Future of Health IT: Trends and Scenarios

Personal Tech: Medical Apps for the iPhone

From NY Times Personal Tech: Medical Apps for the iPhone

After a lot of time reading "best medical apps" stories online, asking Twitter users for their suggestions and reading online reviews, I finally boiled the list down to about 50 promising apps. I tried them out and further winnowed the list to a bunch that I ultimately demo'ed in my talk. Eventually, the video of the talk will be posted at ted.com/talks, but in the meantime, here's what I covered.

(I haven't really given them full-blown testing, so read the online reviews before you spend good money on them. Except for the free ones--you've got nothing to lose!)
--Dave Pogue

I read David Pogue's personal tech blog at the NY Times to keep up on consumer IT trends, but this post from a couple weeks ago seemed really relevant to the readers of FutureHIT. I've been putting off posting because I wanted to say something eloquent, but work and home life have made that impossible. I'll settle for a few hints at what I believe are the most interesting among the items Pogue lists. I'm focused on the ones targeted at health professionals, but the consumer tools have a lot of potential as well.

• OsiriX. "An amazing viewer of medical images (X-rays, scans of all sort)".  I think this is probably just a DICOM viewer, but it requires special server software, so it may be adding some value. Regardless, it's very cool.
• AirStrip OB. "Lets an obstetrician monitor a patient’s status, right down to the baby’s heartbeat, from elsewhere in the hospital (or the town)."  As Pogue points out, this is a good pointer at the types of remote monitoring applications we can expect to see as ubiquitous/pervasive computing moves into the mainstream.

Actually I will mention a thought I've had about one of the consumer apps...

• Retina. "It’s for color-blind people like me. You hold it in front of something—clothes in your closet, for example—and it tells you by name what color you’re seeing."  This is an examplary augmented reality application, intriguing not so much for what it does -- which is of great value, I don't mean to denigrate it -- but for what it portends.  As image analysis becomes more sophisticated, it's easy to picture diagnostic tools that will look at the patient in visible light and infrared and point out diagnostic signs the clinician might overlook. A more prosaic application not yet built but within the reach of current technology would be a program that "looks" at the patient and points out relevant facts and decision guidelines based on the part of the patient's body on which the phone's camera is focused.

I think all this is intimately related to the technology I spotlighted in my recent post on the Open Data Kit, which is aimed at moving advanced tech for the clinician into community settings. As I said in that post, these types of tools will serve the developed world as well as the developing world, because even in the most advanced economies there are segments of the population that are underserved because they can't or won't go to a traditional healthcare provider setting.

There are challenges in all this that take some of the rosy glow out of the picture, notably patient privacy and truth maintenance, i.e. making sure the various information stores relied on by the remote devices have the most up to date information, and can update it as well. In addition there is the very real concern I feel as a patient that healthcare providers may become overly dependent on distributed computing and communications technologies, and be at a loss when connections break down (and they will, oh yes, they will).

Nonetheless, on balance the future for these technologies is bright and getting brighter, and the value they add is potentially enormous.

Stimulus Fuels Gold Rush For Electronic Health Systems: Huffington Post

I heard about this story on Huffington Post from David Kibbe, founding father of the Clinical Groupware Collaborative (CGwC). Here's a quote that struck my eye:

Federal officials won't decide until early next year which types of systems to certify. But some of the world's largest companies, including General Electric, Microsoft, Dell and German-based Siemens Corp., already are working hard to sign up doctors and hospitals.

The potential market is vast: Fewer than one in five of the nation's approximately 600,000 doctors and 5,000 hospitals now use the technology, but by 2015 all are supposed to be keeping their records electronically.

The government's spending, part of the Obama administration's $787 billion economic stimulus, promises to give as much as $44,000 to each doctor to spend on digitizing his or her health records.

