Converting to Electronic Health Records: fits and starts

The people of the United States are finally pulling together around the goals of reducing health care costs (by far the highest per capita in the world) and improving outcomes (we have the worst health of any developed country). Everyone seems to recognize the critical importance of data and communications in these efforts. So several of us at O'Reilly Media, having been involved with information technologies for some time, are tracking the issues that come up in deploying computer technology in health care--not just to streamline payments, not just to facilitate access by doctors to records, but actually to create new ways to deliver and track health care.

I recently attended a forum on how my state, Massachusetts, is facilitating the move to Electronic Health Records, a prerequisite for many things doctors, patients, and insurance companies can do to improve health. It's notable that the chief sponsor of the event, the Massachusetts Health Data Consortium, derives a lot of its support from insurance companies. Lots of invective has be\ en thrown at these companies recently, but the questions of technology can pull together the insurers, providers, and patients in a common quest. [AO: My original blog said that insurance companies set up MHDC, but this was incorrect.]

My own understanding of the progress and frustrations in deploying heath care technology was enhanced by the conversations I had that day and the statistics bandied about.

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What sociologist Erving Goffman could tell us about social networking and Internet identity

I just finished Erving Goffman's classic sociological text, The Presentation of Self in Everyday Life. A friend told me to read this for an exploration into what "identity" means online, and I did find that the book offers some useful frameworks.

I have to admit, to start with, that it's a rather distasteful work: personally, I don't see my entire life as a performance and everyone around me as an audience. That seems to be just what Goffmn wants me to do. (He calls this attitude his "dramaturgical perspective.")

Furthermore, the book was published in 1959, just before the social revolution of the 1960s exploded the expectations of formality it documents--all the assumptions about proper behavior, social distinctions, making a good impression, and so forth. These distinctions remain, of course, but people tend to behave in ways that consciously disavow differences in class and status instead of highlighting them (at least in the United States).

Goffman's underlying framework is still valid, though, and it casts a useful light on some of the dilemmas of going online.

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Vendor Relationship Management workshop

Nobody knows you as well as you do. Or do they? Let's run a test. Do you know what percentage of your food bill went to processed products? Or what type of coupons (store coupons, newspaper coupons, etc.) is most likely to get you to switch brands? I bet someone out there knows.

This kind of data mining is the modern companion to Customer Relations Management, which is the science of understanding customers and trying to get repeat business. CRM can offer many valuable benefits, but ultimately the control lies with the vendor, not the customer.

This bothers long-time marketing maverick and Cluetrain Manifesto coauthor Doc Searls. Several years ago he thought up an alternative that would put the data and the control back in the hands of customers, and called it Vendor Relationship Management. He's been pursuing that dream for two years as a Berkman Center fellow at Harvard, and this week he ran the second workshop hosted by Harvard on the topic.

I dropped in and out for a few hours and picked up some ideas, annotating them (as always) with ideas of my own.

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How the Zeo sleep device works around the limitations of home monitoring

The Zeo is part of a trend toward using technology to monitor our own bodies. People have always been concerned about their health, of course, and have tried different things to see what works (including rather absurd superstitions). But now there are ways to bolster one's curiosity with real scientific data.

The Zeo makes this data available for people who may have sleep problems--and quite a lot do, judging from a 2005 National Sleep Foundation (NSF) poll (a recent poll covering a wide range of adults):

26% say they had "a good night's sleep" only a few nights a month or less. Another 24% report having "a good night's sleep" a few nights a week.

This blog is meant to be a technical discussion, not a consumer guide, so I took the opportunity to talk to Ben Rubin, CTO and cofounder of Zeo, just a couple weeks after the official release of the Zeo to get some information on two aspects:

• How it collects data during sleep
• How they analyze the data to help the customer sleep better

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ICANN without restraints: the difficulties of coordinating stakeholders

People interested in coalitions and policy-making on a global scale--topics that are increasingly relevant in a world whose borders are irrelevant to carbon dioxide, flu viruses, and other critical entities--need to learn from other organizations that are dealing with these issues. This week brings particularly important news about the Internet Corporation for Assigned Names and Numbers (ICANN), which has been making policy for eleven years under a number of difficult premises:

• It was created hastily and arbitrarily without roots in the communities most interested in its mandate.
• Its concept of stakeholders is boundless, potentially involving anyone who uses the Internet or gets information that has passed at some point over the Internet.
• Its reach is global, and its decisions are affected by issues of language and culture.

