Innovation changing the Telecom Industry

This is the last blog for the class. I think what I learned from Dr. White's class is that blog is not only an extension of thought and perspective but a reflection of self and expression of values. I think it is interesting to see if I will continue to blog but I feel it brings me back to journal writing and really sharing what I value the most and where it could better understanding and joy... Thanks Dr. White for getting me back to my roots..

Well, back to the blog....


Free texts to hurt carriers' bottom line?
http://news.cnet.com/8301-1035_3-20117904-94/imessage-to-hurt-carriers-bottom-line/?tag=mncol;cnetRiver

Just when the Telecom was embracing Apple's strategy and products, Apple release another feature that allows you to send messages to other devices that run on their famous iOS software. It is not like SMS where you will get charged by the telecom.

Like the Blackberry Messenger, "it sends the message over a wireless Internet data connection." Again, telecom makes a mound load of money in texting and this could be another game changer. Microsoft is trying to accomplish that as well and I wonder if an universal platform will ever be created...

At the end, telecom was expecting the technology to improve and change the way they do business (they are all unlimited fees now). I will not be surprise if text is bundled into the standard service fee of the phone down the road...

For me, it reminds of Netflix changes except consumers would like the cost saving. Netflix's decision to split their services to two entities makes sense of shedding the old for the online services but they did it at the expense of its consumers. This will benefit the consumers I believe in the long run and forces telecom to innovate their service or have people bypass their costs if possible.. They raked in billions for years and they need to innovate and invest back to improve their products or start losing those revenues.

Maintenance is keep

I tell my doctors that computer maintenance is key. Just like your car need routine maintenance and oil change, so does the computer. The same concept applies in health and the tooth. Having a check up is key to short and long term benefits. But why do people not utilize the same model structure in computers?

If your PC picks up a virus, whose fault is it?
http://www.zdnet.com/blog/bott/if-your-pc-picks-up-a-virus-whose-fault-is-it/4039?tag=mantle_skin;content

The article seems to hit a great point that updates are necessary in the computer world. Software and hardware was safe at one moment. Then it is a liability the next week. It is imperative that all software needs to be updated.

What most professionals and clients, they feel it is a waste of money. Why? Because nothing happens! That is why maintenance is working!!! That is irony of IT. It is there to make things run smooth. They are the first one in the budget to be cut thinking there is no need for it.... I give the best analogy to compare. If you do not have a tooth ache, would you stop brushing your teeth?

Some interesting points from the article:

"With the firewall enabled, the mean survival time of the Windows XP SP2 systems increased to 336 days. No system with this control enabled was compromised in less than 108 days.

The result? Users who were infected became victims because they were missing security updates, typically for third-party programs.

In the results of the 640 hosts that were used for this experiment, no system was compromised with a zero-day attack. Many new and novel attacks against known vulnerabilities did occur, but not a single compromise was due to an unreported vulnerability. Further, no attack without a patch was used to compromise any of the systems. This means that if the systems had been patched, none of the attacks would have succeeded.

(Basis of rootkits on rogue website to attack your computer)
On the basis of the total statistical data of this study it is documented that following products frequently are abused by malware in order to infect Windows machines: Java JRE, Adobe Reader / Acrobat, Adobe Flash and Microsoft Internet Explorer."

It shows value to our company and team in providing maintenance contract and services. No one value it until they are hit hard and then they see the value. I hope people really see that maintenance takes time and preparation. It might be simple but it is the most overlooked process in IT

Do you really want to run everything on DRAM?

I know everyone is talking about the death of Steve Jobs and I was aware of it while researching on my Green Envy paper on iPads yesterday. I would leave and say that innovation starts with an idea.. Jobs has done something many can't do... Make the idea into fruition and reality. It does take two things.. Passion and Persistence. He is known for both and may he rest in peace..

RAMCloud puts everything in DRAM
http://www.zdnet.com/blog/storage/ramcloud-puts-everything-in-dram/1546?tag=mantle_skin;content

The article in idea is to eliminate the Hard drive, solid state drive, etc. Everything will be running on memory..

Why?
"Imagine a world where data layout doesn’t matter, where apps are optimized for sub-millisecond storage, where 100 byte I/Os are faster and just as efficient as 8KB I/Os. The architectural implications are huge and would take a decade or more to get our heads around"

I eliminates the need for hard drive where performance speed is bottled at hard drive speed.. My example is having a supped up computer that has a lot of hard drive space, have a lot of data stored, and its RPM is low (5400rpm just say). You will see a lag because the read and seek time to find your needed data. It might not be significant now but consider if you have TBs of data.

The issue, the information is volatile. Just like what RAM is, it will lose everything if you have an interrupted power outage. Also, the article points out that DRAM is costly at this current stage.

The whole concept is that it eliminates another variable to the processing flow. It does not need to go to hard drive to read, write, or seek if all could be done on memory.

I do not see that happening in the future or my profession. Would someone by UPS, backup generator, etc. to ensure your information is safe? Some would but not all would (economically). Also, if the memory goes bad (electrical), it could impact your back up log (which is the way it protects the data). This is all hinging that memory rarely goes bad (in my experience, I dealt with many over time).

Great idea but might be bad in application. Maybe with more R&D, it might change again for actuality

New iPhone: Solid but a Disappointment

Takeaway from the iPhone event: Solid phones, end of an era
http://www.zdnet.com/blog/mobile-news/takeaway-from-the-iphone-event-solid-phones-end-of-an-era/4812?tag=content;feature-roto

I know the author's belief and don't change what is selling but that is what made Apple what it is today... It disappoints because of Applegate and that fact that my wife and I were going to upgrade our phone this year (I have iPhone 3GS and got it right before 4G and my wife does not have a smartphone).

With all the baggage of the 4G in the past year, I would think they would change the phone design and remove the reputation of the 4G phone. With the improvement of Siri (voice speech feature), it would be a buy. BUT Siri could also be provided in an update to all previous iPhones.

"Sure there is a faster processor and better camera to update the technical specs of the iPhone 4S, but iPhone owners have never cared about that. They want the iPhone to do what they want nicely, and no doubt the iPhone 4S will serve their needs, better than the earlier model."

That is the point the author makes that hits the argument. It is all about innovation and functionality. It is never about the spec with Apple products and it has to just work. The author forgets that.. Will the phone work? Yes but it is not a innovation that I would expect from Apple.

Looking online, you hear all about the iPhone 5. Be it design issue or production issue, quality control should have been a must for Apple. Ironically, I feel the CEO is following what he knows best. He is definitely not Steve Jobs and the conference was less than anticipated.
(confirmed: http://gawker.com/5846600/the-iphone-5-failboard-how-everyone-got-it-wrong)

Lastly, Apple could be doing this because of contract of telecoms. It would be hard to purchase an upgrade from 4G to 4GS when you renew last year. Added, the LTE 4G infrastructure is not there to handle the network (though that seems to be an excuse I do not buy since the features of iPhone 5 is all about potential holographic and infrared/laser display keyboard and rich features of the phone).

http://www.thetechlabs.com/tech-news/iphone-5-features/
http://www.youtube.com/watch?v=lzsBwnv_dAg iphone 5concept

Lastly iPhone 5 resembles the concept Mozilla seabird phone
http://www.youtube.com/watch?v=t2lj109xEZw

Your Social Media could Cost you (or Save you)?

Oracle Big Data Appliance: Scary-big cloud data is coming
http://www.zdnet.com/blog/btl/oracle-big-data-appliance-scary-big-cloud-data-is-coming/59543?tag=mantle_skin;content

The the ever changing IT environment, this article seems to show the biggest concern for social media. Whatever you leave out in the public (or by your own friends), you could pay more or be denied promotion (let alone employments).

As Oracle rolls another appliance, they changed the model to deal with unstructured database (compare to their strength, structured). It is in light of the social media and the vast knowledge and tool to obtain more information about people.

As the article points out;
"The big data software for this insurance company could set the standard rate for the customer and then provide a discount (or penalty) based on more thorough data analysis. The first analysis would be based on structured data (driving record, legal record, credit score, etc.). The second analysis could be based on an unstructured source of data such as the person’s social graph (Twitter stream, YouTube views, etc.). People that do a lot of parental stuff on their social graph would likely get a discount, while those whose social graph is full of thrill-seeking activity would likely get a penalty.

