Future of Health IT: Trends and Scenarios

Rogue Wave: The Synergistic Convergence of Multiple Disruptive Information Technologies

Reading a page on the McKinsey site called Clouds, big data, and smart assets: Ten tech-enabled business trends to watch, I came across something that resonated with an obsession of mine over the past three decades of my involvement in high tech: the synergistic convergence of multiple disruptive information technologies. I firmly believe that this is the driving force behind the massive and increasingly rapid changes in modern society and culture.

Starting around the turn of the century, I wrote a series of scenario planning papers called Rogue Wave in which I first published my thoughts on this concept. I felt the metaphor of the rogue wave was especially apropos. Here's how I introduced the metaphor in my papers: 

Rogue waves have been the bane of seafarers (and the joy of surfers) since time immemorial. Rogue waves happen when the crests of two or more wave patterns happen to synchronize, momentarily producing a much larger wave than any of the participating wave patterns could have produced alone. Rogue waves are the bane of seafarers because their energies can be tremendous, and therefore potentially very destructive to a ship holding to a particular course—detrimental not just to the ship’s ability to hold the course, but to the very ship itself. The inertial energy of the vessel’s mass interacts with the momentum of the wave patterns, stressing the vessel in unexpected and massive ways.

But to surfers, a rogue wave is a dream come true. Rogue waves can take you farther and faster than any normal wave, providing a much wilder, longer, and more satisfying ride, but only if you are ready to ride when the moment comes to catch the wave.

Contrary to our perceptions, ocean waves of all kinds, including rogue waves, are created not by the movement of water, but by the flow of energy. It is the energy flows that create the rogue wave, inundating the sailor’s vessel and providing the surfer’s wild ride. There are wave patterns in society as well—energies that move through our existence, and sometimes turning the status quo on its head. Technological evolution, religious and ideological movements, population bulges and dips, economic boom and recession, all are examples of the wave patterns buffeting human society.

The recently trending term Black Swan is a metaphor that characterizes the effects of Rogue Wave phenomena. 

Disruptive technology is a concept introduced by Clayton Christensen in his book the Innovator's Dilemma. He contrasts them with sustaining technologies, which reinforce the status quo in the course of deriving maximum value from it. On the other hand, disruptive technologies threaten and ultimately overturn the status quo. They are game-changing by nature.

Discovery-based planning, another concept introduced by Christensen, is based on the premise that disruptive technologies require learning strategies as opposed to the execution strategies that work well with sustaining technologies.

…in disruptive situations, action must be taken before careful plans are made. Because much less can be known about what markets need or how large they can become, plans must serve a very different purpose: They must be plans for learning rather than plans for implementation. By approaching a disruptive business with the mindset that they can’t know where the market is, managers would identify what critical information about new markets is most necessary and in what sequence that information is needed. Project and business plans would mirror those priorities, so that key pieces of information would be created, or important uncertainties would be resolved, before expensive commitments of capital, time, and money were required. [italics added]

Information is the critical element in learning strategies. Information technologies are critical tools for deriving value from information. Such technologies facilitate the capture, storage, search and retrieval, analytics, and many other aspects of information processing, and thus are critical drivers of learning strategies.

Moreover, new information technologies themselves are often disruptive by their very nature, changing the learning strategy game even as they facilitated by it. And information technologies, just like all others, are beneficiaries of their own disruptive effects and those of other new information technologies. In a world where multiple new disruptive information technologies have been emerging in parallel for  at least the past five decades, four of them paced by Moore's Law, the disruptive effects are synergistic, increasingly so over time.

The 2002 edition of the Rogue Wave paper set forth the Theorem of the Disruptive Value of Information, aka DVI Theorem:

Di = 1 / ( (Tu - Ta) * Ca )

The disruptive effect (Di) of a unit of relevant information is inversely proportional to the temporal distance between its moment of access (Ta) and the moment of its use (Tu) multiplied by the cost of its accessibility (Ca).

Simply put, the theorem states that relevant information is most disruptive when it is instantly accessible for zero cost. The value produced by the formula is a real number between zero and infinity. A value of zero means the information has no disruptive effect on the technological status quo; infinity means it has infinite disruptive effect. Since information always costs something to obtain and always takes some time to access, Di will never reach infinity, but lower cost and more immediate access greatly increase the disruptive effect of relevant information. At the other end of the spectrum, information that costs too much or takes too much time to obtain has little disruptive effect in spite of its relevance.

