Direct should be in NPPES

For those wondering, the Direct Project is a secure email protocol based on SMTP/S-MIME for doctor-doctor and doctor-patient secure communication. It is all-but-required in Meaningful Use version 2 and it is intended to replace the fax machine for the transfer of health information in the United States. I had a hand in designing the protocol.

NPPES is the authoritative source of doctor contact information in this country. <shamelessplug> DocNPI.com is probably the best way to actually search the NPPES data,  and we have an API and everything. </shamelessplug> But you can download the NPPES data yourself and almost every insurance company, clearinghouse, HIE vendor, etc etc does this on a regular basis, in order to ensure that they have updated contact information for doctors, hospitals and other organizations in the healthcare system.

The NPPES publishes the NPI, which is basically the “social security number” for doctors and hospitals as they conduct business. Anyone who is legitimately connected to healthcare can get an NPI and you should, just so you understand what the signup process looks like.

When you register for your NPI, you have the opportunity to insert your contact information. Once you have an NPI, CMS publishes that contact information. This is the list of every possible contact field in the NPI data:

  • Mailing Address Telephone Number
  • Practice Location Address Telephone Number
  • Authorized Official Telephone Number
  • Mailing Address Fax Number
  • Practice Location Address Fax Number
  • Mailing Address
  • Practice Location Address

This bundle of information is what a physcians is required, under HIPAA (the parts no one pays attention to) to keep updated. Right there in the middle you can see two fax numbers. As long as the NPPES data does not have a Direct Mailing address listed in addition to Fax numbers, the message from CMS is clear “Use Fax for health information exchange, not Direct”.

Here, are the reasons that NPPES is really the only place that a centralized Direct provider directory can be kept.

  • It is the only contact information that a physician has a legal obligation to keep updated.
  • The NPI is the basis for “HIPAA covered transactions” which could be conducted over Direct if there were a clean linkage
  • Direct is designed to handle Cert discovery, so there is no need for NPPES do bother with any kind of x509 stuff..
  • The alternative is “competitive” directories from private industry which directly (and already) translates to balkanization.
  • At the stage, all CMS needs to do is starting asking for the address as part of the NPI signup as a non-required field… This would not need to be a mandate
  • But even having a space for it in the record would cause Direct adoption to explode
  • By publishing Direct Addresses in NPPES, it would be trivial to detect and call attention to “certificate balkanization” which is the biggest threat to Direct’s success
  • There might be complicated reasons for also doing some other provider director solution. Which is fine as long as it is additional to putting Direct emails into NPPES..
  • There is literally no other, better, way to get Direct into the conciousness of every doctor in the US. Until you start requiring Direct Email for Meaningful Use Attestation, but that is a post for another day.

Mostly, I just wanted to write this down as a brain dump so that others can easily email a link around as to why this is not a terrible idea.

I have proposed this several times, in person and I believe in some comment to Meaningful Use or something else on regulations.gov. I am certain that I am not the only one, but I tend to be more vocal than average about Health IT policy implementation details. But I cannot find what I have already written anywhere, and it is probably included in something longer I wrote. I am unfortunately given to ranting when people formally ask for my opinion. So I wanted to write a short post about why this is clearly the way forward for Direct Project adoption.

If you have anything to add to my bullet points, email me at fred dot trotter at that email service that google runs.

-FT

 

 

 

 

Expert Healthcare Hackers

(This is a preview of a talk that I am going to give next week at Healthcare::Refactored, with Karen Herzog)

There are two definitions of the word “Hacker”. One is an original and authentic term that the geekdom uses with respect. This is a cherished label in the technical community, which might read something like:

“A person adept at solving technical problems in clever and delightful ways”

While the one portrayed by popular culture is what real hackers call “crackers”

“Someone who breaks into other people computers and causes havok on the Internet”

People who aspire to be hackers, like me, resent it when other people use the term in a demeaning and co-opted manner.  Or at least, that is what I used to think. For years, I have had a growing unease about the “split” between these two definitions. The original Hackers at the MIT AI lab did spend time breaking into computer resources… it is not an accident that the word has come to mean two things.. It is from observing e-patients, who I consider to be the hackers of the healthcare world, that I have come to understand a higher level definition that encompasses both of these terms.

Hacking is the act of using clever and delightful technical workarounds to reject the morality embedded default settings embedded in a given system.