Your social graph having a financial impact on you personally may sound a little scary — and let’s be clear that this example is only conceptual at this point — but everyone should be aware that this is the kind of thing that companies are going to be able to do in the future. This shows how businesses will soon be able mine public data with products like the Oracle Big Data Appliance. You can already do much of this now by hacking something together with NoSQL and Hadoop, but Oracle is ready to commercialize it in a big way."

It is not funny that someone post a picture of you (or fake picture) of you and it cost you more that otherwise would not be known. Your public life becomes your private and perception of you in the public could change everything about you.

As a rule, if you are going to post it..... Well, make sure you ask two questions: Would you post it when it could impact your image to the public?
How does images online impact your reputation in your private life?

It is scary to see that companies are doing just that. Utilizing social media to obtain more information about you. This could deny your future employment because you believe in the theory of socialism or you are anti-corporatist (though you work for a corporation).

Who makes the most profit out of Android?

World's most profitable Android company? Microsoft!
http://www.zdnet.com/blog/open-source/worlds-most-profitable-android-company-microsoft/9651?tag=mantle_skin;content

This is a continuation of legal battle and lawsuit of patents.. Out of all people involve with Android, the biggest winner of profits is no other than Microsoft.

"Goldman Sachs estimates that Microsoft will pick up $444-million in revenue from its Android patent deals for fiscal year 2012. For those of you playing at home, that’s $3-$6 per Android device. Yes, that may well be more than Microsoft makes from its own troubled mobile operating systems."

So the irony is that Andriod that is "open" is not really open. With patent violation and legal matters, Microsoft seem to made out a bit on the Android. The better question is another legal lawsuit is pending.

When Cost and Innovation reaches a Crossroad

Digressing from normal blog, I wanted to reflect about how America could get out of this plague and see why we are in here in the first place.

HP: Is it a broken company?
http://www.zdnet.com/blog/btl/hp-is-it-a-broken-company/59293?tag=content;feature-roto

I know my blog goes away from the article to a point but it sees to reinforce the issue we are dealing with.

How does a company generate revenues and stay profitable in a dynamic environment?
To have a competitive advantage!
What competitive advantage could be focused on operations, products, and strategy.

HP has becoming the laughing stock because they have become the fool they made themselves to be especially going away from their roots.

HP was founded and focused on research and product development. HP was all about innovation and was the biggest reason for their success.

When the economy started to tank in 2000, companies got focused on business operational cost. This led to Dell and its outsourcing of their business to India. Then companies followed like HP. Seeing that it still did not resolve their budget, they cut research and development instead developing better products.

I remember how Mark Hurd was given so much accolades for his profitability. But it was clear that he was all about cut business costs (including R&D) and did not really improve on new product lines (see the past 5 years of HP product lines). Now, Mark is gone and all his directives are clear and visible in that it helped the short term but failed on the long term.

As the article points out:
"Add it up and I argued that HP’s problems will outlast Whitman’s tenure:

Whatever HP decides it wants to be when it grows up it needs to focus on research and development and carve its own path. The current model revolves around being someone else—IBM, Cisco, Apple, whoever’s next. The problem is that HP has starved R&D at 3 percent of revenue all through the Mark Hurd years. Now HP doesn’t have the financial heft to suddenly jump to 6 percent (IBM levels) or even higher. That’s why I’m arguing that Whitman can’t turn around HP. HP’s R&D problems will last longer than Whitman’s tenure if history is any guide."

So HP can't be Cisco or IBM. They do not have the manpower to research and innovate new products. They can't develop their own competitive advantage. Cost is as low as HP could focus on strategy (but that is already an issue at hand).

This is the same issue with corporations today. R&D development is in what companies do internally. Instead, it is all about acquisitions and mergers. So there is a lack of fluidity and continuity and makes innovation harder to achieve efficiently. To constantly make profits short term could hamper the long term goals and revenues.

Why I am so adamant? It is the same thing of placing American workers as commodities and expecting profits short-term. Selling goods at a premium while not fairly compensating Americans workers for their hard work. Who do you think is going to buy your goods? All I hear is that American workers are lazy but the reality is far from the truth. Do Americans have to lower their cost of living? Maybe but the extent seems a bit unfair and naive on both fences. Companies tell us to re-invest ourselves at our own cost but won't pay necessarily premium wages. Our education is by far more than the wage but that is easily justified one way (workers) but not with corporations (R&D and self-innovate)...

HP is reflective of corporations' mentality of trying to get most for little. At one point, investment has to be made and requires commitment for success. Do I think companies need to be lean? Of course but being lean and starving are two different things. It is important to understand that even well-trained athletes just can't be lean but be strong to perform. Why does corporations fail to acknowledge that?

Wait and See with Windows 8

I know there are many people who is wowing about Windows 8 but one thing caught my eye (like the author). Really? The spec requirement won't change?

Another Windows Version. Another Hardware Upgrade.
http://www.zdnet.com/blog/virtualization/another-windows-version-another-hardware-upgrade/3849?tag=mantle_skin;content

The article details how they state one thing and with every upgrade, there is a big change which require a significant upgrade..

You have to ask with Windows integrate to work in mobile or desktop, I would think it had to have same or lower requirements. But to work with multiple driver platform (from Intel to ARM), you the computation and coding has to increase.

What would it be? History seems to favor the author..

Apps are becoming a mainstay in Health

4 Best Types of Apps for Hospital Use
http://healthcareitnews.com/news/4-best-types-apps-hospital-use

At the end, apps are important for several things.. To make the life of health professionals simple, mobile, reliable, and productive..

As the article points out:
1. Those that free providers from offices or workstations.
2. Those that offer access to lab results and medical imaging.
3. Those that convert a smartphone into a medical device.
4. Those that offer practice management.

At the end, the apps help to make smartphone or tablet into a productive unit. One to keep them as wireless as they can, read results conveniently, read and obtain measurements, and do work related to the duty at hand like prescription.

Though it seems great but I take it with a fine comb.. The person who is utilizing it with be the biggest question..

Telehealth likely to increase

Growth in global telehealth forecast at more than $1B
http://healthcareitnews.com/news/growth-global-telehealth-forecast-more-1b


Looking at our current assignment, I wonder if outsourcing is the only means of hospitals being competitive. I thought about mobile units (since I dealt with some of them) but it might not easy for clients. With various industries working, the monitoring of patients could be done at their convenience and home.

The article believes the growth is substantial (1 billion by 2016) and minimize healthcare cost and expenses.

I think it is promising but it does not guarantee reduction. It might be better patient care and alerts but not guarantee healthcare improvement. I believe it could be but it all depends upon implementation. Lastly, it will apply well in rural area and how patient monitoring is being done is a bigger question.

I see healthcare industry converging... It has in dentistry and more in the health field..

Feel like this is a concern to address: Infringement

Have you noticed how many IT companies are suing and counter-suing back... I understand you are protecting intellectual property but when does it become known as universal or common knowledge? I guess that is why I had legality. You could make anything into a lawsuit if you really want to think about.. With the IT sector, it is no different.

After much lawsuit from Apple to Samsung and HTC, Oracle to Google, Google to Apple, and Real to Microsoft, this one caught my eye... Via suing Apple

Via patent suit may give Apple the most trouble
http://www.zdnet.com/blog/mobile-news/via-patent-suit-may-give-apple-the-most-trouble/4654?tag=mantle_skin;content

I found the lawsuit title to be an oddball. Via is a chipmaker (personally, I do not like their product) and Apple is manufacturer of their iProducts. The article points out one important relations to the lawsuit:

"Two, Apple makes its own chips used in the products the suit claims infringes on Via’s patents. The three patents Via claims are being infringed by Apple:

* US Patent No. 6253312, Method and apparatus for double operand load
* US Patent Nos. 6253311 & 6754810, Instruction set for bi-directional conversion and transfer of integer and floating point data

Notice those are microprocessor related? Via claims Apple infringes on these patents with nearly its entire mobile product line: iPhone, iPad, iPod, and Apple TV. What do these have in common? Apple makes its own processor for them."

I understand that it is a how the chip processes these certain tasks. But how could you really prove that process is a patent infringement? It is a process and how it processes it could seem the same but might not. Maybe I am wrong but technicality is important but to what extent?

What I am worried is that there will be copyright lawsuit on everything. It is happening in the biosector with human genome. What makes you think one code or one word could be copyright violation. Yes, I am know "you're fired" is a trademark now but saying publicly that you're fired (by mistake on television) could render a lawsuit?

