Electronic Medical Records – What if the Doc Can’t (or Won’t) Use Them? January 9, 2012

True story, with some (potentially) interesting implications –I recently spent some time in the emergency medical system, and got to see some of the benefits and foibles of electronic medical records. Some of it was great! But other parts gave me pause – I’m interested in your experiences.

In December, I suffered what turned out to be a minor injury. During an exercise with one of my volunteer groups, I was doing a training exercise that involved falling and allowing the members of the group to catch you. I had not (in hindsight!) fully trained my group, and when I was falling, I ended up falling into the hands of a single individual. He did his best to catch me, but was unable to do so (not his fault!), and as I fell I struck his knee with my throat.

That blow took my breath away, and made my voice increasingly hoarse. Since I only have one airway, I thought perhaps it would be best to get it checked out to make sure it wouldn’t swell shut during the night J. My local urgent care clinic looked briefly, and immediately referred me to a nearby emergency room, as they didn’t have the tools to check it out. The emergency room (where I went post-haste) was excellent – conducted a brief triage (but got no real information from the original clinic), assigned me to a bed in the ER, got me seen by a doc pretty quickly, and then scheduled for a CT scan. There was a PC in the room that the nurses, the phlebotomist (who inserted an IV line in my hand) and others used to record what had happened with me thus far.

When the doc came through (pretty quickly, I thought), he brought a scribe with him. Turned out she was a local college student, studying to be a nurse. Her task was to enter data on my case on behalf of the doctor – a nice compromise which allowed the doctor to focus on me and my case, and not pay attention to a laptop. I suspected that it made the doc’s time much more efficient.

Then things got interesting. They took me away to run a CT scan on my throat, and brought in a throat specialist to run a scope in and look at my vocal chords (the structure most likely to have been damaged). The CT scan was delivered electronically to my records, so the throat guy could review it. He arrived very promptly (all things considered, since they brought him in from home on a Sunday night), checked things out, and prescribed a medication to be given intravenously (good thing I had that IV in already).

Some time later, the original ER doc came by to check in on me. In the pre-digital era, that would have involved him looking at my paper chart to see what had happened with all of his orders, and what the other doc had found. But not this time! Turned out that he asked me for a recap of events – had I seen the throat specialist? What did he say? What did he prescribe?

Now I suspect that if I had been unconscious or less than fully functional, he might not have used that approach. But it struck me as odd, and perhaps indicative of an issue in the ER. Perhaps the process for the ER doc to access and review records online is cumbersome? Perhaps there’s not an easy way for the doc to review patient info while retaining the efficiency he got while using his scribe to record information?

And that, of course, led to questions. What could be done differently? Is there some way, other than a laptop, that an ER doc could use to efficiently access patient information? Was he trusting my report of the information to be complete and correct, or did he go back and review the actual records later? (I assume he did, but have no way of knowing for sure.) In a more holistic way, could the original clinic have put information online in a medical record that could have been accessed by the ER doc directly, to reduce the friction in getting me into the ER system?

Have you ever experienced medical care in a digital records (paperless) environment? Have you seen anomalies that surprised you? Have you seen the benefits of those online records? I’m interested in your experiences!

Customer Service, Tech Support, and the Perils of Outsourcing (or Offshoring!) August 28, 2011

Source: autoclave.com

It seemed like a simple idea at the time. My DSL modem that provided my Internet connection at home had broken, and I had to get a new one. I could do it through my current provider, for about $100, and stay with my $30/month fees for moderate speeds. Or I could go to a new provider (call them “Novel Internet”, or Novel for short), get a “free” modem, and pay only $15/month for double the speed. What’s not to love?

Well, here goes. Novel had good radio publicity and endorsement of a talk-radio technology guru, and an endorsement from a family member who’d used them for years. So I called them to start the process – so far, so good. Got the modem in the mail a couple of days later – all still good. But then the fun begins. In short, after several hours on the phone with their tech support, who all seemed to honestly care and to sincerely try to help, NO ONE got it right until it was too late. Here are the details:

Novel’s web site, during the signup process, said very clearly “do not contact your current Internet Provider until your new service is working. Then you can call and cancel.” So I followed that rule, read the rest of the instructions with the modem (which said that service would be activated by midnight the night that it arrived), hooked everything up, and waited patiently.

