The shape of things to come

What's Apple going to do in a few years, when smartphone technology plateaus, and people don't spring for an upgrade every 2-3 years? There's been speculation about a car, but I think the world's most profitable company isn't going to add much to its profits by selling something out of the reach of most of the world (and those that can buy an Apple car probably won't do it as often as they buy an iPhone).

Instead, I think the answer is now apparent, with the new product introductions of the Tim Cook era - Apple Watch, AirPods, and the forthcoming HomePod. These interconnected "smart" devices are all relatively inexpensive (as far as Apple products go). Interactions are largely through voice, or a few taps. You forget you're wearing the Watch or AirPods, and the HomePod looks pretty unobtrusive.

A smartphone is pretty much required to use any of these devices today, but you can imagine that won't always be the case (recall the iPhone required a Mac or PC running iTunes, in its early years).

While none of these devices are essential now, when you need them they're really nice to have handy. They're definite improvements on dumb watches, dumb speakers and regular headphones. I already use my Watch to pay for coffee and taxis, respond to texts, and in the years to come it will probably assume more of my phone's role. The HomePod right now is limited to music, HomeKit, and simple cloud queries, but it seems a safe bet that in the years to come its capabilities will grow (merging with or running Apple TV, serving as a phone, sending and relaying messages to contacts, etc).

Macs will continue to be around, for "serious" work (though they've made up a tiny fraction of Apple's revenue and profits and that seems unlikely to change). Other screened devices, like iPads and TVs, will be around for play, photos and short written notes. If there's one element missing it might be a standalone TouchID keyboard. But more of our future, I think, has come into view this week - and it's mostly screenless, distributed between wearables and innocuous furnishings like the HomePod.

Health IT, under attack

With the recent news of the WannaCry ransomware attack and how it particularly hurt UK hospitals, I figured it was appropriate to link to our writeup of An Academic Medical Center's Response to Widespread Computer Failure (PubMed / ResearchGate). This was our experience in the hours and days following a botched 2010 McAfee's antivirus update, which began attacking a core component of Windows, and rendering PCs unusable. While accidental, in many ways it resembled a cyberattack.

Of course, there's been great coverage of the attack and its implications. Halamka was quoted:

“By prioritizing clinical functionality and uptime, healthcare organizations may not always have the most up-to-date software. Thus, healthcare, in general, may be more vulnerable than other industries to cyberattacks, and the scope of the impact to the NHS in the U.K. illustrates the problem." 
He said that some mission-critical systems were built years ago and never migrated to today’s modern platforms. In 2017, there are still commercial products that require Windows XP for which few patches are available, he said.

Other useful perspectives on healthcare IT's vulnerabilities emphasize HIPAA / business associate concerns when accepting patches. Lessons abound. Hopefully we'll learn them well enough to prevent future episodes.



A year without blogging

It's not I've stopped writing - besides the peer-reviewed stuff there's articles and commentary at EPMonthly and Telemedicine magazine, tweets @nickgenes, and the occasional piece for Medscape.

But coming to blog at this site doesn't just feel like a chore - it's laden with a sense of guilt. I was so very wrong about the potential of blogging and social media.

There were warnings. Back in 2010 I commented on a WSJ blog about our experience implementing electronic medical records in our ED. Another commenter then accused me of practicing "Tuskegee medicine" and experimenting on patients without consent, because EMRs hadn't been shown to be safer and more efficient than paper records in randomized trials. I'd seen trolls before but not for academic discussions like this - and the troll was signing his note with an MD's name (though not someone I could find in US physician databases).

Elevating the status of online discourse is something I've wondered about for years - it's the reason this blog adopted Facebook-authenticated comments. Our research found value even in the web's darkest corners, like YouTube comments. But of course in general, commentary kept getting worse. Last winter I lamented that the media framed stories much like Vegas sets the spread, to ensure maximum pageviews, debate and ultimately, vitriol.

All this was before the 2016 presidential election really heated up. Eventually last year, every news story was quickly put in terms of your team vs the other team. Our team is always noble and wise, but the other team is misguided at best, hypocritical and probably evil, often dumb or short-sighted, and if they're making any gains it's because they're cheating. Interacting with old friends online became a fraught exercise. Even the #FOAMed community began to see polarization and personal attacks.

So blogging and using social media, for me, if it's going to continue, must take the form of record-keeping and journaling - links to useful resources, or snapshots of what I'm up to at a particular point in time. Anything more would be a waste of time.