This puts “Hacking” more on the footing with “Protesting”. This is why crackers give real Hackers a bad name. While crackers might technically be engaged in Hacking, they are doing so in a base and ethically bankrupt manner. Martin Luther King Jr. certainly deserves the moniker of “protester” and this is not made any less noble because Westboro Baptist Church members are labeled protesters too.

Like protesting, Hacking is all about taking a certain set of ethical issues that are important to you, and then performing an act whose central purpose is to restore ethical balance. People with screwed up ethical compasses will give good protesters and good Hackers a bad name.

I like this broader definition because it really shows that Hacking is not at all limited to technology. It relates to “systems”, as long as the “system” is complex enough to encode moral notions. This means that protesting is really just a special kind of Hacking, in fact we might rename it “public opinion hacking”.

Consider Richard Stallman. Stallman realized when he couldn’t get access to printer control software because of a proprietary license, that the license itself was encoding something he had an ethical problem with. Rather than accept that embedded morality, he created a workaround solution (copyleft licenses) that created an alternative with an embed morality that he could live with. The system that Stallman was hacking was copyright and licensing and the modern Open Source movement is the result of this hack.

The notion that technology and other complex systems can have moral notions embedded is neither new, nor mine and I recommend Lessig’s Code and Other Laws of Cyberspace for a full discussion.

I came to this conclusion as we renamed our “meaningful use” book to “Hacking Healthcare“. David Uhlman (my coauthor) and Andy Oram (my editor) seriously considered “Hacking Healthcare Software”, as an alternative title. But in our discussions it became apparent to us that David and I were really hoping to teach people how to use software to change the Healthcare system itself. The software was merely the type of hack that we were proposing, rather than the system being fixed with the hack.

Any efforts to hack healthcare should be embraced because the default settings on the Healthcare system really suck.

We have too many medical errors. We have overtreatment, undertreatment, fraud and disconnected care. Worse, until very recently, we had incentives that were virtually guaranteed to make these problems worse. These problems are merely symptoms of the wrong set of morals being encoded into the healthcare system.

Which leads me to introduce Karen Herzog to you. Karen makes my efforts to hack healthcare look somewhat childish. Like other, more famous e-patients like e-patient Dave and Regina Holiday, Karen, along with her husband Richard Sachs refused to accept the default settings of the healthcare system when their daughter Sophia was born with a rare genetic disorder. Shortly after Sophia’s birth, Karen and Richard were informed that their daughter disease was incurable and that she was dying.

The default settings for the healthcare system in these circumstances could not have been worse. Karen and Richard were offered occupational therapy, physical therapy, grief counseling and “when she turns blue let us know..” by their doctors in a manner that was obviously code for “we cannot help you, sorry for your situationa but get out of our hair”.  Karen and Richard refused to accept this. They did go home, but rather than allow the healthcare system to “wash their hands” of Sophia they created a garden. This literal garden was the first step in creating a community of care that re-engaged their doctors, who were themselves feeling hopeless and overwhelmed a safe environment to try to make Sophia’s life better and to seek a cure. Like all of the greatest “Hacks” Karen and Richard repurposed simple solution and made it apply to a problem that was regarded as unsolvable. They created a literal space that was so welcoming that it inspired collaboration in a group of clinicians that were not used to collaborating worked beautifully. They found ways to make it obvious that Sophia’s space would not be a deathbed, but a different kind of space altogether.

Eventually Sophia died, but only after receiving care that was orders of magnitude better that what could have been accomplished if Sophia would have been hospitalized full time. Hundred of clinicians, friends and family came together to make Sophias garden into a success, in a collaboration that never could have occured inside the walls of any given healthcare institution.

This success was hard-fought. Together, Sophia, Karen and Richard experienced just about every significant problem that patients and caregivers can have. For each hurdle, Karen and Richard continually refused to accept the “default settings” that the healthcare system offered, by responding with hack after hack.

I am humbled to be speaking opposite Karen. Since Sophia died, Karen and Richard have pivoted their design group into one of the preeminent “Patient UX” shops in the country. They have leveraged their troves of poor experiences with the healthcare system, and their methods of working around them, into a series of fundamental insights about how to improve patient experiences with technology and design. They are my default recommendation for design work in the healthcare space.

I have been watching what e-patients like Karen and Richard are able to accomplish for years and I have come to realize that in many ways, they are far more deserving of the honorific of “Hacker” than the bozos who deface websites to make political points. In much the same way that the recognition that MLK Jr was a protester, makes it embarrassing that we have to label the Westboro church members with the same label.