But it didn’t work after midnight, so I called tech support. After politely going through the list of things they always want you to do (check the power, look at the lights, check to see if it’s plugged in to the DSL filter properly, …), I escalated to second-level support. Four calls and 2 hours on the phone w/ Tech Support yielded several claims that “we can’t share the line with your current provider” and “did you call them to turn their DSL service off?”

Of course, I didn’t make that call, since the instructions on the Novel signup page said not to, that Novel would do it.

On the near-final call to a third-level support person, Novel said that the old provider would have to come out to my home to do something in order to make it work. Novel tech support said the night before that Novel had not yet called the old provider to make this change; it appeared someone had dropped the ball. Then the message changed – I would have to call the old provider to turn off my Internet service.

Just when you think it can’t get weirder, it does …

Given all the trauma so far, I asked what, specifically, I should ask the old provider to do. Novel’s third-level support person asked me if I had my phone service with the same company. Since I did, he said, I’d have to ask them to turn off both phone and Internet service, wait for Novel to get Internet working, and then call the old provider to get my phone turned back on.

Conveniently, while I was on the verge of totally losing my temper, the line to Novel’s tech support dropped. They called back 30 minutes (!) later, but by that time I’d already called my old provider to ask them to send a new modem and turn things back on.

And then it gets weirder still!

The old provider says: “We’re sorry, but Novel called us on your behalf a few days ago to cancel your Internet service, so we have to start from scratch. It’ll take a few days, but we’ll open a new Internet contract for you.” Conveniently, this meant that I was treated by the old provider as a new customer, so I got both pricing and speed competitive with what Novel had promised.

Total time on the phone so far: Approximately 6 hours, AFTER the stated activation time provided by Novel.

While all this was going on, I found a tech support forum for all sorts of DSL providers. There, I happened across a direct access path to the general manager of Novel’s operations, so I dropped him a note with a more raw version of what’s above. He promptly connected me with the guy who turned out to be the last US-based tech support person for Novel – we’ll call him “Fred”. Fred clearly understood what had happened, called me on the phone to apologize, tried to make things right technically, and appreciated my sharing my insights with him.

Then we get to the financials! After trying four different methods (all recommended by Novel’s customer service staff) to cancel my relationship, they finally agreed to do so, but they couldn’t refund any of my money, and were going to charge me to restock the modem. Several laps around the stupid loop there led me back to the general manager, who assured me he’d take care of it, and, indeed, he did – Novel made my accounts whole, though they didn’t compensate me for the 6 hours of phone time, the cost to return the modem, or the cost to my mental health!

Now this isn’t a rant about offshoring – far to the contrary. Even as I was obviously frustrated, the folks I talked with clearly were sincere about trying to help, and never lost their cool. But they were also clearly new to their roles, and neither trained nor experienced with the products they were implementing, nor did they have a system that enabled them to see what was going on with my issues.

No one ever said “I see you just talked to Bob, and we’ll pick up where he left off.” Every call started with the first steps: Is the modem plugged in? What do the lights look like? Turn the modem off and back on again … This indicated to me that they had no continuity of service records, or didn’t know how to use them successfully. This problem could happen no matter whether the service operation is inside the company, or if it’s outsourced inside or outside the US.

Why am I writing about this? It’s a bit of a cautionary tale – good recommendations have to be current as well! My friends who recommended it: a) had implemented before the service and support were outsourced, b) almost never called tech support, and c) had started with this service, and weren’t trying to convert. So I was trying a scenario that was unproven, and perhaps had just been broken by their outsourcing moves.

I wish Novel all the best in resolving their issues – if they don’t, it’ll kill the company, and deservedly so!

Thoughts? Have you run into situations like this? I’d be curious to hear about it (without company names, please!)

