Stop Burning Stuff

Wildfire

Wildfire is the uncontrollable spread of fire through a large area. It typically occurs when small fires spread from the forest floor into the crowns of large trees via "ladder fuels" and are spread by wind driven embers. 

Three factors contribute to wildfire. Ladder fuels, air temperature and moisture

Our forests have been damaged. First by being clear cut and then by suppression of small naturally occurring fires which normally clear out ladder fuels without developing into wildfire.

Burning the Forest to Save It?

Currently there is a large effort to eliminate ladder fuels by manual thinning. When the ladder fuels are thinned, you end up with a lot of wood debris. What to do with this?

Currently, these fuels are piled and burned in place or trucked to a landfill or incinerator. Burning is the least desirable way to deal with these fuels. Proposed incinerator facilities at the Truckee Landfill and at Northstar will impact all of us with pollutants. 

There is absolutely no evidence that burning biomass on the forest floor has any beneficial effect. All of the effects of this burning are damaging to human health and the environment. Most significantly, burning of the forest floor does not reduce the potential for wildfire. Biomass left on the forest floor improves forest health by improving moisture retention, nutrients, and reducing forest temperature. 

The current policy is to burn this biomass. This recalls the Vietnam era slogan "We had to burn the village to save it."

CO2 Air Pollution

Burning releases the CO2 that the plants have captured from the atmosphere and stored in wood. This CO2 contributes to global warming and climate change. It is irresponsible to burn biomass which contains valuable stored carbon.

NOx, CO, O3 Air Pollution

In addition, burning creates new toxic molecules such as NOx, CO and ozone  which can move deep into lungs causing cancer and other lung diseases. 

Particulate Air Pollution

Wood smoke creates particulates which can enter the lungs and cause asthma, lung disease and cancer.

VOC Air Pollution

Wood smoke also creates chemicals called volatile organic compounds (VOC) which can also cause lung disease, heart disease and cancer. These compounds are not removed by air filters and settle on surfaces in homes where they are slowly released into the air. The only way to remove these is to clean all surfaces.

Burning Stuff is Bad for your Health and the Environment

These pollutants are created by wildfires and also by controlled burns. Even short term exposure to these pollutants can cause lung and heart disease and trigger cancer.

(A loophole in the Clean Air Act means that fire smoke air pollution is not tracked or reported when you see the "air quality" index for your area.) 

Is there an alternative to controlled burns?

Why not just leave the biomass on the forest floor where it is no longer a ladder fuel for wildfire?

It is much preferable to mulch the wood in place and leave it on the forest floor. This mulch improves soil health by retaining moisture and reducing the forest floor temperature. Both of these things reduce the likelihood of wildfire. You don't have to transport the biomass, just spread it on the forest floor. Mulch on the forest floor does not contribute to wildfire. It is cheaper and easier to just leave the mulch from forest thinning in place on the forest floor than to burn it or transport it for burning or landfill.

Larger logs may have commercial value and can be sold as lumber products. Smaller longs can be left on the forest floor where they slowly decompose and are not a threat for wildfire.

Stop Burning Stuff

Humans have been burning stuff since they discovered fire. When the global population was low, forests and grasslands could easily replace the burned biomass. However, as the population increased and industrial farming cleared millions of acres, CO2 started to rise. The shift to fossil fuels further accelerated air pollution until the situation we find ourselves in today which is the current climate catastrophe of widespread air pollution and climate disruption.

We need to stop burning stuff. In the case of "controlled burning" of our forests we have a better alternative. Leave the biomass on the ground where it will improve forest health and reduce the likelihood of wildfire.

I would expect that the air quality districts would require solid scientific research to support the destructive burning. Both the damage to human health and the environment are substantial. In order to justify this burning, there must be some overwhelming compensation to human health and forest health. I have found no evidence of any benefit to human health or forest health.

Q & A

Don't some trees rely on fire to spread their seeds?

Yes, they do. However, when you've just spent a lot of effort to thin the forest, the last thing you need is to encourage is more new trees.

Are there other alternatives to open air burning?

Biochar

Another alternative is to make biochar which is wood heated in a closed kiln without oxygen. This creates  pure carbon. Manufacturing biochar requires a specialized kiln and converts about half of the biomass into biochar. The remainder is released as CO2, particulates, and VOC. Depending on the design of the kiln, some of the VOC and particulates can be captured.

Biochar is mainly used for soil application and is known to improve soil nutrient availability, aeration in soil, and soil water filtration. Biochar is in demand by farmers as a soil amendment. Biochar locks up the carbon for literally centuries.

Is Ukraine Russia's Vietnam?

"History repeats itself, first as tragedy, second as farce" - Karl Marx

“History Doesn’t Repeat Itself, but It Often Rhymes” - Mark Twain

The Vietnam War

I was at University in 1968 when the politicians and military decided what was needed to "win" the war in Vietnam was a lot more cannon fodder so they ramped up the draft to support a half million strong army in Vietnam.

Then they abolished student deferments. 

This left me (and thousands of others) with three options: war, jail, or Canada.

I had decided on Canada if I received a draft notice since the first two options were much worse. Fleeing to Canada would be a life altering disruptive experience but it was the least bad option.

Once they had exhausted the poor and minorities, the politicians decided that they would have a draft lottery to make the draft more "fair". Fortunately, my birthday was selected as a fairly high number which meant that I had only a small chance of being drafted. I was relieved but my friends with lower numbers were not.

The experience of the war years and having to make this decision forever altered my world view.

Years after the war I had a friend who was drafted into the Marines on short notice and sent to Vietnam. I believe he had PTSD. He committed suicide.

This mobilization was the catalyst for more demonstrations. I believe that this eventually helped lead to the abandonment of the war effort... although it took years and the destruction of both Presidents Nixon and Johnson. However, it does not seem to have discouraged the US from inserting itself into new wars around the world.

The war exacted an enormous human cost: estimates of the number of Vietnamese soldiers and civilians killed range from 966,000 to 3 million. Some 275,000–310,000 Cambodians, 20,000–62,000 Laotians, and 58,220 U.S. service members also died in the conflict, and a further 1,626 remain missing in action.

(I recommend the Ken Burns documentary on the Vietnam War.)

The Ukraine War

There are many parallels between the Vietnam war and the war in Ukraine.

What effect do you think the Ukraine War will have on Russia?

Already, international sanctions have had a profound effect on the economy.

Will the mobilization lead to changes in Russia?

 

Tourism is a Dirty Business

Now that we are in the throes on a "back to normal" summer, we are again being assaulted by hoards of tourists.

I really think our community needs to have a better model for its economy and society. Tourism is a dead end. It damages the environment, saps the life out of the community and offers meager benefits to just a few people. First, let's look at the impacts of tourism.

Environmental Impacts

Tourists arrive by plane and cars. They spend their time driving around in cars and on boats and other mechanized recreation. They "consume" heating in winter and air conditioning in summer.  These activities are heavily dependent on fossil fuels and create massive amounts of pollution. It is estimated that a third of total emissions are created by tourism.

Food

Tourists consume food from groceries and a large amount from restaurants. Restaurants are notorious for wasting food. A surprising amount of restaurant food is thrown out. Food and restaurant take out packaging creates mountains of waste plastic.

Community

Tourists take over restaurants, shops, and popular recreation sites, displacing community meeting places and disrupting community social interactions. 

After hearing "shop locally" for years, I have given up on visiting restaurants and shops. The prices are high, service is poor. It's impossible to dine out at a restaurant. Instead, I buy things online where selection and pricing is better. We've also taken to shopping in Carson City which is less crowded with better selection and pricing. We've found a few reasonably priced restaurants where we can always get a table.

