Future of Health IT: Trends and Scenarios

The future of computing and communications: random thoughts, part 5

The New Scientist recently published an article entitled "Cell phones could be used to build 'audio Internet'". (I'm not sure if the article requires a subscription to obtain full access, and I apologize if it doesn't, but the link should at least lead to the abstract in that case.) This is one more indicator of the proliferation of modalities for human-computer interaction (HCI) that has been a major theme of my random thoughts in recent months.

The spoken web is an attempt to bring the power of the internet to rural India. Despite India's highly touted knowledge economy, around 70 per cent of its billion-strong population lives outside its cities, and most of them earn just $4 per day or less. And even for those who can afford computers, attempting to access the internet remains a futile exercise, either because they cannot read or write or the information on the web is simply not relevant to them.

The answer, says Tapan Parikh of the University of California, Berkeley, is speech. "An audio format would provide much more access and opportunity for local people to contribute," he says. "While a farmer may not be able to write a memo, or an email, or a summary of his work, he can easily talk about it."

Between a quarter and a third of India's one billion-plus population have access to a cell phone, with the number growing at 8 million per month. This is far greater penetration than the World Wide Web in India, especially in semi-rural and rural areas. Moreover, the content of the Web is not useful to India's poor, either (or both) because they cannot read or the content is irrelevant to their daily lives.

So how to leverage cell phone technology to bridge the Digital Divide? The answer posited by the New Scientist article is the spoken web.

...Conceptually, the spoken web is a network of VoiceSites, just as the internet is a network of websites. A VoiceSite can only be accessed by a phone, and only requires the user to be able to speak and listen. Callers can create their own VoiceSites or access those of others. They can also surf the spoken web, jumping from VoiceSite to VoiceSite using speech.

In developing the system, the team took their cues from the growth of the internet. "The thing that really fuelled the adoption of the World Wide Web is the ease with which you can create websites," says IBM IRL's Amit Nanavati. So they focused on developing a simple way to create VoiceSites.

Say a plumber wants new customers. First he calls a number and software called VoiGen then guides him, in his local language, through the process of setting up a VoiceSite. Relevant information, such as a welcome greeting and the plumber's contact details are recorded. Behind the scenes, the VoiGen system then creates a VoiceSite. A phone number, analogous to a URL, is then assigned to the plumber.

Anyone who calls the plumber's VoiceSite number is greeted with his welcome message, and then given help to navigate the information. For example, the caller can say "address" to hear the plumber's address, or "appointment" to request a call-out with him.

Conceptually, the spoken web is a network of VoiceSites, just as the internet is a network of websites. A VoiceSite can only be accessed by a phone, and only requires the user to be able to speak and listen. Callers can create their own VoiceSites or access those of others. They can also surf the spoken web, jumping from VoiceSite to VoiceSite using speech.

In developing the system, the team took their cues from the growth of the internet. "The thing that really fuelled the adoption of the World Wide Web is the ease with which you can create websites," says IBM IRL's Amit Nanavati. So they focused on developing a simple way to create VoiceSites.

Say a plumber wants new customers. First he calls a number and software called VoiGen then guides him, in his local language, through the process of setting up a VoiceSite. Relevant information, such as a welcome greeting and the plumber's contact details are recorded. Behind the scenes, the VoiGen system then creates a VoiceSite. A phone number, analogous to a URL, is then assigned to the plumber.

Anyone who calls the plumber's VoiceSite number is greeted with his welcome message, and then given help to navigate the information. For example, the caller can say "address" to hear the plumber's address, or "appointment" to request a call-out with him.

The vast majority of people on this planet are poor and illiterate, but more and more of these folks are acquiring access to cell phones, partly due to initiatives like GrameenPhone, but mostly due to the fact that cell phone infrastructure is profitable even in developing countries, in turn due in part to compelling economic reasons to want telephone access.

One example: I have read accounts of fishers in Kerala, one of India's poorest states, using cell phones to find out where to get the best price for their catch, eliminating their dependence on a single local bulk buyer. They can learn the price at various ports within sailing distance and mentally compute the tradeoff between the cost of traveling to a given port and the value of their catch at that port. A classic reduction of market friction.