One week in

I've commented before that politics is increasingly like sport - more and more we're just rooting for our side. Ultimately it means policy and ideas don't matter; only winning does. One side has already made this an explicit part of their strategy; they're playing to win, not respecting "norms," and using every tool at their disposal to keep winning.

A quote from The Economist, on the occasion of President Trump's inauguration:
All populists are at heart conspiracy theorists, who pretend that easy solutions exist to society’s woes and have only not been tried to date because elites are wicked and deaf to the sturdy common-sense of decent, ordinary folk.
 So how can populism be challenged? A lesson from Venezuela:
Your organizing principle is simple: don’t feed polarization, disarm it.
This means leaving the theater of injured decency behind.
The Venezuelan Opposition struggled for years to get this. It wouldn’t stop pontificating about how stupid it all is. Not only to their international friends, but also to the Chavista electoral base itself.
“Really, this guy? Are you nuts? You must be nuts.” We’d say.
Don’t waste your time trying to prove that this ism is better than that ism. Ditch all the big words. Why? Because, again, the problem is not the message but the messenger. It’s not that Trump supporters are too stupid to see right from wrong, it’s that you’re much more valuable to them as an enemy than as a compatriot.
The problem is tribal. Your challenge is to prove that you belong in the same tribe as them: that you are American in exactly the same way they are.
But if you want to be part of the solution, the road ahead is clear: Recognize you’re the enemy they need; show concern, not contempt, for the wounds of those that brought Trump to power; by all means be patient with democracy and struggle relentlessly to free yourself from the shackles of the caricature the populists have drawn of you.
Unfortunately these tactics against Chavez were never truly successful; he was never ousted and died in office. His reputation among the people remains good, even though he didn't do enough strength Venezuela before its economic crisis. 

I suspect, like Chavez, Trump's reputation will remain strong with his core supporters, no matter what messages the opposition adopts. Like anti-vaxxers and climate deniers, too many people are just too isolated from the consequences of their beliefs; there's not enough pain or suffering to make them doubt the messages they're hearing. Unless we have a similarly bad economic crisis while Trump is in power, or another 9/11 or Katrina-style catastrophe that he obviously mishandles, this will continue. 

#SAEM16 panels

SAEM's Annual Meeting is in New Orleans this year. While a lot has changed since San Diego, I'm fortunate to again be participating in several didactic sessions this week. The program is available online - links to slides are forthcoming. 
  • Tuesday @ 1:45pm or so in Napoleon Ballroom C2 (3rd floor): As part of the Social Media Bootcamp, I'll be talking with Megan Ranney about using Social Media for research - slides

  • Thursday @ 8am in Napoleon Ballroom B2 (3rd floor): DS-22: I'll speak about conducting EM research using social media tools, in a panel with Megan Ranney & Austin Kilaru - slides & references

  • Thursday @ 9am in Napoleon Ballroom B2 (3rd floor): DS-28: Nidhi Garg moderates a panel featuring me, Esther Choo and Megan Ranney on disseminating research through Social Media - slides & references
If you're interested in any of these topics, and at SAEM, you probably also want to attend the Social Media committee meeting Wednesday at 1pm in Evergreen (4th floor). Also on Friday morning Ken Milne talks about knowledge translation through social media, in DS-58 (Grand Ballroom E, 5th floor).  In the same room, right after, Rob Cooney and others talk about social media as an adjunct to resident conference (DS-62).

So, four social media-related didactic sessions, plus a bootcamp. Meanwhile, I can't help but notice the typical informatics panels (some of which I'd participated in, last year) aren't present this year. I don't even see an Informatics Interest Group meeting. Not sure if anything can be read into this shift, but at the very least there's an opportunity to reintroduce an important topic to SAEM, next year. 

mHealth Toolbox at #ICEM16: Cape Town, April 16&17

I'm honored to be participating in the mHealth Toolbox next month. The two-day event is taking shape with a terrific lineup of physicians, entrepreneurs, technology enthusiasts, and many, many gadgets. Check back for links to presentations and resources.

Post

Another bit about software - iOS mail clients.

Federico tweeted that iOS mail clients are today what Twitter clients were a few years back. Sure, but I never cared so much about reading and writing tweets because my job(s) didn't depend on it. E-mail is mission critical.