"We've got to make sure the products sold are high quality," said Sharona Hoffman, a professor of law and bioethics at Case Western Reserve University School of Law who believes software defects could endanger patients and squander taxpayer dollars.

via www.huffingtonpost.com

Elsewhere there was a quote from Jonathan Bertman, a family doc from Rhode Island who has put together a low-priced EMR product I hadn't heard of before: AmazingCharts. The fact that I haven't heard of it is not surprising, given that I have become interested in EMRs for family practice fairly recently, and in the context of clinical research, not market research. Their product page had a quote that sums up concisely my personal view of the EMR/EHR industry:

Most EHRs are ridiculously priced and overwhelmingly complex, requiring servers, intricate networks, and hours upon hours of training which, in essence, are required to re-teach you and your staff how to practice and document the way their confusing program was designed.

from www.amazingcharts.com

I should make clear that with my two minutes on their site, I am in no position to pass judgment as to whether the AmazingCharts product actually solves the real problems involved in computerizing health care. In my experience most problems associated with deployment of new IT systems are related to the issues Jonathan Grudin identified back in the early '90's and wrote up in his ACM article, Groupware and social dynamics: Eight challenges for developers. The eight challenges he lists are for the most part social, not technical. Here's a key quote from one of the challenges that also serves as a succinct statement of the core problem:

Groupware may be resisted if it interferes with the subtle and complex social dynamics that are common to groups. The computer is happiest in a world of explicit, concrete information. Central to group activity, however, are social, motivational, political and economic factors that are rarely explicit or stable. Often unconsciously, our actions are guided by social conventions and by our awareness of the personalities and priorities of people around us, knowledge not available to the computer. ...[research has shown] that the social element can be central even to clerical work that seems routine.

The key technical elements in designing a system that can be successfully deployed are user experience design, and in particular user interface and workflow flexibility, extensibility, and adaptability. These are necessary, but not sufficient, components of the deployment process, which inevitably involves some degree of workplace transformation.

The transformation can be highly beneficial, but can only work if the in situ stakeholders are involved in the process, and involved to such a degree that they feel they own the system. This can only occur through intensive communication, both formal and informal, between the vendor, end users, and practice leadership.

With respect to the Huffington Post piece, what is most fascinating to me is the spectrum of comments. I don't have time to go into it now, but one thing is clear: there's a lot of controversy around the Federal initiative to computerize health care, and the controversy is growing.

"Meaningful Use" competition for CCHIT - from FierceHealthIT

It's the news we've been waiting for since June, when the Healthcare IT Policy Committee recommended that there be multiple entities that certify EHRs for compliance with federal "meaningful use" standards: A group has come forward to say it may compete with the Certification Commission for Healthcare Information Technology.

The Drummond Group, Inc., an interoperability testing lab based in Austin, Texas, has expressed interest in expanding its testing programs to include EHRs, Healthcare IT News reports.

via www.fiercehealthit.com

This is potentially great news for lightweight EMR vendors, like my consulting customer Cielo Medsolutions, whose product Cielo Clinic is very close to fitting the bill for the ARRA "Meaningful Use" criteria. The cost of certification has been prohibitive, and a more competitive certification environment will benefit them and others like them.

Wiser OWL learns to unravel doctor talk (The University of Manchester)

I saw a really good news bit today, actually two days old but that's how far behind I am on non-critical email:

A good example of the scale of the problem facing medics and computer scientists is the NCI Cancer Thesaurus that has swollen from 20,000 medical terms in 2004 to over 50,000 terms today.

As new terms are being added all the time, ensuring that all these terms are described, updated and linked together correctly is a mammoth task for humans. However, by using OWL 2 definitions can be written in such a way that computer programs can tirelessly update these terms, enriching the structure of the Thesaurus and pointing out where there are errors.
 
"The first stage was writing the NCI Thesaurus in the original version of the language, OWL, but now OWL 2 enables computer programs to interpret these terms in a much more human-like way, for instance reasoning that if a fracture is located on a bone which is part of a leg then that fracture is a fracture of that leg," said Bijan Parsia of the University of Manchester’s School of Computer Science.

via www.manchester.ac.uk

I can't write more about it now, but it's a critical step in the right direction for the evolution of the Semantic Web. Some maintain it hasn't even been born yet, much less started to evolve. There's an element of truth in that, but it's a sign of the change in our sense of time that we would expect something as complex as the Semantic Web to  move along more quickly than it has so far. Kudos to the folks at Manchester and Oxford who made this manifest earlier this week.

