Kaiser Ontology Interview

To the novice, the term “interoperability” means that two systems can talk.

To the expert, it means that they can understand each other. To much of our current data interchange is “meaning poor”.

To get past that problem, we need to do lots of work with ontologies, which, loosely put, are knowledge dictionaries. Most clinicians in the US have no training in ontologies and their real-world experience is limited to billing ontologies like CPT and ICD. As a result, the value of proper coding is largely lost on the average clinician in the US. ( I wonder how this issue is understood by common clinicians outside the US…)

Those of us who obsess with the future of Health IT recognize that we need to find ways to make Ontologies more productive.

At this year’s health 2.0 conference, I caught up with Dr. John Mattison of Kaiser Permanente to discuss a tremendously important contribution that they are making to the Open Source Health IT community. I have already blogged about this significant ontology development from Kaiser. So I was really pleased to be able to get these kinds of details from the horses mouth. These details include that the license will be the Apache 2.0 license.

Part 1

Part 2

Direct Project Updates

The Direct Project has a new name (formerly NHIN Direct),  a new website directproject.org and an excellent write up over on O’Reilly Radar called Healthcare communication gets an upgrade.

I am also interested to see that the O’Reilly folks seem to agree with me that this new NHIN thing really should be thought of as a “Health Internet”.

I see so much potential in the NHIN, and I really think it will be a communication revolution in healthcare on par with the original Internet’s communication revolution for.. well… every other industry except healthcare… I am glad to see that they are thinking about it in the same way…

-FT

The ethics of weight and body fat on Twitter

Update 12-16-2010:

I have just purchased a Withings scale. Indeed, as I discussed in my original article, it will only let me twitter my weight instead of my body fat. How frustrating. But, you can customize the static portion of each tweet. I will be tweeting my weight with a bit.ly link ( http://bit.ly/gS05Nz )to this article and @withings in each post.  Eventually, they will get tired of this and reply to my blog post or otherwise acknowledge this issue.

They also ask for my twitter password, which is no longer the right way to authenticate…

I originally blogged this while hanging out with Alan from videnitity.com ( originally met at health 2.0 ) at an mhealth conference. I should have mentioned videntity before.. they do cool work with Django and python for life streaming. In fact the discussion that I am about to go over prompted him to cover, in detail, some of the work he did using the Wii balance board to lifestream your weight. Hardware hacking for healthcare. Pretty cool stuff.

Almost immediately on seeing Alan again, our conversation turned to our mutual interest in quantified self. We are both interested wifi enabled scales.

But almost immediately I stumbled upon a mutual frustration. The most popular and well-known wifi scale in the space is the withings scale. The withings scale measures both weight and body fat percentage (impedance method). We were both frustrated with the default ability for the device to post to Twitter.

Take a look at the search for http://withings.com on twitter. Notice anything? Thats right folks… the withings scale posts weight. Just weight.

I do not need to bother to tell my readership ( clinicians and health interested IT folks) the problem with this. Our culture continues to have an obsession with weight at runs contrary to health. My own life is a great example. I weigh about 270 pounds. I am overweight, but my relatively high level of physical activity ensures that much of my weight is muscle. If I could manage to lose 10 pounds of fat and gain 10 pounds of muscle it would be better for me long term (as my muscle helped accelerate further weight lose) than just losing 10 pounds of fat. There is some debate about whether BMI or body composition is a better measure, but pretty much everyone agrees that thinking in terms of either BMI or body composition are vastly superior to simple weight measurements, because both take height into account (explicitly or implicitly).

So here we have the basic ethical quandary.

  1. Focusing on weight contributes to an unhealthy obsession with a single number that cripples our ability to compare two people effectively. This obsession can merely be inconvenient for people like me, who are capable of seeing past the number but are frustrated that I have to constantly do that work… Or it can be dangerous for those with certain eating disorders.
  2. The withings scale is capable of publishing both the body fat percentage/BMI and/or weight to Twitter providing social pressure for those who seek to manage their health.
  3. The withings scale chooses to publish only weight to Twitter.
  4. To add insult to injury, salt to the wound, spittle to the slap, and gratuitous cliches to the sentence: Withings knows that its users are requesting body fat percent in the tweet stream, they know they are requesting full templating of tweets, and they are taking a poll on what users want, but the poll does not have full templating (which would allow tweeting of body fat) or simple body fat tweeting as poll options.