Cycling to raise money for a young man in Africa January 11, 2011

Not my usual geek-centric commentary, just a plug for a friend doing some great work. Heather Anderson has been a friend since she was born, and I’ve had the privilege of watching her career in international service blossom through the years. She’s served in numerous overseas posts, including Jamaica, Lithuania, and several countries in Africa.

On that last front, she has been working with and is now raising money for the education of a young man in Swaziland, Celemusa. Her story is much more compelling than my retelling, so I’d encourage you to check it out at http://www.travelpod.com/travel-blog-entries/cycle4celemusa/1/1294088451/tpod.html. You can find instructions for how to donate and how to spread the word at http://www.travelpod.com/travel-blog-entries/cycle4celemusa/1/1294089690/tpod.html.

Even 10 years ago, getting this type of project off the ground would be much more labor-intensive than it is now – but Web 2.0 and its tools and relationships have helped make broad connection and distribution much easier. Thanks in advance for checking it out, and for your support!

Facebook as your single password on the Internet? January 6, 2011

Source: stock.xchng, plusverde

A recent blog post by Simson Garfinkel (of MIT Technology Review) raises an interesting possibility – that Facebook may be positioning itself to be your pathway to a myriad of other Internet sites, so that you don’t have to manage a plethora of user IDs and passwords. Interesting, strategic, potentially scary – lots of words come to mind when thinking about this possibility.

Facebook introduced Facebook Connect in 2008, and it’s now part of a collection of tools Facebook calls Facebook for Websites. To understand Facebook Connect, think about two different styles of building security. In one model, with a whole lot of exterior doors, you have to have a separate key to each one to get into the individual rooms – analogous to your separate passwords for each website you visit.

With Facebook Connect, you have the potential for a new model – a single exterior door, controlled by Facebook, and a single key – your Facebook user ID and password. Once inside, you can then have access (with no new keys required) to any room allowing use of the Facebook key, and you won’t have to get your key out again (retype your password), either. So instead of carrying many keys (user IDs and passwords), you need only carry one, at least for all those sites that support Facebook Connect. Techies call this single signon.

Facebook for Websites gives the sites that implement Facebook Connect access to a number of additional tools. Those sites allow users to “Like” things on non-Facebook sites, to allow users to easily register for a new site (with data pre-filled from their Facebook account, and Facebook Graph, allowing the site to see all of your Facebook Friends so it can leverage that information for marketing and other purposes.

Facebook Connect (and Facebook for Websites) was created, I believe, with the intent of making Facebook a more central part of its users’ Internet experience. Assuming that people used Facebook as their path to other web sites, that makes Facebook itself even more “sticky” as a destination for its users. Dropping their Facebook account would then require re-creating accounts at those places where they had previously logged in with Facebook.

As Garfinkel notes, this idea makes some sense for users. 500 million of us already have a relationship with Facebook, and have a lot of data there, making it already “sticky”. But there are potential issues, of course, in that Facebook doesn’t have a stellar track record of protecting the privacy of your data that you post there. And if your Facebook account password is compromised (by Firesheep, by someone guessing it, or by any number of other means), you’ve now lost “the key to the kingdom” – all accounts to which you connected with Facebook are now compromised.

Technologists have tried lots of things to solve this problem for consumers – having browsers remember your passwords, separate devices that could store them, specialized services like myonelogin.com to do single signon, etc. All have downsides in terms of both their risk profile and their usability, and Facebook Connect does too. What do you think? How do you manage your Internet passwords?  I look forward to hearing from you.

The Church Divided – not by ideology, but by technology! December 15, 2010

Working with laptop

Artist: len-k-a, stock.xchng

Like many other areas of life, churches are being impacted by the development and adoption of new technologies. A recent article by Terry Mattingly points out the challenges the church (Catholic, Protestant, and probably many others) have in reaching the younger generation who are used to connecting not by paper, phone, or even e-mail, but by Facebook and Twitter and text message.

Businesses ran into this problem some years ago, and someone coined the term Digital Darwinism. This refers to the habit some businesses had, like Polaroid, when they failed to see the change in technology coming and lost their market to a competing technology. The church doesn’t have quite that problem – there’s not a digital salvation that I’m aware of. But the church does need to find a way to reach people, young and old, to get its message out to them.