Clay Shirky wrote an acerbic commentary 2002 on the tendency to sentimentalize the "digital divide". In Half The World, Shirky wrote:

Because wireless infrastructure does not require painstaking building-by-building connectivity, nor is it as hampered by state-owned monopolies, it offers a way for a country to increase its telephone penetration extremely quickly. By 2001, there were 25 countries where cell phone users made up between two-thirds and nine-tenths of the connected populace. In these countries, none of them wealthy, a new telecommunications infrastructure was deployed from scratch, during the same years that keynote speakers and commencement invitees were busily and erroneously informing their listeners that half the world had never made a phone call.

This shift suggests that characterizing the "digital divide" in terms of access to broad- and wideband connectivity is naive. The power a cell phone provides to a poor fisherman is impressive, as one can see from this quote from a 2006 Washington Post article:

Rajan said the dealers don't necessarily like the new balance of power, but they are paying better prices to him and thousands of other fishermen who work this lush stretch of coastline. "They are forced to give us more money because there is competition," said Rajan, who estimated that his income has at least tripled to an average of $150 a month since 2000, when cellphones began booming in India. He said he is providing for his family in ways that his fisherman father never could, including a house with electricity and a television.

The spoken web could extend the leverage described by this fisherman to myriad small businesses and to individuals in the general population of the developing world. As with the World Wide Web in its infancy in the early '90's, it is impossible at this point to imagine the potential of the spoken web.

Another question: when high-bandwidth connectivity does reach into regions where the population is largely illiterate, will we see the emergence of an audiovisual web, which could merge the spoken web with multiple visual and audio media? Only time will tell, but the possibilities are not remote: in India a little more than a decade ago there were no cell phones, and Web-enabled multimedia cell phones were a pipe dream. Wherever a cellular network exists now, the potential for a 3G/4G Web-enabled cellular network already exists. Unless a better technology emerges in the interim, an audiovisual web targeted at semi-literate and illiterate population segments seems to me to be inevitable.

BBC NEWS | Virtual health care gets UK trial

You can read about the Aberdeen Royal Infirmary's venture into the brave new world of virtual healthcare in the  BBC News article entitled Virtual health care gets UK trial.Here's a taste:

Cutting edge telemedicine technology, that will allow medical staff to offer "virtual" health care, is being trialled at Aberdeen Royal Infirmary.

HealthPresence, a system developed by Cisco, links up doctors with patients through a video conferencing booth.

Blood pressure, temperature, pulse rate, weight and lung function can be assessed at a distance in the booth if patients can not make appointments.

If the trial is successful, booths may be set up in locations across the UK.

Possible future locations for the mobile health suite could include schools, workplaces, shopping centres and even people's homes.

(picture from BBC news story)

This trial uses kiosks manned by a human attendant; the kiosk can administer simple diagnostic tests, in addition to providing audiovisual teleconferencing. The presence of the human attendant goes a long ways toward allaying my fears about patient data security.

While not exactly a groundbreaking innovative concept, the Aberdeen trial is one of the first uses of rich Internet-based telecommunications media in the mundane world of primary care. I'm excited to see it, especially on behalf of my less well-off rural relatives and friends who currently have limited access to high-quality healthcare.

Now, if we could only get them health insurance coverage... :-)

Microsoft Explains HealthVault Strategy

I didn't get around to writing about this at the time, but a couple weeks ago I read in eWeek about how Microsoft Explains [its] HealthVault Strategy. There are a couple of analogies I wouldn't have made myself: MS compares HealthVault to XBox and PayPal.

The goal was to provide ways for consumers to better understand their health and health information and manage that information for themselves.

Conn [Grad Conn, Healthcare and Life Sciences senior director for global consumer strategy] explained that with consumers as the aggregators and the controllers of to whom, how and when their information can be shared, the traditional health information model is turned on its head.