Withings is playing “the users are too stupid” card on this one. From the comments of the blog post in question, in response to Paul who suggested a templating system:

Hi Paul, we first wanted to do so but as I said in the post above, we noticed that fully customizable tweets are too confusing for non computer-skilled users.

Moreover, a fully cuztomizable tweet can lead to unrelevant tweets.
Lets say youre trying to lose weight and your tweet is my current weight is %wc% and I only have %wo% to lose to reach my objective.
If ever you pass your objective on a specific weigh-in, the tweet will be unrelevant (it will say you still have -2 lbs to lose for instance) unless you think of changing the default tweet message just before weighing in…

Oh thank you pointy haired bosses at Withings. You have answered a tremendous consumer demand with a technology that further perpetuates fundamental healthcare mythologies. You have given us something at is 95% similar to what we need, but now serves a subtle destructive force instead of what you could have done which would be to apply social pressure to the right problem…and now as your user community suggests methods to allow us to fix your mistake… You tell us that we are not smart enough to do handle the tools we need to do that… Oh thank you from saving ourselves from ourselves!

This is the fundamental problem with Health IT today: we as health IT programmers are constantly making very subtle ethical decisions, and we regularly flub them up. More importantly, we ignore our users when they urge us to fix ourselves…

Withings made an ethical mistake in having the default tweetable data weight instead of body fat. Their UX justifications would be valid if they had made the right ethical decision to start. If I could only get body fat percent… That would be a frustration, but I could deal… As it stands they are just wrong.

But I understand why. Imagine the meeting:

Developer: we should integrate with Twitter
Pointy haired boss: cool do it.
Developer: we do not have time to do a complex integration. We can use weight, body fat percent or BMI…
Pointy haired boss: no one understands body fat percentage or BMI. This is a weight scale. People understand that… Lets go with that….
Developer: but body fat percentage….
Pointy haired boss: would not be as popular. This is a marketing and time question. We only have time for one of the two and most people will want weight…

The pointy haired boss is right. The fact is that people do understand weight better. Withings has probably sold more scales by choosing just to only tweet weight. This is not just a principle vs. profit issue. Assuming scales make a difference for people, more scales equals more difference. Frankly I do not blame Withings for starting with this decision. They were wrong, but their heart was in the right place.

But the arrogant position on templating systems and the fact that the poll they setup on the issues did not even give an option to chose body fat percent as an option is pretty unacceptable.

The other problem that Alan pointed out is that to get at the Withings scale data, you currently had to integrate with the Withings server rather than with the scale itself. So you have a device that records data about you, and then to get at that data, you need the by-your-leave of the device manufacturer… Not OK.

This device should be a “home health appliance”, and it should integrate with the Withings server -as a convenience- not as a requirement. I should be able to point this system anywhere I like. I should be able to easily point the data that the device generates anywhere I want to.

Withings need to take the following steps, and soon.

Support templating as a fundamental method of data export.
Support sending that templated data to any Internet location via simple POST, without going through Withings servers
Support full XML and JSON data export with those posts
Make body fat percentage the default measure sent to Twitter and give users the option to change it back to weight

If you support this idea… Please leave me a comment here, and retweet this article, with the @withings tag. I am pretty sure withings watches twitter.

-ft

Health Internet

For whatever reason people simply do not get what the NHIN is and what its implications are.

This feels like a repeat of what happened to me more than a year ago.

The NHIN (which has been rebranded the “Nationwide Health Information Network” or NWHIN from “National Health Information Network” in response to these silly trademarks) is going to be the foundation of a new Health Internet. The US Government wisely will not call it that, because of the paranoid privacy histrionics that this would induce, but nonetheless it -is- a Health Internet. The definition of the word “Internet” is: Any set of computer networks that communicate using the Internet Protocol. The Internet, the largest global internet

The Health Internet by extension is the “largest Internet devoted to Healthcare Data”.

