Usability of electronic health records: test cognitive cost first

Obama raised mileage standards for my industry.

Ok, so it wasn’t him personally, and it’s not mileage, and I don’t exactly own the health care “IT” industry. Even so, I can better imagine now what it was like to work for GM in the 70s when mileage standards were first set.

For my industry the ‘mileage standards’ are known as ‘meaningful use’, as in MU1, MU2 and MU3. Despite the confusing name these are effectively increasingly stringent performance standards for electronic health records, akin to mileage and emission standards for automobiles. They’re reshaping the industry, sometimes for better and sometimes for worse. (Should we, for example, measure the value of all of our measuring before we do more measuring?)

The industry has moved through MU1 and is now digesting MU2 with MU3 on the horizon (assuming Obama wins, though Gingrich was a great fan of this sort of thing.) MU3 is still under construction, but one consideration is the inclusion of ‘usability standards’.

For various reasons I’m not thrilled with the idea of setting usability standards, but the term is broad enough to include something I think we really ought to study: The impact of complex clinical documentation and workflow systems on the limited cognition and decision making budget of the human brain…

I’ve written about this before …

Gordon's Notes- Electronic health record use and physician multitasking performance 4/2010

Llamas and my stegosaurus: Living with a limited brain
Some interesting research has come out recently about the processing capacity of brains. For example, that the medial prefrontal cortex can only handle two tasks at once, or that working memory can only handle about 7 items at a time (but what's an item?), or that when people are actively trying to remember something complicated, their impulse control is reduced…

Since then this topic has gotten a bit more attention, particularly from a study of Israeli judges …

Do You Suffer From Decision Fatigue- - NYTimes.com 8/2011

… There was a pattern to the parole board’s decisions, but it wasn’t related to the men’s ethnic backgrounds, crimes or sentences. It was all about timing, as researchers discovered by analyzing more than 1,100 decisions over the course of a year. Judges, who would hear the prisoners’ appeals and then get advice from the other members of the board, approved parole in about a third of the cases, but the probability of being paroled fluctuated wildly throughout the day. Prisoners who appeared early in the morning received parole about 70 percent of the time, while those who appeared late in the day were paroled less than 10 percent of the time…

… Decision fatigue helps explain why ordinarily sensible people get angry at colleagues and families, splurge on clothes, buy junk food at the supermarket and can’t resist the dealer’s offer to rustproof their new car. No matter how rational and high-minded you try to be, you can’t make decision after decision without paying a biological price….

… These experiments demonstrated that there is a finite store of mental energy for exerting self-control. When people fended off the temptation to scarf down M&M’s or freshly baked chocolate-chip cookies, they were then less able to resist other temptations….

Patient care is an endless series of decisions (though over time more behavior, for worse and for better, becomes automatic). All physicians start with a cognitive budget for decision making, and every decision depletes it. Unfortunately using an EHR also consumes decision making capacity – perhaps far more than use of a paper records. There’ve been a few studies over the past fifteen years hinting at this, but they’ve gone largely unnoticed.

So, if we’re going to study ‘usability’, let’s specifically study the impact of various electronic health records on cognitive budgets. We now know how to do those experiments, so let’s put some of that MU3 money to good use, towards supporting tools that enable better decisions – because they’re less tiring.

Think of it as meeting mileage standards through aerodynamic design.

The Chameleon Candidate

Now he's pro-choice:

Norm! | TPM Editors Blog
Romney surrogate Norm Coleman caught on tape assuring Ohio voters that Roe v. Wade is safe in a Romney presidency.

Has any presidential candidate in US history changed his fundamental policy positions as frequently and as radically as Mitt Romney?

It's not a rhetorical question. I'm curious. We live in unprecedented times ...

xkcd: Congress. America's most extreme right wing ever.

Minnesota's Coursera eviction will be reversed

A few weeks ago Minnesota got some app.net attention. Alas, it was because we looked a bit silly ...