Lastly, these development can't be just abstract and needs to really define how hardware and firmware works to achieve that process. If that is define, Via might have more than a lawsuit (especially if Apple products hinge on that process).

HP do not know what they want..

After reading the ousting of Leo Apotheker, I was checking back on why it does not work. With my numerous issues with HP (I had my PC shipped out for warranty a record 3 times in the past 3 months and it does not include 4 misdirections and numerous complaints to BBB), I wonder why the company has so much problem. So there is what upper management seem to have a poblem.

HP Is Having An Identity Crisis
http://news.cnet.com/8301-13924_3-20109667-64/hp-is-having-an-identity-crisis/?tag=content;siu-container

Not only did HP forget its root, it tried to change everything at once. It is like telling the whole company that we are not hardware but software. Thinking that the change is seamless and easily changeable. That is a significant issue.

As the article points out:
"You can't ignore legacy. [That's] what your value is," said Bob O'Donnell, an analyst at IDC. "They have a huge amount of value in the PC space. There's no way around it, it's just a huge, huge business."

The way HP made a dent and took market share was through hardware (especially their printers) and customer service. To me, they are horrific and numerous hardware issues are common in many blogs and postings. They seem to forget how they got big in the first place. They could say that the hardware business is not profitable but that seems to be naive when you consider it has a significant percentage of your revenues. I would have phase it out little by little.

Again,the article makes one key point:
"You just can't cherry-pick a sector that you want to be in and expect explosive growth. The genesis of the company was PCs and instrumentation. They don't have to be IBM [which sold off its PC business in 2005]. They can be different and still be very profitable."

That is the point I keep addressing time and time again to many companies.

Dual Boot the Thing of the Past with Windows 8?

I was reading more while I was downloading Windows 8 SDK when I came across an article that seems to change my eyes..

Will Windows 8 block users from dual-booting Linux? Microsoft won't say
http://www.zdnet.com/blog/microsoft/will-windows-8-block-users-from-dual-booting-linux-microsoft-wont-say/10772?tag=content;feature-roto

What has been common in the past was Windows will allow dual boot and I could run two Windows (like 2000 and XP) or Linux and Windows (which I have done). What is being noted in the article is the new secure boot process. But Red Hat developer mentions:

"Garrett’s interpretation of Microsoft’s shared information on the topic:

“Microsoft requires that machines conforming to the Windows 8 logo program and running a client version of Windows 8 ship with secure boot enabled. The two alternatives here are for Windows to be signed with a Microsoft key and for the public part of that key to be included with all systems, or alternatively for each OEM to include their own key and sign the pre-installed versions of Windows. The second approach would make it impossible to run boxed copies of Windows on Windows logo hardware, and also impossible to install new versions of Windows unless your OEM provided a new signed copy. The former seems more likely.

“A system that ships with only OEM and Microsoft keys will not boot a generic copy of Linux.”"

Is the industry going to fight the openness and go back to partnership and people having to take sides? Could this lead to competition war like VHS and BetaMax in the computer OS war and tablet war? That is the question I want to address since the dental industry has gone through that as we speak (and currently is)...

At the end, you have make your decisions wisely on what could be an EOL compare to the winner in the industry... As for me, I want to see how Windows 8 work and how could it work for me and see if I really want to jump to 8 down the road

Tablets.. Why it is not accepted except iPad

As I was going back and seeing how HP left the market and many more are flopping. I wonder why Apple is succeeding and not its competitors. Though the article is last month, I wanted to reaffirm what I thought was the answer...

Why Consumers Won't Buy tablets (unless they're iPads)
http://www.zdnet.com/blog/mobile-news/why-consumers-wont-buy-tablets-unless-theyre-ipads/3782?tag=nl.e539

The articles points out why Apple has been successful:
1) Devices are targeted to "regular folks"

"The only way for any tablet maker to hit big sales is to break through the mainstream consumer market."

2) Great Marketing
As the article points out, HP and various vendors have unclear marketing message and do not spend much marketing on their devices. Compare to Apple, it forefront and in front of you

3) Have their stores to control and hit their message from marketing to the store...

At the end, it is all about exposure and knowing what you are selling

How much do you love your computer?

As I thought about how IT has changed, I reflect and think how many doctors tell me that computers are a necessary evil.. Are computers that hated? So while searching for an article, I happen to come across how Americans feel about their computers.

We like our PCs - but love our Macs
http://money.cnn.com/2011/09/20/technology/pc_satisfaction/index.htm

The article points out:

"An American Customer Satisfaction Index report released Tuesday shows that consumers are the happiest that they've ever been with their computers. The 16-year old survey found that PCs scored a rating of 78 out of 100, matching the record score set last year."

What is surprising is that Apple satisfaction is higher than PCs
"But Apple's (AAPL, Fortune 500) satisfaction rating climber higher this year, blowing past its rivals with a score of 87, up from 86 in 2010. This year marks the eighth straight year in which Apple led the PC categories."

At the end, PC has an effect on this society and my profession is here to stay.
I guess I need to brush up more on OS X and hoping more Apple application software in the industry

Apps is another growing sector

As tablets become the norm, apps are in demands to run programs on those tablets. Companies are wooing to get app companies and makers..

Cell companies woo app makers with offices, lattes
http://www.cnn.com/2011/09/19/tech/mobile/verizon-att-innovation/index.html

Cell companies are trying to change their images of being receptive and cooperative to app companies. They are looking to increase their internal talent to make apps. At the end, people with the skill set and talent will inside an evolving and high-demand profession.

As for me, I need to get some skill set updated especially coding.
Lastly, it is a good positive sign for an industry that seems to be hurt in the US (with outsourcing)

Platform to run Windows 8?

Windows 8 opens door to new chipmakers

http://money.cnn.com/2011/09/16/technology/windows_8_chipmakers/index.htm


With the introduction of Windows 8, one event changed. It is no longer a Wintel focus but rather others.. ARM chipset has been well known for performance and battery and knocks Intel in many way shape and form. To see that it is open to them was a big change.

Though it is very welcomes and embraced, it is going to be an issue for me and the health care industry.

One obvious point is the software compatibility. "It's certainly going to be an uphill battle for the ARM group, since most legacy Windows applications won't be supported on that architecture."

If you can't run software, it is not going to work for the healthcare industry

Another point is most equipments for healthcare are manufacturer specific and tested. To change architecture changes more than just the vendor. So the transition is not a good thing nor accepted.

What is important that competition is good thing but you have to ensure what you are betting (and investing on) is going to work!

iPads applied into Medical Curriculum in Weill Cornell Medical College

iPad 2 a boon to Weill Cornell Medical College students
http://healthcareitnews.com/news/ipad-2-boon-weill-cornell-medical-college-students


As tablet infiltrate into the personal and business world, it is leaving a mark into
the educational and EMR software. First and second year medical students were given tablets and incorporated into their training, education, and grades. It has become the medium in obtaining notes.

I remember the day when it was the PDAs and then laptops. Tablets are the "new" medium to apply information exchange and education. I believe more institutions will embrace the tablets and incorporated as the mean or complements to other devices (like laptops and cell phones).

As for me, it does not change the perspective of how tablet could be used in the Healthcare sector. If EMR could be applied, I hope more directives are placed for eDR software

Change of Subject.. PC is Extinct?

I was reading CNN yesterday and today and I ponder what would the world be like without PC... I doubt it will happen but the better question dawned on me.. Well, the article hits the same point... What will Microsoft do with the changing dynamics of tablet and Apple?

Can Windows 8 save the PC from extinction?
http://money.cnn.com/2011/09/14/technology/windows_8_pc/index.htm?hpt=hp_t2

Microsoft is approaching their new OS to fit well with tablet and enhance the user experience. As the article states "With Windows 8, Microsoft is in a sense betting the house on form factor. The company believes that when people buy an iPad, what they really want is a PC on the go that's just not available to them yet.".

In some sense, I have to concur that tablet is in because it is the closest thing to a PC on the go. The only argument to Microsoft's bet is that netbook would be the closest thing but sales are plummeting.

The reason to netbook is the operating system is like "bloatware" on the computer. The operating system is wrong for netbook and why Windows 8 seems to work from tablet and then up....

For me, it is learning another OS for support and implementation. At the end, tablet is here for good.

Cable TV involve in Healthcare IT?

