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.

Apple stores teeming with germs

A leading Australian expert in infectious diseases says people who use display iPads and iPhones at Apple stores are risking serious infections and the company should do more to maintain hygiene.

via www.smh.com.au

Another good reason to carry that little bottle of Purell® with you when you go to the mall...

Cielo Clinic, Meaningful Use, and ACOs: My New Obsessions

As regular readers probably already know, I've been hiding out for several months now, getting up to speed in my new position as Chief Technology Officer at Cielo MedSolutions LLC. It's a natural next step for me, because Cielo is commercializing a University of Michigan Health System spinoff technology with which I was intimately involved in my previous position as a research informatician.

The spinoff technology was ClinfoTracker, a relatively simple and straightforward prompt and reminder system for primary care providers (PCPs). Now it has evolved into Cielo Clinic™, a clinical quality management system that can dramatically accelerate a practice's ability to participate in pay-for-performance (P4P) and pay-for-reporting (P4R) programs.  Participation in P4P/R programs translates directly into additional revenue for the practice, and it does so by facilitatinbetter quality care through delivery of evidence-based medicine in situ in the PCP-patient encounter.

There are other applications that support P4P/R participation, of course; some of these also provide alerts that are crude equivalents of Cielo Clinic's prompts and reminders. By "crude"

Cielo's compelling advantage stems from its focus on capturing and using clinical data rather than relying on billing data to drive its rules engine.  Rather than rely on ICD-9, the standard for coding problems in the US third-party payer world, Cielo Clinic employs ICPC and ENCODE, which are specifically designed for the primary care setting. Billing data has been shown to be unreliable for quality management in primary care.

Moreover, Cielo Clinic tracks clinician's response to the prompts. This ensures that, for example, if a physician has already advised a patient to undergo a colonoscopy based on a prompt driven by current clinical guidelines for colorectal cancer screening, and the patient refused, that prompt will not reappear for one year (or at a longer or shorter interval of the clinician's choosing, based on their knowledge of the patient).

We've been working on a new product that will soon become manifest in the marketplace, focused in part on the obvious buzzword of the day: Meaningful Use (MU), the benchmark the HITECH Act will use with its implications for direct patient care providers of $44K in incentives to adopt health IT.

However, we see HITECH and MU as blips on the strategic radar. The real opportunity -- and challenge -- in primary care health IT is in the development of Accountable Care Organizations (ACOs).

Lisa Bielamowicz, MD, Managing Director with the Health Care Advisory Board, the research division of The Advisory Board Company (ABC), recently posted a video entitled Keys to Success With Accountable Care Organizations on the MedPulse Business of Medicine newsletter from Medscape (free membership required to access). It's an 8-minute video that gives some good insights into how PCPs, their local hospitals, and the specialist practitioners with whom they collaborate can work together to improve patient care while reducing costs under the aegis of ACOs.

Conceptual modeling in systems analysis: the Five-Minute University class

Back in the day, the comic persona Father Guido Sarducci developed a series of skits he called "The Five-Minute University", which were hilarious more often than not, but often had some meat to them.

Writing an email this morning, which I may or may not end up sending, I wrote an outline of the conceptual modeling process in systems analysis, that on retrospect looked a lot like one of Fr. Sarducci's classes, albeit without the world class humor. I thought it would be worth sharing, if only to get comments that tell me what I'm missing here.

Without further ado, here's my 5-minute university class in conceptual modeling:

1. Assume we are starting with a narrative document the customer has written describing what the system is supposed to do. Such narratives are rife with tacit assumptions and misleading terminology. Our job is to weed these out and come up with something the customer agrees is right, and that will also make sense to the engineering team.
2. Look for nouns to identify object candidates. Some will likely be external actors.
3. Look for verbs that reveal relations between objects and system behaviors (of the internal objects or external actors).
4. Identify system outputs, and work backward from the outputs to the inputs to determine what processing is required and who (i.e. which object) is responsible for what processing. As you carry out this step,
   • You may realize you need additional objects for internal processing. Don't get too far down in the "weeds" here. 
   • Give all objects and behaviors names that the user will understand in functional terms, e.g., SecurityManager for an object responsible for authentication (aka "Log In") and authorization (aka "Check Permissions").
     • Avoid technical jargon like "Bean" and "Database" for now; these will appear in the design, when the target audience is the programmers.
     • Avoid the tendency to include objects and behaviors that are for internal bookkeeping and housekeeping, with no relevance to the end user, and possible unintended but ominous misinterpretations. A good example is "commit", which the user will associate either with a crime or a determination of mental incompetence.
5. Apply Occam's Razor to eliminate unnecessary objects, relationships, and behaviors.
6. Clarify the boundary between the system and external actors.
7. Review the model with the customer to find out if this represents what the system needs to do. If so, you have a good starting-point conceptual model of the system. If not:
   • If your model is close to the mark, iteratively refine the model until it is satisfactory to the customer. If this works, you are done.
   • If your model seems way off to the customer, or if your efforts in 6.1 seem to diverge rather than converge, go back to the original narrative and rewrite with the customer to get a clearer picture of what the customer wants the system to do.

If you read this far, you deserve a peanut, so here's one of Fr. Sarducci's skits:

The Cost of Fear | Why Docs Don't Embrace Technology (Dr. Rob)

I recently read a post on Dr. Rob's Musings of a Distractibel Mind blog on the barriers to adoption among primary care providers and their consultants. I found it very insightful. It opens with a description of an interaction between Dr. Rob and a consultant, in which he offers to exchange information via email and met with silence followed by a polite refusal. He goes on:

This is a typical reaction I get from my colleagues when suggest using the new-fangled communication tool called email.  The palms sweat, the speech stumbles, and the awkwardness is thick in the air.  It’s as if I am suggesting they join me in an evil conspiracy, or as if I am asking them to join my technology nerd cult.  There is a culture of fear in our healthcare system; it’s a wall against change, a current of stubbornness, a root of suspicion that looks at anything from the outside as a danger.  Instead of embracing technology, doctors see it as a tool in the hands of others intent on controlling them.  They see it as a collar on their neck that they only wear because others are stronger than them.

via distractible.org

Email, Fax, and HIPAA

Comments on the blog suggested that the objections might be based in part on security concerns. The consultant may prefer fax over email as a better way to protect patient privacy.

Sadly, many folks think that faxes are somehow encrypted and therefore secure, but they are not. Their advantage over email in this respect is that faxes contain image data, which would be harder to mine for useful information than the plain text of most email. Transmitting HIPAA PHI in either is a violation of the HIPAA Security and Privacy Rules.

There are ways of encrypting both fax and email transmissions. The former requires a commercial product of some sort, the latter either a commercial solution or arcane and cumbersome freeware technologies.

It seems like a better approach would be a shared system that uses HTTPS for all communication. GMail can do this, and HTTPS is now GMail's default transport layer for its user interface, but whether or not communication with any remote mail system is secure is situation-dependent and opaque to the sender and receiver. It is unclear whether the GMail databases are HIPAA Security compliant. Our Health System uses Groupwise for internal communications, which is encrypted both in transport and storage, with all storage maintained inside the data centers and behind the firewalls of the covered entity.

PHR systems like Google Health and Microsoft HealthVault offer another alternative. In both cases the information is "owned" by the patient, who must grant access explicitly to others; all inter-system communication over public channels is encrypted. DOD's MiCARE system (http://bit.ly/dlz2iW) interfaces with both PHRs, providing relatively painless and secure sharing of health information between and among primary, secondary, and tertiary care providers, consulting clinicians, and non-clinical care providers. The only catch is that the patient must trust the MiCARE system to identify, authenticate and authorize external systems that need to read from or write to the PHR.

Whether Google Health and HealthVault are truly secure is an open question. I have found no explicit assertion from either that their back-end databases are encrypted, though both employ extensive physical and administrative controls at their data centers. Not providing any details of their technical controls (e.g. encryption of databases) is probably wise, since any information at all would be potentially useful to hackers. Still, an assertion that the back-end database are encrypted would be appreciated by patients and by liability-sensitive providers accessing their systems.