Here are the basic features of the Health Internet:

  • You will be able to ’email’ your doctor.
  • Your doctor will be able to ’email’ you.
  • Faxing health records will go away.
  • Eventually, your medical records will auto-magically follow you around the country, appearing when they are most needed in a moments notice.
  • All of this will be done securely and in a way that fully supports peoples legitimate need for privacy.
  • New innovative services will appear, that leverage the Health Internet data channel to create applications that were previously unthinkable.

How is this being accomplished? Simple as one two three:

  1. The EHR stimulus money will be given out in response to “meaningful use” standards which include interoperability requirements, which will require connecting and sharing data, without specifying a specific technology stack. These standards will become more and more pronounced as time moves forward.
  2. ONC is supporting the development of two Open Source projects that will serve as reference implementations of the two NHIN protocols: IHE and the newly formed Direct Protocol. Those projects are the IHE projects: (CONNECT Project if your are a federal agency and the Aurion Project if you are anyone else, updated 8-19-11) and the Direct Project (Direct). I recommend you watch this OSCON video for a basic explanation of these two projects.
  3. The Federal Government will expose its considerable health data resources (i.e. DoD and the VA) using these two protocols. Agencies which accept the reporting of meaningful use measures will accept that reporting using one or both of these two protocols.

So are these protocols being mandated? No. But then neither were HTTP, STMP, SSH, SSL, or DNS. Its just what everyone uses. The VA has the single largest pile of detailed health records in the history of mankind. They will be available using either CONNECT-complatible IHE or Direct-compatible Direct protocol. They will probably not be available using your-favorite vendors idea of a proprietary health data exchange protocol.

This is going to happen. Hell, it already is happening. These reference implementations are entirely Open Source. They are designed to eventually handle the cases of communicating across national boundaries. This is going to the start of a international Health Internet. First with Canada and Mexico, and nations promoting Medical Tourism and then everyone else. It will take time. Adoption might be slow. But there will be a Health Internet, it will use these protocols. It is only a question of how long this will take to be adopted, and how long it will take people to stop talking in the abstract about the issues of Health Data Exchange.

This is happening. Adjust.

-FT

Checking with Facebook Places before voting

Hi,

So I wrote a new facebook application that gives you credit for supporting my fathers congressional campaign. My father is running in Texas District 20 (the Alamo District), and I am writing this article as a specific guide to his supporters with iphones/ipads and facebook accounts. (If you do not have a facebook account… now is the time to signup!!)

But no matter where you are this election day, you should use Facebook Places to checkin at your polling station. Why? because anyone building a facebook political applications (like me) will be able to use your checkin to prove that you were at a voting station. This very simple piece of information, where, when and most importantly the -implication- that you actually did vote means that you are a player in what will soon become a very very active political space on facebook.

Remember, there will be a host of facebook applications that check for this data in the coming years. You can be an early adopter of this type of technology even before knowing what application you will be using. This is also good advise no matter who you support politically!!

For many of you, this could be the first time you have used facebook places to check-in anywhere. So I thought I would write you a little guide to checking in. This guide will assume that there is already a location available for you to check-in to, but if there is no such location available, you can follow my instructions to create a Facebook places location to make one for yourself.

First you need to load your Facebook application. These instructions are identical for the iphone and ipad, and should be similar on the Android. If you have not installed the application yet, you need to search for “facebook” in the app store application and download it. Then you should see an application icon like this one on your iphone:

Click the facebook application
Click the facebook application

Next you need to checkin. The simplest way to do this is to click the little geo-tag icon to the right of the text field:

This is where you typically start
This is where you typically start

After you click there you choose which location you want to check-in too. In this example I am checking in to campaign headquarters. If there is a not already a facebook location for your polling station, you should add one.

Choose a place to check-in to
Choose a place to check-in to

Obviously your polling place will not be called “Trotter for Congress Headquarters”. It will be something like “the Smith elementary school”. It does not really matter to much where exactly that you check in to… the application will specifically store your latitude and longitude. Any half-way intelligent facebook application will be able to tell that you were at a voting station, even if you actually check-in at the Burger King across the street. Still better to check in at your actual polling station, even if it means creating a new location in Facebook Places.

