Are emergency rooms really that big a drag on the medical system?

(Originally posted in 2009 as /archives/2634)

By Thierry Geoffroy (Thierry Geoffroy) [CC BY-SA 3.0 (], via Wikimedia Commons

My how things have changed since I wrote this essay in 2009. Governor Romney pandered to the voters in the 2012 Presidential Election—by continuously insulted the President of the United States for adopting a national health care plan—that is almost exactly like Governor Romney’s plan for Massachusetts. Massachusetts’ plan works, and Romney knows it; that’s why he signed-it, and that’s why the United States adopted it.

Our country has adopted Governor Romney’s and Massachusetts’ health care plan, and Governor Romney pandered to the Republican voters by insulting the

This is a new version of my contributions to Are emergency rooms really that big a drag on the medical system? on The Straight Dope board (A message board for fans of The Straight Dope).  I highly recommend The Straight Dope.   If your favorite newspaper doesn’t carry it, then go here. Everyone knows The Straight Dope has a different purpose, but it is Snopes equal in the fight against ignorance.

Emergency rooms shouldn’t be free, but they must help everyone, and some never pay the bill. If a patient doesn’t pay her bill, then who ends up paying it? The hospital does at first, but ultimately we all do. As Shodan said, “If you are mandated to treat everyone whether they can pay or not, you have to charge those who pay more to cover for those who don’t.” We now have a national health care system without a detailed policy for those that cannot pay. The patients, the insurance companies, and the Physicians have little means of controlling those costs.

I was in poverty for many years. I am certainly not against care for the poor. Being “against” national health care is meaningless. We have had it for some time (whether we are talking about Medicaid, Medicare, or yes, those that simply don’t pay). The question is whether we want control over what is happening, or not, and “not” is just bad business.

How bad is the problem? Go here to read Malcolm Gladwell’s Million Dollar Murray. Here is a teaser quote: “Culhane estimates that in New York at least sixty-two million dollars was being spent annually to shelter just those twenty-five hundred hard-core homeless.”

Being against national health care is unreasonable. We have it, we just do it really badly. Lets stop doing it badly.

Republished by Blog Post Promoter

How Enterprise Software Is Sold, and Delivered, Today

(Originally posted on 2008-11-23 as /archives/1557)

Computer systems: By Agiorgio (Own work) [CC BY-SA 4.0 (], via Wikimedia Commons
I see-and-read way too many presentations that both start with doom-and-gloom, and then overstate the case that the author wants to make. This seems to be the only way that software consultants know how to begin a presentation: “Information is getting harder and harder to manage.” No its not. “Software is getting harder and harder to write.” No its not. “The sky is falling!” Actually, no its not.

“Our software will help you manage your Enterprise.”

Or your software will cause headaches and heartaches for countless people.

Your future client will read reports by an “independent” technology research firm. Then she will hire a consultant, and ask that consultant to write an evaluation of all of the available enterprise software applications for a given need. (Here is what Doug Savage has to say about this. Cluck, Cluck, Bawk!)

The consultant will produce a large report that says exactly what the independent technology and research firms say, in spite of the fact that neither said consultant, nor any employee of the research firms have any practical experience with the enterprise software in question.

Here is why:

  1. There are only a couple of large independent technology research firms. They don’t have the resources to become experts with every product, so they do their research by meeting with the vendors and viewing their presentations.
  2. This gives the product vendors incredible leverage. That’s why you can look at the descriptions of three completely different products where one started as a document repository, another started as a code versioning system, and another started as a Web UI toolkit. These products’ architectures have little in common, yet they are all called Enterprise Content Management Systems, and they all have the same listed features. Those feature lists are written to satisfy the independent technology research firms’ evaluations, and really tell you little about a given products’ actual capabilities.
  3. CIOs and other executives subscibe to, and read, those independent technology research firms’ evaluations.
  4. Then those executives hire the consultants. They ask for the consultants evaluations, but they really are looking to validate what they already believe. Consultants quickly figure this out after hearing “But [Insert-Name-Here] Research said” a couple of times. The consultants learn to mimic what the independent technology research firms say, in spite of the fact that the original research is based on little more than writers watching PowerPoint presentations.
  • Here is a universal piece of advice: never buy anything unless you get to prototype with it before you write a check.

Your future client will then ask the consultant to write a request for proposal (RFP) to send out for bids. That consultant will write the RFP in such a way that only his company can fill all of the “requirements” in time.