Minnesota Gives Coursera the Boot, Citing a Decades-Old Law - Wired Campus - The Chronicle of Higher Education

... The state’s Office of Higher Education has informed the popular provider of massive open online courses, or MOOC’s, that Coursera is unwelcome in the state because it never got permission to operate there...

... Tricia Grimes, a policy analyst for the state’s Office of Higher Education, said letters had been sent to all postsecondary institutions known to be offering courses in Minnesota. She said she did not know specifically whether letters had been sent to other MOOC providers like edX and Udacity, and officials there did not immediately respond to questions from The Chronicle.

But Ms. Grimes said the law the letters refer to isn’t new. “This has been a longtime requirement in Minnesota (at least 20 years) and applies to online and brick-and-mortar postsecondary institutions that offer instruction to Minnesota residents as part of our overall responsibility to provide consumer protection for students,” she wrote in an e-mail....

I asked my illustrious state representative, Michael Paymar, about this. He responded by paper letter (that's the way it works). Briefly the Office of Higher Education will work with legislators to change the law. The Director Larry Pogemiller said that nobody should bother registering and Coursera was fine in Minnesota.

Unsurprisingly this was a well intended law designed to protect students from old-style educational fraud, but it's obsolete now.

How and when will Apple give up on Siri?

I usually wait for my iPhone upgrades, but I was an early 4S adapter. That meant I used Siri when she worked.

She didn't work for very long. Apple couldn't scale the Mathematica code that underpins Siri. Over the past eight months I've seen some good days, but since the iPhone 5 launch the service has been largely worthless for me. Soon the iPad Mini will come and I expect things to get worse.


So how long will Apple keep trying to make Siri work? Maybe it's just a matter of building enough data centers, but perhaps Apple bet on the wrong technology. Maybe it's not economical to scale Siri.

So what can Apple do? What might they be doing now?

Despite my prior comparison to the Newton, things aren't quite as dire as all that. The iPhone is very useful without Siri, and since most of us don't rely onSiri there's not much true functionality to remove. Apple can focus on a few key hands free voice recognition areas and re-implement those partly in iOS and partly on a non-Mathematica server foundation. Scaling can then focus on those key areas. The AI part of Siri can then be treated as a toy -- until Apple can either scale it out or replace it.

I hope they're well along in this process, because I sure would like to be able to set a hands-free reminder or take a memo.

Update: Clark had a good takedown of my Mathematica aspersions. He's right, Mathematica isn't the problem. He says he's in love with Siri, but reading between the lines his experiences aren't really much better than mine. He's just overlooking her flaws after a few dates. Soon he'll be ranting with me.

I suspect iPhone 5 users have a better experience than 4S users thanks to better noise canceling, and I wonder if some users do better based on time zones, carrier, and geographic server assignment. I liked this suggestion:

I suspect they’re going to have to move more of the analysis onto the phone rather than the server. However I bet memory issues are the biggest limit there. What we might find, if this theory is correct, is that Siri will make some drastic improvements as RAM on devices hits 2 – 4 GB and Apple can move more code off the servers.3

Canada travel: Activating a Rogers paygo SIM for your iPhone or other unlocked GSM phone (voice only).

I realized this should have been on my tech blog, so I reposted an updated version there.

Nguyen Chi Thien - the toughest SOB poet that ever lived.

Nguyen Chi Thien Obituary | The Economist: "From 1995 he managed to get shelter in America. He lived humbly in Little Saigon in Orange County, California, lodging with fellow countrymen.".

Read the entire thing. He won an international poetry award in 1985, but nothing more. No Nobel, no Pulitzer.

Electronic health records and payment increases: It's not fraud.

There was a bit of press about an extensive CPI series investigating increases in charges by physicians using electronic health records. I know this domain, and I've been watching for someone to explain what's really happening and why.

Today John Halamka pointed me to what I was looking for. The explanation comes from Don Berwick:

Hospitals grab at least $1 billion in extra fees for emergency room visits | The Center for Public Integrity: 

... Dr. Donald Berwick, the immediate past administrator of the Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program, said a small portion of the billing increase is likely caused by outright fraud, but in the majority of cases hospitals are legally boosting profits by targeting the vulnerabilities of Medicare’s payment system. “They are learning how to play the game,” Berwick said about the hospitals.... 