Who Benefits?

The only beneficiaries are business owners of restaurants and shops. They can charge high prices. They offer low wage seasonal temporary jobs. It is not all good news for them, however, since they must contend with wildly varying demand and off-season slack periods. 

Wouldn't it be better to have a restaurant or shop that can depend on steady local business year round?

What should we do?

First, stop digging. We should stop promoting tourism. It is toxic to our environment and community. We already have too many tourists. The latest trend in promoting tourism to the area is to focus on the "off seasons". Presumably the goal is to attract hoards of tourists year round thereby making all seasons unlivable for locals.

We should also consider actively discouraging tourism. One way to do this is with capacity controls and fees on roads, parking and accommodation. A fee to enter the basin and pollute would help discourage people from coming. This could easily be implemented using the existing "FasTrak" system.

What next?

I think we have seen a solution in the recent influx of new residents who are able to work independently and are not tied to tourism. These people will hopefully become permanent residents and active members of the community. 

(BTW, these kind of people have always been here, quietly working and socializing in the community.)

Suckered by the US Health Care System Again

I have avoided getting my annual Medicare (non-physical) doctor visit since they don't really do a physical exam, just a "wellness visit" to remind you to stay healthy. See The Annual Physical for more information.
However, my wife went for her exam a few months ago and everything seemed fine until this week when we received a letter from the doctors billing office that we owed them money and they would cut us off from care until it was paid.
It turns out the she got a flu shot at the time of the annual exam. This is supposed to be covered by Medicare so she didn't think it would lead to any charges. She could have walked across the street to have the flu shot at the pharmacy ($25 paid for by Medicare). The doctor's office didn't disclose how much they would charge at the time of service. (I know of no other business that never tells you how much they will be charging and thinks nothing of sending outrageous bills months later.)
Of course, it is naive to think that the doctors won't find some way to generate extra income. In this case, they charged for the administering the vaccine and a posted a separate charge for the flu vaccine itself. Total was $246.00! Medicare rightfully declined to pay the outrageous charges.

Beware, the doctors are a danger to your (financial) health. Through a combination of obfuscation and greed, they will try to take your money.

Raspberry Pi - A low cost computer - Now Faster Version 2!

When working in resource poor environments, it is often a challenge to get access to working computers.  Either there is no equipment available or it is old, underpowered, malware-ridden or otherwise not usable.
The Raspberry Pi is a small single board computer that costs $35 and can do many common computer tasks.  The processor is ARM which is different than the Intel architecture found in most computers. ARM processors are commonly used in tablet computers and smart phones.
In addition to the original Raspberry Pi, there is now a version 2 of the computer which is the same price and runs the same software but is about six times as fast since it has a 4 core processor and twice the memory. This new version runs even complex web based applications like DHIS.
The software for the Pi was originally Linux. Linux offers a rich software ecosystem which has software to perform just about any task you would require.  In particular, the most common computer applications for web browsing, word processing, spreadsheets and email are well supported and free of cost.  Linux is also immune to most computer viruses. The new version 2 of the Pi also runs Windows but this is not recommended since Windows is vulnerable to computer viruses which can compromise your computer system.
The Raspberry Pi computer only requires about 3 watts power and can be run from a battery or cell phone charger.  In order to make a complete computer, you will need to add a keyboard, mouse and display.  The display will be the most expensive part and also consume the most power.  Small LCD displays require about 25 watts power.  The Raspberry Pi can be used with a monitor that has either a composite (yellow RCA jack) or HDMI input.  It can also be used with a DVI input using an adapter.  Most new monitors have HDMI input while older monitors can usually accept composite input.  It does not work with the VGA inputs that many older monitors have.
The total cost for a computer system would include:
- Raspberry Pi $35
- Keyboard $10
- Mouse $10
- LCD Monitor (18"-20") $100
- Monitor cable $5
- Case for Raspberry Pi $10
- SD memory card (4GB) $10
These prices are US prices.  Often prices are higher in developing countries.   You may be able to locate used monitors and keyboards at lower prices.  You should be able to put together a computer for less than $200.

Software:
(All of this is free software)
- Raspbian (Debian) Linux - The basic operating system
- Several web browsers are installed in the default distribution and Google's Chrome browser is available in the repository
- Word Processing: Abiword is a lightweight work processor compatible with Microsoft doc formats
- Spreadsheet: Gnumeric is a lightweight spreadsheet program compatible with Excell formats
- Email: There are several good email clients available

Management of the computer
If the computer is connected to a network, you can use ssh to configure and control the computer which helps with support.  There are also several other utilities to make the computer more versatile:
- Samba to share files on the network
- dnsmasq is useful to control network use

Mobile Data Collection Solutions

There is a lot of interest in (and need for) mobile data collection solutions in health.
The basic rule of "If you don't measure it, you can't manage it" applies.
There are lots of different options for mobile data collection and the choice for a given application will depend of lots of different factors unique to that project.
Some of these factors include:
- skills of project staff
- phone cost and availability
- single use or ongoing
- budget
- data location
- data analysis tools

There are lots of software choices for mobile data collection and they each have unique features and requirements. In order to help sort out the options, I have adapted a spreadsheet which was originally put together by the World Bank with information on some of the options. I plan to keep this updated with new information as it becomes available.
I've posted the spreadsheet as a Google Doc and enabled comments so if you have questions, additions or corrections, please leave a comment and I'll update the sheet.

The Cost of Free Software.... and Non-free

There is continual debate (and unfortunately confusion) about the cost, use and value of "free" software. I am hoping to clear up a few things with this post.

First, we should define:
Free Software is Free Open Source Software (FOSS). This software is free of cost to use. It also has free access to the source code which allows you to make changes to the software and allows you to distribute these changes to anyone for them to also use the software.
A program is free software if the program's users have the four essential freedoms:

• The freedom to run the program, for any purpose (freedom 0).
• The freedom to study how the program works, and change it so it does your computing as you wish (freedom 1). Access to the source code is a precondition for this.
• The freedom to redistribute copies so you can help your neighbor (freedom 2).
• The freedom to distribute copies of your modified versions to others (freedom 3). By doing this you can give the whole community a chance to benefit from your changes. Access to the source code is a precondition for this.

Non-Free Software places restrictions on one or more of the four freedoms. There might be restrictions on where and when you can run the software. The source code might not be available for examination and changes. You might not be able to distribute copies of the software. Someone else controls the software.

It's not (just) about the cost.
Yes, free software is free in that you don't have to pay for the software. However, many people fail to look beyond cost to the other values of free software. Most people don't think that they will ever need the source code to modify the software. But... most people at some point will think that it would be nice if the software did something new or different. Free software allows anyone to make changes to the software and to distribute these changes. Once a free software project reaches a certain point where it becomes useful, there is usually a community of developers and users who exchange ideas on how to improve the software and incorporate those ideas into new versions of the software.
Most people don't consider that they will spend a lot of time working with software to learn how to use it and in entering data. What happens if non-free software stops working or the company supporting it goes out of business or stops responding to questions and suggestions from users? The users' investment in time in learning the software and entering data will be wasted. Their data may also be inaccessible.
What happens if the data one is collecting is confidential and must be stored on computers under the direct control of your organization? Some software uses cloud servers. Some non-free software does not give you the option of running your own cloud server. You may not be able to use this software if your data must be under your direct control.

