Private Equity came for my wife’s psychiatric private practice EHR, Luminello. Luminello sold to SimplePractice, which is owned by EngageSmart, which is owned by Vista Equity Partners Management.

From the press release:

“Both SimplePractice and Luminello were founded by clinicians looking to simplify the business of running an independent solo or small group mental health practice,” said Ken Braslow, MD, Founder, Luminello.

“Today, we remain equally committed to removing the administrative burdens that practitioners face and look forward to combining the strength of our collective experience to serve even more practitioners and their patients.”

Apparently, Luminello’s “commitment” was worth $19.6 million.

In short order, SimplePractice announced they were shutting down Luminello.

In fact, Luminello is being shut down so fast that SimplePractice doesn’t yet have the features needed to run an actual medical practice. They’re pressuring docs to transition despite the reality that SimplePractice is currently mostly used by nonphysician therapists and is half-baked as an EHR: They don’t have labs! They don’t have snippets or dot-phrases! They don’t even have e-prescribe! (You get the idea.)

Communication about the transition has been generally confusing and poor, but here’s the fun daily DocuSign reminder that assumes you’ll take it on faith that SimplePractice is going to work for your practice and are coming along for the ride:

In typical tone-deaf private equity fashion, they’re happy to spend money upfront for a roll-up to buy (instead of earn) some growth but then completely botched the execution because they don’t actually know what they’re doing. Instead, they’d rather anger thousands of doctors by bullying them into switching to a product that literally can’t do many of the things their current offering does while pressuring them in the sleaziest ways possible.

Luminello is flawed, but it works worked. In the meantime, its customers are being told they only have until April to sign on to SimplePractice before their EHR stops working.

Meanwhile, the data export function the docs need to save their records (and, coincidentally, to transition to a different EHR) seems to be magically broken. Their patient information is being held hostage.

Just for fun, the entire lab-ordering tab has disappeared.

Starting a few days ago, for some users, the Luminello calendar began intermittently showing empty appointment slots:

And, just today, the site began alternating between intermittently lagging into unusability and just flat-out crashing:

Now, why spend millions to basically buy customers and then immediately turn around and make all of their lives harder instead of just waiting a few more months until you have feature parity? Why not make switching an easy no-brainer upgrade?

Because, in my opinion, they don’t think it matters.

They don’t seem to care about their customers or about the patients (“clients” in SimplePractice parlance) their customers serve, and–most importantly–they’re relying on doctor’s learned helplessness: they assume a critical mass of physicians using Luminello–many in solo practice–are resigned to the enshittification of healthcare or too busy to actively pick something else.

I hope they’re wrong.

There’s a Derek Sivers quote about business in Anything You Want that I think applies well to healthcare. I’ve replaced “customer” with patient”:

Never forget that absolutely everything you do is for your patients. Make every decision — even decisions about whether to expand the business, raise money, or promote someone — according to what’s best for your patients.

One key here is that you can’t just consider what only best for your patients right now, but also what will be best for your patients in the long run. We can ask that question as individual doctors, as groups/practices/hospitals, as specialties like radiology, and as healthcare professionals as a whole.

You, your business, and your industry need to be healthy and strong enough to keep providing the best possible care into the indefinite future.

We can’t prioritize short-term thinking through dashboards, growth, and other easy measurables over second-order thinking.

From Humankind: A Hopeful History by Rutger Bregman:

That’s right, Buurtzorg [a nurse-led home healthcare organization] is better for patients, nicer for employees and cheaper for taxpayers. A win-win-win situation. Meanwhile, the organisation continues to grow. Every month, dozens of nurses leave other jobs to sign on with Buurtzorg. And no wonder: it gives them more freedom and more pay. When Buurtzorg recently acquired part of a bankrupt counterpart, de Blok announced: ‘The first thing we’re going to do is raise staff salaries.’

Don’t get me wrong: Buurtzorg isn’t perfect. There are disagreements, things go awry–really, they’re almost human. And the organisational structure is, if anything, old-fashioned, with de Blok’s aim always having been a return to Holland’s uncomplicated domestic healthcare services of the 1980s.