... Berwick, the former CMS head, said patients haven’t changed. What’s changed is the aggressiveness of how hospitals bill. “They are smart,” Berwick said. “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get.”...

Don't be fooled by his background leading CMS. Berwick has a long record in health reform, and an unimpeachable reputation. He got one year in CMS before the GOP got rid of him. He's telling the truth.

The deeper story goes like this:

• In the 1990s reformers tried to come up with a fair way to reimburse for the work physicians did, particularly 'cognitive' work vs. procedural work. In part they wanted to to equalize the playing field between medicine and surgery. This was a horrendous task even before the AMA got their hands on it.
• By the time the AMA was done a new kind of accounting system was created to track what doctors did. It was called "Evaluation and Management" coding, which looks to the uninitiated like a set of 10 or so "CPT Code" (also AMA controlled).
• This introduction of E&M codes changed medicine -- for the worse. Immediately. I won't bore you with the details, but basically doctors worked to the accounting system instead of focusing on improving patient care. Accounting matters. 
• Four years later proceduralists complained and the E&M codes got much worse. At this point they were almost impossible to understand. There was supposed to be a usability test but it never happened. Somewhat better, but even more complex, codes were stalled in 1999.

After 1999 doctors more or less staggered on with this accounting system. They routinely 'undercoded' to avoid prosecution, but payments for less sophisticated codes rose so it 'worked out'.

During this time, however, electronic record systems grew. It became far easier to capture all the inputs to the coding system. It was also easy to ask a few additional questions and so exploit a loophole in established patient encounters. (Basically you can do a complete exam for a sore toe and do quite well).

EHRs let billing systems, especially hospitals, fully exploit the problems in a fundamentally horrible accounting system.

There's no fraud here. The fix is to eliminate E&M codes.

Voted. Easy choices. Again.

I'll be traveling Nov 6th, so tonight was voting night for me. If you've read this blog at all you can guess that that the top of the ballot was pretty simple. We have a great slate of Democrats from the Presidency to our State Rep and I'd vote No on constitutional amendments even if I thought they were a good idea. Which they aren't.

The bottom half gets tricky - judges, soil and water commissioner and so on. Voting by mail used to have a big advantage -- but now any Minnesotan can see the ballot in advance and vote intelligently. A quick visit to judicial web sites made it easy to vote for the incumbents. County offices were covered by a Minnesota DFL page.

It's traditional in this sort of post to say something about why I voted for Obama/Biden. It's not hard. I can't think of any policy domain where I think Romney would make good choices. He'd be a disaster in international affairs. I think he'd neglect and even actively hurt the non-powerful He's terrible on science, horrible on the environment, and a disaster on climate change.

Meanwhile, Obama's choices make sense to me within the scope of his constraints. I don't agree with all his choices. He's too involved in choosing drone strike targets, his school reform programs are misguided, and his health care reform initiative is far too friendly to corporate solutions. Unfortunately, even in the cases where Obama is weak, Romney would be far worse.

I'm not happy that my voting choices are so easy. America needs a sane alternative to the Democrats. If Romney loses maybe we'll get one. If he wins, we won't.

RIFty Fifty

It's not personal, it's just that wages are sticky ...

Poorer but Wiser After a Year of Unemployment - NYTimes.com

They are skilled workers who should be at the top of their games, their incomes peaking as they approach retirement...

... For the last 20 years, after each recession, workers have been hired back at lower salaries, with the baby boomers losing the most income. Unfortunately, it makes sense. People that age hold the most senior jobs and make the best salaries. Lowering their compensation saves the most money, or, as the financial analysts say, increases productivity...

Not everyone in their 50s is equally vulnerable to the RIF. [1] Senior leadership, for example, is expected to be between 40 and 60 years old. From a short term return-on-RIF perspective the most at risk targets are highly paid "senior" workers who are at the high end of their pay grades. Even if these workers are currently valuable, they're not going to make the leap to the next level -- that has to happen in the 40s or earlier. They're not going to get more productive either; most corporate knowledge workers are probably maximally productive around ages 45-50. So there's a pretty good return on the RIF.

