Lab Soft News

New Lecture Posted on Integrated Diagnostics

I delivered a lecture/discussion yesterday about integrated diagnostics to a mixed audience of pathologists and radiologists at the University of California San Francisco (UCSF). This is a topic that I have covered in previous notes. Part of the discussion also touched on the development of integrated diagnostic centers and the relationship of the virtopsy/catopsy to these new concepts. The potential patient referral patterns into these integrated diagnostic centers was touched upon, a topic ripe for discussion that I plan to address in subsequent notes.

Flash Drive "Awareness" Bracelets Distributed to Students

Here's a good idea -- flexible "awareness" bracelets are being distributed to public school students in Michigan for storage of their home work, for logging into school computers, and whatever (see: Dexter students sport rubber bracelets as part of technology upgrades). Below is an excerpt from the story:

Using money from a school bond, the Dexter [Michigan] school district recently upgraded its technology, including replacing old PCs with Macs. And giving students a small rubber bracelet was part of those upgrades. Students from fifth through 12th grade each received a bracelet that's a two-gigabyte USB flash drive with two primary functions. It's formatted for both Macs and PCs, so students can take files from one computer to another. But more importantly, the drives will log students in to the computers when they plug them in....However, if students forget their flash drive bracelets at home, it leads to bigger issues [such as not being able to log-on to computers]. If lost, students can replace the drives $7. As with many changes, the school is still taking a wait-and-see approach to see how the bracelets work out. If the flash drives are successful, school administrators will decide whether to buy new ones for incoming students or reuse the ones from departing students.

Logos can be embossed on these flash-drive bracelets, hence the "awareness tag". I don't think that this type of gimmick would have much appeal for adults. most of whom are studiously trying to avoid the various "awareness" campaigns. My need for a flash drive is only sporadic so I keep a pile of them on my desk. I have avoided attaching one to my key chain, which is already too bulky. Still a great idea. One problem is that kids will need to come up with a new excuse when they can't deliver their homework. The "dog ate it" just won't do anymore.

Microsoft's Cell Phone Operating System Lacks Key Functionality

If I say PC and operating system, some of you will probably respond associatively: Windows and Microsoft. If I say cell phone and operating system, most of you will probably stare at me. That's really not a problem. The critical differentiating feature for cell phone operating systems is not it's name but rather what it can do for you. In previous notes, I have presented the idea that the smartphone is the next PC and will have great relevance for healthcare, pathology, and lab medicine. What users should now be looking for in their cell phones is nearly the same, or better, functionality than their PC.

My Palm Pre browses the web so efficiently that I can read email and search the web without any sense  of being inconvenienced. Despite its best efforts and having been in the cell phone OS business for a long time, Microsoft still can't seem to get this right. Some of the details were revealed in a NYT review of a Windows Mobile phone (see: Another Try for a Windows Phone, but It’s Still Clunky). Below is an excerpt from the article:

If you’ve never heard of a Windows Mobile phone, or never particularly cared what kind of software runs on your phone, prepare yourself. In the coming months, Microsoft will release a steady drumbeat of ads intended to make you want a device powered by its software....Windows phones have been around for years, mostly competing with BlackBerrys for the allegiance of business users. But while BlackBerry crossed over into the consumer realm with more user-friendly phones, Windows Mobile remained in its corporate cube, because of devices that could be so frustrating to use that few people would choose one without a corporate mandate....For much of the last year, Microsoft has been saying that its new mobile software upgrade would significantly simplify the user experience. And the upgrade does simplify things, but not much. Instead of poking around with a stylus, Windows now features icons that are big enough to hit with your fingertip. That helps you navigate the phone’s software menu and interact with various programs, but when it comes to the one application smartphone owners use the most — Web browsing — it falls far short....But unlike the iPhone or the Palm Pre, a Windows phone still lacks a multitouch screen, so you can’t pinch and pull the display to a chosen size. Instead, you press buttons and sliders in a scheme that sorely lacks precision....Likewise, instead of simply connecting you to a free Wi-Fi hot spot, Windows forces you into a three-step decision tree that would make a technician’s heart sing, but would strike fear into the heart of just about anyone else who just wants to log on.

There's a lot that's wonderful about the current crop of smartphones. Although I am very fond of my Pre cell phone from Palm, I recently purchased an iPod touch, which is an MP3 player that lacks cell phone capabilities. However, it can connect to the internet effortlessly using W-Fi so I can still place VOIP calls anywhere in the world using a Skype application that I have downloaded and installed. It is quite a remarkable device.

For me, the greatest feature of my Pre is being able to effortlessly surf the web with the essential enabling element being hand-gestures such a "pinch" or "pull" interpreted by the device's touch screen as a zoom-in and zoom-out. Similarly with the Pre, I can change applications, still keeping all of them resident, with a finger-sweeping gesture on the screen to the right or left. The review of Windows Mobile above provides further evidence for me that Microsoft is still wandering in the wilderness. Fortunately for us, there are cell phone OS developers who understand the web and the need on the part of users for a friendly user interface in order to surf it.