What about the cost of free software?
Free software is free. This means that it doesn't cost money to use it.
However, we all know that the cost of implementing a software system includes more than the cost of the software itself.  There is the cost of the hardware to run the software, the cost of training, the cost of support and maintenance.

Let's look at the total cost of implementing software. This is sometimes called "total cost of ownership" or TCO. We'll use the example of software which allows users to collect data using a mobile device. This is a common function in most development organizations. This is also a common configuration for modern software which is usually composed of two components: a client piece which is installed on a PC or mobile device and a server piece which holds the data.

Fortunately, we have a lot of choices for mobile data collection software. There is a good comparison of 24 different mobile data collection software systems at Humanitarian Nomad.
I'll compare the cost and the advantages of three different data collection platforms. Two of these are in the Humanitarian Nomad data set and the third is not. I've chosen these systems for comparison primarily because I am familiar with them.
These systems are:

• Open Data Kit (ODK) which is a set of software applications (one for the the mobile device and one for the data collection server. You can set up your own server or use Formhub as a public server to collect and analyze your data.
• Magpi (formerly EpiSurveyor) which is a software application which runs on mobile devices to collect data. You must use the data collection server provided by Magpi. There is no option to set up your own.
• DHIS2 (District Health Information System) software is much more comprehensive than the two options above in that it is designed to collect data from multiple sites and aggregate this data up through many levels of an organization. It also includes a set of sophisticated analysis tools (including mapping). It is free software which runs on a server and is accessed through a web browser. Mobile data collection can be through a mobile device web browser or through a mobile java client.

I won't try to do a full TCO comparison but will look at the most common costs and in particular look at where these costs differ with these three systems. Namely software cost and server cost. All of these systems allow data collection on mobile devices such as phones and tablets. All of them send their data to a server for aggregation and analysis.

	ODK	ODK Formhub	Magpi	DHIS2
Software cost	Free	Free	$0.20-$0.25 per form submitted	Free
Server hardware cost	Self*	Free		Self*
Per use cost	Free	Free	(Free for 500 forms/mo.)	Free
Free software	Yes	Yes	No	Yes
User-controlled Server	Yes	No	No	Yes

The server cost is one of the differences here. If you use ODK and Formhub, there is no cost for the software or the server. If you use Magpi, the software and server are provided as part of their service. It is free for limited use (20 forms, 100 questions, 500 forms/month) but more than that cost $0.20 to $0.25 per form submitted. You must "pre-purchase" blocks of forms for $5,000 or $10,000. There is no option to set up your own server so if you have confidential data that must be under your direct control (either by law or by your organization's policy), you cannot do this with Magpi.
*The cost to set up a server for ODK or DHIS2 will vary depending on the skills and resources of your organization. The server hardware itself can cost anywhere from a few hundred dollars to several thousand dollars, depending on capacity. There is also the option of hosting the server on a cloud service where you rent the server by the month which usually costs about $100 a month.
The server software for both ODK and DHIS2 is free and if your organization has IT skills, you can install the server software yourself. If not, you will need to hire someone. I am not highly technically skilled and I have set up servers for both ODK and DHIS2 and it took me about a day (including some head scratching time). If you have to pay someone, figure a days work (although I have seen skilled people set these servers up in just a few hours). This can be done remotely for either a cloud server or a server on your site so there is no need for travel. Most software is updated periodically and it is wise to keep your software current. This can be done in a few hours a few times a year.

So, yes, free software is indeed less expensive to implement. It also gives you more options for configuration, use and features. Most importantly, it gives you the assurance that you (and you only) control your data and your software so that you are not suffering at the whim of another organization which may have different priorities.

I hope this discussion has shed some light on the subject of the cost of free software. There are many other costs including training and there are, of course, differences in features between software choices. All of these should be evaluated carefully.

The Cost of Free Software

A recent post (more like a rant) by Joel Selanikio on Datadyne's web site:

Global development: where “free” means “expensive”
JOEL SELANIKIO ON 29 MAY 2013
In global development, I often hear people talking about “free” technology, particularly free software.  Well, as part of the team that has created Magpi, I’m a great believer in free software.  But my definition of free — “doesn’t cost any money to use” —  seems to be very different from the definition used in global development discussions.  Which is odd since “free” seems like a pretty basic concept.

Right off the bat, Joel misses the point of Free Open Source Software (FOSS). Yes, it is free of cost which he seems to understand but it is much more. To quote Richard Stallman:
"Free software means that you, as a user, have four essential freedoms: (0) to run the program as you wish, (1) to study and change the source code so it does what you wish, (2) to redistribute exact copies, and (3) to redistribute copies of your modified versions."

FOSS is much more than just free of cost. It gives you control over the software. You are not beholden to another who may put undesirable restrictions on your use of the software. This is especially important when you will typically invest a large amount of time and resources in configuring the software, training people to use the software and entering data into the software. You don't want to wake up and find that someone else has put restrictions on the software preventing you from using it as you wish.

Joel goes on to say:
"So what part of “free” doesn’t global development understand?  As it turns out, quite a lot — because international development consultants often use the word “free” when recommending systems that are VERY expensive to implement (usually open-source systems)!  Even worse, they seem to think it’s the end-users’ fault if they don’t understand that when a consultant says “free”, they mean “it will require many consultants”."

I can only say to Joel, "So what part of "free" doesn't Joel understand?"

As an international development consultant, I have never misled people about the cost of software. I often recommend FOSS software and I always point out that it will cost money to configure the software, train people and enter data. These costs for FOSS software are usually comparable to the costs for proprietary software (although they can be less since there is usually an active community of users willing to help).

Joel then goes on to compare the cost of his Magpi survey software with the DHIS2 (District Health Information System) software. This is an odd comparison since these software packages perform very different functions. Magpi (formerly Episurveyor) is survey software (designed to collect data from surveys) and DHIS2 is used at clinical facilities to keep track of clinic statistics and individual patient information and roll these numbers up to be analyzed for purposes of monitoring and evaluation of programs, management of services, planning and policy. It is much more complex software that performs many more functions. Really apples and oranges.

Anyway, if you look at Joel's cost comparisons, he is really trying to point out the difference in cost between setting up a server on site versus having external hosting ("software as a service" SAAS). Joel compares the cost of Magpi's "free" (there's that word again) service with the cost of setting up a server in the host country.
OK... a few obvious problems here right off the bat... First, Magpi's "free" service level on only free if you don't plan on using it very much. People who use the software a lot will have to pay $5,000 or $10,000 a year... so not really free. He then vastly overestimates the cost to set up a server for DHIS2. Since I recently contracted to have this done, I know exactly what it costs and it is no where near his inflated estimates. The cost was less than $20,000 for an on site consultant to install, configure and train people and the ongoing cost will be only a few thousand dollars a year (if that) for maintenance, upgrades, etc. Much less than the $50,000 a year he estimates.

It would be a much better to compare Magpi to a similar software, Open Data Kit ODK (opendatakit.org) which is also survey software similar to Magpi. ODK seems to have more features and a more active support community but for purposes of discussion, we'll assume they are equivalent. ODK Collect and Aggregate is FOSS and there are several options for SAAS hosting which are free FormHub (formhub.org)  and Enketo (enketo.org). There is also a nice link to Google App Engine if you want to host your own in the cloud. They are part of the JavaRosa project. Unlike Magpi, all of the code and services are "Free" as in free of cost for use and hosting or you can set up your own server.

Magpi says that it is "free" (of cost) but only for limited use. Anything more will cost you. Also, Magpi doesn't provide the source code and you can't host your own server so you don't have control of the software or your data so it is not free, but rather subject to Magpi's terms and conditions.