Kind of sad if you're the one wearing the arrow, but that's the nature of the hive. In the ancient world wages rose until retirement, in the less sentimental world of 2012 they're likely to peak around 50 and fall from there.

So what should we do about it?

One reasonable response is just to gather ye rosebuds while ye may. After all, none of us gets out this alive. Take the family vacation, spend the money, enjoy it while you can. Winter will come, but Fall is sweet. When the RIF comes, expect to dye hair, chop all dates from your resume [2], and find a lower paying job.

There are other responses of course; but at this age circumstances vary a lot. Sometimes it might, for example, make sense to switch employers and trade current income for a better long term employment picture. I like to get the house paid off, so income loss need not mean house loss. Most of the time, though, it makes most sense to ride the horse until it dies. Then live more simply.

[1] Reduction in Force. Nobody is fired any more, they're simply part of a 'reduction in force' that just happens to catch the expensive or the unwanted (best of all - both at once). Many corporations, perhaps most, routinely "RIF" about 6-10% of their workforce every year on the principal that a little bleeding strengthens the body.
[2] LinkedIn profiles are the worst. They require years of attendance to be attached to schools, which makes age calculation pretty trivial. FWIW, i just chopped all schooling from my resume and all positions > 10 years past. 

Baumol's cost disease: medicine, education and post-AI disruption

William Baumol was born in 1922. In 2012, 90 years later, he's listed as first author on a new book: The Cost Disease: Why Computers Get Cheaper and Health Care Doesn't.

Damn. It's one thing to win the brain lottery, but winning the longevity lottery is really piling on. Even if all he did is read the page drafts he's doing pretty well.

That's not the most irritating thing about Baumol though. The most irritating thing is that I keep forgetting about his fundamental insight, one that I first blogged about 8 years ago...

... The disparity between rapid productivity growth in mechanized sectors and slow productivity growth in human-service jobs produces Baumol's disease—named after the economist William J. Baumol. According to Baumol, in a technological economy falling prices for manufactured goods and automated services eventually increase the relative cost of labor-intensive services such as nursing and teaching. Baumol has predicted that the share of gross domestic product spent on health care will rise from 11.6 percent in 1990 to 35 percent in 2040, while the share spent on education will rise from 6.7 percent to 29 percent.

The shifting of relative costs need not in itself be a problem. If Americans in 2050 or 2100 pay far more (as a percentage of their spending) for health care and education than they did in 1900, they may still be better off—if they pay correspondingly less for other goods and services. The problem is that as the relative cost of services like education and health care rises, more and more Americans will find themselves in service-sector jobs that, unlike the professions, have historically been low-wage...

Today Education and Health Care are famously afflicted by Baumol's disease. Law used to be, but then full-text search decimated legal employment (and yet, legal costs have not fallen ....).

Baumol argues that even if these professions remain labor intensive, and even if health care comes therefore to claim 50% of our GDP, that we'll be able to afford it nonetheless.

His argument is persuasive, but is that likely to happen? College education today is experiencing widespread disruption including iTunes U, coursera (Caltech, University of Toronto and many more), edX (MIT, Harvard, Berkeley), California open-source eTexts, Stanford Online, Khan Academy and numerous for-profit ventures. Education is deep in whitewater times.

Health care, particularly medical care, isn't changing as quickly. The fundamental tasks of sorting out what's going on with a particular patient, and how best to manage that problem in their personal context, and then how to manage the patient's psyche and health -- those haven't changed much [1] over the past century. 

We're accumulating more health care data though -- for better and for worse [3]. "Analytics" is the "hot" area in health care IT now, including running Google/Facebook style algorithms against large clinical and financial data sets [2].

That doesn't necessarily sound disruptive, unless you know that the techniques used in extracting meaning from large data sets are the same technologies that power our post-AI world. (Yeah, I used the forbidden acronym.) If you know that, then you know "Analytics" can be thought of as the current pseudonym for "Medical AI". Whether it's disruptive or not remains to be seen, but I suspect that we'll get to health care cost disruption well before health care hits 50% of a much larger future GDP.