"Right now, the mechanism for this is through HIPAA, which dictates how to control patient privacy when patients don't control the records," Conn said. HIPAA, he said, has very clear rules that patients can request to see, copy, add to or delete any piece of health information in their record, and HealthVault uses those same procedures, but in a digital format.

So far so good. This (when properly implemented, whether by Microsoft, Google, or some other "fourth party") will accomplish in nimble form what is already one of the clumsiest and least effective of the HIPAA provisions, the portability requirements. Your health records are indeed available to you as a patient, but the care provider has the option of charging you for the cost of making a copy, and in virtually all cases will only supply the records in hard-copy format, even when an underlying EMR or EHR is in use.

Now, on to the first of the startling analogies:

"Better Than Free": Lessons for Open Source healthcare software systems

In The Technium, Kevin Kelly's "Better Than Free" post should be a wake-up call for Open Source project leaders, in particular those in the healthcare arena. I first got wind of his post via The Edge, and when it popped up again in Seth Godin's blog, I had to stop and take a look.

This super-distribution system [the Internet] has become the foundation of our economy and wealth. The instant reduplication of data, ideas, and media underpins all the major economic sectors in our economy, particularly those involved with exports -- that is, those industries where the US has a competitive advantage. Our wealth sits upon a very large device that copies promiscuously and constantly.

Yet the previous round of wealth in this economy was built on selling precious copies, so the free flow of free copies tends to undermine the established order. If reproductions of our best efforts are free, how can we keep going? To put it simply, how does one make money selling free copies?

I have an answer. The simplest way I can put it is thus:

When copies are super abundant, they become worthless.
When copies are super abundant, stuff which can't be copied becomes scarce and valuable.

When copies are free, you need to sell things which can not be copied.

Well, what can't be copied?

A great question. Fortunately, Kelly has an answer ready, though I think he left out one important point.

IEEE Spectrum: Visualizing Electronic Health Records With "Google-Earth for the Body"

I haven't much time to write today, but I absolutely had to let you know about this article from the January issue of IEEE Spectrum: Visualizing Electronic Health Records With "Google-Earth for the Body":

Andre Elisseeff leads a research team at IBM’s Zurich Research Lab that in September demonstrated a prototype system that will allow doctors to view their patients’ electronic health record (eHR) using three-dimensional images of the human body. Called the Anatomic and Symbolic Mapper Engine, the system maps the information in a patient’s eHR to a 3-D image of the human body.

There's more...

Unified Communications: The Next BIG Thing in Healthcare | Bill Crounse, MD | Channel 10

The future of health IT is everywhere (at least, intimations of it). Keeping up with it is not easy. I found the post discussed here a while ago in Dr. Bill Crounse's blog at Microsoft. It's called Unified Communications: The Next BIG Thing in Healthcare. I have a bunch of these posts that are partly done, and I'm trying to work through the backlog. There's interesting stuff here.

Healthcare is a communication intensive business. Good communication has a profound effect on the quality and safety of patient care. Communication also has a huge bearing on patient satisfaction. Yet historically, the options for how we communicate with each other in the healthcare industry have been somewhat limited. We are hampered by an industry that has far too long relied on old fashioned telephone, paging, fax, and mail (both postal and interoffice); not exactly the most contemporary communication infrastructure.

This makes me realize how spoiled I am working at one of the top academic health centers. Email is the ubiquitous communications medium here, but we also use MSN Messenger (replete with voice, video, file transfer, and application sharing); Skype (which can do many of the same things); blogs, wikis, and integrated Sakai-based collaboration and communication environments; issue tracking and project management software; and of course all this is in addition to our enterprise and departmental IT and telecommunications systems. Did I mention clunky old pagers, which most of us avoid, opting instead for text messaging each other's cell phones when we need to.

The Future of Leadership - The Enabler

CIO Insight recently provided some insight into where biomedical informatics is heading in an article entitled The Future of Leadership - The Enabler.  It tells the story of Sandy Aronson, Director of IT for the Harvard Medical School–Partners Healthcare Center for Genetics and Genomics.  He's wrapping up an advanced degree, not in computer science or business management, but in molecular biology. 