The DVI Theorem is the key to leveraging discovery-based planning. Entrepreneurial genius is involved in developing the disruptive technology and in identifying the key pieces of information that must be acquired, but the DVI Theorem sets a limit on how effectively the planning strategy can be carried out. Learning too late or too expensively is equivalent to not learning at all.

I'm going to revisit the Rogue Wave concept and the DVI Theorem in future posts and try to refresh and enrich it with things I've learned in the meantime.

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.

Memristors: a promising new development in computer architecture

Circuit theory is generally a pretty dry subject, in and of itself. For one thing, there hasn't been a new fundamental circuit discovered in the past 150 years. Or rather, there hadn't been until this year, when Hewlett-Packard researchers announced the realization of the memristor. The discovery process is described in this article from the IEEE Spectrum: How We Found the Missing Memristor.

Think of a resistor as a pipe through which water flows. The water is electric charge. The resistor’s obstruction of the flow of charge is comparable to the diameter of the pipe: the narrower the pipe, the greater the resistance. For the history of circuit design, resistors have had a fixed pipe diameter. But a memristor is a pipe that changes diameter with the amount and direction of water that flows through it. If water flows through this pipe in one direction, it expands (becoming less resistive). But send the water in the opposite direction and the pipe shrinks (becoming more resistive). Further, the memristor remembers its diameter when water last went through. Turn off the flow and the diameter of the pipe “freezes” until the water is turned back on.

That freezing property suits memristors brilliantly for computer memory. The ability to indefinitely store resistance values means that a memristor can be used as a nonvolatile memory. That might not sound like very much, but go ahead and pop the battery out of your laptop, right now—no saving, no quitting, nothing. You’d lose your work, of course. But if your laptop were built using a memory based on memristors, when you popped the battery back in, your screen would return to life with everything exactly as you left it: no lengthy reboot, no half-dozen auto-recovered files.

But the memristor’s potential goes far beyond instant-on computers to embrace one of the grandest technology challenges: mimicking the functions of a brain. Within a decade, memristors could let us emulate, instead of merely simulate, networks of neurons and synapses. Many research groups have been working toward a brain in silico: IBM’s Blue Brain project, Howard Hughes Medical Institute’s Janelia Farm, and Harvard’s Center for Brain Science are just three. However, even a mouse brain simulation in real time involves solving an astronomical number of coupled partial differential equations. A digital computer capable of coping with this staggering workload would need to be the size of a small city, and powering it would require several dedicated nuclear power plants.

As described in the Wikipedia article on the memristor, the idea actually goes back to UC Berkeley professor and IEEE Fellow Leon Chua's work in 1971, and it built on the work of other scientists at that time as well.

Two characteristics of memristors are especially intriguing to me. First, unlike a transistor, which holds discrete information values, a memristor's state is infinitely variable, which offers the possibility of freeing us from the tyranny of the bit. Back in the late 1970's and early '80's when I was getting starting in my IT career, we used to joke about discovering a third value for the bit as being the next big breakthrough in computing. Memristors go a long step past that point.

OK, its state is not infinitely variable, that was admittedly hyperbole; but a memristor's state is a continuous value, analogous to a floating-point number vis-a-vis an integer. Analog (living) neural circuits are continuous rather than discrete, hence the apparent potential for mimicking the brain. Harkening back to my days (or rather nights) studying expert systems at the Harvard Extension School, I can see memristors providing an elegant solution to the problem of representing uncertainty as a facet of state.

The second interesting characteristic of memristors is the inherent persistence of state without power consumption (disregarding structural enthalpy for the moment). The example of instant-on computers is trivial, as the referenced article suggests. However, when coupled with continuous variability, the persistence of memristors' state may afford the creation of machine learning systems as effective as neural nets without their inherent opacity. Training data sets "nudge" the neurons in a neural net into an appropriate configuration for emulating the behavior of living neural circuitry, but the "black box" nature of neural net state means it is impossible to use formal methods to predict the limits of its effective behavior (an unfortunate characteristic it shares with its biologic counterpart). A memristor-based neural net might be more conducive to the creation of transparently descriptive and ultimately predictive models of system behavior.

The architecture for such a system would likely be very different from the current neural net architectural paradigms. I'm not in a position to speculate on what form such an architecture would take. What I can do is to marvel at the possibilities. I can't wait to see the first fruits of memristor-based computer architectures.

