Luminello, my wife’s (now former) small practice EHR, just shut down, so I thought we’d end our sold-to-private-equity-just-to-be-shuttered-with-gusto story with a final litany of needless suffering and smarm.

Timing

To pressure people to switch to SimplePractice, busy psychiatrists running small private practices were given just two months before their current EHR shut down to research, pick, and migrate to a completely new platform. The plan for this acquisition was presumably always to shut the smaller company down and use its customers to gain a toehold in the physician market. Remove the time pressure so that people have the breathing room to look around, and you might lose some of the customers you bought.

Now technically the April 19th shutdown just was for solo practices. Group practices actually had longer to figure stuff out: until June 14. Haha wait just kidding SimplePractice just changed their mind: now it’s May 15.

Bulk Download

Luminello created a bulk download function to export charts as PDF files. The service intermittently worked and sometimes took over a week to generate the zip file. With that kind of uncertainty, some users felt compelled to request their downloads in advance to make sure they were ready to migrate to a new platform before the shutdown. Little did they know that Luminello would decide the feature was a one-time process and disable the button after using it. The patient care information generated while using the EHR after making the request wasn’t included, which would mean lots of manual document saving.

With enough complaining, you could get them to turn it back on.

Read-only

Luminello repeatedly advised users over and over that access would become “read-only” on April 19th and that no more changes could be made after that date.

Instead, on April 19th, current users were greeted by only the magic bulk download button. You can’t actively look at the EHR contents, and anything not included in that bulk download (calendar, billing, etc) is totally unavailable. That is not what “read-only” means to literally anyone.

They quietly changed the language and now call it “export-only mode.”

People complained.

Users were told that they could have access reinstated if they opt-in to transfer to SimplePractice (and then opt out again before the assigned transfer date if they don’t want SimplePractice to have their data for no reason). An example:

Maybe a monthly fee or two for SimplePractice doesn’t seem like enough money for this to be worth it, so one possible explanation is that this last-minute rug-pull is to juice the opt-in numbers of switching customers so that the sale looks better. For what it’s worth, $3.6 million of the buyout was reportedly tied to post-sale metrics. One imagines this is one of them. Encouraging people to fake switch makes a lot more sense if there are a few million bucks in pending performance payments. (Note: What’s happening is what’s happening. Why it’s happening is just my guess.)

Billing

Last fall, after Luminello sold but while they were still maintaining that nothing was changing, they changed their billing plan from monthly to annual. My wife and many others paid for a full year. At some point later into that new payment term, SimplePractice announced that Luminello was shutting down. (They did eventually switch back to offering monthly billing before the announcement.)

They stated no refunds would be forthcoming.

After a lot of bitching online, Luminello agreed to refund people for the unused months of a product that was shuttered in the middle of a prepaid cycle. I’ll believe it when I see it.

But, for those on the re-instated monthly plan, Luminello has continued to freshly bill some customers after the service closed and entered read-only “export-only” mode. In addition to general incompetence, it’s hard to ignore the more cynical possibility that they assume a fraction of the overbilling will be overlooked or accepted because any customer service interaction or credit card dispute is a hassle that takes time.

Data Shenanigans

One of the fun things in SimplePracrice’s terms of service is that they want to play with your data:

Nevermind that the software you use for patient care has no business pretending to own people’s private health information or your practice’s work, but I personally find it offputting that they want to use everyone’s practice information for data mining and other sketchy stuff like some tech bro startup. I don’t think anybody wants their notes to be used without specific permission or compensation for training some AI tool (or anything else).

The Irony

The irony here is that by most accounts, SimplePractice is actually a decent product. It has a clean design and is—as promised—simple to use. While some of the physician features (better templates and dot phrases) are not fully baked and others don’t exist (lab/imaging order integration, flowsheets for vitals etc), the mission-critical ones like e-prescribe are now functional as promised.

If they had just waited a few months to actually have a physician ready EHR ready to demo and use before all this drama and communicated better, they would’ve had a higher sign on rate and fewer angry physicians.