Like the original Hackers who built the Internet and the first computers, e-patients are blazing a trail through the healthcare system. Decades from now we will look back on this class of patient and realize that they remade healthcare by simply refusing to accept the aspects of the healthcare system that typically suck. In the future, when the new norm for doctors is respect patients enough to actually let them finish sentences, we will have this generation of e-patients to thank. Much the same way that we recognize that our iPhones and Androids would not be possible without the pioneering Hackers of the *nix community.

Karen and I will be doing a “dueling keynote” at Health::Refactored, asking each other difficult questions about the state of the art in design and technology in healthcare. I hope that the audience will learn some tidbits from me about how to work with software to help fix healthcare, but I think I have made my case that Karen will be the real healthcare Hacker on the stage.

-FT

 

How to change the world over the weekend

I love hackathons.

I love winning them. I love competing in them. I love winning them.  I love judging them. I also love not losing them.

This weekend, I am acting as a mentor to the first Health 2.0 hackathon in Houston Texas. As far as I know (which is not that far, really) this is the first hackathon in Houston to be focused exclusively on healthcare. Serving as a mentor rather than having the opportunity to directly win might seem counter intuitive, given how competitive I am. But I have had complaints about being a “professional” Health IT expert entering these contests, and as one of the organizers of the event, I do not want to be seen as unfair. This was a hard decision to me because in most cases, if I have to choose between winning and being unfair, I choose winning.. but my Houston Health 2.0 co-conspirators prevailed upon me this time…

I do well in hackathons because I know how to avoid the number one pitfall in healthcare hackathons: It is too tempting to make toys.

To really rock a Healthcare Hackathon you have to have a real strategy to build something that will make a difference, but something that you can still prototype in two days. Here are general thought strategies that have worked for me:

  • Have you carefull searched the web for someone implementing your first-blush idea? The android iphone app stores? Your idea is probably not original?
  • Rather than focus on original “ideas” to find “original problems”, clinician partners on your team are critical for this perspective!
  • Seek problems where there is no money to made solving them. Problems that already have money already have attention, it is hard to do original work in those spaces!
  • Only a few doctors are enlightened enough to pay attention to the hacking approach. How can we multiply the impact of a very few doctors?
  • Most patients are not e-patients, they are reactive and unwilling or unable to change their own healthcare behaviors. How can we minimize what each patient must do, but still have an impact?
  • Are there patient pain points so strong that we can rely on at least a few highly motivated beta testers?
  • How can we leverage the cloud, even with HIPAA limitations?
  • How can we crowd-source effectively, ensuring that every participant is evenly and instantly rewarded for contributions? How can we make crowdsourcing fun?
  • How can we leverage pre-existing Open Source code or APIs? Stand on the shoulders of giants… Hello! Obvious!!
  • How can I flesh out my team at a hackathon by pitching to clinical, educational, design, art or video collaborators?
  • If a programming task is hard for me, can I find a geek that can do in a few minutes what it would take a whole week for me to learn?
  • Getting a good idea is easy. Getting a good idea that is small enough for me to finish in two days is hard. How do I trim all the fat?

Here are some ideas that I will be pitching to participants to this weekends hacking contest. If I can find geeks with the required programming skill-sets and the team to ensure that they have the clinical and design backup that they need, I think these are all doable in two days.

Big Data on medical students:

Medical students are the only ones who understand the problems in medical school. I have designed a hack that will allow us to use big data on them directly to discover and fix the issues with our process for making doctors. I think this will require a team who can code in cross-platform Java… but a web-platform programmer could be tolerated in a pinch. SQLlite experience is a plus.

Better medical wikis

Only Wikipedia has the critical mass to sustain itself, so the only way to make a medical Wikipedia is to do it inside Wikipedia. But how do we ensure that the medical parts of Wikipedia are accurate enough for clinicians and experts, but simple enough for the average patient to find them useful. I think I have found a way to use the Wikipedia API’s to dramatically improve the quality of Wikipedia articles on health issues, but I will need a team who knows how to either build a chrome or firefox module…. are perhaps super fancy JavaScript bookmarklet

Cross the channels at health conferences

Every healthcare conference has a back channel, and in my experience at healthcare conferences, many of the real experts are in the crowd tweeting. Conversely the people who line up to ask questions at a microphone are unvetted, a tragic portion of those who ask questions are actually pitching their own projects, or exercising an obsession, or asking a stupid question (and yes… there is such a thing as a stupid question… or at least there are many morons who feel comfortable wasting my time with questions). I am pretty sure it will require something like Node or Pythons Twisted, but I think we can use Twitter to hack health conference Q&A for the better….