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Review of Guobin Yang's "Power of the Internet in China"

I've posted my review of The Power of the Internet in China: Citizen Activism Online, a combination of research and sociological analysis, here:

Book review

Relevant comments are welcome on this blog.

Worldwide Lexicon: matching up technologies and culture to end the language barrier

I've reported before on the Worldwide Lexicon, the brainchild of my friend Brian McConnell. His most recent breakthrough, which I blogged about in August, was an impressive Firefox plugin that exploits both human and machine translations on the Web to provide pages you can read in your primary language.

As attractive as the Firefox plug-in can be, it's only the first stage in four that Brian plans toward a computing environment that encourages and leverages human translation. On the browser side, the next logical project is to reproduce the Firefox experience for IE users. Ultimately, he hopes the functionality becomes a standard part of every browser. Even better, he's working on a way to include the functionality on the server side so that it's browser-independent (although that technology would require support in the server software, of course).

And there's even more to come. He lays out his vision in an essay boldly titled The End Of The Language Barrier. The bottom of the article points to an equally important statement written for the World Economic Forum by Ethan Zuckerman, founder of the Global Voices site that extends the reach of weblogs to people in many countries who previously lacked access to such forums.

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RSS never blocks you or goes down: why social networks need to be decentralized

Recurring outages on major networking sites such as Twitter and LinkedIn, along with incidents where Twitter members were mysteriously dropped for days at a time, have led many people to challenge the centralized control exerted by companies running social networks. Whether you're a street demonstrator or a business analyst, you may well have come to depend on Twitter. We may have been willing to build our virtual houses on shaky foundations might when they were temporary beach huts; but now we need to examine the ground on which many are proposing to build our virtual shopping malls and even our virtual federal offices.

Instead of the constant churning among the commercial sites du jour (Friendster, MySpace, Facebook, Twitter), the next generation of social networking increasingly appears to require a decentralized, peer-to-peer infrastructure. This article looks at available efforts in that space and suggests some principles to guide its development.

Update: a few days ago, OpenID expert Chris Messina and microblog developer Jyri Engeström published an article with conclusions similar to mine; clearly this is a felt need that's spreading across the Net. Interestingly, they approach the questions from a list of what information needs to be shared and how it needs to be transmitted; I come from the angle of what people want from each other and how their needs can be met. The two approaches converge, though. See the comments for other interesting related blogs.

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Computerization in Nilekani's Imagining India

Imagining India: The Idea of a Renewed Nation promises to occupy a central position in discussions about India as well as the world economy this year. The book was released last year in India, came out in the United States just this past March, and has racked up some prominent reviews recently. Particularly relevant to this blog are the book's observations on computers' role in the economy and society.

Author Nandan Nilekani can speak with quite a bit of authority on computers, having founded and led Infosys, an early success story in modern Indian commerce and a major player in the historic rise of outsourcing.

Imagining India is a huge book with many big agendas; it covers education, infrastructure, environmental challenges, government intervention, and the role of historical narrative, among other things. Biggest among its agenda--and the one that I wager will generate the most debate--is Nilekani's own version of a modern combination of neoliberalism and neoprogressivism that seems to be gaining ground. The general idea is that governments should take a leading role to promote social progress by creating an infrastructure that allows individuals to form their own destinies (good education, good health care, good physical infrastructure, a light-touch form of regulation that ensures quality, and occasional direct welfare payments) rather than preserving oases of protection and easily abused subsidies for particular interest groups, notably unions, small businesses, and disadvantaged castes.

But all that lies beyond the scope of the Radar blog and of my own powers of analysis. I'll just comment on the following points from the book, because they concern the role of computers and because they resonate with trends I see in the U.S. and elsewhere.

• Technophobia shouldn't be assumed
• Internet access goes along with transparency and egalitarianism
• Software leads innovation in other areas

A lot of technologists glibly anticipate that computers and Internet access will be rejected by some group of people who are implicitly labeled ignorant or clueless: racial minorities, poor people, the elderly ("how can you get my grandmother to use this?"), etc. In every case, the key to adoption turns out to be access and sometimes the availability of useful applications. When presented with the opportunity, these populations always prove eager to take advantage.

