How can Angry Birds and Facebook change e-health?

Well, not through clinical versions of these applications of course. That would be an interesting approach though, especially the social networking idea may have many applications in health IT, but I’d like to talk about something else that is happening in front of our eyes.

Facebook, Twitter, Angry Birds and other big names of the mobile application market are doing something for us that would normally take a lot of effort, and would not probably be as effective, these applications are training clinicians for mobile device usage.

We were having a conversation with Professor Ingram (Professor David Ingram of UCL) last week, and he was talking about some mobile applications he has seen, which aim to provide information to clinicians on the iPhone.

This led me think about the success of iPhone and iPad, which id pretty much obvious, at least based on Apple’s company value and sales numbers. That success has led to a new computing platform that has a user base from all ages. Now this is quite interesting, because if you introduce a computing platform with a completely different user experience (touch vs mouse & keyboard) and a completely different operating system, that would normally be a huge challenge for your sales and marketing. People usually do not switch that easy, because learning to use new devices takes time.

Even on the same hardware and software platform, introducing a new application into healthcare is a tough task. When I was working for HIS vendors back in Turkey, everytime we used to introduce one of our products into a hospital or to a pharmacy we had to deal with the training of users. If you had an application that you were replacing things would get even harder, because users would ask for pretty much the same features to walk around the learning curve. “But we used to to use ctrl + F7 to switch to patient search!, This new program does not do it, it does not work!”

What has been harder, is to get clinicians use computers. Even if when they don’t have to type anything, getting a heavy weight professor to use a computer to check out computer records for a patient is not an easy task. They would almost loathe the use of computers, and if you ask them, some would say they are too busy to learn new stuff when they’ve got so much work to do (read: they’re too old to learn new stuff).

What is interesting is, the same professor would be checking his e-mails on his iPhone between patients, and he may even be checking the pictures of the grandsons and granddaugthers on Facebook. The grandson, at the age of 6, probably already has a Facebook account, opened by the parents (yes, there are parents who do that)

Medical students? Oh yes, they all have Facebook accounts, they tweet, they play angry birds, and they would probably skip courses about using computers for clinical practice.

Through various applications, an incredible amount of people are using mobile devices, and they’re getting good at using them. I don’t remember such a large number of people getting so good at using computers (which all smartphones and tablets are) so fast at any time in the last 28 years or so (I was seven when I started using computers, and I’ve been in front of them ever since)

So if I were to introduce a mobile app, whether on iPhone or on a tablet, chances are that other applications will already have trained the users for using the device. Desktop computers never caused such interest from end users. People used them because they had to, MS Office, Internet browsing and maybe gaming made people use them, but I don’t think it has ever been like what we’ve been seeing for the mobile platforms.

So there is a platform that is in the pockets and bags/backpacks of many clinicians, all the way from students to professors, and if you manage to put something there, it will probably be quite accessable to them. This is a big opportunity for people who are trying to introduce computing as a tool into the clinical practice. Sure, we can’t move everything to these platforms easily, they’re mostly information consumption devices, due to their design, but if it makes it easier to reach clinicians to provide them information, then it is still an advantage over the problems we have to deal with desktop platforms today.

So let them play Angry birds, and check Facebook. The better they get in using those devices, the less friction your next application is going to face. What we need to do , is to find out how to develop interactions that maximize the capabilities and common patterns of these platforms, because they’re different than what we’re used to. If we can do that, we can improve at least some aspects of health IT, simply because we’re able to reach a larger user base.

Web based tooling for openEHR

The web is swallowing everything in the software world. Everything from accounting applications to clinical apps are turning into web applications. The trend is there, and it is so strong, that betting on emergence of a web based application for pretty much anything is possible now.

You think that there are many things for which you can say “that’d never be a web app”? Think again. Sure, it is taking some time, but the trend is very strong.

The reason behind this is one of the most costly aspects of software life cycle:  deployment & maintenance. Maintenance usually includes repeated deployments, so I’ve joined these phases.  If you develop any product, you’ll see that issues around deployment and maintenance is taking a huge amount of your time, and therefore costing you a lot. The cost is so great, that pushing applications to web, even with considerable limitations is paying off for the vendors.

In doing this, vendors are aiming for even lower costs by investing into certain web technologies, since the web based application domain is much more fragmented than a first comer would expect. For many solutions javascript + HTML is enough. It is a good combination, especially if you’re interested in the mobile extensions. Personally, I think javascript + HTML is introducing a significant cost into software development for the web. Due to nature of the development process with these technologies, you will have a higher alternative cost in many cases, usually without noticing it. There is hope for this combination though, but I’d give it at least 3 years before we can carry the mature practices of other technologies into this space. This is a big topic, so I won’t go into it in depth here.

Now an interesting question is: what would happen if we move some key tooling in EHR domain into web. I’m talking about modelling tools like archetype & template designers & editors, and more. Personally I think this is a good idea. The problem (at least for me) is: I have some evil plans for very capable user interfaces for next generation of these tools, and I want to use proper tooling platforms for creating them.

