Musings by Seref Arikan

Just in case you have not read Gateway, please do it. Pohl’s sci-fi is very impressive, focusing on a lead character who is quite defective. He is not even an anti-hero, he is just the guy in the focus, and I really appreciate that kind of balance about the depiction of lead characters.  Certain aspects of this work reminds me of the Rama series, and there are two books following this one, making it a trilogy. The first book introduces so much potential for follow ups, and I hope Pohl’s following books are built on the right aspects. I may have found my new impressive sci-fi trilogy, years after reading Gibson, but it is too early to say this. Let’s see how the two other books are.

Suarez wrote a quite interesting book with Daemon, which I would call a pop tech thriller. What makes it interesting is its reasoning is build on things which exist today, and he is not pushing the limits too much, so technical people would not lose the aspect of believability  easily. If you are a little bit too involved with code, AI and distributed computing however, you may still feel that familiar “that would not really work ” feeling. Still, worth taking a look at.

I’ve been writing some stuff about the things that I keep seeing in the healthcare IT world, especially regarding EHR implementation. Most of it is in draft from now, but I wanted to write down about a particular one, the addiction to perfection.

My PhD is in a way focusing on the lack of perfection in certain domains, and accepting  it as it is, for better decision support. In the last 13 years or so, I’ve been involved in thousands of conversations with people demanding solutions, and a particular pattern in healthcare is becoming more an more obvious for me.

Almost all the stakeholders in the demand side of this discussion, always have very high expectations, and almost zero tolerance about what a proper EHR solution would look like.  We have a raining set of documents with tens of thousands of pages arriving in our mailboxes everyday. Everyone, and everyone is so diligent when it comes to providing opinions about what should an EHR implementation provide.  That’s good of course, seeing that attention to details. The only problem is, everybody, but everybody takes this huge amount of requests as indispensable. We must have perfect security, perfect performance, perfect simplicity, ease of use, you name it. And if you can’t provide these to the level we want you to, then this is not a successful outcome.

Really? I mean really? Let’s take a look at the level of imperfection in the processes and tools in healthcare. Any text about patient safety will tell you that walking into a hospital carries some incredible risks, even if it is only for a very simple procedure. What is the response to this? Well, it is a problem, and we need to do better. Good, but you are not shutting down the whole healthcare system because there are mistakes. Take a look at the tools. There is a sensitivity and specificity for many medical tests. There are gold standards of course, but you don’t get to use gold standards all the time, as they are sometimes too expensive, or invasive, or slow etc. The practice of medicine accepts this fact. Clinicians and administrators will explain to you the reasons behind false positives, and false negatives, and for those who are having trouble, check out this excellent paper from BMJ. Medical devices have their rate of error. Medical tools are imperfect, tests have their error rates, and yet, the practice of medicine is not grinding to a halt due to this. The very people who demand perfection in IT systems are running their operations everyday, accepting other deficiencies, and saying that they are continuously being improved. Whenever someone says that “but without proper <insert your favorite aspect of EHR implementation here>, the results would be disastrous!”, they should be reminded of the already existing disastrous results which is not stopping what they are doing. Believe me, they are not that hard to find.

So why is it the case that when it comes to EHR systems everyone keeps demanding perfection as a starting point? The world is full of huge projects soaked in vision and pan fried in indispensable principles. When they usually fail, the creativity which does not exist in the project itself is usually there to provide a perfect explanation for the failure. In fact, in many of the large scale projects, perfection only exists in justifying the mess.   This is mostly because the bar is always so high, and the scope is so wide. Demand side of things is always evolving into this outcome, and supply side is mostly happy about it, who would not love a millions of pound/dollars contract?

I am in no way defending lousy outcomes here. I am trying to understand why perfection is an absolute starting point, or a shiny frictionless base on top of which we should build everything, rather than being taken as a goal, arrived to in steps.  Iterative approaches can help a lot here, but people seem to avoid them passionately. Perfectionism is good, but how come you accept lack of it in almost every other aspect of your practice and demand it for EHR systems?