The Real Issue

All that said, the most substantive objections to the use of email in the minds of healthcare providers are probably social and psychological rather than legal or technical. Use of email may be perceived as a slippery slope to being lured or compelled into more extensive IT adoption. Primary care physicians in particular are late adopters of technology, and with the lack of emphasis on usability in many systems currently available, it is difficult to blame them for their reluctance in this regard.

I recently sat through a vituperative diatribe from a family physician whose employer adopted one of the major EMR provider's systems over a year ago, and she stated that the system actively interfered with her ability to provide care. Her objections were multiple, but most prominent were twofold.

First, the system demanded excessive navigation due to inflexible and poorly designed user experience design and information architecture, leading to severe reduction of direct contact with the patient and broken concentration. Second, the system overwhelmed her with prompts and reminders she had long since determined were irrelevant for a given patient. The system provided no way to suppress them, which she was told was due to liability issues.

Another physician I overheard in the YMCA locker room was lamenting the fact that computerization had led to a requirement that he spend more than half of what had previously been his lamentably small amount of free time on nights and weekends updating the EMR. This was in his view better than attempting to use the EMR system in situ.

I know there are many success stories in primary care EMR adoption. Dr. Rob is one of them, and I personally know of a number of others, including my own family physician. The Federal initiative to computerize primary care is laudable, even though the road ahead will be rocky for some time to come.

Hopefully the systems that end up dominating the primary care EMR marketplace will succeed based on usability, quality, and workflow flexibility rather than on company name. The enterprise-system vendor offerings in the primary care arena tend to be dumbed-down, check-the-box knockoffs whose designers seem oblivious to the unique and highly variable requirements of primary care clinics and practices. Which vendor(s) will succeed, and on what basis, and with what ultimate effect on the public health, only time will tell.

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.

Driven to Distraction - At 60 M.P.H., Office Work Is a High-Risk Job - Series - NYTimes.com

On Wednesday, the Transportation secretary, Ray LaHood, called the broader phenomenon of distracted driving a “deadly epidemic” at a meeting on the issue in Washington. Real estate brokers, pharmaceutical sales people, entrepreneurs, marketers and others say they have little choice but to transform their cars into cubicles. In this merciless economy, they say, they have to make every minute count, and respond instantly to opportunities and challenges.

And they argue that the convenience of constant contact — and the chance to tick off items from an endless to-do list while driving — far outweigh what they think are slim chances that it could lead to a wreck.

via www.nytimes.com

The NY Times has been running a series on the perils of multi-tasking while driving. Today's installment highlights how work pressures, often self-imposed in the case of knowledge workers, are causing people to kill themselves as well as innocent bystanders through stupid mistakes made while trying to be on the telephone, send email, and drive all at the same time (or similar combinations of ICT activities).

It may be that in our culture, this pattern of behavior is Darwinian natural selection at work, though the loss of innocent bystanders doesn't quite fit the pattern. It does represent a continuation of the obliviousness we feel with respect to the dangers of multitasking. In addition to this kind of life-threatening danger, there are less obvious but more pervasive effects. In a paper published earlier this year in PNAS Early Edition, "Cognitive control in media multitaskers", Ophir and colleagues described a controlled behavioral trial in which they showed that media multitasking degrades personal productivity and effectiveness:

A trait media multitasking index was developed to identify groups of heavy and light media multitaskers. These two groups were then compared along established cognitive control dimensions. Results showed that heavy media multitaskers are more susceptible to interference from irrelevant environmental stimuli and from irrelevant representations in memory. This led to the surprising result that heavy media multitaskers performed worse on a test of task-switching ability, likely due to reduced ability to filter out interference from the irrelevant task set.

In all likelihood, many of us in the knowledge business will be as oblivious to this evidence as we have been to the numerous past studies of the dangers of using cell phones while driving. Sad, but true, I fear.

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 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.

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.