My tooling platform is Eclipse, everyone who has worked with me longer than a week knows that. Eclipse is great, but in terms of UI technology, its various limitations worry me. Yes, people have build lots of complex tools with Eclipse, but I still want more power for UI layer, and I still want to keep the framework’s good bits.  On top of all of that, I want to extend my tooling to the web. Now this is pushing the limits of technology we have. I can always develop solutions to problems I encounter on the way, but it is too expensive to do so! I’d rather see these concerns incorporated into my framework of choice.

Eclipse  people have been following trends, and they have been hearing about this kind of issues for quite some time now. So the next generation of the framework, E4, is going to be a huge jump forward in terms of its architecture. The whole tooling concept matured in Eclipse is going to move forward with web rendering support. This means running the tooling framework in the browser. Needless to say, this will be a big, big step forward. Eclipse is targeting Flash runtime as its web front end. And silently, this is proving all my points about the limits of HTML, even with HTML 5.  I’ve not had the time to look into documents in depth, but I guess it won’t be hard for others to plug silverlight rendering engines, or even HTML 5 rendering to E4 architecture, in the future.

For the moment, Flash is certainly the right choice. First of all, Flash player 9, has a huge installation base. The current player version is 10, but version 9, released in 2006, has managed to find its way into almost all desktop computers, even the ones in slow changing corporate & enterprise setups.

I can’t emphasize the importance of this enough. You’ll find alternatives like Silverlight and JavaJX out there, but JavaFX requires Java runtime 6.13 or later (or something like that) and Silverlight requires its own plugin installed. I also don’t see Silverlight taking off in  non-MS platforms (another long discussion I’d like to avoid for now) Flash is simply out there (imagine X-Files  intro playing  at the background)

Now if you put together all the things I want for openEHR tooling: Eclipse + Nice & capable UI + Web enablement + easy deployment (drums rolling…)

The answer is Eclipse + Flash integration with current technology (possible) and migration to E4 in two-three years or so.  I’ve also been looking into other technologies to support Eclipse’s UI layer, namely the QT framework, but that locks me into desktop space.

I have a feeling that an early entry into web based tooling will become a huge advantage in 5 years or so. If I invest into desktop technologies too heavily now, I’ll probably get stuck in it. The fact that everyone learns after their first 10 years in software business is: products & business models get stuck into whatever founding technology & architecture they are build on. It is incredibly hard to re-write products, or jump into other domains like distributed architectures, or web based applications.  So not giving up on power we need, but investing into desktop technologies that has a link to web is the critical strategy. CKM on its own is a success story, but its advantages in terms of collaboration is slightly masking its other benefits around the issues I’ve listed above. CKM does not build models, it only helps keep track of their evolution. Why not move the rest of the clinical tooling into this space? Archetype editor? Even the IHTSDO workbench. We either have the necessary technology now, or it will be there in almost a couple of years.

You see, just because of this vision only, Eclipse is worth investing into. Of course I need to take a better look into docs for E4, because my assumption is, I’ll be able to merge the complex Flash based GUIs in Eclipse I’ll be building soon, into emerging architecture in the future. If that assumption is wrong, I’ll have to reconsider some things, but architecture wise, I can’t see it being very hard.

So, this whole thing is about a trend, where not only end users, but also more technical communities begin to migrate to web. The technology is emerging, and cost argument is valid for everyone. Today, I believe Flash (Flex framework running on top of it) is the right choice for this. In 5 years or so, I expect Adobe to provide tools that’ll simply keep everything same, but render to HTML5 instead of Flash runtime. I’ll be betting on that.

So here I go, and announce my vision for openEHR tooling (heroic, but also emotional strings at the background): an Eclipse based framework, that will become web  enabled  in two years or so. I’ve managed to put together a large amount of work in many technologies to enable this, and very slowly, I’m binding them together. Let’s see how it goes.

Microsoft leaving HIS market!

Wow! I do not know how I should feel about this. Heather Leslie of Ocean Informatics wrote on Twitter that MS is leaving the HIS market, and as you can read here, it is true.

Now I’ve written about Amalga more than 2 years ago,  and I was excited about what it may become. I was hoping that with support and competition from Microsoft, the hospital information system business would go forward. Competition in this kind of very high cost markets is important, and only actors with lots of resources can push this kind of competition.

It appears Microsoft was not big enough! I’ve always felt that it was almost impossible to sustain a business model with a HIS product, and solutions in HIS market would survive only if they reach a really large scale. Reaching that scale is very hard on the other hand, since HIS software is no small piece of software, and its entry into a new hospital always takes a lot of effort in every way you can imagine.

It appears the amount of difficulty I kept observing in HIS business was not overestimated. Microsoft has sold lots of products with no profits at all. They have been selling xbox consoles for years now, and I’m not sure they started making profit in that market, but they still push it for the future value.

They won’t be doing this for HIS market. This is a very important sign for many stakeholders. If MS can’t dare to scale up its operation in such a well known domain, what does it tell you?