Open Data Kit

This past week, I read an exciting article on the Open Data Kit (ODK), "Open Source Data Collection in the Developing World", in the October issue of the IEEE Computer magazine. You can download a copy from the University of Washington's Computer Science and Engineering site. To give you an idea what it's all about, I've embedded here a short video from the ODK's project page at Google Code:

The technology is wonderful, but the article got me thinking about something only tangentially related, implied in the story: what constitutes the "developing world"? I've visited people in northern Peru who live on a dollar or two a day, with reasonable quality of life as long as things don't go wrong (which of course they always do, eventually, for each and every one of them). One remote village I visited, La Arena in the region and province of Piura, has been in existence since 1826, and hasn't changed a whole lot in its 183-year history. Their medical care is probably better than it was a century and a half ago, but not by much, and the ODK has promise to make some quantum-leap improvements in that realm.

I began to wonder if the "developing world" isn't much closer to home, though. There are pockets of poverty within two hundred miles of Ann Arbor, in both rural and urban areas, that are similar in some ways to what I saw in La Arena, perhaps not in the level of income but in other factors: the degree of disparity between their economic situation and that of the richest segment of the country's population, for example, and the degree of hope for a better life for one's children.

I can see a lot of ways in which the ODK could improve health care delivery in Michigan's less economically advantaged areas, especially if coupled with a lightweight EMR system like the one marketed by Cielo Medsolutions (disclosure: I consult for Cielo at times, and its principals are friends of mine). Because my involvement in biomedical informatics is in the area of clinical research, I can also see a lot of ways in which ODK could further in situ research in areas such as comparative effectiveness and health disparities. This would be especially effective if the research were conducted through the practice-based research network (PBRN) with which the University of Michigan is affiliated, the Great Lakes Research in Practice Network (GRIN).

If time permits, I will be exploring the ODK further. If I do, I'll report my findings.

Agile Methodology and the Conversational Meta-Methodology: Part one

I'm involved in a project that uses an online Agile project management system. It's not a big project in terms of number of participants, but the personnel are distributed across four institutions in three different states, none closer than a hundred miles to any of the others. When it becomes manifest, it will be a major achievement in the world of biomedical research, and it may result in technologies with commercial potential, even though they will be delivered under an Open Source license.

As stated in the opening sentence, the project employs the Agile approach. It's the first time I've worked on a project branded as Agile. I'm capitalizing the word to distinguish it from the adjective "agile", because the methodology may be Agile, but that does not guarantee Agile projects are agile in practice.

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I should say up front, in case any reader knows the project of which I'm speaking (and I'm sure some will), the project is moving along nicely. It has its ups and downs as with any project, but it is on track to be successful.

My critique here is directed at how the Agile approach as we are practicing it is getting in the way of the project approaching its full potential, which potential is well beyond the contractual scope as originally defined. The limitations I'm describing here could easily cause a different project to fail, but that isn't happening on my project. I'm happy with it, but I could be happier.

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The problems I'm seeing with the Agile approach may relate to subtle misapplications of the Agile approach in projects involving distributed teams, and I suspect these are widespread in the industry. These problems stem from tacit cultural biases and preferences.

I say 'misapplications' because people I respect and admire are ardent Agile enthusiasts: for example, long-time friend and colleague from my commercial product development days, Rich Sheridan of Menlo Innovations. If Rich says it works for projects like mine, and he does, I know I have some learning to do. I'm still at odds with his viewpoint at present, but I know I'll probably be convinced.

An example of the kind of tacit cultural bias to which I'm referring is the tendency of software engineers to want someone else to talk to the end user. This is not at all due to laziness or indifference. Often shy and introspective by nature, most productive when left alone in silence, software designers and programmers often believe that the process works best when there is someone who can tell them what needs to be done, and then leave them alone to do it. There are often organizational policies that proscribe developer conversations with end users, and these factor into the equation as well.