The calculus of pain

In healthcare we have policies that help to ensure that “drug seekers” are unable to access excessive amounts of opioid pain killers. Assuming we define “denying a patient pain medications as a positive”, then these policies are “high sensitivity”  (has few false negatives). Said another way, they have been shown to reduce the number of deaths from medication overdoses in those states that apply them. But good policies are also “high specificity” (has few false positives). In this case, a “false positive” is to deny a patient who has legitimate untreatable-without-opioid pain access to effective pain control. The debate is mostly rhetoric here, with law-enforcement and organizations who represent pain patients both resorting to rhetoric  because there is no way to accurately measure false positives. But what if we could create a dynamic visualization that estimated false positives from the data that we do have? Essentially, we could create a “calculus of pain” diagram that both sides could ‘agree’ on, but use differently. As you might expect, this ‘rhetoric negation GUI’ will require extensive D3/javascript expertise.

Simple games for fitness

I am interested in creating tools that use Geocoding and QR codes together to motivate health. I need IOS and/or Android developers for this one.

Twitter plus epatients

Lastly I am interested in the ways that e-patients tend to favor twitter and I might be interested in developing an e-patient specific twitter tool. Need to code in a web-friendly language.

Quantified Self device hacking tools

The QS community very clearly needs a specific tool that I have gotten alot of requests for. You must know either hardware interfacing (usually C or C++ for usb drivers etc) or web authentication (OAuth et al)

Do something awesome using Natural Language Interfaces.

One of the API sponsors for this hackathon is Ask Ziggy which is essentially a “Siri as an API” for app developers. Its a clever idea and there are lots of possible uses here… no specific technical requirements other than to us this API.

Do something awesome with DocGraph

This is of course, our own data set.. and you can read about it at the main DocGraph site.

Do these sound vague enough?

I hope these are pretty vague ideas. I intentionally am leaving out the critical “how” part of each idea!

I hope this list is enough to spark some interest and get developers to attend this conference. I will not be the only one pitching ideas, and teams attending with pre-baked ideas typically do well at these kinds of events. Still if you want to use my ideas, and hear me explain how to do them and why they will work then you need to meet my specific criteria. First, you must be willing to develop  in the open, and under Open Source licenses. I am giving you a hackathon winning idea for no money. (and I am fairly certain, given that I have judged more health 2.0 contests than anyone else) Even if you do not win the contest, these ideas are so good that I will probably be able to make you fairly famous in the Health IT and Health 2.0 communities.

By working on my ideas you kind of hedge against losing at all. If you are able to pull of the projects, then I will give you credit publically for your awesomeness, which is valuable to anyone looking to make a name. For this valuable insurance service,  I need to be able to start from where you left off if you decide to abandon the project after the hackathon… That means github and the FOSS license of your choice (I like the AGPL)

You also -must- have the skillset that I require for a given project for me to give you the details on a project. I cannot have my best ideas just “out there” for people to run off with!! I am pretty sure that I have at least one project for every kind of developer that I can think of listed above. If I could do all of these ideas myself with my programming skill set.. guess what… I would have already done them or I would save them so that I could win some other hackathon! Each of these projects leverages a very specific hack of some kind. Either hacking hardware interfaces, user expectations, software design, data levers or something like. After I describe the “how” of each project there will be an “aha/wow” moment, when you think “We didn’t I think to do that?” (Note I felt this way after seeing IFTTT for the first time). If I am handing you a “wow” world-changing hack then I have to know that you will make us both look awesome when you pull off the hack. Don’t worry if you do not have a specific skillset I define here. I have lots of other ideas based on what you are good at! This especially applies to designers and other artistic types and to clinicians!! All of these projects could use clinical/design help!!

If you have not signed up yet, then I would get over to the signup page now. So far, every Houston Health 2.0 event has sold out so far, and we expect this one too as well. I have some pretty awesome project proposals but I can tell you now that these will just be a few of the awesome ideas that we are bringing to the table for this Hackathon. Most importantly, if you already have a project in mind, then you will be able to find a team to help you hack on your project! All you need is alot of motivation, a little skill and a willingness to collaborate. Or even just one of those three would do…

Looking forward to seeing you there!!

-FT

 

 

 

 

Two important dates

There are two events coming up soon that you do not want to miss.