It's not often that an IT professional earns an advanced degree in an entirely unrelated field for the sake of his job. But to Aronson, it makes perfect sense. "As IT professionals, it's really important to understand the content area we work in with as much depth as possible," he says. "You need to understand the non-IT processes you are working to support, so you can play a positive, efficient role in the process." For Aronson, that process isn't just about cutting costs or improving productivity. Aronson's group supports a user base of more than 600 researchers, scientists, technicians and healthcare professionals, all working on genetic-based healthcare, a concept that could re-write the rules of modern medicine.

I understand totally where Sandy is coming from. My own Master's, which I'm inches from completing now, is in information science with a focus on Human-Computer Interface. I've learned a lot, but in the meantime I've been helping to maintain existing and design new clinical research informatics systems. I've had to learn continuously about many things there - HIPAA; the Common Rule for the protection of human subjects; 21 CFR Part 11 and other aspects of the FDA's Good Clinical Practice predicate rule as they apply to computer systems; information security; the culture of a major academic health center; clinic and laboratory practice; and even a smattering of biology and medicine.

I'm betting Sandy's experience is similar. No matter what you study in school, there is so much more to healthcare informatics that no single course of study is going to provide all the knowledge you will need.

It's an exciting time to be in biomedical informatics. I've written about the synergistic convergence of multiple disruptive information technologies in my Rogue Wave scenario paper, and this field exemplifies perfectly the characteristics of the convergence.

Disruptive technologies are uncommon but not rare. The twentieth century witnessed the birth of numerous such technologies. The major events of the past twenty-five years in the world of IT have been the result of the ascendance of two different disruptive technologies about a decade apart. The first disruptive technology was the introduction of the personal computer and in particular the IBM Personal Computer and Microsoft’s DOS operating system in the early 1980’s. The second was the emergence of the World-Wide Web in the early 1990’s. Each of these changed the face of life in the advanced economies of the world in ways most of us would certainly call significant. Yet the changes we have thus far experienced pale in comparison to what the next four years hold in store. The reason: as we stated earlier, what we are about to experience is not just another emergence of a single disruptive technology, but the synergistic convergence of multiple disruptive technologies.

What do we mean by “synergistic convergence”? Synergistic convergence means the technologies harmonize, their disruptive forces melding in additive fashion. Rather than mitigating the effects of each other, their energies join just as the energies of the sea combine to form the rogue wave.

Information technologies are by definition enablers for other technologies, which on the surface may not appear related to IT. I used to work in the automotive industry, and what I saw there was that IT was a pervasive influence, affecting the processes of design, manufacturing, and sales, and enabling better and faster diagnostics in the service bay.

This picture is very incomplete, of course.  A modern automobile typically has multiple local-area networks embedded in it, with almost every dynamic aspect of the vehicle's operation under computer control.  High-end vehicles are beginning to use information technologies like Doppler radar to implement adaptive cruise control, and can communicate by satellite with monitoring systems that respond instantaneously to events like extremely sudden stops and the deployment of the vehicle's air bags.

Modern automobiles are complex beasts, but any single organ in the human body is orders of magnitude more complex, operating under the dynamically adaptive control of genomic, proteomic, and metabolomic information systems (technologies?). Aronson's academic studies have no doubt provided him (directly or indirectly) with insights into the ways in which such systems can be represented and simulated.  Even if his work is in the mundane arena of data processing that is used to manage clinical or basic science research operations, this knowledge will pay off.

I'm glad I focused on HCI, having seen how abysmal are even the best user interfaces in research and clinical IT, but if my budget and my wife will allow it, I can foresee further education in my future. It may focus on the complex knowledge domains on which Sandy has focused in obtaining his Master's degree. On the other hand, there are equally complex challenges in better understanding the cultural and socioeconomic dynamics operating within and between healthcare research organizations. It's a difficult choice.  The Chinese curse applies: we have indeed been born into an interesting time.