Nilekani cites one instance after another of rural village dwellers, farmers, taxpayers, and others who quickly grasp what computers and Internet access can do for them. Whether it's the chance to learn English, check crop prices, or pay a utility bill, Indians at all levels come to depend on the computer once it's introduced. (The hard thing, as you might guess, is persuading agencies and local officials to install systems that undercut their power as gatekeepers.) And we've all heard of the Hole in the Wall Project, where Indian kids in slums come to enjoy and figure out how to use computers with little or no adult help.

Nilekani may be citing anecdotes selectively, but his observations echo other reports I've heard about disadvantaged or lagging communities. The problem is not the people, but other factors such as availability, cost, and usefulness.

Internet access goes along with transparency and egalitarianism

One reason the Indian population loves computers, according to Nilekani, is that it attacks favoritism and outright corruption. This advantage matches up with the promise of open government in the United States and other developed countries.

In some cases, Indians are burdened by extremely crude forms of corruption that crumble the instant computers are installed. One example in the book is the registration of changes in land records, which farmers are required to report to the government every year. Agency staff could easily steal land by deliberately filing wrong reports, or extract bribes by delaying the filing until the desperate farmer caves in. But a computerized system takes the staff person out of the process.

Bringing sunlight into government activities in most developed countries has somewhat subtler effects and becomes a more long-term project, but the essence is the same and depends on computerization to work. In the US, we have a lot more control over the stimulus package, thanks to Recovery.gov, than we have over expenditures in Iraq or the bail-out to the finance industry. Indians are similarly learning how to watch over their governments and raise their voices digitally, according to Nilekani.

The sunny role that people around the world are granting to the technologies of going online is not intrinsic to these technologies, because they also lie at the center of modern surveillance, warfare, and regimentation. The benign role is hard won, and represents a collective choice by the public that has adopted the technologies. As Nilekani puts it:

The idea of technology as something ominous and scary that is used by "Big Brother" to control our lives and eliminate jobs has given way to the idea that it empowers, liberates and gives us access to all the services that are due to us, as citizens and consumers.

The reason that the computer industry was the first to take off in 1990s India is that it required practically no infrastructure. Of course, it required a computer, which might require six to twelve months for an import license in those days. It also required electricity, which could be obtained in major cities and supplemented by private generators. (In areas of unauthorized urban growth, the slumlords strung the wires.) So in a regulatory environment that scrutinized and imposed conditions on every allocation of equipment, it was much easier for entrepreneurs to set up a computer firm than any business that had more physical manifestations.

As is well known, the relative independence of computing from physical infrastructure also made Indian companies lucrative in a world increasingly linked by the Internet. Nilekani says that this physical flexibility was also valuable internally, helping IT-savvy businesses cut across the logistical and political barriers that have always geographically segmented the Indian market.

Nilekani seems to believe that there's nothing about the computer industry that's uniquely suited to Indian talents and business acumen. Now that the computer industry set an example, the same advantages have been applied to many other industries. In the 1980s, economists doubted that India could succeed in any industry, and a few years ago they wondered whether India could succeed in any industry except computer services. The evidence is now strong that the country will become a leader in many areas.

Indian industry is just one example where computerization has shown light on a path that social change can take. A worldwide example is provided by the open source movement, which Nilekani mentions only in the most fleeting manner in his conclusion--unfortunately enough, because free software can be a compelling wild card in story of international development, especially as part of a trend I dubbed tech-splicing in another article.

The first open license was a software license (the GNU General Public License). When it was released, the phenomena of allowing unlimited changes and sharing these changes looked like a peculiar aspect of software. But many years later, these ideas seeped out into fields of innovation with a more physical basis, and research by Eric von Hippel showed they always had legs.

Software was also the inspiration for gene splicing and other aspects of synthetic biology, even to the extent that biologists share their innovations in repositories that look like software libraries (check out the BioBricks Foundation).

Finally, the popularity of scripting and other software hacking initiated--or revived, or perhaps just legitimized--a tradition of solving a problem through invention instead of settling for a standardized, commercial solution. The DIY movement found in many areas of the world--including the Indian practice of assembling local motor vehicles called jugaad--makes it more and more likely that products of many types will come out of small, even amateur workshops.

Products of creativity and pure thought embody a freedom that allows them to metamorphose and spread quickly. The added formality and clarity that software brings to these activities doubles the power of that freedom. So my guess is that software will often lead the way in social innovations by a decade or more.

World Wide Lexicon Toolbar changes the reading experience for the other 99% of web pages

Brian McConnell's latest coding effort, World Wide Lexicon Toolbar, meets my criterion for a piece of critical infrastructure: after two days with it I can't get along without it, and I plan to avoid any browser that doesn't have it installed.