And it’s more than just outreach and evangelism. In my studies of churches using social networks, some use them for evangelism – trying to reach new people who have not previously been a part of a church, or who are looking for a new church. This is the case that Mattingly is initially concerned with – how to help the “digital natives” find their local churches, since they now look online, not on the street corner or in the phone book. The churches I studied also used their online presence to enable their members and sometimes others to interact – to organize, to discuss, and to support one another.

Beyond that, Mattingly writes of a recent (Catholic) Council of Bishops meeting where the bishops have been considering how to engage in the online world. The starting point is a web site, what Bishop Ronald Herzog calls a “one-dimensional” reality for the culture. Going beyond that is the “two dimensional” world of blogs, where anyone can state an opinion, and all opinions look at face value to have equal validity. In that world, the culture expects a dialog, to be able to engage with church leaders to discuss issues of faith.

But that takes time, and it takes risk for church leaders to take that on. I think it will be necessary for church leaders of all kinds of churches to engage in the online world – the “digital natives” will expect it, and at some points that will be where we’ll find them. That doesn’t mean the online world replaces the in-person world – just as in business, it’s a complementary channel that we’ll have to figure out how to best leverage and manage.

What do you think?

Social Media Metrics and Analysis November 13, 2010

Source: Marc Smith, http://everystockphoto.com/photo.php?imageId=6077678 (license at http://creativecommons.org/licenses/by/2.5/)

Facebook is all the rage among consumers – we know that from discussions among friends and around the water cooler. Companies are trying to manage how Facebook is used in the workplace – both from a “time used” viewpoint, but more importantly from a “what are our employees saying about our company” perspective. And, most importantly, how do we leverage this social networking thing to our company’s (or celebrity’s) advantage?

I ran across a report from SAS, based on an eMetrics conference session in May, 2010, in San Jose. This came up in some consulting I do for White Glove Productions (www.whitegloveproductions.com), a small company that focuses on providing fan sites that celebrities can control directly – giving fans access to “behind the scenes” activities and comments from the celebs.

The authors (Katie Delahaye Paine and Mark Chaves) make several interesting observations:

1.       Hits are a passé way of identifying impact of your web presence. It might measure the number of people (or scraping robots!) that have visited your page, but the authors claim there was no reliable way to translate those hits into real value for the company. Paine goes so far as to offer an acronym for “hits” – “how idiots track success”. (Yes, I know that hits roughly correlate to “impressions”, from the marketing world, but the authors are questioning whether online “impressions” carry the same weight as those offline.)

2.       It’s now all about engagement – can you get those folks who have had an impression of your brand to respond to it in some way? Click on a link, post a comment, participate in a forum, etc. Paine suggests a taxonomy of engagement, as follows:

a.       Searchers – those who scan online sources, but don’t pay much attention to the social media sites. You also don’t get much information about them – just perhaps a count of unique visitors.

b.      Lurkers – those who observe social media interactions, but don’t participate.

c.       Casuals – these folks participate a little in social media – they might follow your page, become your friend on Facebook, follower on Twitter, etc.

d.      Actives – regularly post comments and engage in conversations, “retweet” to others, and so on.

e.      Defenders – those who actively promote and support the brand, whatever it may be.

3.       It’s going to be increasing important for commercial enterprises using social media to clearly define their ROI – or in Paine’s terms, explicitly defining the R and the I.

a.       The Return (R) might be measured by how people engage – brand awareness, improving the company’s perception, allowing fans to interact with one another, etc.

b.      The Investment (I) needs to be measured and tracked as well – it’s not free, even if Facebook doesn’t charge you to post content there. It still costs staff time to interact with those visitors, and perhaps development time to create content to share with your audience.

They go on to identify further steps to measure impact, analyze results, and modify strategy as required. Some of those analysis models include looking at simple measures of numbers of posts, friends, etc., at links between friends and followers (social network analysis), and at analyzing the text of individual postings.