I loved Mailbox but it never did Outlook. Acompli was a leap forward, flawlessly blending Outlook and Gmail; I even liked its built-in calendar and recent files feature. I thought it was good that Microsoft bought it - but then innovation stalled and they removed the one feature I was really enamored with - programmable long swipes. Yeah, this may have been a power user feature that confused newbies, but this power user was waiting for someone to re-implement this helpful feature.

Then came Airmail, the most customizable iOS mail client yet. Sure, the new app has a few rough edges, but I'm happy to struggle through a few rough edges, because it has long swipes! And, easy integration with organizational apps like Todoist (you can swipe to Todoist, which almost makes me look forward to emails).

The Big To-Do

So, I've become one of those people that blogs about organizational software. I'm sorry. Just writing this post will probably squander every extra minute I'd have ever saved by using such software. 

For years I've been using OmniFocus, and it's been pretty good. Before that I was using Apple's own Reminders solution (I was a big fan of the Siri integration, which Omnifocus also takes advantage of). Before Reminders, I used Remember the Milk and Wunderlist. 

I've been on Todoist for a few weeks, and it's pretty great. 

The spread

It's been more than fifteen years since hanging chads dominated discourse, but they made a big impression on me.

No one had any idea what hanging chads were, or how they should be interpreted, before the 2000 Presidential election - but as soon as it became clear which interpretation favored Bush, and which interpretation helped Gore, pundits assorted themselves along established party lines. It really showed me there was no over-arching ideology behind what columnists and talking heads were saying - everyone was just supporting their team.

It's really no different than sports - look at last year's discussions of DeflateGate, or recent commentary when the Yankees signed a closer with pending charges of domestic violence. If you love your team, you'll find a way to rationalize or dismiss disturbing details. There's a small percentage of undecideds, largely indifferent or uninformed - and all the arguments to persuade these folks for or against a position are really just sophisticated cheers for the home team.

In sports, gamblers have come up with a clever way of dividing issues right down the middle: the point spread. For each game, the house sets the point spread such that even if one team is much better than another, you'll still get maximum participation in betting, with approximately 50% siding with the better team (which has to not just win but overcome the spread) and 50% favoring the worse team (these people are essentially betting that their team is bad but not that bad).

Of course it's in the house's interest to set the spread accurately, to maximize the number of bettors - the house takes a percentage of each bet.

The media is now playing the same game, trying to maximize the number of clicks, shares, comments, and eyeballs - because that's largely how they're paid. This is why so many stories are framed so provocatively - to make it seem as much like a game as possible. We're all familiar with simple clickbait ("You'll never believe what happens next") but that's just the equivalent of sports highlights - everyone likes to see a great play.

The media's real bonanza comes when they can frame an issue to evenly divide us. Starbucks going with simple red cups for the holidays isn't noteworthy, but when some fringe character decides it's a sign of the War on Christmas, suddenly every mainstream media outlet is running a story, and people on your Facebook feed are debating a boycott.

The Paris attacks were a huge story to begin with, of course - there will always be a legitimate function for reporters to report facts, and for readers to seek details. But when a story passes from the reporting phase to the commentary, it's often framed as an matter of supporting a team. "Team Civilization vs ISIS" is (fortunately) not very controversial, and wouldn't generate many more clicks - but framing the issue in terms of gun control, or immigration policies, is sure to keep people frothing, clicking and commenting (even if neither issue has much bearing on the attacks).

No part of our discourse is immune to framing issues in terms of teams. In the ad-supported tech press, it's Apple vs. Android, or Silicon Valley VC's vs the rest of the world. In the weather, every storm or unseasonable hot or cold streak is evidence that human-induced climate change is fake, or real.

This goes beyond the journalistic practice of seeking balance for the sake of seeming objective. It's as calculated as setting the point spread to maximize betting - and far more cynical. This practice turns any issue into an opportunity for cheerleading and grandstanding. You're either with your team or against them - there's no room for nuance, learning, seeing merit in both sides.

I used to think that ad-supported media and social networks were both overwhelmingly positive things, that would inform the population and expose us to a diversity of well-reasoned opinion. But now that most every story is shoe-horned into familiar narratives, now that social networks act as echo-chambers to parrot the talking points of entrenched interests, I have to wonder - is anyone still undecided? Is anyone being persuaded by the mountains of comments, of shared stories advocating one side or another? Or is it all just preaching to the choir, or more accurately, pointing to your team and cheering?