This in turn is related to a more pervasive cultural bias, the assumption that intellectual constructs like the requirements or design for a product can have persistent, stable existence independent of the minds of the stakeholders (most importantly, the customers, sponsors, and implementers).If they did have that sort of stability, requirements could be written down and "thrown over the wall" as the saying goes.

Some projects must force this level of stability, for systems engineering reasons -- the software for the NASA Shuttle is an example -- but for most projects, requirements are fluid and dynamic, and worse, are never the same from one stakeholder's mind to another even at any specific point in time. Moreover, this fluidity is not limited to requirements analysis: the same can be said for detailed product design.

I'm not against creating requirements and design artifacts, whether in Agile user stories, in IEEE-standard formal documents, or UML models, as long as everyone who matters in the process understands that the documented version is always incomplete, always wrong, and never incomplete or wrong in the same way twice, i.e. at any two points in time during the life of the project.

In project management, the saying goes, Plans are nothing, but planning is everything"; I would paraphrase that here as "Requirements documents are nothing, but the requirements analysis process is everything."

To see the fallacy in the assumption of stable, documentable requirements, recall the cliched party game "Telephone". One person starts with a somewhat lengthy and usually gossipy anecdote, and whispers it into the next person's ear. That person whispers it into the next person's ear, and it proceeds in this sub-rosa serial fashion until the story has been told to everyone at the party. At the end, the last person recites out loud what the story has become in the series of translations, usually to the merriment of all present.

The telephone game metaphor in software development produces something like the ubiquitous "What the Customer Wanted" cartoons, an example of which is shown here, stolen from Allan Jardine's blog (click to open full-size in a new window):

 

The lesson of the Telephone game is that communication often happens without comprehension. When done well, projects using the Agile approach should be characterized by lots of communication.It is the ongoing conversation, not the artifacts, that ensure a successful project.

For that reason, when I listen to any software development methodology, I look for the points where meaningful conversations will occur. A 'meaningful conversation' in this context is a timely and thorough conversation about product and process that builds and continually refreshes a shared mental model of the vision, mission, and goals of the project -- a mental model that all participants acknowledge will evolve over time.

If these conversations occur throughout, involve all relevant stakeholders at their points of occurrence, and form the real basis for the collaborative work, the methodology will result in a successful project, barring the occurrence of any of the political, financial, and other disasters that can kill even the most promising efforts.

Rich Sheridan agrees with my premise that we were doing Agile development back in 1986 -- in fact, all the successful commercial projects we knew about used some methodology that would fit into the Agile paradigm. What we lacked was a trademarked brand wrapped around a coherent description of some incarnation of our "methodology". Rich learned that lesson well, and his group has registered a trademark for the term High-Tech Anthropology®. Menlo peddles a methodology, to put it crassly, but it's no con game -- what they teach you is eminently workable in practice, and I highly recommend their services.

That said, I think Rich would agree that their flavor of the Agile approach works as well as it does because it is an incarnation of what I will now name the Conversational Meta-Methodology, rather than as a result of any rote technique that they teach you. In fact, one of the things they will teach you is that all the rote techniques are intended to do is to work toward a shared mental model of the project as it evolves over time. It's the process, not the artifacts, that are the key to success.

To disclose my personal interest in this matter, I wrote a book back in 2002-2003 called Design Conversations: Envisioning Content-Rich Enterprise Systems. It's as much about requirements analysis as it is about design. I've gotten great feedback from many of the several dozen people who have read it (including a few who downloaded it to their Kindles), but it hasn't started a movement. Maybe it's time to trademark the Conversational Meta-Methodology^TM, write a manifesto, work up some curricula and a YouTube video or three, and found an institute of my own. :-)

I'll come back to this in a soon-to-be-written post and show how it relates to my current project.

Obama and Biomedical Research Informatics: Reason for Hope?

Recently a friend at work sent an email to our workgroup in which he said:

In his weekly radio and video address describing what he called the American Recovery and
Reinvestment Plan, Obama spelled out five main goals. He said his plan proposes to:

-double renewable energy production and make public buildings more energy efficient;
-rebuild crumbling roads, bridges and schools;
-computerize the health care system;
-modernize classrooms, labs and libraries;
-and provide tax breaks to American workers.

