Future of Health IT: Trends and Scenarios

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:

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.

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.

SERENDIPITY: Older Wiser Wired

While looking at the Guidelines Sorting Tool, a cool feature of the US DHHS's usability.gov guidelines tome, I stumbled across the AARP's subsite on computer use by adults over 50 - Older Wiser Wired - Adults over 50 Online, Life and Living - AARP. 

This is a great find for those of us interested in making our Websites usable to persons other than college sophomores and baristas, who in any case spend most of their time on MySpace, YouTube, Second Life, World of Warcraft, and Google Everything rather than visiting the sites and applications we build and the blogs we write.

Irving Wladawsky-Berger: The Importance of Human-Oriented Design to Avoid Drowning in a Sea of Complexity

I follow the blog of Irving Wladawsky-Berger of IBM Research (hereinafter "W-B") because his insights are often more profound than one generally finds in blog posts. A great example is his recent post entitled The Importance of Human-Oriented Design to Avoid Drowning in a Sea of Complexity. This post talks about usability in very concise, practical terms grounded in concrete examples.  Where a usability pundit like Bruce Tognazzini ("Tog") issues lists of First Principles of Interaction Design, W-B's post gives you a deeper understanding of why usable applications are usable . This helps you understand when Tog's rules apply and why it is sometimes useful to violate them.

'Most Wired' Hospitals Study: What it means for your career in health IT

An eWeek article describes a study highlighting and analyzing the correlation between healthcare IT excellence in the secondary/tertiary care hospital and its ability to reach patients using state-of-the-art information technology:  'Most Wired' Hospitals More Likely to Reach Patients at Home.

On the surface, this is a no-brainer - or as the hoi polloi would say, Duh! What caught my eye, though, is the key reason why this is so. Turns out it's not about the gadgets - its about organizational learning. If you are a bits-and-bolts guy like me, this should be a wakeup call.

A Toy Story - Patrick Baudisch's projects

Some people definitely have jobs that are more fun than mine. Take a look at Patrick Baudisch's projects and you'll see what I mean - his job is probably more fun than yours is too. Patrick works for Microsoft Research, one of the great sources of innovative ideas, even if its parent organization is the Borg. Whatever. This post is about toys, not commerce or politics.

I got turned on to his work through a recent article in IEEE Computer that I finally got to read over lunch today. The article was called Interacting With Large Displays, and it describes some of his work regarding the pains that accompany the joy of having a wall-size display "monitor" for your computer. His solutions for these problems are truly fascinating.

Positive Technology Journal : Tangible query interfaces

I admit it. I can't keep up.

That's why I've been watching Dr. Andrea Gaggiolo's Positive Technology Journal blog ever since before I started FutureHIT. His brief post yesterday on tangible query interfaces is an example of the sort of find he comes up with many times a week. Such interfaces are inevitable, and I can't wait for them to arrive. It won't be long - they're already working in the laboratory.

More on the Linux Wearable Computer

(Click to enlarge)

Yesterday I put up a quickie about a post in The Positive Technology Journal regarding a wearable Linux computer targeted at the healthcare market. I took a look last night at the Web page describing this new toy, the Zypad WL 1000 from Parvus Corporation. I have mixed feelings about it - I love new gadgets as much as anyone, am enjoying learning to hack Linux, but feel like this may be a bit ahead of its time, at least in the healthcare market.