So, to get back to DHIS2 which was inexplicably compared to Magpi... Yes, you can run DHIS2 in a SAAS "cloud" and that is exactly what a number of countries are doing. Yes, it does cost something to run the cloud servers (but much less than Joel's estimates).

The software industry has long recognized that the "cost" of software purchase is only a part of the total cost of ownership. In fact, they have always promoted the idea of TCO studies when contemplating any software change. It would be naive to expect otherwise.  I don't know what set Joel off on his rant but it really doesn't do anyone any good to spread FUD.
Software has costs. FOSS software doesn't have a purchase price but does have many of the other costs of any software installation. FOSS software also gives you the freedom to control the software and your data which is the most important part of "free".

Free is a pretty basic concept and it's surprising that so many people get it wrong.

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Some additional background information from Wikipedia:

Technology deployment can include the following as part of TCO:

• Computer hardware and programs
  • Network hardware and software
  • Server hardware and software
  • Workstation hardware and software
  • Installation and integration of hardware and software
  • Purchasing research
  • Warranties and licenses
  • License tracking - compliance
  • Migration expenses
  • Risks: susceptibility to vulnerabilities, availability of upgrades, patches and future licensing policies, etc.
• Operation expenses
  • Infrastructure (floor space)
  • Electricity (for related equipment, cooling, backup power)
  • Testing costs
  • Downtime, outage and failure expenses
  • Diminished performance (i.e. users having to wait, diminished money-making ability)
  • Security (including breaches, loss of reputation, recovery and prevention)
  • Backup and recovery process
  • Technology training
  • Audit (internal and external)
  • Insurance
  • Information technology personnel
  • Corporate management time
• Long term expenses
  • Replacement
  • Future upgrade or scalability expenses
  • Decommissioning

In the case of comparing TCO of existing versus proposed solutions, consideration should put towards costs required to maintain the existing solution that may not necessarily be required for a proposed solution. Examples include cost of manual processing that are only required to support lack of existing automation, and extended support personnel.

Connected Health

Interesting keynote from mHealth Summit on the perils and potential for connected health (mHealth to some).

Connected health (through mobile devices) has the potential to allow individuals to take control and improve their health.  However, there are powerful forces which have the potential to prevent this as they co-opt these powerful tools into their existing health care delivery paradigm, thus preventing individuals from realizing the benefits.

Are we about to make the same mistake again?

December 02, 2012
Robert B. McCray, President and CEO, Wireless-Life Sciences Alliance

For the past 50 years, lives have been extended in industrialized societies, but in the past 20 years rates of obesity and certain chronic diseases have skyrocketed in rich and poor countries. The prime culprit seems to be behavior-driven damage to our own bodies. Starting with the discovery of antibiotics, vaccines and antivirals, medical technology has saved millions of lives. Too many of us have a mindset that technology will save us from the consequences of our own behavior. This assumption threatens our lives, our pocketbooks and our social contract.

The physician community is full of wonderful individuals, many of whom have devoted all or portions of their careers to improving the health of populations in need. As a medical industry, though, the profession has promulgated the notion that the physician-patient relationship is nearly sacred and that virtually no other individual or entity should be able to monitor or manage the physician’s actions. Key institutions representing doctors and other providers have devoted most of their efforts to protecting the prerogatives and enhancing the incomes of their members. The medical industry has claimed intellectual leadership for healthcare, but the system it has built is failing to serve most of the world’s population, and it's getting further behind the growth of human need and medical knowledge. New technologies have saved many lives but have not addressed the large-scale shortage of services in most of the world, nor has it maximized population health benefits in the rich world.

mHealth offers the promise of saving this situation, but we cannot leave it to the medical establishment to lead this change. We as citizens and consumers, not as patients, must step up individually and via the institutions that we control to take charge of our own health and to set the expectations for the institutions that deliver healthcare and health supportive services.

(A note on the terminology: The term “mHealth” is used out of deference to the mHealth Summit sponsor, though I believe it is too limiting – this is about much more than mobility – and is being overwhelmed by thousands of "mHealth apps" on the market that are developed without grounding in science and for which totally unsubstantiated claims are made. I prefer “connected health” as the term that best describes the value of the convergence of technology and healthcare, including mobile communications infrastructure, digitized information, big data, cloud-based systems and behavioral economics.)

Blame can certainly be allocated, but most pertinent is Pogo’s observation at the dawn of the environmental movement in 1970: “We have met the enemy and he is us.” Our twin enemies are transaction-based medicine and inertia (personal and institutional). Residents of rich countries like the United States have adopted lifestyles that are destructive, and they have ceded responsibility for fixing their health to institutions paid by third parties. Neither the individual nor the provider has responsibility for outcomes in this model, though the patient, his or her family and fellow taxpayers certainly suffer the consequences.

Consumer-directed health (not just healthcare) can save this situation. The tools of “mHealth” include access to all the knowledge that is needed to reduce the need for healthcare and to select the best healthcare approach when it's necessary. As a movement, we can also reset public and private priorities so that they are supportive of healthier communities. We can also demand transparency in healthcare so that financial sponsors of services, be they individuals, employers or governments, can make informed choices about their expenditures and hold service providers accountable for outcomes.

So what is the role of physicians and the medical community in this effort? Individual physicians are in a unique position to improve our world. They retain the confidence of the public and have the power of both persuasion and the pen. Specifically, physicians can take an interest in improving the health of their patients, rather than just caring for their diseases, and “prescribe” healthier living habits by directly addressing the harmful lifestyle choices that their patients present. These approaches are being institutionalized by practices ranging from the largest (e.g. Permanente Medical Group) to individual practitioners. As a politically influential industry, the medical community could become a major force for positive change. This is unlikely, given the pending disruption to the medical businesses of those who have succeeded in transactional medicine.

The mistake citizens and consumers must avoid is to assume that someone else will take care of the problem. We must embrace the responsibility and demand the tools that are needed to discharge it. This is not easy. It is difficult to change personal habits and the public’s mindset about health and healthcare. Entrenched bureaucracies, professions and institutions will continue to fight to maintain their positions. While difficult, technology and the knowledge that it's creating make it possible to identify and implement the changes that are necessary to achieve my goals of improving life and creating wealth globally.

Rob McCray is the president and CEO of WLSA, a member association (http://www.wirelesslifesciences.org/). The mission of the WLSA is to remove the barriers described in this essay, and we will do so by continuing to bring together the most committed organizations and thought leaders from all sectors of the community.  Please contact us if your share our goals.

Disease Burden Study

A recent question came up:  "What is the best way to conduct a chronic disease burden study?"

Interesting question.
You want to measure the burden of chronic disease.

First, the data.  If you can find good quality data that already exists, this will greatly simplify things... however, in most cases, you will not have access to good quality data.
Good data will be comprehensive (cover the entire population or a representative sample), reasonably current, accurate, and have sufficient detail.  It will need to be collected at the individual person level.

Some possible sources of data:
Surveys:
- If there is a recent DHS (Demographic and Health Survey) this might have enough detail on chronic diseases.  Most DHS data is of good quality.  However, you might not have access to a recent DHS since they are usually only done at intervals of 5 to 10 years.
- Other organizations may have done health surveys and may give you access to their data.  You will have to canvass government, NGOs, and aid agencies.