The synergistic revolutions in biomedical research and information technology

We are on the cusp of a revolution in biomedical research information technology, driven by two other  revolutionary advances and a mandate.  The emergence of systems biology has made it possible to envision a far deeper understanding of the processes of life, both in health and sickness and at every stage of development.  In the realm of information technology, computation, communications, and access to virtually the entire fund of human knowledge are about to become ubiquitous and invisible; computers are shrinking and becoming transparent, taking us into an age in which many of our creations will be imbued with intelligence. I have been thinking about this for a long time, and wanted to share some ideas about the implications of the changes that are about to happen in the realm of biomedical research IT and the opportunities and challenges they present.

Second Life and CSCW: a corporate PR viewpoint

Last week I wrote a post reflecting on the Shirky/Jenkins/Coleman debate and  a related post by IBM's Irving Wladawsky-Berger in which I speculated about the implications of 3D virtual worlds for the field of computer-supported cooperative work (CSCW).  Today I found a PR company called Text100 that is actively working in this realm; from what I glean from a quick read of their site, they are helping businesses leverage the affordances offered by Second Life in much the same way SocialText has done with enterprise wikiwebs.

In their blog I found an entry entitled The Impact of Voice Chat for Businesses in Second Life. In that post they described a number of benefits voice capability may be the tipping-point feature in making SL a truly viable enterprise collaboration tool. For example, they write this about the immediacy afforded by voice chat:

Second Life: the next paradigm for Computer Supported Cooperative Work (CSCW)?

Last week I wrote in my First Annual Chinese New Year Technology Predictions post that "Serious Games, especially 3D Virtual Worlds, will start being taken seriously by mainstream academic health researchers." This prediction is my small contribution to the storm of controversy around Second Life. When I made the prediction I hadn't yet seen a post in the blog of Irving Wladawsky-Berger (hereinafter W-B) entitled  A Dialogue on Virtual Worlds, in which he contrasts his view with that of perhaps the three most prominent voices in the Second life debate, Clay Shirky of NYU and Beth Coleman and Henry Jenkins of MIT's Comparative Media Studies program.

W-B's post reports on the point of view he expressed at a panel on Transforming Healthcare, Education and Business through Virtual Worlds at the Westport (CT) Public Library. (Sounds like a great public library, by the way!) W-B's point of view is unlike either of the two most prevalent views in the technology predictions space, which I referred to in my Predictions post as the enterprise prognosticators and the gadget geeks.  As an IBM executive it can be argued that his viewpoint is closest to the enterprise prognosticators, but as chief of IBM Research he takes a longer, wider, and deeper view than that expressed in the business mainstream.  I watch his blog closely because he is in a position to see further down the road than most IT mavens. 

Clay, Beth, and Henry's viewpoints, while strongly divergent with each other and to some degree with W-B's and my own, are of similar quality to that of W-B's in my estimation. Clay in particular is prominent in the health IT arena, most recently as chair of the Technical Subcommittee of the Markle Foundation's Connecting For Health initiative.
 

Many are trying to figure out whether [virtual worlds and Second Life in particular] are serious subjects that go beyond games and entertainment.  Some of us believe that this is the natural evolution of the Internet and World Wide Web, and therefore worthy of the considerable attention being increasingly devoted to it by the technical and business communities, as well as by the media.  Others, however, feel that this is all the marketing hype of a hungry IT industry looking for its Next Big Thing.  Perhaps the biggest skeptic about the future of virtual worlds and Second Life is Clay Shirky, a consultant, writer and teacher who is Adjunct Professor at NYU's Interactive Telecommunications Program.

He, Beth Coleman and Henry Jenkins have started a very interesting dialogue on virtual worlds and Second Life through their respective blogs.  Henry Jenkins is Professor of Literature at MIT, where Beth Coleman is Assistant Professor of Writing and New Media.  They are both also on the faculty of MIT's Comparative Media Studies program.  Here are Henry's, Beth's and Clay's blog entries to kick off their discussion.  I would like to contribute to this civilized exchange by explaining my own point of view on the subject, which I come to from a somewhat different angle than Clay, Beth and Henry.