Time Warner Cable tests suite of telehealth offerings in Maine

http://healthcareitnews.com/news/time-warner-cable-tests-suite-telehealth-offerings-maine


Time Warner is launching a trial run of delivering healthcare services to the patients! What this details:
1) Reduce time to drive (since some of the area is rural and sparse to get to a doctor)
2) Live conference and quicker face to face interaction with doctor and patient
3) Up to date information of patient for diagnosis and education

As the article states:
"One of my patients is over 90 years old and she can’t leave the house," said Patch. With the Health Solutions technology, he can "conduct a private appointment with her over the computer and discuss her care with her family without forcing her to get into a car and drive an hour for an office visit. From a patient’s perspective it’s an added convenience that could potentially decrease their healthcare cost".

What does that mean for me? Everything is converging like telephony was back then.. And the industry is only getting bigger.. Finding solution to meet the clients' needs are greater enhanced

Watson.. From Jeopardy to Healthcare

Wellpoint to help IBM bring Watson technology to market
http://healthcareitnews.com/news/wellpoint-help-ibm-bring-watson-technology-market


I remember how well Watson competed with the Jeopardy champions and wonder how it will be used commercially. Well, it seems like the answer seems to be in Healthcare.

With Watson's "human" approach in answering question and its fast computation and power, the synergy of both could help answer millions of patients with that human touch.

As the article points out, Watson could help doctor in diagnosis of patients. The diagnosis could take longer with human computation but Watson could do it faster and promptly. ""There are breathtaking advances in medical science and clinical knowledge, however this clinical information is not always used in the care of patients. Imagine having the ability to take in all the information around a patient's medical care – symptoms, findings, patient interviews and diagnostic studies. Then, imagine using Watson analytic capabilities to consider all of the prior cases, the state-of-the-art clinical knowledge in the medical literature and clinical best practices to help a physician advance a diagnosis and guide a course of treatment," said Sam Nussbaum.

At the end is that Watson might be able to handle simple calculation but would it be able to handle harder diagnosis. That is what I am worried (wrong diagnosis, etc). For me, healthcare IT has progressed to another level of computation power. Like the calculator was in its heyday.

Social Media is popularity.. why?

Besides the obvious, social media seems to have many ways inside healthcare institutions. Is that good thing or not?

Strong popularity' of social media seen at U.S. providers
http://healthcareitnews.com/news/strong-popularity-social-media-seen-us-providers

Though many people are utilizing social media, "one-third use it as a part of their professional obligations."

As the article points out, "one-third of institutions do not allow access to social media for employees, typically due to security issues and concerns about employees’ productivity. The majority of institutions that allow access to social media employ some policies to control that access."

I always state that without a clear and define security policy, social media utilization would be high. Now, I am not saying that social media is bad but rather institutions should set parameters so that it is beneficial for all stakeholders (including the institution; the article points out about marketing and name recognition through social media).

At the end, social media is a double edge sword. It could help as well as hurt a company depending upon how it is used. At the end, I have to keep a policy definition of how social media would be used.

Physicians Could be Graded!!!

One new update from one vendor caught my eye.

How would it be nice to see your doctor's grade?


http://healthcareitnews.com/news/vendor-notebook-athenahealth-launches-real-time-physician-performance-dashboard

"Athenahealth has launched a new online dashboard to provide clear visibility into the performance of physicians on the athenahealth network against meaningful use criteria.The regularly-updated dashboard offers insight into how the thousands of providers currently participating in athenahealth’s reimbursement program are progressing toward meeting Medicare meaningful use measures. Through its cloud-based EHR, with providers sharing a single instance of software, athenahealth has a real-time view into how its providers are performing, enabling the company to identify client pain points and focus its array of client services on addressing these challenges for all clients on the network."


The only issue is how the performance is measured. As long as the definition of measurement are clear and concise, it will help us hold physicians "accountable" in taking care of their patients (proper diagnosis, time waiting, repeat visits, etc.)

Preparation is Key!

I enjoy this article and how the world needs to expect when they are getting set to deploy a project.

The 7 Deadly Sins of EMR Implementation
http://www.healthcareitnews.com/news/7-deadly-sins-emr-implementation

As the article points, signing the dotted line and going forward with eMR (or eDR) is not the final step but just the beginning. Understanding the process will help achieve a smoother transition and deployment.

Key Points the articles makes of being a deadly sin:
1) Not doing your homework:

As the article points out:
"Avoiding supplier problems means background research and thorough evaluations of vendors and products. And beware: vendors tend to make promises they can't keep."

I hate overpromises but no delivery. So you should check with your association of professionals on "reputation" and success.. It is always know the strength and weakness of the software

2) Assuming the EMR is a magic bullet
I always state that it is not the end all of everything. As the article points out, it is change of doing business. Not necessarily an improvement.

The best quote I got:
"Most people think an EMR solves problems," he said. "But an EMR will only amplify problems that already exist in the practice."

3) Not including nurses in the planning stages
Stakeholders!!!!

4) Not participating in training
Big one that they read the manual and just do it

5) Thinking you can implement the same processes as paper
I get this the most that why can't we do it in paper? I state that you could but do not expect it to be efficient nor optimal (especially if one employee who is critical on the process get sick)

6) Not asking for extra help
Doctors are smart but they got a mentality that they know everything. They are doctor in their field but not necessarily in computers. They have "pride" to not ask... It is important to know your limitation and ask. The problem could be a quick fix instead of a longer, time consuming solution that could save you more money

7) Being short sighted
As the article points out, "(according to Waldren,) it's important to find an EMR that supports not just the current healthcare industry, but what the industry will soon become."

I have seen doctors go with the cheaper solution only to purchase another solution and pay twice for the same thing (let alone time lost and utilized)

At the end, you need to know what you are buying.. You get what you buy...
As for me, I focus on these pitfalls for the doctors and most of our solutions have been successful.. Not only knowing the strength but the limitations.

Apple iPad Becoming more Universal

As Apple iPad become more mainstream, the application of utilizing it seems to be the norm..

Patient Check-in Moves to iPad
http://www.healthcareitnews.com/news/patient-check-moves-ipad

As the article writes, iPad is becoming the primary device for sign-in machine in hospital.

"Just three weeks after its iPad-native EHR made news for gaining ONC-ATCB-certification, drchrono has launched an iOS app to replace paper-based patient check-in."

As the article states, it is to optimize the sign in by letting the patient "do it themselves" and update their profile according like their photo profile and changes to their medical history.

Instead of it being on paper to write, they would take the information in. Again, the article states it best:

"That saves "time and money" says Nusimow. "Putting in insurance info and all that minutiae takes a lot of time." With medication and allergies pre-entered, "the next time [patients] go to the doctor, they can just engage with the doctor."

As for me, it is important to see how any device could apply into any client or business. Then it was the handheld device. Now, it is the iPad. Lastly, it is important to understand the capability. I do not think the iPad could do tremendous amount of calculation but it could be utilize for certain aspect of the practice.

Open Source for Patient Records

This is the great question of eDR and eMR... Will it ever be open source? At least it seems like it is going that way to a point.

VA CIO: 'When we get it done, it will be open source'

http://www.healthcareitnews.com/news/va-cio-when-we-get-it-done-it-will-be-open-source

VA Offices state that they will be open source after their implementations.

"VA is developing an open source track to modernize its VistA electronic health record and will incorporate the approach with DOD in the joint system. DOD has become more excited by open source and “sees it as a strong contributor as we move ahead,” said Roger Baker, VA CIO.

How did they reach the objectives? By making the vendors comply with the institutions.

"VA and DOD are also requesting that vendors with proprietary standards move them into the public domain or assure that they are publicly available if they want to be used so that both departments can rely on them to communicate and exchange information."

That is a big step but the question is to what extent with vendors do that? Will the private sector head that direction? I believe once a mandate has been established, records will head to that direction.

One thing of concern is that my selection of technology to apply into offices have to be thought out. My analogy is getting BetaMax instead of VHS.. Token compare to Ethernet. Trying to ensure that the technology gets it ROI and minimize re-investment of technology into my clients and my company.

Is Centralized Patient Record the Solution?

As I go back to the importance of Patient Records, the question were addressing the critical question as shown in the title...

We see the benefits but there comes a lot of concerns:

One Medical Journal speaks of the matter and centralized or non-centralized (or they call demand aggregation).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068075/?tool=pubmed

Some of the concerns and issues are:
1) Security in terms of access, modification, and lost

"For many years, the authorities have understood the risk of losing all of the data of a centralized system if the system is destroyed."