Using crowdsourced librarians to outsmart Google

Thanks to Ian Jones, I found a very interesting article on Ars Technica entitled Using crowdsourced librarians to outsmart Google. It's about a project that aims to "out-Google Google" using the collective brainpower of librarians in crowdsourcing mode. It's based on what the project leaders say is sound science. There is a growing body of research on the credibility of online material, so their claims may be valid, but I haven't had time to vet them yet, so I am making no claims of my own here.

Still, the idea is very interesting. I've been hyperfocused on the problematic findability of quality consumer health information via the commercial search engines. If there is a better way of building an online search engine in terms of returning credible results, I'm all for it, and who knows? This could be it.

The Reference Extract project hopes to turn all of this credibility research into something practical. The team consists of professors like Lankes and the OCLC, an academic technology organization that counts more than 60,000 (!) libraries among its members. The initial work is funded by the MacArthur Foundation. Their first goal is certainly ambitious: use the web sites that librarians suggest most often as the basis of a more credible search engine that can return reliable results.

Reference Extract already believes that it can best Google, even before work has begun in earnest. That's because it has already used librarian-recommended sites to populate a custom Google search engine. Simply doing this produced search results that testers ranked as "more credible" than searches run on the main Google index, even when the testers had no idea that one of the searches was based only on librarian-approved sites.

I don't have time to think about this much at the moment, much less write intelligently about it at any length, being in crunch mode on a couple of projects all at once. Still, I wanted to pass it along. Others with a similar passion out there may find this very useful.

IEEE Spectrum: New Brain-Machine Interface Reactivates Monkey's Paralyzed Muscles

I just noticed this in the October issue of the IEEE Spectrum: New Brain-Machine Interface Reactivates Monkey's Paralyzed Muscles.

Though it will be years before spinal bypass surgery reaches even the clinical-experiment stage, researchers at the University of Washington (UW) and the Washington National Primate Research Center, both in Seattle, have figured out a way to get macaque monkeys in their lab to manipulate temporarily paralyzed muscles in their arms using brain-controlled electrical stimulation. In research reported last week in Nature, they describe what happened when they attached electrodes to neurons in a monkey’s motor cortex—the part of the brain that controls voluntary movement—and used fairly simple algorithms to translate activity in these cortical cells into electrical signals that tell muscles when, how much, and how forcefully to contract.

This is very encouraging news on a number of fronts. Of course it is good news for spinal trauma patients and patients suffering from degenerative structural nervous system disorders. But it also potentially bodes well for some unusual types human-computer interfaces.

Picture the scenario described above, but with the downstream actuator side of the circuit embedded in the body of someone other than the person whose brain is generating the signal. Imagine a surgeon teaching a surgical resident a very tricky procedure, and able to guide the resident's hand just as she would her own. Although the stimuli are coming from the outside, I'd bet that the resident's nervous system would retain the "muscle memory" of the surgeon-guided actions, aiding the buildup of tacit knowledge that characterizes expertise.

That's the first outside-the-box use that's occurred to me in a few minutes of reading and thought, but this is outside my current scope of activity (darn it!). I'll bet many other and better ideas will arise in the fertile minds of the biomedical engineering community as this unfolds.

The future of computing and communications: random thoughts, part 4

Here's another example of where HCI is headed: multi-touch sensing.

If you have seen an iPod touch or iPhone from Apple, or the Microsoft Surface coffee-table computer, you have seen early examples of what multi-touch computing is all about. Single-touch computing operates like a mouse: touching moves the mouse pointer, tapping is like clicking, tap-and-drag works like click-and-drag.

These early commercial products in the multi-touch realm add a second recognized touch point, allowing you to resize and rotate screen objects using two separate fingers. Multi-touch doesn't have to stop at two touch-points though, nor is it limited to the kinds of two-dimensional operations we associate with mouse-as-pointer interaction. Check out Jeff Han's (NYU) page regarding multi-touch interfaces:

While touch sensing is commonplace for single points of contact, multi-touch sensing enables a user to interact with a system with more than one finger at a time, as in chording and bi-manual operations. Such sensing devices are inherently also able to accommodate multiple users simultaneously, which is especially useful for larger interaction scenarios such as interactive walls and tabletops.

The Perceptive Pixel company is the vehicle NYU has spun off to commercialize Han's inventions. You can search YouTube to find more videos of Han showing off his inventions at various conference and media venues.