You will charge your client $1.5 Million. You will first ask for more, and after weeks of negotiations you will convince your client that you can go no lower than 1.5 Million, and that nobody gets your software for less, meanwhile all of your clients are actually paying 1.5 Million, plus training, plus development, plus support, plus travel, and the pluses just keep on coming.

  • I worked with one product at three different companies. Each of the company’s managers told me something like, “They normally charge X, but we got them down to 1.5 Million instead, because they really want our business. They won’t do that for anyone else.” Oh. Really.

Your client will spend many times the expected amount on employees and consultants. These people’s job will be to manage the mess that you create, and you client will have to live with that mess, lest she admit that she wasted millions on your “Enterprise” software.

You will convince your client that the mess was actually caused by her incompetent employees, in spite of the fact that her employees are actually proud, hardworking, well trained, and intelligent. You will then provide high-priced consultants to replace your client’s employees.

  • What else can they do? In some cases the enterprise software vendor’s management team is in survival mode, and will continue passing-the-blame-to-their-customer until they have a mature product.
  • In some cases, they may truly not know that their product doesn’t work, because the support team is filtering-out the bad news. This happens when you measure support success by how quickly problems get solved. The tickets get closed quickly, but the root problems rarely get solved, because that takes too long.
  • Either way the vendor has no incentive to admit that their software is actually not stable.
  • I once worked for a consultancy that was helping an energy company implement a new content management system (CMS), and the CMS vendor’s chief technologist simply repeated, “You have the DTD. That’s all you need” over-and-over again in front of the client. What we were asking for was the proprietary query language’s (non-SQL) documentation. Imagine if you had to learn a language with nothing but a description of the noun-verb-noun syntax. No dictionary. No thesaurus. No books. No teacher. No examples. Nothing. That product was not ready to be sold, and the chief technologist was able to seed doubts about us  simply by saying, “You have the DTD. That’s all you need” over-and-over again. That product was highly recommended by the two large independent technology and research firms.

Your client will put up with this “gladly”, because how else is she going to explain why she wasted so much money on your “Enterprise” software, when there was actually something better out there for free such as:

If you are going to write enterprise software, then start out by solving the hard problems, because the easy problems are already easy. I don’t know how many vendors told me, “We can do session management!” So? Anyone that knows what a Static Class and a Hashtable is can write a session manager in an afternoon. “Our sessions can survive a reboot!” OK, anyone that knows what a Static Class is, and also knows how to embed a relational database can create a session manager with sessions that survive a reboot. Solve the hard problems for me.

Before “SOA” made integration “easy” it was “N-tiered”, before that it was “RAD”, before that it was “CORBA”, before that it was “OOP”, before that it was “SQL”. Then there were all of the “Managements”: “Document Management”, “Content Management”, “Service Management”, etc. Obviously a couple of these technologies matured to the point where they helped enormously, and others didn’t. Either way integration will never be easy.

Project management, and software engineering are incredibly difficult, and that’s what makes this work interesting. If it were easy, then there would be no way to get me sitting in front of a computer screen for so long. Doing this stuff well is a true reward.

I have been meaning to write this essay for years, but I never bothered, because I didn’t believe that anyone would read it; it would be lost in a sea of more exciting tech news. The truth is that it caused a spike-in-viewing during what is traditionally a slow-day here.

Then there is the worry that a potential employer would see this world-view as negative.

Ironically it was an anthropologist’s (Dr. Michael Wesch) video that inspired me to finally write the essay. To see many of the real advances in the Web-realm presented in a few minutes, made clear many of the non-advances. The video’s name: “Web 2.0 … The Machine is Us/ing Us” sounds provocative, but the video looks optimistic to me. I suspect that different people see a completely different message in this video depending on their background, and that’s cool too.

Republished by Blog Post Promoter

Too Much Stuff In A Car Story

(Originally posted on 2007-07-04  as /archives/38)

During my freshman year (1986) I lived in Hood Hall (under my old name: W. Paul Caligiuri). Some other guys that lived there would circle the place for hours in an old white convertible. I think it was a 1959 Cadillac deVille.  When it was time for a dorm picture, the driver drove the car over, and offered for us all to get in it, and on it, in the tradition of how-many-people-can-you-fit-in-a-phone-booth? Folks opened the doors afterwards, but they wouldn’t close.  For a few seconds people were trying to figure out what was wrong when I loudly said, “That thing is shaped like a ‘U’!”  Needless to say we never saw that car again.

Why this image? I like it. It’s a wrecked car. No, it’s not the one in the story. John Allan [CC BY-SA 2.0 (], via Wikimedia Commons

Republished by Blog Post Promoter