Meaning that if he destroy the brain, the body will be lost. Their analogy of comparing the ARPANET and the defense mechanism was to have a "independent but heads" network. So if one head is out, they still have other heads to execute objectives. In laments term, there is no one central spot if destroyed would place the system below life support. Also, the question is authority (Security, privileges) and who has access becomes a great issue since the user level is on a national level.

Another note is what about changes to the data... Concurrency issues are increased since there are more users who could access, modify, and write.

2) Lack of flexibility and maintenance
Since most organization has the standardization of terminology, does the coding have to be "standardization"? That is the question... Some would argue it would make everything easier but when there are many various organization, groups, and associations that dictate the standardization for their industries. When there is a conflict, who dictate the standardization? Since a platform has to be universal, cost of upgrade, maintenance, and performance could be extremely high. This is why I believe universal interface will be emphasized (and pay as a service like cloud computing services)

3) The infrastructure investment is higher. The argument (the journal) is that dedicated service is not better than on-demand.

"Finally, to maintain the completeness of the EMR, every single actor has to be connected to the centralized system to notify it of every single operation he makes. Regarding the case of drug prescriptions, for example, the regulation of traffic load and security could be very difficult to manage."

The workload to change instantly, would require a bigger investment in capital, human capital for performance and maintenance, and protection and monitoring

The other listed are in addition to the article that came up when thinking and analyzing

4) Operational and Procedure issue. Will the data generate locally and poll into the database? Instantly? You see the issue on how the national EMR database is utilized with produce another set of question (as well as contingency plan issue when a disaster occurs). Added the issue of HIPAA and how the data is made, sent, or changed is questionable.

5) Unwarranted access and cost to the patient (like insurance). With a complete patient record, insurance and other parties could charge a higher premium because they could base it on your whole record. (See it like credit report could generate a higher premium even if the information is right or wrong. Another example, higher premium because you are in higher incidents though no fault of your own.) There are a lot of ethical question in have a patient profile and potential denial of service (higher concern and liability though treatment might be crucial).

These are some concerns and the importance is how important that data is, who has access, how they utilize the data, and checks and balance. If those could be addressed, some of the issues could clear itself out. But they are not defined nor explained and this "quasi" standard will not resolve the issue at hand.

Let's talk about Adaptive Diaster Recovery

Coming into Thursday, I had a full load of appointments to run some updates and upgrades. Then the dreaded emergency call.. The 7:48am call and voicemail that abruptly woke my wife and I up.... Checking out, the call was from one of my clients in Albany (2.3-3.5 hour drive).

Add Murphy's Law with my Internet being down, it seems like today is not going to be a good day.. Luckily, the disaster was not as much of a disaster after executing an actual disaster recovery plan..

Though the disaster recovery took 3 hours (most of my recovery go from 15 mins to 5 hours depending upon the type of back up solution, type of disaster, and amount of data that needs to be restored), we had a partial recovery... Well, it was more like 99.999% because the software corrupted one data file and the last time stamp on CDP backup was on 11:00am (so we lost all the data changes on that file from 11:00am to 4:00pm).. Talk about griefs of all the data entry changes that was lost for that file (it is one of the most heavily used files). Secondly, why was there no other updates or changes?

So we went back to our DRP plan (though this was not a drill, they have experienced and tested it out)... And here we get to the article and additional notes to consider the disaster plan:

Do You have a Disaster Recovery Plan (DRP)?
http://netsecurity.about.com/od/disasterrecovery/a/Do-You-Have-A-Disaster-Recovery-Plan-DRP.htm

Like my previous post, the article hits the same detail with a little more in depth of defining the critical files, how to backup, your plans, downtime, etc. For some, it might be enough. But even with a decent thought out plan, there some things you can't control..

What was the problem was the application software actually generated a corrupted the file but was still accessible and "functional". But due to the corruption, it was not write-able on the backup at 6pm (though I am trying to figure how it was read, access, and modified).

Like GIGO (garbage in, garbage out), the corrupt could be updated into your data set and you have a problem (depending upon type of backup). Also, since the application did not warn of any problem, the error on the file could potential crash the software at any time....

As the article points:
"Whichever method you choose, make sure you set a schedule to backup all your files at least once weekly, with incremental backups each night if possible. Additionally, you should periodically make a copy of your backup and store it off-site in a fire safe, safe deposit box, or somewhere other than where your computers reside. Off-site backups are important because your backup is useless if it's burned up in the same fire that just torched your computer."

Even with the setup, we would have to go back to the last "complete" backup (which would have been the day prior). But all the entry on the other aspect of the software is lost... So you see the issue at hand... What would you do?

The amazing thing that is forgotten in all disaster plan is Know your tools at hand.. The software has an amazing audit trail of all entries (update/delete) and since that file did not get damaged.. You could "duplicate the error". Could we go back 1 day prior? Yes, with just one file, it was not worth going back 1 whole day. It was best to back half-day and "rebuild and data enter" the data set to the current.

As the article states:

• Support phone numbers (for ISP, PC manufacturer, network administrators, tech support)"

Additionally, there was a contingency plan to consider how the office will function without data. Luckily, they are keeping some form of hard copy and they have electronic journal in the software. Both would have worked and they were able to back track the information.

Lastly, they had accounting tools at hand from the day prior, and the audit trail verified the numbers and was no issue. The software support added the last tools to ensure the data is not corrupted in other aspect and the team confirmed the entries were correct. Though a lot of mental and time-consuming validation. They were up in 3 hours!!!!! Added this involved multiple stakeholders.

What impressed me was that the CDP provided all increments and differential on the file (except the time of corruption). They do not back up every second but they update 1-2 hours or no activity.

Though I was not back for my whole day appointment til 9:00am (yes, I had a 24 hours work day schedule), I am glad that the office had a disaster, respond to the disaster, and execute their plan flawlessly... Lastly, any out of control matter... We just managed it and develop a solution with some thought and executed it... That is adaptive and creative thinking..

Disaster Recovery Solution? CDP

Continuing with the last blog, disaster could hit us at any time. The question that seems to arise:

What are some solution to protecting your asset?

One of the growing trend is: Continuous Data Protection

How to Use Continuous Data Protection to Improve Backup, Disaster Recovery

http://www.eweek.com/c/a/Data-Storage/How-to-Use-Continuous-Data-Protection-to-Improve-Backup-Disaster-Recovery/

As Wikipedia defines:
Continuous data protection (CDP), also called continuous backup or real-time backup, refers to backup of computer data by automatically saving a copy of every change made to that data, essentially capturing every version of the data that the user saves. ...

In laments term, it is a CDP software or appliance that detects a change in the data, run and "capture" the data, and back up the data.

What is impressive is that CDP is chronologically "documenting" all the changes in your data. It is better than an image snapshot because it is able to continuously take snapshot of each individual data. You could edit your disaster recovery with some data at one point in time and another data set on another date.

It allows the optimal solution in backing your data and recovering your data. As the article points out:

"When used properly, CDP technology can unify local and remote data protection processes, combining replication and backup into a comprehensive solution that minimizes data loss, speeds recovery, and reduces or eliminates the need for tape-based data protection"

One the amazing application of CDP is that, it could do what they call a "bare metal recovery", you could run the CDP and create a recovery disk for a computer. Have the CDP running to save backing up the whole computer. If a computer hard drive fails, you could run the recovery disk to get it back and the use the CDP to bring the unit up to date with its data.

Some units have the capability to transfer the hard drive information from one unit to another by removing drivers with adding generic drivers onto the new unit. It is not always simple but the capability to image your hard drive to a completely different unit is amazing.

Are you Ready? For a Disaster?

I am sidetracking from the normal blog of Cloud Computing and Centralized Data Storage in Health IT to go back to a basic fundamental. After the news of Hurricane Irene coming into the NYC area, many people were panicking and various government officials urged people to follow a disaster plan. Why? To ensure safety for many residents, communication and update, and prompt performance in case there was a major disaster. Though nothing but minor issues occurred in NYC, I ask the same question to many clients and peers about understanding disaster. Natural or artificial (by lack of proper policy as an example), how ready are you if a disaster happens to occur?

Many peers and companies have to realize and determine the value and cost to lost and/delayed data needed for "normal" operation. I know we do not have bottomless money resources to make a "complete" disaster recovery (DR) but time, effort, and money are needed in case something bad happens.