And to their defense, this isn’t Vista Equity Partners Management’s first rodeo. I would guess that—despite a vocal contingent of very upset physicians—the majority of doctors took the path of least resistance and stayed with them as customers. Researching the EHR market and migrating to a new platform on short notice is really hard.

Reportedly, for many users, the migration process has been relatively smooth, even if customer service isn’t always helpful.

Everything I’ve described here and in the last post is entirely needless.

The foundational problem here is that there is a difference between having a good product and being a good company. What does it mean for healthcare if we keep rewarding the not-so-good companies?

This post is for anyone who is lost and dejected after failing one of the Step exams.

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First, I’m sorry that you’re going through this. The path to becoming a doctor is long and hard, but there’s something unique about high-stakes testing that adds stress and uncertainty.

I know this may sound a little odd/dramatic, but I think dealing with a big testing disappointment is ultimately the same as any other grieving process. The world today isn’t the world you wanted to live in, and it takes some time to bridge the gap between where you thought you were and where you currently are. The silver lining is that—unlike losing a loved one or a serious injury—you can still get back on the path.

At the same time, while it would be nice to get the failure notice and be able to immediately double down into an amazingly efficient targeted revision process for your next attempt, you’re also a human being. You’re a human being who deserves to grieve.

Maybe you won’t go through the classic stages of grief like denial, anger, bargaining, depression, and ultimately acceptance. But you might, and there’s nothing wrong with that. Just because there are so many worse things in the world doesn’t magically make this experience not suck. Don’t add insult to injury and beat yourself up for being acutely sad.

(On a related note, I think this would also be a good time to take a serious look at your media diet)

Once you have the timeline for your next attempt and know your school schedule, it’s time to be systematic about how to use that time effectively. That should absolutely include some time initially to reset psychologically. For a week or two, make specific time and force yourself to do some things that you enjoy and find centering. You need a less heavy heart to remember why you are on this pathway and why you’re willing to work hard to get to your destination. You can’t only punish yourself for this disappointment with things that rub salt in the wound.

Next, it’s time to analyze your current performance abilities for areas of weakness, both subject matter and testing approach (see below). It may be tempting to add a bunch of new resources or completely change how you study. In some cases that may be the right choice, particularly if you haven’t been incorporating enough questions or have never heard of spaced repetition, but for many people the answer is doubling down on a limited number of high-yield resources and not breadth. If you were close to passing, you probably don’t need to reinvent the wheel.

You do need to prioritize your mental and physical health (trite but true). Diet, exercise, and sleep are huge performance factors that you have a lot of control over.

The bottom line is that you are allowed to feel sad, and you’re allowed to mourn for the world where your pathway to becoming a doctor was smooth and straightforward and where you never need to question yourself or prepare a story for others. It’s something you can and absolutely will deal with, but there’s no reason to pretend that you don’t deserve to be bummed. That’s just toxic positivity. It does suck, and it is a bummer.

But you also need to believe that you will absolutely get past this. It’s a hurdle. And hurdles are meant to be overcome.

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For further test-taking reading:

• How to Approach NBME/USMLE questions
• How I read NBME/USMLE questions
• The Gunner “Methods to Success” Fallacy
• Dealing with Test Anxiety and Demoralization
• Focused Nonchalance
• Learning & The Transfer Problem

The US government—specifically the Department of Justice, Department of Health and Human Services, and the Federal Trade Commission—is asking for public input about consolidation in healthcare.

A summary quote from FTC Chair Lina Khan from an article in the WSJ:

FTC Chair Lina Khan said that while some private-equity investment could be beneficial, too many buyout firms focus on profit to the detriment of medical care. Government regulators have heard numerous reports from doctors and other medical workers about the negative consequences of private equity-driven consolidation.

The comment period runs until May 6, 2024, and you can only submit feedback through this official docket on the Regulations.gov website. (more…)

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.