What it tells me is: do not attempt to build healthcare IT products with large scope. The cost of creating such products is incredibly high, and it can easily take you down. Everybody has a lot to gain from building smaller, well connected, specialized solutions. Clinicians, software developers, and even patients. Microsoft’s exit from HIS market is not the only sign. CSC having lots of trouble in delivering Lorenzo in UK, NHS slowly walking away from the idea of big contracts for the whole country..

These are the signs that show that gigantic, magical all in one solutions are simply not affordable, not for UK government, not for MS. So what makes you think you can afford it?

Instead we need to focus on systems using the agreed, open standards, specializing in various clinical domains, but sharing information to help with the whole operation of healthcare services. HIS market is way too expensive for newcomers, and even the well established players are having trouble in addressing the needs of customers. It looks more and more like airline industry: economies of scale with thin profit margins, with survival depending on addressing as many customers as possible.

I can’t claim, with full confidence that the future of health services lies in small web based applications, but there is certainly enough signs to claim that the market is going to give this approach a try.

Medical tourism (or outsourcing): is it the perfect use case for EHRs?

Wow! I can’t believe I have not written anything for two months.Well, time to catch up then.

Ibelieve that EHR implementation is not taking off because of some fundamental problems, and I’ve written about them before. Check out my previous posts for anti-patterns in  EHR implementation.One of the things I have not mentioned (or maybe I did) is the lack of commercial motivation for investment in EHR implementation. Pretty much any project has a commercial aspect, and it offers some profit to one or more stakeholders. Sometimes though the offer is not significant enough to attract big players into the project, and at the end, unexpected costs lead to financial constraints and less then desired level of implementation.The big players are governments, private insurance companies, trusts (for UK) and private practices, and large IT domain players like Accenture, IBM, Oracle and Microsoft. However, if you have these names on the table, you have to be very careful to not to create a monster instead of a project. Unfortunately, what happens most of the time is that grand visions (with grand bills) emerge, and billions are spend while actual results turn into fairy tails.If you go for smaller projects like PHRs, the commercial driver, the motivation that comes from profits is hard to build and harder to keep alive.

People can’t really provide convincing business models for PHRs, unless the PHR is some sort of side benefit in a larger system. It is almost always about patients having access to their own records, which are kept in a bigger system.Don’t get me wrong, there is nothing wrong with PHRs, it is just that they are not very easy to commercially justify, especially if they are disconnected from other systems.What we need is smaller (read my anti-patterns posts), but commercially attractive targets for implementation. Smaller pieces of software, connected to major flow of money. GP software is a good example of this, especially for USA.

I’ve been thinking about  medical tourism for some time. It is normal for me to think about this: a visit to a dentist costs you hundreds of pounds for a very simple procedure in London, and if you have a fairly complex operation or a series of operations to have, good luck with that. Meanwhile, flying to Turkey, having the operations in Istanbul, staying at a nice hotel and coming back can easily cost you much less, and you’d probably feel much better at the end. Especially if you do not have huge amounts of money.The level of clinical care in many countries including Turkey, is surprisingly good, and the difference in cost is even more surprising. I can see a huge potential in establishing a proper “medical outsourcing” network among various countries. It would work for everyone, including payers, care providers and finally (and obviously) patients.The amount of cost savings would be huge, and many practices would love to offer prices which would be cheap for patients living in other countries, but still leave them a nice profit, quite likely to be higher than their domestic operations.

The thing is, pulling this kind of setup off would take serious investment. Ensuring that the practices performing the outsourced medical procedures provide proper care, dealing with legal issues around privacy and location of data (still matters a lot), and integrating financial operations is a much larger task than an EHR platform for shifting medical data. The benefit is huge though.Governments (think EU here) can cut off so much spending, they can avoid long waiting times for many procedures, and therefore improve care.Unlike many other use cases for EHRs, medical tourism can very easily justify the investment in money turns, and I think this is what makes it different. If you are a clinician or a developer you may argue that money is not everything, and EHRs should not be implemented on the basis of commercial aspects. Well, you may be right (you probably are), but in this world, money turns most, if not all the wheels, and if your approach is not adopting to the way the financial workings of the healthcare market is organized,  you are going to have a very, very hard time.I know I am not the only one who has thought about this, Professor Kalra mentioned months ago a project they have been involved in. I am not sure if anyone has focused on the huge commercial aspects of medical tourism (I’d rather call it medical outsourcing actually).From a clinical point of view, it is very hard to discuss priorities, and I’m not equipped to do this anyway. However, actual financial figures may get very powerful actors interested in projects which are quite small in clinical scope, which is hard to do. When a medical outsourcing network offers a couple of billions in savings, suddenly the funding for the core EHR system becomes incredibly small, especially compared to administrative work that must be done.

So maybe we are supposed to include these kind of use cases in our presentations and discussions more, to attract the financial support we need to build the better systems we want to build.Having seen many EHR projects fail even to get started, no matter what the clinical benefits are, I am more and more inclined to focus on services which would earn us the resources we need. Otherwise, I can’t see how we can break the cycle of half implemented, budget constrained, isolated projects.Medical outsourcing may allow us demonstrate all the benefits we have been promising, and it can help all stakeholders justify their investment much better than other setups.