I’ll keep posting more on the anti patterns and I’ve got a lot to say about supply side of things too. Till then, take care.

Ok, this is a paper that should provoke a huge discussion. This paper with two of its authors from Harvard says that the picture in hospitals with computers is quite different than the one we always thought we would see.

Obviously one should read the paper before discussing it, and I  did so. First of all, I have to say that the paper seems to give little thought into why software does not seem to decrease costs. There are three potential reasons mentioned in the conclusion part of the paper, but the final one is quite interesting. Quoting from the paper: “Finally, we believe that the computer’s potential to im-
prove efficiency is unrealized because the commercial marketplace does not favor optimal products. Coding and other eimbursement-driven documentation might take precedence over efficiency and the encouragement of clinical arsimony”

Yes! The marketplace does not let us push out better technologies easily. You’d think that once you have a better solution for a problem, the world would give you a warm hug and thank you for your work. The reality of the marketplace is cruel: there is huge politics and conspiracy around healthcare informatics, and working towards better solutions is not enough on its own. It is such a pitty that there is a huge amount of people trying to make things better, and the lack of desired outputs is not only related to capacity of the solutions we are building.

I’d like to see some honest discussion about this paper, and please let me know if you come accross any riplle effects regarding this paper.

Superbugs, and not-so-strong-but-still-a-problem bacteria are threatening patient safety. All those publications out there, and excellent books like Atul Gawande’s “Better” explain the reasons behind this problem, so if you’re curious, you can take a look.

What I came across today during my never ending surfing, is a really promising method of increasing the efficiency of killing bacteria and viruses. A new device  that uses plasma is able to diminish the chances of carrying harmful bacteria to one in a million.Take a look

Ok, slightly off topic, but if you are interested in my reading list for the last couple of months, here is a brief summary.

Atul Gawande, “Better “. Professor Ingram gave this book to me. If you want to see how doctors see certain things, and how hard it is to perform some tasks which they are expected to perform without any errors, read this book. Gawande discusses some interesting topics, including ethics, with quite unusual examples. Would you become a lawyer after years of being a medical doctor, and sue your own colleagues for malpractice cases? Could you use your medical knowledge to end someone’s life, for an execution? A great read.

Stephen King, “Cell”.  King is not the King I’ve admired for so long anymore. He has his style, he never loses it, you get the same feeling everytime you read his work, but Cell made me feel that I am reading a recycled version of his creativity in the past. You’ll find many common points with this book and his previous works. I do not want to believe that he is done with his universe, after finishing the Dark Tower, but I am failing to enjoy his recent works.

Vernor Vinge, “A fire upon the deep”.  My first encounter with Vinge, and  I think this is a good book. Vinge reminded me of Asimov in many ways, and he manages to build a different type of society which is real enough to keep you in the story. A couple of interesting ideas about the universe, including the slow zone, allows him to explore the outcomes of a partitioned universe. I have found some important parts of the book to refer to Gibson’s Neuromancer trilogy, but it is hard to avoid him when you’re writing about AI.

Neal Stephenson, “Snowcrash”.  This is the book that come closest to Gibson’s world in Neuromancer, among the others listed in this post. It almost gives that feeling I get when I read Gibson, but the main story did not create a powerful impact on me. Still, a good work of cyberpunk. I’d like to get my hands on this kind of books more, but I’d like to see a little bit darker material.

David Mitchell, “Cloud Atlas”.  A serious demonstration of talent. Can’t say the genre, because Mitchell shows that he can write four or five genres in the same book! Tom gave this one to me as a present, and it is one of the most interesting works of fiction I’ve read in the last couple of years. It made me realize that I need to go back to non-science fiction more often.

I am now reading  The Graveyard Book from Neil Gaiman, but I have to say that I want him to focus more on adults’ stories. His genious in Sandman and American Gods shows that he can be very impressive when he constructs complex stories, but all his other works I’ve read after American Gods are a little bit too simple (maybe flat is a better word here). Anansi boys was good, but I want something in the lines of American Gods. I’ll always follow him, but he seems to be a little bit too much into writing books for young people recently.