Then you will be presented with the check-in interface, which looks like this:

Check in to a given place
Check in to a given place

You can put anything you want in the “What are you doing?” field (including nothing at all). However, while an application can understand the implications of your latitude and longitude, your facebook friends might not. You might give a little context to your check-in by saying “Here to vote” or “Dropping my mom off to vote” or whatever. My facebook social election game, does not attempt to figure out if you actually voted, you can score in the game if you just show up at a polling station on election day. It does not matter if you are under-age, or not voting, or vote for the other guy… I cannot say for sure, but I think other vote-oriented facebook applications that exist to serve a particular political candidate will probably follow suit. Otherwise, someone will try to claim that the application “rewards” voting a particular way, and is somehow illegal/unethical.

However, I imagine that you will also see a large number of facebook applications that are not associated with a particular candidate that will ask about exactly how you voted. These style of applications will turn Facebook places into a kind of real-time location-aware exit polling engine… lots of potential uses for that type of application.

But none of these apps can operate without data. In this election (2010) this will be new, and we will struggle to get the word out… but in 2012 and beyond.. this will be more than normal.

Enjoy!

-FT

Facebook Places powers the first social election game

Today, Farrin Anne ‘Crane’ Gustafson, the manager of the social media strategy for the Clayton Trotter (my father) congressional campaign became the first person in history to use Facebook Places to check-in to a new kind of application: a social election game. She earned the “At the Voting” badge by checking-in using Facebook Places as she early voted today on the first social election game that I have been frantically coding for the last few weeks. The game concept is simple: it rewards real-world political activity with points and badges. There have been a lot of discussion about how Foursquare et al. might be used politically. This is especially true of Gowalla, which has been targeting politicians.  There are also people who have talked of using a facebook game to energize supporters. But as far as I know, my application is unprecedented for the following reasons:

  1. The application is the first to allow its users to specifically earn badges for checking-in at polling stations during voting. This is much different then using the application to mark political rallies etc etc. Obviously, you do not have to vote to get the badge, you do not even need to be of voting age, or registered to vote in the state. All you have to do add the application on facebook, check-in at a polling station during voting (even after hours) and you get credit for the badge. Of course -most- of the people who do this will be registered voters who want to essentially participate in -perfect- exit polling.
  2. The application is built directly into facebook. That means that a users “check-ins” are something they can share directly with their facebook friends. There is no longer any need for a third-party application, or the need to limit the reach of the application to the very very few users of the geo-game like foursquare. This is an app for everyone on the largest single social network.
  3. You can check your friends in when you vote, and that counts too. So one iphone+facebook application can support several different users.
  4. The game does not just support check-ins. You can sign up for vote reminders, get credit for volunteering, and most importantly, use the application to provide a structured endorsement on your wall.
  5. Because it is powered by the facebook social network, you get full credit when your friends score. When your friends show up at the polling station or sign up for a vote reminder, you get credit too. You “win” by cooperating to get the candidate elected. Because there is a powerful proxy for detecting real votes (polling station check-ins), it will be easy to tell who the “vote influencers” were.
  6. The design of the application allows for a deep integration with the ability for the crowd to communicate back to the candidate. If my father is elected, he will be able to use the application to mine the facebook social grid and engage with his constituents in a fundamentally new way.

I believe that all of these elements together (and not just GEO apps or just political games) are the foundations for a new class of facebook game: For now I am calling them social election games. I believe they are the future of politics.

Up until now political power in the United States came from essentially two places: sources of money and sources of fanatical single-issue voters. Democrats cater to different type of unions. Republicans appeal to evangelical Christians. Democrats appeal to environmentalists. Republicans appeal to big business. Each small group would either deliver either a small cache of extremely loyal voters, or expensive advertising, or both. People who were able to directly influence candidates and politicians were either donors, or the leaders of these extreme groups. In short, the people with political influence in this country have become those with agendas that are generally out of sync with anything remotely mainstream. I made it clear, in my endorsement of my father, that I do not agree with all of his extreme views. I support him primarily because I know he will be more careful with defense spending than his opponent has been, and that is a very important issue to me.