Routine data:
Some routinely collected data such as that from health facilities can be useful if it has detail on chronic diseases.  However, there are several problems with routine data.  It may not cover the entire population.  There is usually no way to track individual patients to come up with a person count as opposed to a visit count.  There may be other distortions in the data due to poor recording or patient selection.  If you can find routine data that covers the population comprehensively, there are ways to adjust for multiple visits.  However, you still may miss people who don't visit the facilities.  If there are community outreach workers, they may have data which will give better coverage.

Collect your own data:
You will probably be faced with the task of collecting your own data if you can't find existing good quality data.  You will need to do a survey and it does not need to be a large survey if you choose your sample carefully.  A small representative sample can give good quality results.  The sample should be chosen to be representative of all components of the population, age, sex, location (urban, rural), socioeconomic, etc.  A good place to start is the national statistics or census office who often can help you with designing a representative sample.  You should design a questionnaire which is as short as possible and tightly focused on the diseases of interest.  Consider using biomarkers (measure such things as blood pressure and blood tests) if you have the budget.  Here again, community health workers may be a good resource to assist with the survey. 

I assume that you will be using one of the common methods to calculate disease burden such as DALY (Disability Adjusted Life Years).  DALY results in a number which measures the impact of disease by taking into the degree of disability for a disease as well as mortality.  It is also discounted for future years of loss which is appropriate since the society has the opportunity to compensate for this loss.  The DALY is the most useful number for planners to use when deciding on allocating resources if they take into account the cost to prevent and cost to treat each disease.

Hospital Coding - The ICD Conundrum

We Need Good Hospital Data

Developing countries need timely, accurate data on patients admitted to the hospital so that they can understand the hospital demand and patient problems and use this data for planning and management as well as improving clinical care.
How can we get good hospital data?

The ICD Problem

The WHO ICD coding system is a magnificently comprehensive nomenclature for precisely specifying any disease or condition for any patient.  The ICD-9 contains about 15,000 codes and ICD-10 expands that to about 90,000 codes.  It is used extensively in the US and other developed countries to code hospital and clinic visits for reimbursement, patient care and research.
WHO would also like it to be used in developing countries and has been sponsoring training sessions for years.  These sessions typically take a few weeks and give coders a basic understanding of the system. 
I have seen the data produced by these coders in many developing countries and I have never found any data that could be used for planning or management.  In some cases the quality of the coding is reasonably good but it covers on a very small (unrepresentative) set of patients and is months to years late.  In other cases it is just very poor quality (and also usually very late).

A Proposed Solution

We are considering this problem now in the country where I am currently working.  They currently have no data from hospitals.  WHO has trained about 20 coders but none of them are doing any coding since they don't feel competent to do ICD coding and they have been assigned other tasks. There are 19 hospitals but the coders (who have not drifted away) are all concentrated at the national referral hospital.
We need a coding system which can be used effectively with minimal training and which gives timely and reliable information about patients in the hospitals.
I took a look at the DRG coding system and decided that this could be used as a starting point for a simplified hospital coding system.  The DRG codes were designed for hospital reimbursement and they lump a large number of diagnoses codes into less than 1000 different codes which are assigned a "length of stay (LOS)" and reimbursement factor.
I went through these codes and simplified them further.  For the most part, I eliminated the codes which accounted for severity and complications subsets  of the basic disease category.
For instance, most of the codes appear as a set "with co-morbidity and complications" and without.  These distinctions are important for reimbursement but not for basic hospital data.  To keep the coding simple within the expected capabilities and training available in developing countries, these were consolidated.  They can be added back as coding skill improves.
I ended up with a list of less than 300 codes which are comprehensive of the expected hospital admissions in developing countries.
It is also much easier to code using this limited set.

Example

Here is the simplified set of codes for the Respiratory System:
Surg    Major Chest Procedures  
Surg    Other Resp System O.R. Procedures  
   
Med    Pulmonary Embolism  
Med    Respiratory Infections & Inflammations  
Med    Respiratory Neoplasms  
Med    Major Chest Trauma  
Med    Pleural Effusion  
Med    Pulmonary Edema & Respiratory Failure
Med    Chronic Obstructive Pulmonary Disease  
Med    Simple Pneumonia & Pleurisy  
Med    Interstitial Lung Disease  
Med    Pneumothorax  
Med    Bronchitis & Asthma  
Med    Respiratory Signs & Symptoms
Med    Other Respiratory System Diagnoses  
Med    Tuberculosis

The steps in coding a hospital admission would be simplified to:
1. Determine the organ system (i.e. cardiovascular, pulmonary, GI tract, etc.) (There are 25 of these in the code set.)
2. Determine if it was a medical or surgical admission (Was a procedure performed?)
3. Choose from the options within that group (there are between 3 and 15 options at this point).

This would greatly simplify the coding.  It would also give very useful information about hospital use and patient conditions.  Over time as the coders become more experienced and trained, the ICD codes could be introduced for the more capable coders.

For example, if a patient was admitted with "pneumonia" the coding process would be:
1. Determine organ system: Respiratory System (Set 4)
2. Medical or Surgical: Medical (no procedure performed)
3. Then choose from the (14) codes in this set: "Respiratory Infections and Inflammations" (code 179)

This is much easier that performing a full ICD code determination and it should be possible to train the coders to do this much more quickly than ICD coding.  The experience with this coding will also help start them on the path to ICD coding which will require much more extensive training.  I think that this DRG derived coding is a good first step (crawling) before ICD coding (walking).

The Codes

If your are interested in the details. I have uploaded my spreadsheet which contains the full DRG code set as well as the simplified codes.

I'd appreciate comments from anyone.

 

DRG Derived Codes 

IT Solutions - Development and Sustainability – What is your goal and what is the best use of resources?

IT Solutions

Because the currently available IT skills, electrical power and connectivity in many developing countries falls short of those necessary to set up and maintain the data centers for web based applications, external assistance will probably be required for some years. Fortunately, there are skilled international groups who are willing and able to perform these services and the software, being web cloud based, is easy to administer remotely when installed in a reliable data center. (This is in stark contrast to the difficulty of administering software which must be installed and maintained on local computers at each site.)

Because of this situation of limited resources and skills, a solution is required which will make the best use of resources. This means focusing on the goal and determining the best way to achieve the goal. The goal of the health information system is to improve the operation of the health ministry by providing timely, accurate data about health status and health facilities.  The issue is how to best implement this information system at least cost and greatest efficiency in the low resource and skills environment. An information system can be thought of as having three areas. First, there is the requirement for connectivity, second, there is the information system hardware and software, finally there is the output of the information system which is high level analysis leading to use of the data for decision making. The goal is not the information system itself, it is the use of the data to make decisions. We need to make it as easy as possible to implement the information system so we can get to the goal of useful data.

Developing countries with weak IT capacity are best served by focusing their limited resources on two areas. These are the bottom layer of basic connectivity and the top layer of data use:

- Maintaining the basic Internet network functionality

- Developing higher level data analysis and use skills

The “middle part” is the set up and administration of the data centers. This is the level between basic network functionality and high level data use. This level requires specialized technical skills and equipment. It is difficult to set up and maintain these data centers, especially in resource poor countries. This is why it is best left to international organizations who are experts in the software maintenance and to Internet cloud data center providers who are experts in supplying computing resources over the Internet.

Some people are concerned that farming out this function will deprive the local economy of the development opportunity to create their own data centers and the skills involved in running them. This is a worthy goal in its own right but it is not a core objective or function of the ministry of health which has a goal of improving the delivery of health services and it needs data in order to do that. Setting up a data center is not the goal. Access to timely accurate information is the goal. If the ministry can get more reliable and less expensive access to its data using a rented international data center, then that is the course to pursue.