 [1] It's interesting to read articles written in the 1970s during the early days of diagnostic lab testing. They imagined patients walking into a series of lab test queues staffed with low wage workers, then emerging with a set of diagnoses and plans. Similar plans arose during the last period of genomic enthusiasm. They will come again ... 
[2] The base stats is generally pretty simple stuff, if only because more complex algorithms don't scale well to terabyte data sets. The trick is that simple stats on large data sets enabled by cheap computation can produce surprisingly useful answers. This is best described in the terrific Halevy, Norvig and Pereira paper: The Unreasonable Effectiveness of Data.
[3] In 1996 I was part of a theater-style presentation called "Dark Visions: 1996-2010" that included a fanciful and intentionally dramatic timeline of dystopic data sharing. By 2005 India was the world center of clinical AI, and by 2006 elite health care providers had moved to more private paper records. Maybe we were a bit hasty :-).

See also:

• Free exchange: An incurable disease | The Economist 9/2012
• Baumol's cost disease - Wikipedia, the free encyclopedia
• Gordon's Notes: On redistribution 6/2004
• Gordon's Notes: Why college tuition continues to increase: Mankiw 12/2006 (before Mankiw sold out)
• Gordon's Notes: Life in the post-AI world. What's next? 9/2011

Why are OS X solutions easier to find than Windows solutions?

When something goes wrong on a computer, we all turn to Google. 

Almost all. I suppose Apple employees have to use Bing.

I can usually find OS X fixes fairly easily, even though when I need an OS X fix it's often a pretty obscure issue.

Windows 7 is another story. I rarely find solutions. Searches run into unanswered questions, paywalls, and wrong answers; it doesn't matter if I use Bing or Google.

Why is OS X search so much better than Windows 7 search? Windows 7 is still much widely used than OS X.

Has anyone else noticed this? Maybe it's just me.

Islamic rage and free speech.

A guy with a big chip on his shoulder isn't going to do well. He's easy to play with, but even without manipulation he's going to wreck his life.

A lot of the Islamic world is like that, probably because the population is young, social structures are intensely patriarchal, employment opportunities suck, education is distorted by religious doctrine and the world is a very scary place. Just be glad the "The End of Men" isn't a video. Threats to patriarchal structures are not entirely imaginary.

But it's not just Islam. The anti-Japanese riots in China look awfully to Cairo; and does anyone remember burning cities in 1960s America?

So national rage isn't as simple as a cultural trait unique to Islam.

What about free speech, how simple is that?

As any high school student should be able to describe, we don't practice completely free speech in the US. The NYT mentions a couple of examples but Wikipedia has more ...

Freedom of speech in the United States - Wikipedia

... the Miller test for obscenity, child pornography laws, speech that incites imminent lawless action, and regulation of commercial speech such as advertising. Within these limited areas, other limitations on free speech balance rights to free speech and other rights, such as rights for authors and inventors over their works and discoveries (copyright and patent), protection from imminent or potential violence against particular persons (restrictions on fighting words), or the use of untruths to harm others (slander)...

... Publishing, gathering or collecting national security information is not protected speech in the United States ... The unauthorized creation, publication, sale or transfer of photographs or sketches of vital defense installations or equipment as designated by the President is prohibited.[13] The knowing and willful disclosure of certain classified information is prohibited ... It is prohibited for a person who learns of the identity of a covert agent through a "pattern of activities intended to identify and expose covert agents" to disclose the identity to any individual not authorized access to classified information, with reason to believe that such activities would impair U.S. foreign intelligence efforts.. 

Julian Assange could say something about national security and restrictions on free speech -- though the material he published was widely redistributed in the US without much consequence. The US didn't exercise blocks on web servers. Other information is more restricted. Although the wikipedia article on nuclear weapon design is pretty detailed, more practical 'make your own terror weapon' recipes are hard to find.