So the computerization of our Health Care system
becomes a National Priority.

The implication is that Obama's presidency bodes well for our workgroup, which is devoted to biomedical research informatics. I wanted to share his thought and my reply, which follows:

While I share the enthusiasm for Obama's recovery plan, it may not
have much direct impact on research informatics units like ours, if
any at all. The effort to computerize healthcare was a key goal of the
Bush (W) administration, and while some progress has been made in
terms of determining evaluation criteria for EMR systems, from what I
have seen thus far, little or no interest has been exhibited with
respect to incorporating research informatics in the picture, in spite
of lobbying on several fronts.

The challenge of getting every American's health record computerized
is monumental, conceivably beyond the effort thus far put into space
exploration, and is fraught with contradictory economic and political
interests and motivations. This is not just an academic research
issue. Big Pharma has a stake in the integration of research
informatics into EMR systems (e.g. post-marketing surveillance), and
when Big Pharma's lobbyists can't get much traction, you know the
obstacles are formidable.

That said, another of Obama's campaign promises was to double the
budgets of the NIH and NSF. Let's cross our fingers and hope that
these promises are fulfilled as the massive economic stimulus and
recovery effort gets underway.  If they increased the government's
research agenda by even a fraction of what he promised, it will
benefit us significantly. Biomedical research informatics in
inextricably tied to biomedical research itself; progress in research
will be impossible without significant investments in biomedical
research informatics.

Moreover, all types of translation are becoming increasingly dependent
on informatics. Moving basic science discoveries into clinical
innovations and thence into evidence-based medicine and improvements
in public health can be greatly accelerated by computer and
information science.

All in all there is reason for hope, barring total economic meltdown
and the end of civilization as we know it.

In retrospect, I continue to hope Obama keeps his promise about doubling the NIH and NSF budgets. However, we have thus far in the past few months spent trillions of dollars on bailing out Wall Street, and a few billions on bailing out the auto industry. I wonder how much money will remain once we embark on our New New Deal.

The future of computing and communications: random thoughts, part 3

To continue the thread I started in posts on 17 September and 20 September, here's another peek into the future of user interfaces.This is a short post but I guarantee you food for thought. I'm going to start trimming down my post size so I can increase the frequency, but I'll do my best to make sure they are still worth your while.

Take a look at this page from Tokyo designer Mac Funamizu's petinvention blog (opens in a new window or tab, depending on your browser settings). Scroll down and you'll see some examples of his Futuristic Glass concept applied to Internet search, and further down links to several other blog posts giving other example applications of the concept. Here's a picture I stole from his blog to lure you into taking a look:

This illustrates another facet of the revolution in HCI devices I discussed earlier: in addition to rendering far more realistic simulations, they are becoming a lot more varied in form and function.  Prices of LCD screen components are becoming less expensive, as is touch-screen input overlay technology. The integration Mac describes is fanciful, but no more than five to seven years away from commercialization in all likelihood.

His glass looks like a portable windowpane, but glass is glass: this could as easily be a heads-up display on a vehicle windshield or a set of goggles worn by a surgeon to give a multidimensionally enhanced view of the patient under the scalpel.

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... :-)

EMR/EHR definitions via the Software Advice blog

  A reader pointed out this post on the Software Advice blog, which among other things brought into one place the NAHIT definitions for EHR, EMR, and PHR. Here's the first two:

Recently, National Alliance for Health Information Technology (NAHIT) established definitions for electronic medical records (EMR), electronic health records (EHR) and personal health records (PHR).

The NAHIT has produced the following definitions for EMR and EHR:

EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.

EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.

...and here's the definition for a PHR, also from NAHIT:

NAHIT has provided the following definition of a PHR:

ePHR: An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual.

To be most effective, a PHR should include cumulative health information ranging from past and current illnesses, demographics, allergies, prescriptions and more. Given the nature of the PHR, it’s the individual’s responsibility to decide what information is stored, and who has access to it.

The post has a good deal more analysis and some great comments and pointers to other useful posts from Steve Beller, PhD. Well worth your time to explore if you have an interest in any one or more of these three concepts.