A good analogy is the situation with cars and roads. Most developing countries are dependent on large industrial countries to supply cars. However, there is local capacity to maintain roads and also to repair cars. The local population have been trained in the use of cars and can use them to get wherever the roads allow. The same situation applies to the use of computers and the Internet. Computers are the cars and the Internet is the road. Developing countries are also dependent on large industrial economies for the supply of computers. However, there is local capacity to maintain the Internet and to repair computers. Just as with roads, the Internet is better in some places than others and there are places the Internet does not reach. The effort should be to improve the Internet speed and availability to all areas of the country. Internet technology is the most basic technology and the most useful. Once it exists, then computers become useful.

What about Internet cloud data centers? These require specialized technology and skills which take time to develop and are very expensive to do properly. Just as with cars and computer hardware, this is something that is best left to large industrial economies who are happy to provide data center services. No one is concerned that the developing countries do not have the ability to manufacture cars or computers and no one should be concerned that they do not have the ability to build and maintain data centers. Even in large industrial economies where you have good resources and high skill levels, many companies do not build and maintain data centers. They outsource this function to cloud service providers who have the specialized skills and equipment to ensure reliable, efficient service. The Solomon Islands should take advantage of these international Internet cloud facilities just as they take advantage of the large industrial country car and computer manufacturing facilities.

There is an additional advantage of using large data centers and that is that you can “rent” the facility as a service and you don't have to buy it. You can rent the capacity you need for the time you need it and you do not have to make the large investment in equipment, connectivity, and training which is required to have these function reliably and efficiently. You don't have to worry about equipment breaking or becoming obsolete or backing up the data. The data center provides these services cheaply and reliably since they spread the cost over a large number of customers. A first class data center costs many millions of dollars to set up and operate and requires highly specialized technical skills.  It makes sense to rent the capacity that you do need for the time that you need it and not have to bear the entire resource cost of the data center. Just as with a car, it is often more economical and reliable to just rent it when you need it rather than having the expense of owning and maintaining it full time.

It is most important that government efforts be focused on these two areas. First, maintaining the Internet (roads) as basic infrastructure and then at the high end helping the ministry to develop the skills of data analysis and use to improve services. You don't need to know how to manufacture a car to use it to get somewhere. You just need to know how to drive it. Similarly, the ministry should focus on learning to “drive” their data and use it to improve health. Building a data center is an unnecessary diversion of attention and resources when you can easily buy these services. A data center is a tool like a car or a computer. You don't make tools when you can buy them cheaply.

When your goal is to deliver vaccine to a village, you don't start by building a car factory. You just go out and rent a car.

Adventures in US Health Care - 1. Back in the USA

We recently moved back to the US after living in Switzerland for three years. Switzerland has high quality health care and it is superficially organized like the "new" US health insurance system. Everyone must have insurance. Everyone is eligible to buy a "basic" package of health insurance. No one can be refused. The system works well. Health care charges are regulated and insurance companies pay the standard charge promptly (usually to the person who has the insurance but with prior arrangement, directly to the provider).
We were covered by our insurance for four months after our return. I had not had a prostate exam for several years so I made an appointment with the urologist I had seen in the past.

I can only say that the US health care system is extremely dysfunctional.

I had an appointment for 9am and was told to arrive 30 minutes early to complete paperwork. When I arrived early I presented my paperwork and was told to have a seat and wait. No reason to be there 30 minutes early.
After waiting nearly two hours without any information or explanation, I was finally ushered to an exam room. No one made any apology or even noted that I had waited two hours for my appointment. (In contrast, a dental appointment the following week where the dentist was 5 minutes late resulted in profuse apology.)

Total history and exam time with the physician was about 10 minutes. I was charged using code 99245 which is intended for "Consult" visits:
To meet the requirements for an office consultation evaluation and management (E/M) service, consultation criteria must be met. According to the Medicare Claims Processing Manual (IOM Pub 100-04) Chapter 12.30.6.10, to qualify as a consultation service:
- A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patients medical record and included in the requesting providers plan of care in the patients medical record. The consultation service request may be written on a physician order form by the requestor in a shared medical record; and
- After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician."

Clearly this was not a Consult visit since there was no referring physician. I made the appointment directly with this urologist since I had seen him previously. It would have been more appropriate to code this as a "Established Patient" visit.

This visit was also coded as a "Comprehensive History and Exam, High Complexity Decision, High Severity Problem requiring 80 minutes of physician time." This is a gross overstatement of the visit on all counts.
-The History would be best described as "Problem Focused"
-The Exam is best described as "Problem Focused"
-The Decision-making could be described as "Straightforward" since everything was normal and this was a "Self Limited or Minor Problem" (actually no problem at all, just a regular exam). Coding guidelines for this visit would point to a 99211 code as most appropriate as it allows for 15 minutes of physician time and Problem Focused exam and decision making. Medicare payment for this code is approximately $18.00. Coding me as a "New" patient or advancing to a Level 2 visit (30 minutes, Expanded Hx, exam) for an Established Patient would have doubled the amount to $36.00. This is still quite a bit less than the original bill of $450.00 that I was quoted and which seems to be very much too high for the service I received. I was offered a discount from the $450.00 charge to "Medicare Rates" of $229.56 if I paid cash which I did.
I will also not be returning to see this particular abusive physician.

Observations:
Maybe one reason health care is so expensive is that doctors are grossly overcharging.

Principles for Effective Patient Information Systems

Over the coming years, many countries will be setting up information systems to better manage patient information. These systems are fundamentally different from the usual routine health information systems with their register and tally sheets producing aggregate information. An information system to collect individual patient information and manage it over the life of the patient will provide new perspectives on health and disease and new insights and opportunities to improve the health of individuals. It is worth considering a broad overview of what these systems should look like and how they should be implemented and used.

Define success locally
These systems collect individual patient information locally, of course, but what is often overlooked is the value of that information at the point of care to improve health decisions. Many times systems are designed to collect data to be sent to "higher levels" and the local analysis and use of the information is overlooked. When you combine good quality data about an individual patient with decision making tools and resources, you have an important opportunity to directly impact patient care and improve health.
It is also important to understand that "local" for a patient does not usually mean a single point of care. Patients often encounter different doctors, clinics, and ancillary services such as laboratories, radiologists, pharmacies and community health workers. Each of these encounters can benefit from access to good information on the person and in turn collects valuable information that should be part of the persons health record. Therefore, it is fundamentally important that individual patient information systems be designed to allow all relevant parties to access and update the record. This can be done using modern information and communication technologies focused on a personal health record.
In addition to individual care decisions, this local data also creates important insights into the local health environment. Analysis of this information can give important insights into the community access to care, coordination of care, and patterns of health and disease.
The bottom line on the "local" principle is that information systems should be designed to be accessed locally and not to send data off to a "higher authority", never to be seen again. Data extracts and aggregations as well as complete anonymized individual records in some cases can be valuable at higher levels for management, planning and policy as well as operational research but these are secondary uses. The systems should be designed around local use.

