records held by these other parties?  After all, could not the patient simply be given online access to these other records when he or she needs that access?  There are three big reasons why the Dossia founders, of which there are now ten companies, including Pitney Bowes, my old company, have invested in a separate personal health record business (although the founder employers’ only role is to give Dossia access to their employment base for marketing and enrollment purposes. The employers never have access to any individual or population health records.):

• The majority of Americans access more than one doctor, one pharmacy, one hospital, and one health plan.  Having your records scattered all over the place is not a good way of managing your own or your family’s health.  None of us who have to file an income tax return or manage our personal or household budgets would feel comfortable if we had to access relevant financial information in several record systems we did not control and could not consolidate.  Dossia is like Quicken in its goal of consolidating records from multiple and disconnected systems.
• To manage your health, getting records put together in one place is essential.  Bad health outcomes sometimes happen because individuals forget to tell a doctor or dentist that they have been taking a particular medication, or that they have a particular health history.  For example, something as simple as whether a person is taking a blood thinner medication for a cardio-vascular condition becomes very relevant for even the most routine surgical procedures.  Recently, I scheduled a minor surgical procedure to get a mole removed from my back, and was asked if I were taking a blood thinner.  Like most males over 45 years old, I am taking an aspirin tablet, which I was directed to stop taking a few days before and after the surgery, but, if I had been taking Plavix, Cumidin, or one of the more potent blood thinners (which, fortunately, I am not), the consequences of my physician not knowing about these medications could have been serious.
• Sometimes records get damaged, lost, or destroyed.  When we formed Dossia in late 2006, one of the first parts of the country that indicated an eventual interest in a portable patient-controlled record was New Orleans, since many paper and some electronic records were destroyed.  Many residents moved to Houston, Baton Rouge, and other cities but lost permanently any health records that had been in physicians’ offices, hospitals, or pharmacies in New Orleans.  Sometimes, hospitals have a policy of destroying certain records, like imaging tests, after many years of inactivity relative to a patient, simply because the electronic storage of that test is cumbersome and expensive.

Microsoft and Google are better known than Dossia in the personal health record space, but Dossia is different in four key respects:

• Dossia, as the agent for all of its users, secures all of the user population records and gets them downloaded from insurance plans, pharmacies, and providers.  This is called “pre-populating a record.”  Microsoft and Google depend on the user going to each separate data source and directing it to download health records to their “vaults.”  You can imagine how time-consuming and difficult it is to do that, and, as a result, despite their stronger name recognition, the Microsoft and Google vaults are not used actively by many who have signed up for them.
• Dossia’s model is to integrate with other employer-based health programs and benefits, including wellness and prevention programs, chronic disease programs, and health benefits and services.  Microsoft and Google have an excellent array of personal health applications, but they are stand-alone and they depend on the user’s ability to figure out how to integrate them in an overall health plan.
• Dossia has done the legal and conceptual work to allow it to have a single caregiver for a family to open up and manage the records for all the family members.  To our knowledge, no one else has this capability. The health care system is based on a model that each individual manages and controls his or her own health information, and, while I believe that works for most adults, there have always been three populations, children, the elderly, and people with certain kinds of disabilities, that need caregivers who have access to their health information.  One of the best uses of Dossia at our existing customers is the ability of mothers to manage the scheduling of immunizations and school physicals for their children.  Keeping track of who needs what shot at what time is challenging for busy parents.  Dossia helps solve that problem.  Microsoft and Google, like every other electronic health record, expect every individual to access his or her individual health record.
• Dossia has integrated medical and dental records, and, over time, will integrate records from a wide range of non-traditional health-related providers such as alternative and complementary medicine providers, nutritionists, fitness trainers, and behavioral health counselors.  The mistake lawmakers and public commentators make relative to health records is that they believe people have, or should have, a single primary care physician. The term “medical home” implies that there is a goal of having every patient get funneled to the same doctor for all purposes all of the time.  This is not the real world.  People change practitioners. People are mobile and get care whenever and wherever they need it, often far away from home. People seek care from alternative practitioners.  More and more people will access care from outside the United States, as they have been doing for a long time.  We had an emergency hospitalization for one of our children six years ago in Florence, Italy, when we were on vacation, and had voluminous and complex records, which we have no electronic medium in which to store.  Most electronic health record systems are what we call “tethered” to a particular doctor, hospital, or health plan.