Program update

It's an honor to be included among the high-quality EM blogs and podcasts in Brent Thoma's article, in this month's Annals (second line in the figure). But it's also a reminder that blogborygmi.com content has become sparse. More of my on-the-spot EM (and informatics) opinions are posted at EPMonthly.com, specifically the Crash Cart series.

#SAEM15 panels

I'm very happy to be in San Diego for SAEM's Annual Meeting - and fortunate to be participating in a few didactic sessions this week. Here are links to the program, slides and references.

Tuesday  1-5:30pm - Nautilus 3: Social Media Bootcamp - led by Brett Rosen - slides

Wednesday 1:30pm - DS-18 Point Loma Ballroom A: I'll speak on clinical decision support projects for residents, as part of Jeff Nielson's panel called "Emergency Informatics Research: Interesting, Approachable Projects for the Resident or Career Scientist" along with Jason Shapiro and Adam Landman - slides - references

Wednesday 2:30 pm - DS-19 Point Loma Ballroom A: I'll speak on research opportunities in Informatics Education, as part of Ryan Radecki's pane "From Clicks and Complaints to an Informatics Curriculum" along with Jim McClay - slides

Friday 4pm - DS-95 -Harbor Island Ballroom 1: I'll speak about conducting EM research using social media tools, in a panel with Megan Ranney & Austin Kilaru - slides

Pulse check

Now that Medium's gotten more bloggy I expect to use it more - for topics too long for a tweet, but too short for an EPMonthly article.

So head over to Medium to read a few brief takes - like my thoughts on Snellen eye chart apps. Or view my Prezi on medical apps for the #AllNYCEM8 conference.

At EPMonthly, my recent article on healthcare workplace violence is available.

And check back here around May, for links to #SAEM15 resources.

Medium high

So it's been three years since I sang the praises of Tumblr, and about two years since I last logged in. Much like the iPad was a "in between" device whose appeal plateaued as smartphones get bigger and laptops get more nimble, for me Tumblr was always stuck between short Tweets and real sit-down-and-think writing. And both Twitter and real writing are taking up more of my mindshare.

I've been writing and blogging a bunch (not here, of course) over at EPMonthly. Specifically I'm enjoying the weekly Crash Cart, commenting on new EM stories with Bill Sullivan and Mark Plaster. The fodder is chosen by the EPMonthly staff (lately Matt McGahen has been on fire), we try to keep the writing incisive but informative, and the whole thing is fun and rewarding.

Elsewhere on the web, my circle of Twitter contacts and sources has been great lately. And whenever I feel Twitter is grating, I just tweak my lists, add some fresh voices, and it all gets better again.

So for me Tumblr never took off, despite its strengths. The aggregator was spiffy, and I really liked how Tumblr allowed me to elegantly collect posts on certain topics, But I never was able to engage with the various Tumblr communities - posting and sharing things to Tumblr was like decorating a snazzy room that no one visited.

Still, I'm still drawn to the idea of reinvigorating my web presence. Which brings me to Medium, the popular writing platform that's trying hard to not be a blogging platform. Each article is beautiful; a pleasant experience to read and write. But they've deliberately made it hard to aggregate content or set up a 'presence' for yourself (in the mobile app, for instance, you can't view your own writing, or even search for it).

For a while I waited to make the leap to Medium; I just figured more features were on the way. Only now do I kind of understand what Ev & co have been up to: Medium can't be gamed - it will only show you quality writing. Yeah, it's recommendations are based on your interests and the kind of people you follow. But you can't leverage your page design or tags or posting frequency or social connections to increase the visibility of your writing. You just have to write well. It's as if they decided everything else - the blogrolls and hashtags and carnivals and follower counts - has all been a distraction.

So I'm going to give Medium a shot, sharing some pieces from EPMonthly and here that could use a little fresh air.

To be continued...

Order Sets & the Art of Medicine


When I was part of Jeff Neilson's illustrious Informatics Research panel at SAEM in Dallas this past spring (we were recently invited back for San Diego next year) I spoke on the topic of simple clinical decision support projects, particularly evidence-based order sets. I also talked about incorporating clinical calculators into orders, so trainees could enter discrete patient data into the EHR and see if the test they were considering was appropriate.

These are feasible research projects that can have measurable impacts in utilization or even care, don't require big budgets, and can be done in a resident-friendly timeframe. 