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... :-)

The future of computing and communications: random thoughts, part 2

I am testing a new software package I just bought called Dragon NaturallySpeaking, which I was lured into buying due to a substantial discount offered by a spam e-mail that I accidentally looked at -- a real success for the spam industry. It's turning out to be very successful at translating my voice into text.

I tried out voice-to-text software in the late 1990s, and decided then that it was not ready for prime time. This is one example of the kinds of interfaces and affordances I wrote about in my last blog post. If voice-to-text software is working as well as this seems to, and thus far I have had to make only a couple of corrections in this post, I can envision situations in which a keyboard is not feasible as an input device today, but where voice-to-text would be a very acceptable substitute, for example as an aid to surgery where no one in the operating room can spare their hands for a keyboard, least of all the surgeon.

I am still a complete novice at using Dragon NaturallySpeaking, which means I am still spending a lot of time learning how to use my voice to do a number of things that come naturally when using a mouse -- or at least naturally to someone who has used a mouse for as many years as I have. The program actually seems to work quite well at navigating through and selecting text in word processing programs, including Microsoft Word and the Firefox page where I am creating this blog post.

What I have written so far has taken me most of an hour, mostly due to the learning curve that is a natural part of learning an entirely new way of using a very familiar technology. What it reminds me of most, though I haven't done it in many years, is training a dog. In training a dog, part of what happens is you training the dog, and the other part is the dog training you. With respect to Dragon NaturallySpeaking, the bulk of the time is spent on the second part; that is, the dog is training me most of the time.

The most encouraging thing about the experience of the past hour or so is that Dragon NaturallySpeaking has failed to recognize only two words out of what I have written. Most of what I am learning is how to revise text as I write, and the vast bulk of the revisions are due to me changing my mind about what to say rather than errors on the part of the voice-to-text program. [I did find 3 or 4 more misrecognitions on reviewing the text.] When I watch closely what I do with the mouse under similar circumstances, I expect I will find that the ratio holds there as well; at this point, after using a mouse for more than 25 years, using the mouse is second nature to me. If I keep using Dragon NaturallySpeaking on a regular basis, and especially if I use it exclusively for some period of time, I suspect that its way of doing things will become second nature to me as well.

I don't think I will be able to use Dragon NaturallySpeaking on his regular a basis as I would like, though. I do a lot of work in circumstances where I am surrounded by other people, and where speech is not encouraged -- our open plan office at the University, for example, or at the public library. I can imagine using it in a coffee shop, but I suspect it will look very strange to the others around me. Then again, they already think I'm pretty strange, so maybe it won't matter. :-)

OLPC announces next-gen XO-2 $75 laptop

The One Laptop Per Child (OLPC) project has announced its next-generation effort, which will target a $75US price point. InfoWorld has a story (from its affiliate, PC World) about the prototype: OLPC announces next-gen XO-2 $75 laptop.

The nonprofit One Laptop Per Child Project has shown the first images of its next-generation touch-screen laptop that goes by the name XO-2. According to Nicholas Negroponte, chairman of OLPC, the laptop is under development and has a goal of costing $75.

..."The XO-2 will be a bit of a Trojan horse," he explained. He said the XO-2 will be pushed first as an e-book reader with the capacity of holding over 500 e-books. "Currently developing nations such as China and Brazil are spending $19 per student per year on books," Negroponte said. Investing in the XO-2 at $75 should be an easy decision for these countries, he added. But Negroponte pointed out, the XO-2 is much more than a e-book and is a fully functional laptop.

The first-generation XO laptop failed to meet its $100 price point - the article points out that it costs $188 per unit to manufacture an XO. Still, getting to that price point was quite an achievement. If the XO-2 fails to meet its price point by the same ratio, it will cost on the order of $140. That, too, will be a victory.

The gap between the developed and developing worlds is staggeringly wide, but certain technologies have achieved unexpected penetration into the downscale markets. Internet cafes abound in almost any developing-world settlement larger than a village. Cell phones, too, have proven their ability to provide significant value to the poor - if not the poorest of the poor, at least the next segment up. If the XO-2 does manage to catch on, it will be yet another step in the right direction.

Does the XO-2 have implications for health IT? On the surface, no - its target market is education at the moment. But once computing becomes ubiquitous, it will almost certainly be used to move the developing world in the direction of digital medicine. One obvious application compatible with the e-book focus would be as an e-journal platform for medical professionals and para-professionals.

A picture or two can be found at the PC World site.