The first is not this weekend but next: The Houston Health 2.0 codeathon is happening (March 23-24 at Platform in Rice Village)

The second is Health::Refactored from the Health 2.0 conference series. That happens on May 13-14 in Mountain View, CA.

I will be acting as mentor at both events. We are specifically looking for e-patient mentors, so if you are interested in this role, please let me know.

Also, I need to start promoting these different conferences and code-a-thons that are friendly to the “Hacking Healthcare” approach… what is the best way to promote and maintain different events on the web? Is there some kind of automatic event-to-email-to-RSS-I-don’t-have-to-think-about-it tool that is popular for tracking a series of events?

Go to these two conferences. They will be awesome!

-FT

 

ePatient HIMSS 2012 Badge

Hi,

I am happy to announce with psuedo-permission from the Society for Participatory Medicine (by which I mean that they have not asked me not to do this) a Twitter badge for HIMSS 2012.

There are a handful of the epatients who are attending this years HIMSS (alas, I am not among them) and they have agreed to play a game to help get to know the e-patients. Those who complete the game get to have a digital version of the epatient badge for HIMSS12.

The game is simple. Each of the following e-patients have given me a riddle that they will answer for you either over Twitter, or in person. Plus I have given each of the e-patients attending the conference a super secret code word. That means that you have to either figure out the riddle on your own, use the riddle as an excuse to introduce yourself to each epatient over twitter, and you have to find and post a picture of yourself wearing the S4PM badge!

Then I will generate a digital badge for you that you can use on your twitter background, or any you can use in any other website where you can post an image.  The digital badge will have your twitter username written on it, to prove absolutely that you have earned the badge.

This badge will be issued only for people who complete this puzzle during HIMSS. We might issue different epatient badges in the future, but this one will never be issued again. This is truly a once in a lifetime opportunity. Everyone you know will be jealous of the small graphics file that you acquire here. Truly, your completion of this puzzle will be a story that you can relate to your grandchildren (to put them to sleep).

Seriously, this might be a fun way to get to know some new people at HIMSS and to help spark discussions about patient engagement at HIMSS. I wish I could be there in person, but at least I can provide you all with something fun to do while you are there…

You can get the S4PM badges from the Relay Health (#3618) or MedSeek (#1345) booths, or by attending the S4PM Wednesday lunch meetup or one of the following epatient events at HIMSS.

Wednesday – @ReginaHolliday: #Thewalkinggallery meets @ ECollab Forum Wed 2-22 Venetian Sands, Bellini 2102, Level Main/Level 2 6-7:30 pm

Thursday – eCollaboration Forum http://www.himssconference.org/ecollaboration/default.aspx with a variety of speakers, among them: Brian Ahier and e-patient Dave

Thursday – Engaging Consumers in their Digital Healthcare http://www.himssconference.org/Future/default.ASPX with Regina Holliday as keynote speaker

Tweet the picture of yourself wearing the badge for bonus credibility, but all I need is the pictures URL as proof.

To play, all you have to do is complete the form below!

Have a good time!!

Running Motivation: shoe hacking failure

This is not intended to be a “running blog”, but it is intended to be a blog about how I am trying to hack my own running motivation.

I am a pretty big guy (almost 300 at times) and while I enjoy running, it is not because I am good at it. This is why I built my own running motivation software. I am not only the site designer (of course my family helps) but, I am also the demo account. So it is fairly easy to see how I am doing, from week to week.

Last time, I talked about how motivating it was for me to have cool shoes. Now, when I say running motivation, I only mean something that could motivate me to run more than one time. Watching an awesome video, for instance, might get me out the door once, but I need to have consistent motivation. Something that will get me out of the house every week, or at least contribute to getting me out of the house on a weekly basis.

So I was thinking of repairing my running shoes, and I decided to try sugru. The problem is that I should have let the sugru dry while it was on my foot. As it is, the sugru contracted and now I have these really uncomfortable plastic sticking into my toes.

I tried to repair my vibrams with sugru

Oh well. Better luck next time.

Now how has this impacted my motivation. Well Run Or Else is still working for me, I have made my distance each week since I have ruined my vibrams, but I am often walking rather than running.  Of course I am still nursing a calf injury, but mostly it is because I do not want to put on my old heavy running shoes.

So at least for me, having cool running shoes really does seem to impact my running motivation.

-FT

The e-patient reach

As many of my readers know, I am now regularly blogging on radar.