Computer World: Ready for Trouble
http://www.computerworld.com/s/article/101249/Ready_for_Trouble_

Though the article is old, I chuckle on how the article is still relevant today as it did in the past.

The article takes about a scenario and how do you manage disaster in your own home, your client, your employer, etc. As the article points out, there general guidelines to making an effective and successful disaster recovery:

1) Planning for the Unplanned: You have to know your scenarios of disasters and how to properly communicate and document your plan. How could you plan something that is not in writing, easily accessible for many, and known with compliance by the employees? Also, I am not looking for all doomsday scenarios (scope creep and this plan will never be complete and costly) but start with the most common known issues that would impact the stakeholders.

As Glenmede (a company) states: "If the building's power goes out, the critical systems can be brought up within four hours at a "hot site" across town owned by business continuity services and outsourcing provider SunGard Availability Services Inc., a unit of SunGard Data Systems Inc." Meaning, they define how critical certain business processes and understood the cost and value if their own infrastructure went down. Also, they utilize a plan that deemed appropriate so that their business operation could function while they work on restoration on the primary site.

2) State of the Art Technology: Though it could be costly depending upon your current infrastructure, the important part is knowing the existing technologies out there. being familiar with the technology, and implementing that is best for you. your company, etc.

3) Testing Times: This is a no-brainer. Run a disaster recovery to obtain actual real data as well as verify your disaster recovery's success! Why do we believe professors with real world experience? Because they actually do what they preach! Just like that a disaster recovery plan is only as real as actually testing (to expose shortfalls as well as strength). The whole point of testing to ensure you have the right resources, planning/documentations, and know-how for a successful disaster recovery. So when it does happen, we do not encounter an actual disaster without any recovery!!!!

With the old article presented, I come back to the present with cloud computing and how it could be a cost-effective means to disaster recovery. Why? The information is safe in an off-site location and most cloud centers are data centers that have high standard of fault tolerance and redundancy in security, data protection, and service. Again, that is the assumptions

http://www.drj.com/2011-articles/online-exclusive/the-cloud-is-a-cost-effective-option-for-disaster-recovery.html

Cloud Computing could be a good solution to certain users BUT it all depends!! It depends upon you and understanding the strength and weakness of the technology (back to #2)

How does this apply to me and you? We need to really understand what is important to the business. I have seen offices have safe for certain equipment but how much important is your data that keeps your business running? What I address a lot of time with doctors are:
1) How are you backing up your data? That could be easily answered (though the answer might not be correct at times)
2) Do you actually test the data backed up? That could be answered but rather vague
3) How long does it take to bring your data back (DR)? They do not know and didn't really think about...

It is important to understand that backing up your data is good but verifying and replicating your backed up data in a timely manner is CRITICAL!!!!! I hear doctors complain how the back up takes so long. I told them, do you care more about how long the back up takes or how fast you get your data back? The answer is obvious.... But doctors pay significant amount of money backing up with an off-site, Internet-based solution (in Kansas just say) and never tested to see how long it takes for the data to come back from there to here (consider they have image files).. They do not have fiber line channels for high throughput (just high speed Internet) and the data do not dedicate all the bandwidth to them... What we found out was 20GB of Data took anywhere from 8-16hours to just download the data they backed up. What happens if Internet is down? You see the picture about how TIME IS THE ESSENCE of recovery... You have to consider the cost on how it cost You to be DOWN...



Now, with Irene gone.... Are you ready?

Need for Nationalized Medical Records

With my last blog and post on Cloud Technology, I thought about the implications in our health records. Could this provide a means to a standardized or "nationalized" health records in the United States?

I know many people have different views on nationalized systems. I happen to be one that does support it due to the facts and data in Europe, South Korea, and various countries in mandating it. I know some will beg to differ, especially those who worry about "Big Brother".

Again, Peter Parker's quote comes back again. Before we talk about why it is bad. We have to understand why Nationalized Medical Records could be good, we need to see its strength. I hope on my next blog, we talk about what is bad about it.

My previous blog, "History of eXRs", hints toward a nationalized patient records. I will be honest that it does but the scope of nationalization varies (by the adopted vendors and health institutions/self-governing, state mandate, and/or national mandate).

Again, why centralized medical records (not nationalistic speaking)?

The Need for Centralized Medical Records
http://www.pinnaclecare.com/about_pinnaclecare/resource_center/white_papers/the_need_for_centralized_medical_records

Note: This is an open-ed and marketing for this group. But it does hit some main points. I will add another article on the same matter of centralized storage.

It starts out with how are patient records are currently documented and saved:

"If you're like most people, you receive your healthcare from more than one doctor—a family medicine specialist, an OB/GYN if you’re a woman, perhaps a dermatologist, an orthopedist, or a cardiologist. That means the records each physician gathers on your health and treatment are scattered across offices all over town, perhaps even all over the region. Of course, you do your best to inform each doctor of all of your conditions, tests, and treatments, but it's hard to remember everything during an appointment and sometimes you may not know what information is germane"

Remember, the biggest concern and growing aspect of most doctors' and dentists' practices are the LIABILITY of taking on patients (when their focus should be in treating the patient).

Without a full picture of the patient, they:
1) can improperly diagnose or duplicate multiple of tests for the patient
2) mistreat and not optimally treat a patient (second paragraph states my concern: "potentially life threatening")
3) collaboratively work with other doctors to provide the best treatment since issue of the patient could hit a different part of health care (Dentistry, it happens a lot like head trauma due to injury that affects jaw, teeth, and neck/backbone)

What comes down to it is:
1) Improved Health Care and Service as well as reducing waste or repetitive diagnosis (cost of healthcare is reduced)
2) Better and Clearer picture of the patient health
3) Easier Transfer and Means of Patient Records Access (This is a big point that I see first hand when a patient relocate, does not like the doctor)

As the article address, Markle Foundation (private foundation) did a study. "The study found over 70% of those questioned believe these records would improve the quality of care they receive."

Also, this clearer picture of yourself (including your family) could show better diagnosis. This is good for you as a patient of immediate care. (The negative I feel is the concern with all this health records and the risks of you being patient.. Meaning pre-existing conditions and family history of say, cancer... Your cost to insurance.. Address on the next blog).

Though the article hits the point of medical records, a nationalized medical records are still away (though the mandate should be by 2014). What is truly important is that your medical records (like your credit report) are accessible via Internet. It is possible to reach the information if you were traveling oversea.

"Because the information is in a compact digital format, it can easily be transferred at any time to any location around the globe if the need arises. There is also a highly secure online site that allows access to a members' complete health record anywhere there’s Internet access."

That is the intention of electronic Patient Records. The biggest concern and issues for centralization are:

1) Standards and guidelines
2) Who dictate the standards and guidelines
3) Security (since this data is so valuable to marketers and hackers)
4) Who holds the data for access?

Centralized, Electronic Storage of Medical Records
http://it.toolbox.com/blogs/adventuresinsecurity/centralized-electronic-storage-of-medical-records-22748

Again, the same arguments of benefits are addresses as well as some of the minor concerns of that benefits (I hit #2 and #3 which is the biggest no from many who oppose this as well as cost).

As Google (a big, cloud data center) will work on a pilot with Cleveland Clinic to provide medical records over the Internet:

"The test program will allow 1,500 to 10,000 patient volunteers at the Cleveland Clinic to store certain records - on prescriptions, allergies and laboratory test results - in a secure Google account. Patients will have passwords, and only they will be able to access the medical records"

With this technology, the speed of obtaining medical records is instantaneous. Added with the right security, the right people will access the right files. That information could be provided to your doctor/dentists. Have you ever dealt with patient records transfer from one office to another (relocation as an example). It could take days to send, verify, and entered (into the system). What if the patient has major surgery and time is an essence? Also, the handling of information could be very diverse (US Mail, UPS, FedEx, email, encrypted email, etc.) Since software do not necessarily work the same way, the data you get might not be usable to your current practitioner (I dealt with a Veterans Hospital eDR sent to a private dental practice via CD. Checking the CD, we could not read anything except file names. Why? Because the Image Format was proprietary and only readable in their software.. There's HIPAA for you.. =P )

With electronic services becoming the norm in dentistry. Paying your bill online, confirm and cancelling appointments, etc., standardization becomes a bigger variable on how the information displayed, accessed, and modified (as well as format for sharing between health organization like your private practitioner to hospital).