Brian is a highly adaptive programmer. With roots in the telecom industry and several start-ups on his resume, he also wrote Beyond Contact: A Guide to SETI and Communicating with Alien Civilizations for O'Reilly. The World Wide Lexicon project he's been working on for the past several years is again something totally different.

Install the add-on (currently experimental) in Firefox 3.5 or higher and visit a page in some language other than your default. Before your eyes, headings and text change into your native language. You can get similar effects by submitting the page to a popular translator such as Google (which is one of the tools used behind the scenes by the WWL toolbar), but the instantaneous effect of the toolbar makes you feel closer to the people whose sites you visit around the world.

There are several languages that I know well enough to get the gist of a page, but where I miss some of the details and get frustrated by gaps in my vocabulary. Therefore, I set the WWL toolbar to "Bilingual view," so each block element of the original text is shown together with its translation. The bilingual view is considerably less attractive, because it swells the size of each block element, but I can tell already that it will improve my language skills quickly.

WWL is designed for volunteer translations. If it becomes more popular, people will submit translations that are much more accurate than the machine-generated ones the WWL must fall back on currently.

What's the process behind this new dimension to web browsing? McConnell let me in on some of the magic.

Volunteer translations

McConnell invented WWL several years ago with the core notion of encouraging people to translate web pages they thought should get a wider audience. When he first told me about the idea, I was skeptical that he would get many volunteers. But then I heard of other volunteer translation efforts. For instance, there's a whole subculture of people who write subtitles for popular Hollywood films. This runs afoul of copyright law, of course (and so do the copies of movies they're attached to, probably) but they show the lengths to which crowdsourcing has progressed in the translation area.

FLOSS Manuals, a project I do volunteer work for, also finds dozens of people willing to translate its open source documentation.

McConnell's first set of tools were designed to facilitate on-the-fly translations. Web designers could enhance their web sites by downloading from the WWL site some JavaScript that made each text element on the page editable. (I blogged about this in December 2007.) The paste-in displayed a little pencil icon, signaling to viewers that they could do instant translations. All they would have to do was click on an element, and a text box would pop up where they could enter their translation. The web site would then register the translation with the central WWL site.

World Wide Lexicon API

The WWL API covers the entire life cycle of a translation: registering a translation, rating translations for quality, searching for a translation of a particular page into a particular language, and retrieving a translation. Queries can specify a minimum rating.

Toolbar

The latest achievement of the WWL project is the toolbar officially released yesterday. It determines the user's native language through settings in the browser. When each page is visited, the toolbar uses the domain name and various tests on the text to make a guess about its language.

The toolbar then issues an API query to see whether any human translations exist. If so, it displays the translations with a light yellow or green background.

If no one has made a human translation (which is usually the case so far) the toolbar resorts to well-known machine translation services. It can make use of Google Translate, Apertium, and Moses, each of which offers an API, and will also query Babelfish when its API is ready. Machine translations are displayed with a light blue or grey background.

The progressive translation used by the toolbar is also interesting. It starts with the first 10 or 20 elements, then translates heading tags (<H1>, etc.), then the larger texts, and ultimately every element on a page. (I displayed one page that embedded a Google ad, and the translator recognized and translated that text too.) McConnell is working on making the various translations run in parallel. Because translation changes the sizes of elements, the toolbar makes various accommodations to display the page as attractively as it can.

In short, WWL is a cool combination of mash-ups, existing services, crowdsourcing, and Ajax. I'm sure that in a year's time I'll think back to its appearance today and be shocked at how primitive it was. But it will remain a transformative tool for me.

Recent Posts

• Privacy and open government: conversations with EPIC and others about OpenID on August 3, 2009
• Cloud computing perspectives and questions at the World Economic Forum on July 9, 2009
• Personal Democracy Forum conference: initial themes on June 29, 2009
• Personal Democracy Forum ramp-up: adaptive legislation can respond to action in the agora on June 24, 2009
• Twenty-five hundred years of Government 2.0 on June 19, 2009
• Personal Democracy Forum ramp-up: from vulnerability and overload to rage, mistrust, and fear on June 16, 2009
• FCC discusses broadband: the job is a big one on May 27, 2009
• Local forums to implement high-speed networks (broadband): proposal open for votes on May 24, 2009
• Completing the circle on journalists and public participation on May 19, 2009
• Credit card company data mining makes us all instances of a type on May 14, 2009