There, I have written a post called epatients: the hackers of the healthcare world.

It is pretty much a tour of how anyone who is already in the technorati, can become an e-patient. It heavily features the work that I have been doing with the Cautious Patient Foundation, which focuses very much on the information that every patient should know about how to prevent medical errors in the healthcare system.

But it also talks about the core of the e-patient ethos, getting access to data and leveraging it well. Being engaged and involved in your own healthcare. All of these are part of the Cautious Patient concept, and the e-patient concept. It has been very popular with the e-patient community.

Tomorrow, USA Today will be hosting the first version of the classic traveling medical blog summary Grand Rounds at healthypov.usatoday.com

The fact that USA Today is hosting Grand Rounds is awesome. I have just discovered that my e-patient blog post will be one of the ones covered in the first edition of Grand Rounds hosted at USA Today. I am truly honored and wish I had spent more time removing commas from the article, which are, the, bane, of, my, writing, style.

Seriously, it is an important shift when mainstream media starts to pay better attention to medbloggers, the best of whom produce content that is tremendously valuable for our healthcare system. Even below average writers have something to add, but then… you already know that… because you are reading this!

Enjoy,

-FT

Running Motivation: new shoes

Lately I have become interested in running motivation.  I am launching a running motivation app next week, and I thought I would give my readers a little taste of the process that brought me to design and build the new site.

Running is one of the best exercises. There are several that really compete for the throne of “best thing to do for your health” and IMHO it always comes down to a toss up between “control your diet” and “become a runner”. I love to eat. Never met a dessert I did not like. Never stumbled across a second helping that I was not a fan of. I have tried things to control my diet, but it just goes against my grain. In fact, I am going to make myself a PB&J right now…. O.K no bread… having frozen pizza leftovers instead. You get my meaning.

As I was saying. Diet control is just not what I feel like working on right now. I have worked on it in the past, I will work on it again, but for the last several months, running has been my obsession.

So I decided to think very carefully about how I could motivate myself to run. I started to examine, carefully, what stopped me from running each day. Eventually I realized that putting on my shoes was a pretty significant barrier. I am often wearing what would amount to “fitness clothes”, as a side effect of working from home. The only difference from my typical “work from home” outfit and my “I am running now” outfit was my shoes. Working = sandals, Running = running shoes.

So I decided to try Vibram Five Fingers, which is very popular with the Quantified Self community. The basis idea of the shoes is that they change your stride from heel-toe to toe-heel. And they did change how I run. But that was not actually the reason I got them. I got them so that I could feel really awesome and cool when putting on my running shoes. I was trying to daily hangup that was keeping me from running.

Interestingly the Vibram Five fingers have also helped with another project of mine, to become more mindful. I realized that normal shoes were isolating me from any experience of the ground. Normal shoes ensure that I experience grass, or mud, or dirt or concrete or asphalt in all the same way. All I “feel” is the bottom of my shoe, which is always the same, which means that I can effectively disconnect mentally from my environment, at least as far as experiencing the ground goes.

Using the Vibram Five Fingers, I feel just about everything, but I am somewhat protected from the damage that random pebbles and twigs might otherwise do to my feet.

Mindfulness is all about being in your own body rather than in your own head. Experiencing what is around you and being in the moment, rather than giving in to your internal thought monologue. It is extraordinarily difficult for me to be mindful, even a little, but the shoes actually help. They remind me that I am stepping on something, and that this is connected to where I am right now. Generally that pulls me in a mindful direction. I have started going without shoes all together to enhance this effect. It helps.

I wish that I could end this article with a resounding endorsement of Vibram’s product, and if I had “standard issue” feet, that is exactly what I would do. Unfortunately I do not have standard size feet. I have really long and narrow feet. Vibram’s design presumes that my toes should be much wider than they really are and as a result of this my big toe pulls outside of the protection of the rubber sole. This is much easier to show then describe:

You can see how my toe actually pulls to the right of the rubber that is intended to protect the toe.

Eventually, this happens..

As you can see, I have been running on the cloth rather than the rubber because my too thin toes pull out of the rubber protection. I said “rubber protection”… (ha).

So the Vibrams are awesome… unless you have thin feet. I am looking for a “barefoot running” shoe that does not have toe slots as a replacement. Still I like my Vibrams and I am glad I got them.

The real upside is that this running motivation hack, get shoes you think are cool, actually did work for me. My running went up substantially as a result! For most people, these shoes will work just fine!

-FT