But the bottom line is that what Jos de Blok started back in 2006 is nothing short of extraordinary. You might say his organisation combines the best of left and right, spending taxpayer money on the delivery of small-scale care by independent practitioners.
De Blok sums up his philosophy like this: ‘It’s easy to make things hard, but hard to make them easy.’ The record clearly shows that managers prefer the complicated. ‘Because that makes your job more interesting,’ de Blok explains. ‘That lets you say: See, you need me to master that complexity.’

The complexity is both a feature and a bug.

Could it be that’s also driving a big part of our so-called ‘knowledge economy’? That pedigree managers and consultants make simple things as complicated as possible so we will need them to steer us through all the complexity? Sometimes I secretly think this is the revenue model of not only Wall Street bankers but also postmodern philosophers peddling incomprehensible jargon. Both make simple things impossibly complex.

Layers upon layers of bullshit jobs.

Jos de Blok does the opposite: he opts for simplicity. While healthcare conferences feature highly paid trend-watchers auguring disruption and innovation, he believes it’s more important to preserve what works. ‘The world benefits more from continuity than from continual change,’ he asserts. ‘Now they’ve got change managers, change agents, and so forth, but when I look at actual care in the community, the job has scarcely changed in thirty years. You need to build a relationship with someone in a tough situation; that’s a constant. Sure, you may add some new insights and techniques, but the basics haven’t changed.’

There is a ton of inefficiency in healthcare, but most of it is around and distracting from the actual care of people’s health: billing games, crufty software and documentation, and agonizing compliance schemes. But, it’s also true that real healthcare–taking care of actual humans–should also be at least a little “inefficient”: it takes time to treat people like three-dimensional humans deserving of dignity, respect, and a real conversation.

What does need to change, De Blok will tell you, is the care system. In recent decades, healthcare has been colonised by lawyers. ‘Now you’re in opposing camps. One side sells, the other buys. Just last week I was at a hospital where they told me: We have our own sales team now. It’s crazy! We have hospitals with commercial departments and procurement teams, all staffing people with no background in healthcare at all. One buys, the other sells, and neither have a clue what it’s all about.’

The number of decision-makers in healthcare who do not understand healthcare remains astonishing.

All the while, the bureaucracy keeps proliferating, because when you turn healthcare into a market, you end up with piles of paperwork. ‘Nobody trusts anybody else, so they start building in all these safeguards; all kinds of checks that result in a ton of red tape. It’s downright absurd,’ says De Blok. ‘The number of consultants and administrators at insurance companies is growing, while the number of actual caregivers continues to shrink.’

De Blok advocates a radically different approach to healthcare funding. Scrap the product mentality, he says. Make care central again. Drastically simplify the costs. ‘The simpler the billing, the greater the emphasis on actual care,’ he explains. ‘The more complicated the billing, the more players will search for loopholes in the system, increasingly tipping the balance towards accounting departments until they’re the ones defining care.’

“Scrap the product mentality.”

“Make care central again.”

“Drastically simplify the [billing/]costs.”

A passage about the fear of consequences from The Emergency Mind: Wiring Your Brain for Performance Under Pressure by Dan Dworkis MD PhD:

In or out of the emergency department, all emergencies share three common structural characteristics:

• Emergencies involve uncertainty.
• Emergencies have high-impact outcomes.
• Emergencies occur under significant pressure.

Whatever the potential impact of a situation is, fear of this impact can lead to paralysis; you can find yourself unable to make a decision because you are so preoccupied with what the impact might be. Of course, not making a decision is, in and of itself, a decision.

A big part of residency training is just accumulating enough reps that you aren’t paralyzed by indecision, especially when stressed or confronted by novelty.

More broadly: even abdicating a decision to maintain the status quo is itself a decision. There is no escape from time, which will always take us from point A to point B.

The consequences will come. The question is, will you make deliberate choices to achieve the best outcome? Will you reflect on not just your outcomes but also your process to ensure you grow?