As for technology impacting my career?
I hits all angles. I have to be proficient in various governing laws (Like HIPAA, Red Flag, etc.) and state laws and regulations (NY is different from NJ and CT). I can't just be focus on the technology and understands the politic and stakeholders in the industries. Technology is forcing myself to be more of the instigator of technology as well as the ambassador to standardization.

Lastly, this argument is not only Patient Health Care Records. Like this webpage, it talks about the strength and weakness of centralized vs.decentralized filing (in this case, just records.. Who is to say that it could health records if EPA was not written on it).

http://www.epa.gov/records/tools/central.htm

Patient Records into the Clouds?

I know many people have heard of "The Cloud". This is an emerging technology that seems to be the "way" of doing business. I was wondering if practice management software or imaging software could embrace "cloud" technology. Looking into DentistryIQ.com , I came across such software.

New Web-based digital imaging technology allows dentists to capture images directly to the cloud

http://www.dentistryiq.com/index/display/article-display/3380096759/articles/dentisryiq/products/technology/2011/08/curve-digital_imaging.html



What is cloud technology?
As Wikipedia (http://en.wikipedia.org/wiki/Cloud_computing) writes :
"Cloud computing provides computation, software, data access, and storage services that do not require end-user knowledge of the physical location and configuration of the system that delivers the services. Parallels to this concept can be drawn with the electricity grid, wherein end-users consume power without needing to understand the component devices or infrastructure required to provide the service"

(Image Courtesy from Wikipedia's webpage on Cloud Computing)

In laments term, you do not need to worry about the investment and cost of physical assets as well as maintenance. All you need to know is how to access and utilize your data. Cloud computing is over the Internet. I think of those old mainframe computers as cloud computing in that the clients are nothing but dummy terminals (except that it is over the Internet and resources do not necessarily need to be mainframe computers).

Why is this significant?
Dentists are mostly K.I.S.S. type of people. The acronym stands for Keep it Simple Silly (the last S could be different with varying people). Dentists like to keep their operation smooth and clean. Taking the responsibilities of hardware and software purchase and maintenance off their plates, they would focus on their operations (business practices) and minimize cost.

As Curve Dental emphasizes:
"Using the cloud to capture and store patient images helps eliminate the need for a server, affords unlimited storage and a proven backup and business continuity solution, and provides the dentist with access to the data from any computer with Internet access."

As the article points out, the imaging software allows the office to acquire image acquisition with digital x-ray sensors, intraoral cameras, and panoramic/cephalometric equipments. As they stated:

"Switching to our software shouldn’t require the dentist to invest in new digital devices; that is our goal."

With the software being upgraded, maintained, and supplied by the Curve Dental, you would think it is a "no brainer" right?

Peter Parker's quote comes back again to our conversation. We have to consider the cost of technology:
1) Benefits and rewards
2) Responsibilities (including Disaster Plan and Politics)
3) Process

Benefits and Rewards:
I do not see any issue since it eliminates the need to purchase, maintain, and upgrade software. Also, if the cloud provider does what is expected, your data should be protected in case of disaster. There is a lot of pluses there

Responsibilities:
1) Various State, Federal, and International Laws:
Why I address this dictates how compliance are being met by Curve Dental (or their subcontractors). Since clouds are to meet compliance laws depending upon operation location and use. How are prevailing compliance laws implemented and mandated. Like I stated, is the data stored outside the USA? How are the data being backed up and security compliance in who has access to your data?

2) How does the Imaging Software works in correspondence to Practice Management Software (PMS)?

There is a terminology in the dental world called "Seamless Technology". This means does the PMS work bi-directional with the Imaging Software. Both software utilize the database(s) to perform various functions that otherwise would not when they bridge database or are standalone. Meaning, the patient name and their corresponding relations could work from PMS to Imaging or Imaging to PMS (Compare to Standalone, you need to have to separate databases that has no relations. Bridge has few relations and usually one directional; from PMS to Imaging.)

As Curve Dental stated:
"Because our imaging software is ‘native’ to our practice management software, it is more efficient and more stable than an integrated or bridged solution,” said Dorey. “‘Integrated’ or ‘bridged’ solutions equate to separate databases, separate sources for technical support and two applications that may work and look differently from each other.”

Meaning:
To have seamless integration, you need to switch out your PMS to their software. There is a cost in data conversion (let alone training and process changes to practice operations). This is a hidden cost to working the way you want it to work. Note, this has the same question and concern in terms of process

3) (Since we are talking about Imaging Software,) What Equipments will work?
They state they are compatible with many digital equipments but they do not list all equipments. When switching, we have to truly see and verify your digital equipments will work (and work the way the equipments are suppose to work.. This is a big emphasis on intraoral cameras and their buttons to capture/retake/save). TWAIN drivers are a solution but not all equipments are TWAIN capable. Again, with the industry taking sides, what type of relationships does Curve Dental have with the various vendors (and will they be willing to work with them in the future).

Emerging in the Dental Industry is the acquisition of 3-D Images (especially for oral surgeons) which utilizes manufacturers' software and drivers (in some case, their own acquisition machine and their own proprietary image format). How does the software handle these acquisition brings the question of going to the cloud completely or not. Note, we address the size of data later.


3-D Image Acquisition of Patient (Courtesy of Imaging Science iCAT)


Software Analysis 3-D of Patient Face (Courtesy of Imaging Science iCAT)


4) Security and Standards including Internet Data Transfer & Data Size
The important question is how are they are compliant to various health standards (HIPAA, Red Flag) and how are data secured over the Internet (Encryption, VPN, etc). That is a big and obvious question. Even if they answered the question, how are they managing user rights and security for each employee in an employer as well as guidelines when Internet goes down. When you take an x-ray, does it get saved on the machine locally and then to the Internet (process of the software)? Or if you lose connection, you lose the data image and have to retake? How much data compression do you have especially when 3-D Image (if possible to send) could be anywhere between 50MB to 100MB?

To Hit the point: How does the office function when the Internet is down? What is the contingency plan?

5) Cost of the Software
Since it is a subscription based, you are going to pay monthly. How much do you save (short and long term) in comparison to owning your own equipment and data? Subscription based on data size (images will add up and accumulate over time)? Data Conversion (what part of the data stays the same? Primarily accounting and ledger in correspondence to transactions) and its price? Support Cost included with the subscription?

The main point here is to look at the Doctor's vision and see if Cloud is really advantageous (especially if their Internet connection is sporadic or down.. T1 Lines needed and how much more for guarantee High-Availability)? Does owning the equipments consider cheaper comparing to "renting" the equipments?

Process:
How does your office function with the changes are involved. There are no distinct things to look at but general points to consider:

Is the learning curve and training easier?
What does the software allow me to take care (than the previous software did not) and not take care? (This deals with software interaction with the staff)
How are updates notified to the office?
Does the software work with other 3rd party vendor software (like electronic claims)


At the end, patient records are the dentists' livelihood. As a consultant, I want the doctor weigh the good and bad. Technology has many promises but it all deals with my sense of trust with the vendor and how the vendor deliver disaster recovery successfully and promptly. Also, I let it become more standardized and jump on board when all questions are answered to the expectations that my doctor and I desire (Never believe in the promises but the delivery)

How does this technology affect me? It gives another flavor of how to do business for the dentists. Practically, off-site data backup to the cloud seems very logical in terms of service. Also, cloud shows my company a directive to approaching our clients with value add and expertise in looking at the return of investment. Technology has grown in this industry faster than most people think. But technology is allowing the work of dentist (as well as my livelihood) to go faster to the speed of life..

Emerging Technology - Concerns

With some basic understanding of Digitization of Patient Records becoming the "norm" like CD was to Tape (like DVD to CD), there are many implications and "growing pain". The biggest being privacy and security

Security Gaps Leave Patient Records Exposed by health MSNBC.com
http://www.msnbc.msn.com/id/43054034/ns/health/t/security-gaps-leave-patient-records-exposed/#.TlUVC6iNsf4

The article see the centralization of patient records have many concerns but not limited to:
1) Privacy failure
2) Security Parameter and Requirements
3) Implication and Application of the Health information and records

As my career in the health industry grows, my responsibilities became more and more on the liability of the patient information (anything from lost information by user error/failure, hardware failure, or security breaches). It is imperative in our careers, we need to address setting up an optimal security. This is followed by clear and defined rules and guidelines to implement the security. Application (be it by pilot testing or fake sampling) to ensure our implementation meets and exceeds requirements.