I’ll cover those more another day, but will leave you with one interesting site – www.live.firstdirect.com. These folks, at a bank in the UK, have spent time to scrape comments from blogs, Twitter, Facebook, and other sites that refer to their brand. They then analyze each comment for its “sentiment” – did the user make positive, negative, or neutral comments? The results are displayed in a way that gives a visual of the “whole world” view of the company – and they publish it for all to see. That’s another feature of social media – it makes your company or brand much more visible, and potentially much more transparent.

How will you leverage social media to support your brand (or even your personal brand)?

Electronic Medical Records – how will you access yours? October 25, 2010

Source: photoxpress.com

Intuit Financial Services (disclaimer – they bought my former employer, Digital Insight) recently published a survey indicating that about 1/3 of Americans now bank online. Precious few, though, have any access to their medical records online, nor do their health care providers. Medical records in the U.S. are still largely paper-based – a thick file of paper accessible primarily to the provider where it resides – your doctor, pharmacy, or other treatment provider.

As such, we lose out on some significant benefits, which recent health care legislation hopes to change. Health care providers are being incented to invest in technology to digitize their current records, and to move all of their recordkeeping into an electronic format. This might (but won’t necessarily) enable providers to share information among them, so that it’s easier for your oncologist, dermatologist, and general practitioners to see what each has learned about your case, and better coordinate your care.

Once those records are online and available to your health care team, they could also be made available to you. Kaiser-Permanente, among others, is among those making a splash in the media about how and why they do this – to improve care, to save trees, and to enable you to handle your health care in more convenient ways.

But using Kaiser’s, or any other provider’s, system directly will tend to lock you into that provider. Kaiser is also an “all-in-one” shop – good in that you get all your care through their services, but a bit limiting in that their system won’t store information about care you receive elsewhere.

There’s also not yet any good way to move your records from one provider to another, so if you change providers, your records may not move with you. But there are alternatives – Google Health, Microsoft HealthVault, and others that claim to be able to extract information from your various health providers and assemble it into one view, and allow you to enter your own records – exercise records, pulse, blood pressure, and glucose measurements, etc.

This model, though, moves your records into the hands of companies who provide you the service for free, but then may use that data to target ads to you. They can also use the data (in aggregate) to analyze all sorts of things about their users, and sell that information to others. And like any other company, if they have possession of data, it is possible that it may get misused – by outside hackers, or by their own employees.

There are still more options – your pharmacy, and your bank. Your pharmacy already has your prescription information, and often offers online access to your records. It wouldn’t be hard to extend that model to include data from your medical providers, if they allowed it. And your bank already knows how to manage security – and you’ve demonstrated you trust them enough to share information about your finances online. What if they could also offer a gateway to your health records?

So what’s your preference? If you bank online, you’ve already chosen to take a certain set of risks with your information, in return for added convenience and control. If you had access to your medical records online, how would you prefer to access them? Through your insurance company? Your primary care physician? Through a private independent provider like Google or Microsoft? Or perhaps through your pharmacy or bank?

I’d love to hear your ideas – thanks in advance for sharing!

Innovation failure? – Google’s Wave crashes August 9, 2010

everystockphoto.com - jurvetson

everystockphoto.com - jurvetson

You (most likely) never heard of Google Wave, or never tried it out.  And now you likely never will, at least by that name. It’s been out on the market for about a year, open by invitation only, much like GMail originally was. I wangled an invitation from a student so I could try it, but it’s not one of those things you can really try by yourself. It’s a collaboration tool, so it required someone to collaborate with, and, to be meaningful, something to collaborate on. I had lots of collaboration to do, but after playing a bit with it, I concluded that the learning curve was too steep, so chose not to burden anyone else with that.

Google announced recently that Wave development would not get further funding, but that code for some of its fundamental capabilities had already been released as open source. Bloggers at TechHaze note that Wave’s demise is likely due to lack of anyone to collaborate with – in other words, a lack of critical mass. It’s a product that clearly could have thrived from the Network Effect (link here TBD), but Google never achieved enough mass to get that growth to happen on its own.