Given the compelling value proposition for Dossia, why do we not have millions of users today?  There are many possible explanations, but I would suggest three primary reasons:

• Like every start-up business, it takes time to get customers comfortable with the offering.  In this environment, selling to users through employers has been challenging because of the bad economic environment from 2007 on, the uncertainty around the survival of employer-based health care during the pendency of the health care reform legislative debate, and the thinning out of HR and Benefits Departments, which has made large companies much less ambitious on health-related initiatives.
• In the early years, there was a great deal of uncertainty about privacy laws and regulations, which, thankfully, recent legislative and regulatory pronouncements have largely cleared up.  In our first rollout with a major company, 90% of the people who wanted to sign up were scared away by ominous-sounding privacy disclosures and consents, which were put in place to cover a wide range of possible legal risks, which turned out to be unfounded. From this point forward, we expect much easier sledding.
• The expected primary source of health-related information was the claims data from health insurance plan administrators.  This has been harder to secure because insurance companies are not organized to download member data in bulk to health record systems.  They are organized to feed that data to print-based systems to mail individual transaction data, through what is called an “explanation of benefits” statement, to an individual member.  They have attempted to direct members to the insurance plan’s own patient-specific portals, but, by their nature, these portals are incomplete representations of a person’s health history.

I am more optimistic than ever about the future of Dossia for three reasons:

• We have solved many of the technical, legal, operational, and communications problems that we confronted in our early days.  We have some very demanding customers, and have secured their trust.
• We have a more compelling set of applications than ever before, and we are continuing to develop partnerships with prestigious organizations like the Mayo Clinic, Healthways, and Vanguard Health, in addition to applications like the Healthcare Bluebook, which helps consumers select and price physician and other health-related services.  The usefulness of the record is increasingly good and will only improve.
• We have an increasingly large body of knowledge about the value proposition for personal health record systems like Dossia, and are reinforcing the value through continuous research.

More will follow as Dossia enters a most exciting time.  I am pleased to have the opportunity to be of service to our employer customers and those who use Dossia.

I am producing a feature film, and many have said to me, in one form or another, what one investor said in the article about starting a new company:  “You need to suspend disbelief to start a company, because so many people will tell you that what you’re doing can’t be done, and if it could be done, someone would have done it already.”  Segal describes entrepreneurs and people like me who are engaged in entrepreneur-like activity as having to be “just crazy enough.”

As a person in the middle of what seems like a crazy venture, I would say the following about why I decided to proceed:

• I am not a psychotic risk taker who is making judgments based on no objective evidence that would support my belief that my film can be successful.  There are many bits of information and insight that would support my position. I am just assembling the bits in a way they have not been assembled before.
• The notion that, if it could have been done, someone would have done it already is flawed for several reasons:
  • As Thomas Kuhn wrote in his 1960 book The Structure of Scientific Revolutions, most revolutionary thinking that disrupts a marketplace or a field of scientific inquiry is introduced by people outside that field.  The reason is that people deeply experienced in the business models prevalent in a particular field are deeply invested in the continuation of those models, not in disruptive or transformational thinking.  That is the key point Clayton Christensen makes in his great 1997 book The Innovator’s Dilemma.
  • Sometimes, someone new to a field has the insight and the capabilities to do something that people in the field do not have.  For example, in the case of the film I am producing, From the Rough, I have built a team consisting of African Americans who have a better understanding of the multicultural marketplace than the traditional film industry executives, who are great at large blockbuster films, but not as knowledgeable about how to reach niche audiences.  Big studios and distributors are better at producing and marketing big movies than they are at knowing what to do with smaller movies.
  • Sometimes circumstances change in a way that a new thinker can get to the market a little bit ahead of everyone else, simply because the established players have more cumbersome decision making processes.

What people who question entrepreneurs do not understand is that entrepreneurs do not simply adopt established market ideas.  They mix and match ideas from multiple sources to create something new and different.  This was exceptionally well explained by Wall Street Journal writer Steven Johnson in an article entitled “The Genius of the Tinkerer” in the September 25-26 issue of the Wall Street Journal. As Johnson put it:

“But ideas are works of bricolage.  They are, almost inevitably, networks of other ideas.  We take the ideas we’ve inherited or stumbled across, and we jigger them together into some new shape.”

The biggest challenge for established players, especially large public companies, is to explain to public investors in what market they are competing when try to enter a new market.  They are much more comfortable acquiring companies in an existing market because it is easier to explain to people.

Finally, entrepreneurs are wired quite different from people in large companies.  What I have noticed since I began this process relative to the film project 7 ½ months ago is that I have had to change course many times during this period, and to make many decisions on the fly with incomplete information and with a large appetite to take sizable risks.  Large company decision makers usually are not wired to do this.  There have been some messy situations created, but they are an expected consequence of multiple changes of course.

Entrepreneurs do not always succeed, and I might very well be one of those who do not.  However, I feel a whole lot more comfortable knowing that some of what I have considered to be my mildly crazy behavior is not that unusual in an entrepreneurial environment.