There was a question from the audience. Someone wanted to know if order sets and clinical calculators were antithetical to the idea of resident education - that organizing tests and meds by complaint, and building calculators into the EHR, made it too easy to be a doctor. Might we consider abandoning order sets and focusing on memorizing doses and appropriate indications for tests? By focusing on these things, were we failing to train doctors in the Art of Medicine? 

I was surprised by the question. Perhaps it's because I'm in a bubble - surrounded by colleagues who know as much (or more) than me about patient safety, bedside teaching, EHR usability, and evidence-based guidelines for care. 

I don't remember exactly how I responded. I said something about how order sets and clinical calculators are here to stay, unquestionably reduce errors, improve efficiency and encourage appropriate resource utilization (when implemented well) and the only challenge remaining is making them as current and easy-to-use as possible. 

That was a start, but I should have also pointed the audience member to the Checklist Manifesto, which covers the evidence, obstacles and psychology behind getting doctors to put their ego aside, be humble and make sure everything worth doing is getting done. After all, there was probably a time where pilots complained about losing the artistry of flying, but the public cared about their planes not crashing. Similarly, in an era where we are trying to get 100% compliance on core measures, when we're asked to do more, and see more, with less time and less support, it's imperative we make the EHR work for us as best it can. 

The Art of Medicine may have once involved regaling patients and staff with feats of memory; now it seems more appropriately about forming a fast rapport with patients, and explaining Bayesian algorithms for risk stratification. Let computers do what they're good at - lists and calculators - and let doctors have meaningful conversations with patients. This seems like the new state of the Art. 

Analyzing Twitter for Public Health Research - #med2 tutorial

Michael Chary and I presented our tutorial, Analyzing Twitter for Public Health Research, at the Medicine 2.0 World Congress in Maui just recently.

Our audience was a diverse group of clinicians and researchers. There was substantial pre-meeting prep, where we guided prospective attendees through registering on dev.twitter.com and GitHub, then logging into a new account on Codio and forking our repository full of setup scripts and sample code.

At the meeting we presented slides and references, passed around handouts and gave hands-on help and advice to the room.

We think we've given our audience a good foundation to apply new techniques for public health research, collect good data and draw reasonable conclusions from their results.

In the course of preparing this material, we also learned a lot, about how to effectively disseminate these techniques. Now we're looking for new venues to share what we've learned - perhaps there's a role for more traditional media...

More to come.

Modern convenience

I'm glad some people choose to share their health data - be it RunKeeper routes and times, or WiThings weights or blood pressures, or the latest Quantified Self device. There's certainly evidence that social pressure can promote real change in people's lives.

It's just not for me. At least, not at this time.

But I'm finding the problem with these modern fitness apps is, they're each in a deadly competition for VC funding, for market share, for app store rankings. So they're under huge pressure to grow their user base - and that means, increasingly, pestering users to access one's contacts and one's social feeds.

So now, if I want to use RunKeeper, I've got to tap through all these social popups, to decline to share my info, after each run.

Is there a way I can just spend a few dollars to not be annoyed by my own software? I loved the Moves app, which was elegant and minimalist, and with its one-time up-front fee, didn't pester me with sharing popups. But then it was bought by Facebook - so it's likely my data's available for sharing, despite my efforts.

Folks used to argue that Apple could charge a premium for Macs because you were paying to eliminate cruft - so that you didn't have a desktop full of AOL, MSN, or other unwanted services. 

Now, with Google and Facebook matching Apple in terms of sleek design, the premium is simply going to be privacy, and lack of social prompts. 

Coming down on The Night Shift


I've been reviewing episodes of NBC's The Night Shift for EPMonthly. Specifically, I took the pilot, then episodes 5-8, while Dr. Aaron Bright handled episodes 2, 3 and 4.

It's not a good show. The plot twists are predictable. The characters are mostly caricatures. Worst of all, to me, is that the medicine is awful - it's absolutely impossible for an emergency physician to say, "We manage patients like that," or "That's what my job is like."

But I understand there are fans of the show. A lot of them. And they may want a collection of our medical impressions. So, here you go:

Episode 1 - Pilot
Episode 2 - "Second Chances"
Episode 3 - "Hog Wild"
Episode 4 - "Grace Under Fire"
Episode 5 - "Storm Watch"
Episode 6 - "Coming Home"
Episode 7 - "Blood Brothers"
Episode 8 - "Save Me"

Greg Henry also chimed in, with his opinion.