Lastly, technology is not always a start and end procedure but a cyclical process. I understand as a project manager the importance of milestone and close date but technology does not stay stagnant and our roles has to adapt to newer technology (including ones that could compromise the data) as well as process improvements (metric measurement). The word I always state is we need to have all the stakeholders involved, held accountable to the define responsibilities, and ensure the resources are there for stakeholders' success (training, changing the procedural/process flow).

The implications here with the digitization are there will be needs for more project and data managers in the health industry. HIT (health information technology) is a growing segment and with the changing technology, everyone involved has to see the payout as the responsibilities (Remember my 1st quote of Peter Parker in the Spiderman movie).

This is why people need to audit (like the article, one hospital store radiology data in a backdoor room that was lock by tape.. Not even locked). They need to understand the implication of this memory lapse of security. Remember how it feels when someone knows your password to your email. Now, imagine it is 1000 patients. How about a research hospital server was used as a gaming server for hackers (SonicWall Case Study - Southwest Family Medicine- http://www.sonicwall.com/downloads/F204_Southwest_v4.pdf ) because they did not have:
1) Right plan and personnel
2) Understand the severity of access
3) Cost and Liability of this breach

With the rise of Identity theft, the emphasis of security is greatly enhanced in the health industry. What is the biggest and my greatest concern is with globalization, how do we protect our patient records when our information is transmitted overseas? Remember, HIPAA does not apply just say India. How are the technology going to protect us there.

An Article that published indicates how our information reaches global proportion and ramification. Again, there is no HIPAA laws in India (but they state they comply with the laws). What security protocols are there and the emphasis of protecting your information is the heart of all issues.

http://www.workplaceprivacyreport.com/2009/10/articles/hipaa-1/hipaa-data-breaches-in-india-threaten-outsourcing-industry-require-greater-vigilance-at-home/

How does technology impact me? Everywhere from my patient records, my credit card, banking statements, my student loans. What health technology transformation shows are that people can't just be "doers". We have to think outside the box (without project scope creep) and knowing how to add the human element to technology. My success in the industry is to emphasize and understand the implication of the office and making it happen by phases/projects and showing the rewards (Return of Investments) and value in approaching our goals. So HIT professionals have to understand the value of technology, disaster plan for technology, implementations (with cost in mind), and understand the human side (changes in process, etc) to making this change a reality and success.

Lastly, you see the change in technology when you go into a dental office. See your x-rays on a computer screen instead to lighting station for your old x-ray film. That is technology change in how dentists do business and getting quicker impact to the patient (films take a longer time to develop but a digital x-ray take less than a minute)

Understanding Government Mandates and Industry Trend

Government Mandates

1) HIPAA

Mandated and signed by Pres. Clinton in 1996 with complete compliance by 4/13/2003. This was mandated to all health profession and included the dental industry (though health plans might be separate from dental and vision coverage). Though exemptions existed like long-term health plans and limited-scope plans, most dental office were required to comply. Also, the development NPI were created

2) Red Flag

Mandated by Federal Trade Commission (FTC), businesses were to safeguard against identity fraud and theft. All business had to comply by Nov 1, 2008 but did not clearly define dental industry as one of the industry for compliance. With the work of ADA, the dental industry was given an extension to 5/1/2009 for compliance.

Emergence of Practice Management Software

Practice Management Software (PMS) started in the Medical Industry in Late 70s to early 80s (with the advent of computers and software development). With medical and dental field going hand in hand, dental industry developed PMS. With the progression and computing power of the PC, PMS expanded its roles from scheduling in the front side to the “chairside” and clinical part of the practice. Since data are entered into the PMS, it laid the backbone to the emergence of eDRs by being the central depository of data of patient from insurance info, finances, treatment plan, clinical notes, and family history.

Emergence of Digital Radiography

Like PMS, digital radiography focuses on the procedure and diagnosis of patients’ x-rays and “cosmetic” images (from digital camera and intraoral cameras). The physical equipment of digital radiography are reusable (compare to film being an one-time usage item) and require a means to store data in a central depository (imaging software). This provides the same foundation for the emergence of eDRs.

Conclusions:

With my deduction from Pres. Bush integrating oral health as part of the overall health (and CPRs/eHRs) and 10 year mandate of Executive Order 13335, I believe the expectation of eDRs will be mandated with the compliance date of 2014 (unless the ADA steps in to delay the implementation). Added with the increasing usage of PMS and digital radiography (with imaging software), as the means of communicating electronically, eDRs are the de facto vehicle for patient information (in particular HIPAA compliance when a patient goes to another practice as well as e-claim services by insurance).

Also, PMS and Imaging software vendors are implementing eDRs directly into the software (and it’s a logical implementation) without any concerns for most practices who are already utilizing the one or both software. That is an intrinsic cost and value already covered by your support/upgrade package you pay to the software vendor (usually annually).

At the end of the conversation, it is not a question of if but when?

History of eXRs

With technological development and advancement, the way we live and do business change and evolve each and every moment. With these changes, there are many consequences.. Good or bad. As Peter Parker said in Spiderman:

“With great power comes great responsibility..”

Being a HIT (healthcare information technology) advisor, I emphasize that all changes are beneficial, ineffective, necessary, and/or inevitable. Meaning not all changes are necessarily the best for your practice but could be for the overall progress of the industry. One of these changes that are being discussed is Electronic Dental Records (eDRs).

To provide an overall of how eDRs are the current progression of the dental industry, we have to see where it all started: Medical field and eMR (electronic medical records). There is no difference in the concept of eXRs (where X= M or D) except in content and industry (Dental is the lower 3^rd of the head and Medical could be the whole body). This analogy is like looking at cable signal seeing ESPN as being Dental records and HBO as being Medical records. How the data is delivered is conceptual the same but not the content necessarily.

Federal mandates started the initiative of eXRs:

1996 - HIPAA (Health Insurance Portability and Accountability Act)

With an efficient and safe mean of patients’ Information to be transferred, eXRs developed as vehicle and means with the rise of Internet and e-services (like e-mails, electronic claims)

2003 - Medical Prescription Drug Improvement and Modernization Act (MMA)

Medicare’s prescription drug overhaul (with Medicare Part D plans to support electronic prescription with planned implementation date of April 2009)

2004 – Executive Order 13335

Calls for complete computerization of health care of CPRs, computer-based patient records through NHII (National Heath Information Infrastructure), for health records, transparency, cost savings, and bioterrorism defense by 10 years – 2014

Note: NHII is not a government plan to establish a central repository for all medical records

George W. Bush quoted:

“By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care” State of Union Address 1/20/2004

“We need to apply 21^st-century information technology to the health care field. We need to have our medical records put on the I.T.” Collinsville, Ill.1/5/2005

Additional Reasons for eXRs:

2002 – Pres. G.W. Bush First Health Center Initiative (under Federal Consolidated Health Centers Program under Section 330) mandates that oral health be included as an integral component of the process (hence the development of NHII)

2008 – 70% Voters wanted President who would back a Health IT Network (survey by Computer Sciences, Government Technology Reports)

2008 (12/8) –U.S. President-elect Barack Obama has outlined an ambitious plan to give every child in the U.S. access to the Internet and to connect the nation's hospitals with "cutting edge technology.

"We will make sure that every doctor's office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year," he said.

The Federal initiatives and funding combines the theoretical and ideal concept (even if I agree with it or not), the development of eXRs into the platform and development of CPRs. Added with the importance of oral health as part of the patients’ complete health, eDR + eMR = CPR (or eHR – electronic health record).

Is eXRs Mandate and Reasons?

Technically speaking, there is no clear define mandate on eDRs in all dental office (my lament term was the Patient Digital Act which is the Executive Order). Checking all government mandates in reference to eXRs are primarily all related to the medical field. Date for mandate (if any) has be discussed as early as 2012 and as late as 2015 by dentists, HIT experts, and various HIT vendors. So why would I address this as a mandate for the dental industry?

As quoted:

“The electronic health record may not be the result of changes of our choice. They are going to be mandated. No one is going to ask, ‘Do you want to do this?’ No, it’s going to be, ‘You have to do this.’ That’s why we absolutely need the profession to be represented in the discussions about EHR to make sure our ideas are enacted to the greatest extent possible.” - Dr. John Findley, ADA President-elect, September, 2008.

I believe the reason and thought behind the eDR mandate are based on pre-existing government mandate that did applied (and funnel) to the dental industry, emergence of practice management software, and digital radiography