So why did GMail become a raging success, but Wave failed? I think the surface cause was threefold: the lack of critical mass of users, the need to learn to do something new in order to use it, and the fact that it didn’t work with anything else – no interoperability.

That lack of critical mass was in turn caused by the invite-only model, and the fact that even relatively early adopters like me gave up on it (see reasons above), and never invited anyone. Turns out there was a great video available to help jump-start users, but it was an hour long. I think I started to watch it, but decided if I had to devote an hour to a video, it wasn’t likely to be worth my time until someone else tried it first.

GMail, in contrast, was immediately usable (and intuitive, for the most part) to anyone who already had an e-mail account. And, it could immediately send messages to anyone else using e-mail. Users didn’t have to get their friends to sign up for GMail before they could exchange messages.

It’s too bad it ended this way. Google certainly has the resources to make tools like this come to life, and those who’ve tried it say it was great. TechHaze says, and I modified it slightly, “there are two kinds of people: those who love Wave, and those who haven’t tried it” (or never heard of it).

Did you try Wave? For what purpose? What did you think? I’d love to hear from you.

Funky PR stunts & identity fraud July 17, 2010

Opposite the Bank of England, London

Source: everystockphoto.com - Chris Breach

Microsoft recently created a fake bank branch (the “Greater Offshore Bank and Trust”) in New York City, and hired “staff” to convince consumers to divulge personal information. The payoff? A promise of $500 for new accounts that consumers opened.

Consumers were asked to provide much of the standard identification information – driver’s license, name, social security number, etc. But they were also asked to provide such obscure items as their pants size, a snippet of hair for a DNA test, and other such things.

And what was the point of this? To promote Microsoft’s Internet Explorer version 8, which includes tools and capabilities to help consumers catch potential fraud on the Internet. A catchy concept, but very misleading, in my view.

The fact that consumers will walk into a realistic-looking bank branch and divulge personal information is very different from consumers divulging their information to a fraudulent web site. Granted, both can happen – but consumers are much more likely to be lulled into a sense of security by a real physical space, rather than a web site. In that physical world, they have a real person that they can describe to police, there are lease agreements for the building, and other tools to track potential criminal activity. And in this case, the consumers had the promise of a payoff for their information.

In contrast, a fraudulent site on the Internet has virtually none of those attributes to induce consumer confidence (or motivation). Consumers, once educated about the risks, would likely be much less prone to divulging such data without some confidence about who was receiving it and how it would be used. And if we can take the greed out of the equation (“We are looking for someone to help us transfer $20 million for the Queen of Transylvania”), that makes consumers less vulnerable still.

Microsoft’s advertising does make a valid point, even if they don’t emphasize it – it is harder to know who you’re dealing with in the online world. So consumers need to be cautious with their information in both the physical and online worlds, and to find out who they are sending their information to, and ensure that it’s reputable. We know from statistics that way too many people don’t do this – I just wish Microsoft spent its effort promoting this element of safety, and not just its own toolbox.

See the original article here, and commentary here (with video) and here.

One PC secure enough for banking, but still usable for casual Web surfing? June 3, 2010

A wonderful serendipity connected me with some folks at Intel Labs, Nikhil Deshpande and Vinay Phegade. Out of that grew a number of discussions, one of which led to a thought-piece recently published at bankinfosecurity.com.

The gist of the piece is that it should be possible to use a single PC for both high-sensitivity work (like your banking), and for casual web surfing. Now of course, most folks already do this – but they risk their information regularly, due to the plethora of malware out there that can infect their PC and steal their information.

The folks at Intel Labs have a vision for how they might be able to segregate off a portion of the technology in the PC, and use that for the secure functions, while retaining normal PC functions in the rest of the machine. See their overview summary here.

I’m happy to have had the opportunity to work with my Intel colleagues, and look forward to more such opportunities – technology is a great gig because it never stays the same!

Update 6/9/10 – Found a related story by Brian Krebs about a business banking user who on one occasion used his home “casual web surfing” PC for banking, and lost $100,000 in the process.