I feel out of sync with my fathers extremely conservative positions and I feel (slightly more) out of sync with his opponents extremely liberal policies. They have done well as candidates because they have appealed to the extremes. I know of no reasonable person who agrees with either candidate on all of their political stances. (I am aware, and intend, the implication that if I know you and you agree with my dad 100% that I think you are unreasonable; and that my father, in the sense that he obviously agrees with himself entirely,  is also unreasonable. Given the Tea party energy, me saying that my father is unreasonably conservative, will do nothing but help him. I endorsed my father because he was -more- reasonable than his opponent, not because he was reasonable. Frankly, who thinks of their own parent as ‘reasonable’ in any case… I mean really…)

American politics as a whole suffers from the Myth of Polarization. We have turned politics into a kind of entertainment, something like pro-wrestling. Listen to any televised political commentator and tell me they do not sound like they are going to break out at any moment with “aaaarrree you ready to ruuuuuuuumble?” and then present the surprise cage fight…

Why do we have this kind of environment? Because that kind of low-brow drama gets people to vote. But what if we had a different way to get people to vote?  What if we could have simple, polite conversations with our friends about who the next sheriff or Congressman should be? I think if those conversations were easy, if they were simple and if voting itself were a fun process, then we might see a trend back to center. A trend away from blood-sport politics. In this world, the wielders of influence would not be the arch-bishop, but the local priest, with 300 facebook friends who actually trusted him as a human being. Instead of caring about who the chief of police voted for, you would care about which candidate the policeman who lives down the street from you (with 354 facebook friends) endorsed. Instead of caring about who the national teachers unions endorsed for president, you would care more about your kids third-grade teacher (54 followers on Twitter). Instead of caring about some insane radio talk show host, you might care about the opinion of an intelligent college kid from South Dakota with a podcast followed by 300 people.

In this hopeful/hypothetical world, real-world trust relationships, enabled by virtual social networks, will become the new political currency. I want people like my father and his opponent to care much more about someone who has 1000 followers on facebook or twitter, and has shown that 730 of those followers take their endorsement seriously, than the person who can pay for a political ad for them for $100k.

The whole point of social media is that it is -not- a broadcast medium. It is an engagement medium. No matter who wins the election in the San Antonio ‘Alamo’ district in 2010, this application is a template for something much much bigger. The irony is that now that I have proven that it is possible, others will try to mine this for a profit. I will have none of that. After the election, I plan to Open Source the code. I plan to start a project to enable a whole slew of social election applications for different groups and for different interests. This open source project, (which is looking for a project manager) will keep the goal of bringing reasonableness back to politics as a central design goal.

P.S. Polls indicate that the election between my Clayton Trotter (my father) and Charlie Gonzalez will be very very close. I honestly think this application might tip the scales in my fathers favor.  How cool is that?

(Update 11-22-2010) P.P.S Sadly, my father lost to Congressman Gonzalez… oh well..

Happily it does look like this game might be on to something. It was featured on some of the top tech blogs:

http://www.insidefacebook.com/2010/10/24/social-voting/
http://gigaom.com/2010/10/22/if-voting-is-a-social-game-will-it-make-democracy-better/

Pretty cool!!

How to add a new place to Facebook places

Soon, I will be making an announcement about some work that I have been doing with the Facebook places API.

For now, I want to give a little tutorial on how to create a new place, in Facebook places, using your iphone Facebook app.

First, you have to download the facebook application from iTunes, or get someone to help you do this. This tutorial assumes that you have the facebook application already installed… if you really need help with this, go to the Mac store and talk to someone there… should be pretty simple…

The first step is pretty important:

Go to where you want to create the place!

So click on the facebook application to start…

Click the facebook application
Click the facebook application

This will pull up the home screen…

This is where you typically start
This is where you typically start

You can also get to the checkin menu from the main facebook menu in two steps:

This is the main menu, places is right in the middle
This is the main menu, places is right in the middle

After clicking there you will see the main Facebook places interface where you can see your friends recent checkins..