Even videos of this type of restricted material would be unlikely to provoke popular outrage. Neither would videos attacking religious beliefs, politicians, science (the GOP makes those) or history -- denial of American slavery, Amerindian genocide or the Holocaust are all protected speech.

The only exception I can think of would be child pornography. Videos that use children under the age of 12 in sexual or harmful activities are strictly illegal in the US and would create anger and disgust. I can't see riots, though and, of course, the Islamic reaction would be at least as negative.

National rage is not uniquely Islamic, but protected speech is pretty distinctly American. Perhaps a consequence of that protected speech is that while sticks and stones will trigger invasions, "names will never hurt us".

Tom Cook's great test: the response to Apple maps.

Contrary to Joe Nocera's impression, Steve Jobs' Apple screwed up a lot. MobileMe wasn't the only disaster; even iCloud was a regression. OS X Lion was nothing to write home about. Apple did better under threat, worse when they felt confident. Ultimately, of course, Jobs cruel genius coupled with unprecedented power over a public company meant Apple escaped mediocrity.

Post-Jobs most of us expect Apple to behave more like a typically dysfunctional publicly traded company. We expect more products like iOS maps and Siri -- heavily marketed but only marginally useful. (Under Jobs Apple buried flops quickly.)

Of course there's still a chance Cook can find a way to escape this mediocrity. I'm watching for how Apple responds to user submitted map corrections. 

Historically Apple seems to ignore users. Even respected developers have a hard time getting their bug reports reviewed. Google, to their credit, has responded to every map correction I've made. Sometimes I get a response in a week or two, sometimes in a month or two, but I always find out which corrections were accepted and which were rejected. (So far 5/6 accepted, I think the other one had already been fixed.)

This is something Cook can change. If Apple provides feedback to users on the fate of their corrections, then I'll be hopeful that Cook can chart a new post-Jobs course. If they don't then they're on the fast track to Microsoft-land.

What has Apple done for me lately?

The new iOS connector cable. iOS 6 maps. iOS 6 Podcasts. RSS Deprecation. iTunes 11 (train coming). iCloud. Siri. Lion. Embedded webkit hole in iOS parental controls.

I'm sure there are more. Apple hasn't been doing much for me lately. Yeah, I'm in a grumpy mood. The good news for Apple is that Google's done even worse. The past two years have not been great for the 0.00001% like me.

It can't be all bad though. What, with it's zillions of dollars, has Apple done in the past 1-2 years that I like?

I'll grow the list, but here's the start. Send me additions if you can think of them...

• Mountain Lion looks promising.
• MacBook Air.
• iMessage.
• iOS 5 let me override exchange calendar color assignments.
• Six years late, Apple finally delivered iPhoto Pro with it's agonizingly slow and still incomplete Aperture/iPhoto integration project. Way, way late, but it counts.
• Find Friends (I think it will be useful for our family eventually).
• iPhone retina screen - good for old eyes.
• iPhone camera.

The bad and the good are close to balance, which is kind of sad for the world's richest tech company. Of course I'm not their market.

Tachytely and human evolution: implications for the Drake Equation and Fermi Paradox

I haven't done a Drake/Fermi Paradox post for ages. A lot has happened in the meantime; in particular estimates of the number of potentially-life-compatible planets in our galaxy has grown exponentially.

Of course not all life supporting planets will develop sentient tool using species. Unless there's something about sentience and tool use feedback loops that produce tachytelic development. That would boost the Drake estimate into the low thousands. We ought to be tripping over little green things.

But we don't. Of course if technological civilizations all self-destruct quickly this would all make sense.

See also:

• Refining the Drake equation: earth like planets more common? 10/2006
• Another stab at the Drake Equation – from the physics archives 10/2008
• SETI, the Fermi Paradox and The Singularity: Why our search for extraterrestial intelligence has failed 6/2000 originally
• Narrowing the Drake equation - if earth is common then ... 2/2009
• SETI: find one of nine galactic civilizations 11/2007
• How often will sentience evolve on earth? From anthropology to the Fermi Pardox - via the Drake Equation 2/2006