Improve what you have
Rather than embarking on a large project to design and install the "ultimate" computer system, it is much better to take a good look at the existing health information system and assess how to improve it. Often the current system is not working well and there many be computers and related resources that are not used well because of poor design, implementation or training.
Experience has shown that it is not wise to expect big and complicated things to somehow become small and simple. Large information technology projects are particularly prone to failure because people universally underestimate the complexity of large IT projects and overestimate the ability of the organization to change to adopt a new system.
Therefore, an incremental development approach is much preferable to large projects. If you start at the local level and look at work flow and information flow and work on improving this incrementally and continuously, it will give you a much better and more reliable result that tearing out everything and starting over.
Likewise, systems that are designed around relatively simple technology that is easily implemented and that can be readily scaled to larger numbers of users has a much better chance of success than trying to install large complex systems. In resource poor environments, these principles are even more important since the option of adding more people, computers, communications technology, and training is not available.
Even resource poor environments often have access to simple information and communications technology that can be easily implemented and scaled. Most countries have basic mobile phone communication technology available. The low bandwidth of even basic mobile systems (SMS and GPRS) is not an impediment to effective use. If you look at the massive success of Twitter, for example, it is based on very simple mobile technology of mobile phones and low bandwidth computers. It is easy to implement at low cost and the basic design scales to massive numbers of users easily. Each user of the system adds value and improves the functioning of the network logarithmically. It is possible to create valuable health information networks using these same principles. In fact, it is already being done.

Design patient information systems for the smallest unit of care
Unfortunately, most patient information systems are designed for large enterprises such as hospitals or large clinics and are designed to meet the perceived needs of these sites who have complex management needs for the most complex health problems. This results in very complex systems that are expensive to implement and maintain and unfortunately, do not have a good record of success.
In keeping with our principle of simplicity, it is much preferable to start with a minimal system that would be suitable for the smallest unit of care which would be an individual doctor, nurse or community health worker. One should also consider that the system should be designed to give the individual patient access to their own health data.
When you design such a minimal system you end up with a system that is easy to use, affordable, and easy to adopt. When you have a minimal data set of only the essential health information, you also minimize the necessary bandwidth and the complexity of the devices to enter and access the information. Therefore, it can easily use existing mobile communications technology. These systems can easily scale to larger number of users.

Focus on connectivity
Information is only valuable if it is used. It must be communicated to be used. This communication can be at a site (where a patient is seen at the same clinic), local (where results from a lab on the other side of town are available), regional (where a district office manages multiple clinics, or national (where health information is used for policy and planning).
In order to communicate information, it must be put into a form that has a common meaning for the sender and the recipient. This means that you have to have standards for data representation and semantics. In addition, you need to have a communications protocol that will allow the data to be sent and received without loss or corruption.
Having data and communication standards also allows you to have a flexible system design. You do not have to have the same hardware and software at every point in the system. If you think of the Internet and email as an example, there are multiple different devices from phones to terminals, to computers running hundreds of different software systems that can all send and receive standard email messages. You can do the same thing by defining health data standards and communication protocols.
This also avoids the necessity of building and maintaining large data repositories and multiple communication protocols. The only thing that is necessary is that the standards be defined. This fits in well with our simple system design that can be easily implemented and scaled at multiple sites on varied platforms.

Separate data from applications and the data transport layer
The success of the Internet is based on this fundamental principle of having a simple universal data transport layer that can reliably send and receive data. The data is represented in standard formats such as email or HTML (web) syntax that are universally recognized. There are thousands of applications which understand the data standards and transport protocols. These applications can be very simple or very complex and can run on simple technology such as mobile phones or complex computers. The applications themselves can be simple or complex. As long as an application can understand the data standard and the data transport protocol, it can communicate.
When you design a health information system to use data standards and define data transport protocols, you have everything that is required for others to build effective applications for all levels of use. These can connect patients, care providers, ancillary services, and health resources in compelling connected sustainable systems.

Sustainable information technology is driven by the desire to connect
Human beings seek connection. Health requires connections between patients, care providers, resource providers, and others. A system that facilitates these connections will be enthusiastically adopted and will be sustainable. In fact, it would be difficult to stop.
Maintaining and restoring health, preventing disease, and caring for others are among the most basic social activities. Unfortunately, our health systems and health information systems are not usually set up to facilitate these very basic human connections. Often due to reasons of power, control, and money health systems are set up to isolate patients, care providers and others who could and should be involved leading to fragmented, disconnected and isolated health services. Existing health information systems are unfortunately often designed to collect data, remove it and hide it in inaccessible data warehouses away from those who could most benefit.
Patient health records that use the principles we outline here can share data and connect the experience of patients, caregivers, doctors, and others. These will be adopted and utilized and as a result will be sustained.

Report My Flu

Having worked in public health informatics for many years. I have often grappled with the problem of collecting timely information needed to make decisions about current health problems.

The current and coming flu epidemic is a 'perfect storm' in this respect. We have some information about the flu but there is much we don't know. We don't know why some people have mild illness while others severe illness. We don't know how to treat the flu beyond the fact that some antivirals seem to be effective if taken early in the illness. There are many more potential treatments, both supportive and curative, that may be effective but we don't have good information. There is also the problem that flu viruses tend to mutate frequently and the illness can quickly change character. The public health community desperately needs real time information on the flu and there is no good source of this data. There are also several potentially valuable treatments that can be used beyond antivirals but we don't have information about how well these work. Better case reporting information can help sort out useful treatments.

Normal flu reporting takes place through various organizational mechanisms such as the US CDC, state and local health departments, and research projects. Internationaly, the WHO collects some information and various government and research organizations collect case reports. This information is of widely varying quality and completeness and the timeliness tends to be slow.
I have started a project to 'crowd-source' the collection of flu case reports. This will allow individuals to report flu cases. This has the potential to provide a valuable record of flu cases and to provide information that can be useful for guiding treatment and severity as well as looking for changes in the virus.
There are many potential problems with this crowd-source approach and I will be the first to admit that it may not yield useful information. Some of the problems can be addressed by good system design and I will attempt to incorporate the best of my knowledge into the initial data collection design. However, in true crowd-sourcing, I expect that the best design will evolve through suggestions from many of the very smart people out there.
You have probably noticed that I am using the singular in this reference. That is because at this time I am the only person involved in this project. I hope to attract others to the project in time. I should also note that although I am employed by a large public health organization which must remain nameless, this project is not officially sanctioned by that organization. I doubt that any large public health organization could undertake this type of project due to the many uncertainties and the unusual mode of data collection and analysis.

This project will operate with a few basic underlying principles:
- privacy and security
- open access to anonymous data

First, privacy and security.
The first principle is that individual patient information and information on the submitters of data will be kept private and secure. This is an absolute requirement. The data will be hosted in the US which has very strict health data privacy and security regulations and we have an obligation even beyond these to ensure that no personally identifiable information is released.

Second, open access to anonymous raw data
Besides crowd-sourcing the collection of data, I also plan to crowd-source the analysis of the data. This will hopefully attract bright minds to this task. We will not have any restrictions on access to the anonymous raw data. This also is very unconventional in the research world. Most researchers guard their raw data jealously and only rarely release data. It is almost unheard of to release raw data. I think this will improve the quality of analysis. Most researchers spend a lot of time cleaning and adjusting their data to 'improve' it. Unfortunately, this process often has the unintended consequence of distorting data and hiding or obscuring findings. (I adopted this policy after listening to this persuasive lecture by Tim Berners-Lee).

As should be clear from this post, this project has just started and now only consists of a web site place-holder www.reportmyflu.org which I hope to update soon with more information and data collection software. In true crowd-sourcing style, I hope to attract help in this task. Please comment on this post.

I don't want a choice, I want health care!