This is the central places interface on the iphone, but it is not the checkin interface
This is the central places interface on the iphone, but it is not the checkin interface

Now you should have gotten to the check-ins interface… one way or another…

The check-in interface looks like this!!

This is the checkins interface, you are almost to the point where you can create a new place
This is the checkins interface, you are almost to the point where you can create a new place

So now you could choose a place where you would want to checkin… but that is not what this tutorial is about. You want to create a *new* place that will show up on this list and allow other people to check-in. To do that you need to hit the little red button at the top right of the screen, which should bring you to the “new place” interface:

Make sure that the little blue dot is exactly where on the map that it should be!!

The iphone facebook app Add a Place interface
The iphone facebook app Add a Place interface

Now you will be able to check-in to your new place…

The iphone check-in interface
The iphone check-in interface

Now you should go ahead and check-in to your new location. By doing this you will start to “legitimize” the place in Facebooks eyes. You also need to get your friends to start using the place when they check-in.

I hope this helps someone. I could not find a current how-to on making a new place in Facebook places. It is pretty simple. If you ‘own’ a place (like a business or non-profit) then you should also read about the process to claim a facebook place.

HTH,

-FT

MirrorMed, Medical Manager and mm2mm

So originally MirrorMed was a fork of ClearHealth. It was done to satisfy my need to get certain features done… but now ClearHealth has moved far past it… the usefulness of the “fork” part of this has diminished to nothing.

Still there were a few useful things in MirrorMed that have not been replicated in ClearHealth or anywhere else that I know of.

The most useful of these was a tool that I built called mm2mm

mm2mm is a Medical Manager to MirrorMed integration engine. Basically it a php parser for the medical manager data files that allows you to seamlessly move to MySQL. I have used this tool more than any other part of MirrorMed, and so I am now releasing it Open Source (AGPL 3) and completely costless. You can download it from the MirrorMed sourceforge site.

For those who are interested in Medical Manager, you might enjoy reading the history of Medical Manager, which I maintain. Recently someone reminded me that there have now been convictions in the Medical Manager dealership scandal.

Medical Manager was my family business for many years. My Aunt and Uncle still work tirelessly to support clients and my grandfather, now deceased, helped them start the business. The Medical Manager dealership scandal, where Medical Manager ousted small dealerships and apparently accepted bribes to buyout the larger dealerships originally taught me that nothing but Open Source was viable in healthcare informatics.

The release of mm2mm has brought me full circle with Medical Manager. It makes it trivial to use a FOSS EHR like ClearHealth, OpenEMR, OpenVistA or Astronaut VistA on top of an instance of Medical Manager but most of the people who have used mm2mm as beta testers were interested in creating a web-archive of the medical manager database or in entirely migrating away from Medical Manager.

Medical Manager was a great product, but years of neglect and proprietary thinking have doomed it. It might be possible to save if it was released as Open Source now, but it is probably too late.

Oh well…

-FT

betting on quantified self

So I lost the Health Developer challenge to ringful. But they had a pretty good app, so there is no shame in that.

More importantly, I think I really made people think.

Steven Downs of project health design, said this about toeleven.org:

However, instead of using Google Health or HealthVault as a platform, Fred used Twitter. Fred had the notion that people already use Twitter to track what is happening with their lives, so why not track what is happening to their health? That builds upon another key finding from Project HealthDesign: help people track their health information by incorporating the process into their existing daily routine, not adding something new

So basically, while they did not chose me to win the contest, they got the point I was making. If I had time to add some graphical goodness to the app, then I think I might have been able to make a better stab at being more competitive from a user experience standpoint, and I think I might have done better. There is always the next contest.

Still I have made strong headway with the notion that the quantified self movement, is merging with the PHR movement. The quantified self guys are pushing this logging to Twitter thing pretty hard. And toeleven.org is one idea about how to fully move Twitter into the PHR space. We will see how that community reacts to these ideas.

I think it is inevitable that the notions of the “life stream” as per facebook and twitter and the notions of traditional PHR will begin to merge. It is not a question of whether?, but rather when?, and how?

toeleven.org is an Open Source app looking for a project manager.. contact me if you are interested in owning the project…

-FT