The US is currently having a debate about improving our pathetically incompetent health care 'system'.
The insurance companies who make billions of dollars of profit and don't do a very good job of actually paying for health care (over half of the personal bankruptcies in the US are related to health problems and 75% of these people actually have health insurance) have enlisted (or bribed) politicians to defend their profits under the campaign banner of 'choice'. They imply that a rich selection of insurance plans is a good thing and that a government plan will only offer one choice.
Cynically, when I am healthy I would like to have the choice to not spend any money on health insurance but when I am sick I would like to have the choice to have an insurance plan that offers 'full coverage' for everything that I think I might want to have done whether it was effective or not.
Practically, there should only be one choice that anyone would want for health insurance. This insurance should provide preventive services to keep me healthy and provide care services when I get sick. It's like those cell phone TV commercials when they parodied other companies that made you guess how many minutes you were going to use by asking young kids to make these decisions. Choose too many minutes and you pay too much. Choose too few minutes and you pay too much. The cell company wins both ways and you lose whatever you choose.
I don't want a choice. I want health insurance! Everyone wants health insurance.
This means that the best 'plan' is a single payer (this pools all risks) who is motivated to keep you healthy (not make profits). Sounds like Medicare for the rest of us. This should not be tied to employment so we should not have business provide health insurance. We should have a payroll tax (or other broad, progressive tax) to pay for it.
Unfortunately, doctors, pharma, hospitals, and medical device makers all make more money when they can sell you their products and services and their profit blinds them to ignore the fact that sometimes what they are selling is not safe or effective. We need a government agency deciding which treatments are safe, effective, and necessary.

A Health IT Application Store?

You don't need a 'platform'. An interoperability specification is the platform and it needs to be open to ensure wide adoption and innovation. EHRs now are closed systems with limited data import and export over largely proprietary and/or obscure protocols. This keeps the customer captive but stifles the kind of innovation you are trying to foster.
In order for this to work, you will need to have open interoperability specifications. You need to have a way that an eRx application can talk to the patient index to get patient demographic information and also talk to the EHR to get allergy and current drug information.
Each of these modules needs to be able to generate and respond to messages to send and receive the information it needs. This should all be done through open interoperability specifications.
If you do this, anyone can create a new application that can find the information it needs and adds value.
You can give grants and prizes but I think these should be given for the open interoperability specifications and implementations. Once these are in place, the new applications will arrive.

Interoperability and Best of Breed

There is always a vigorous debate on the strengths and weaknesses of the monolithic integrated approach versus the 'best of breed' interoperable approach.
Health care software is a very diverse and complex field and it is just not possible for any vendor to have high quality offerings in all possible areas. When you consider that medical practices potentially need software that does billing, patient records, disease registry, electronic prescribing, best practice alerts, point of care decisions, laboratory and radiology ordering and reporting, and other functions I think that one can see that the skills involved in developing these functions are unlikely to be strong in all areas.
In addition, as the Nutting report points out, implementation and change is difficult and it is better to take a path of gradual modular implementation rather than try to digest a large application all at once.
Interoperability is difficult because most of our software is not designed for it. The standards exist in HL7, ICD, SNOMED, LOINC, etc but they are not well supported by the integrated software that is currently available.
If you look at the case of the internet standards HTTP, FTP, SMTP, IP, etc. you can see that interoperability works well when you have software that supports the standards. The Internet, web browsing, email, etc all works well using software from thousands of vendors running of a wide variety of platforms.
Unfortunately, medical software has been developed on a closed proprietary, monolithic model with poor support for standards. If physicians understand and demand interoperability, it will appear and vendors who support interoperable systems will prosper.
Unfortunately, the CCHIT seems to be perpetuating the monolithic integrated model of software. Hopefully it can be persuaded to open up to focus on interoperability.

Global Alert and Response in the 21st century

On Tuesday 21 April 2009 the CDC confirmed two cases of swine flu in California. I read about it on my BlackBerry while sitting in a meeting at WHO in Geneva the next day. This meeting was convened by the WHO to try to figure out how information and communication technology (ICT) could improve WHOs response to health emergencies.

Google flu trends has been shown to be remarkably accurate in reporting the location and time of flu infections. It looks at people searching Google for “flu”, “cough”, “headache”, “runny nose”, etc. It gives near real time results.

My daughter who lives in California is traveling in Italy. A friend of hers in California shares a new song with Laura who receives it on her iPhone.

Most people understand that the Internet sends more information faster. Most people don't understand the ramifications of the global peer to peer connectivity provided by the Internet.

The International Health Regulations (IHR) are perfectly designed for the world 50 years ago. They impose a strong filter at the source (an elaborate flow chart to decide when WHO should be notified of an event) and a “chain of command” of reporting to the country office, regional office, then headquarters. The information is then analyzed and WHO decides what information will be made public.

This has several problems:
Filters
When communication was limited by low bandwidth and slow speeds, it made sense to impose strong filters at the source to avoid overwhelming the system. In the age of the Internet, this only serves to filter out most of the potentially valuable information.

Control
The WHO assumes that it can control information. In the age of the Internet, nobody can control information and if you try to control information you become irrelevant.

Peer to peer
The Internet is not just more and faster information. It means that everyone is always connected to everyone else. The IHR hierarchical model which uses a chain of command, control of information, and a limited pool of experts only serves to make it irrelevant. The rest of the world will know about the event via Google, Twitter, and YouTube long before WHO makes its pronouncement through the press.

To make the IHR relevant and useful WHO needs to:
Open up communication. You can't and shouldn't control information.
Remove the filters. You can and should receive more information sources.
Use peer to peer. Our connected world offers a rich collaborative workspace... use it.

Is it a good idea to have a universal patient identifier?

The universal patient identifier is a single number that can uniquely identify individual patients. It is usually defined at the national level.

With the advent of electronic medical records that offer the potential of lifetime longitudinal medical and health records, there has been renewed interest in the subject of a universal patient identifier (UID).

As with most things, there are advantages and disadvantages to the UID.

For electronic information systems, the UID offers the promise of a method to link information from many sites (clinics, labs, care and support services) and information that is generated over the patient's lifetime together into a single record (real or virtual) that gives a comprehensive picture of the patient's health history. This comprehensive view can improve the quality of care and avoid unnecessary tests and treatments.
The UID also offers the potential for improved insight into disease diagnosis and treatment. Aggregate information from many patients can show disease patterns and potentially highlight best practices in health care. This information can track population health and provide valuable information for health policy and planning.

However, the UID is not without problems. First is the basic problem of issuing UIDs to ensure that each patient has one and only one UID and that no two patients have the same UID. Patients who present themselves for health services should possess a method of identification. Ideally this will be a UID card and possibly some biometric (fingerprint, iris, etc.) identification. A patient may have lost their card or the biometric information may not be useful. In this case they need to identify themselves using demographic and other information so that the clinic can find their UID in a 'Master Patient Index'. This can be problematic because of similar information or uncertainty of information. Patients may also want to avoid identification for any number of reasons including stigma or financial gain. The result of these problems is that patients may be mis-identified leading to duplicate UIDs for the same patient (when a new UID is issued) or a cross linking of patients where two or more patients are using the same UID. Both of these situations are very bad for the integrity of the data and and extremely difficult to fix.

Perhaps a better solution is to assign each patient a GUID (globally unique number) at each facility along with ancillary identifying information (the usual demographic information plus any other ID numbers that the patient may have. All of this can be submitted to a 'Master Patient Index' which can do the heavy lifting work of sorting out unique patients. Meanwhile, each facility will have a unique record for each of their patients that are uncontaminated by two different patient having the same number. If a patient ends up with several GUID numbers at a facility (and they will have different GUIDs at other facilities), these can all be combined in the MPI.