Storing Cell Phone Data in the Cloud Can Be Risky

It will come as no surprise to IT enthusiasts that storing their data in "the cloud" does present some risks. A problem associated with the Sidekick smartphone was highlighted in a recent article (see: T-Mobile: Missing Sidekick data "almost certainly has been lost"). Below is an excerpt from it:

The Sidekick was one of the first phones to keep all your e-mail, contacts, events, and photos in an online "cloud"; cool, right? But in the wake of a critical server outage more than a week ago, frustrated Sidekick users are learning the hard way that when things go wrong, cloud computing isn't all it's cracked up to be. In what's shaping up to be one of the worst tech train wrecks of 2009, T-Mobile and Microsoft (owner of Sidekick developer Danger) admitted Saturday that any contact, events, or to-do lists that haven't already been restored following a massive server meltdown earlier this month are probably gone forever....Meanwhile, it's still not clear what caused the server outage—which left Sidekick users without any data access at all for days on end—in the first place (although there are some theories floating around)....T-Mobile has already told Sidekick users that it will give them a month's worth of data for free in the wake of the outage, and the carrier also posted a F.A.Q. on how to restore your Sidekick contacts from vCard files, Outlook, or a SIM card. But many Sidekick users looked to be out of luck Monday, with who-knows-how-many contacts, calendar events, to-dos, and e-mails vanishing into the ether. Indeed, more than a few angry users on T-Mobile's message boards were already grumbling about lawsuits. In the end, though, nothing (short of a miracle on T-Mobile and/or Microsoft's part) will bring the lost data back, and that brings us to the moral of the story: Backup your data, especially the stuff that's floating up in a cloud somewhere....That's especially important when it comes to free, in-the-cloud e-mail account like Gmail and Yahoo! Mail—both have methods for quickly exporting all your contacts and events to a local file....

Here is an update on this story in the form of an excerpt of a letter posted on the T-Mobile web site from Ros Ho of Microsoft (see: Microsoft Confirms Data Recovery for Sidekick Users):

On behalf of Microsoft, I want to apologize for the recent problems with the Sidekick service and give you an update on the steps we have taken to resolve these problems. We are pleased to report that we have recovered most, if not all, customer data for those  Sidekick customers whose data was affected by the recent outage.  We plan to begin restoring users’ personal data as soon as possible, starting with personal contacts, after we have validated the data and our restoration plan. We will then continue to work around the clock to restore data to all affected users, including calendar, notes, tasks, photographs and high scores, as quickly as possible.

So, from all of this we learn that the servers in the cloud are fallible. A good rule-of-thumb is to always backup your data no matter where it is stored. At first blush, such a strategy may seem impractical when radiology or pathology PACS image files are stored in the cloud because the reason for utilizing cloud storage in the first place is because of insufficient data storage capacity locally. Well, the obvious answer to this question is to contract for both primary and less expensive secondary storage in the cloud (see: Does cloud storage need backup?). If there is a failure at either point, file restoration is possible. I have no advice if there is failure at both points.

My thanks to Robert Michelle of the Dark Report and Dark Daily for suggesting this topic to me.

Differences Increasingly Blurred Between PCs and Smartphones

Smartphones are rapidly becoming the new PCs (see: Smartphones as the New PCs; Connecting to Healthcare Professionals and Consumers). This trend is now accelerating, if the rumor mill is correct that Dell, historically one of the major PC manufacturers, may bring a version of the Android smartphone to market with AT&T (see: Dell May Bring Android Smartphones To AT&T). Below is an excerpt from this article:

The lines between smartphones and laptops are increasingly blurring as hardware and mobile data networks rapidly improve, analyst says. Dell may be successful in its foray into the U.S. smartphone market if it manages expectations, but it may have difficulties standing out from the crowd, according to an industry analyst. The computer maker is reportedly close to announcing a deal to bring Android-powered smartphones to AT&T. This comes after years of speculation that it would enter the mobile space, and a few months after it unveiled Android-powered smartphones for China Mobile. AT&T and Dell have not confirmed the report....Computer makers such as Acer have already taken the smartphone plunge, while Nokia, the world's leading handset maker, recently introduced a 3G netbook....[An analyst] said Dell's first handset will not outsell Apple's iPhone, but could potentially match the sales of the Palm Pre, which analysts estimate has sold more than 700,000 units since its summer release. The first Dell smartphone will reportedly be an upgraded version of the Mini 3i smartphone that will hit China soon. It features a large touchscreen with an iPhone-like user interface....The computer maker has a recognized brand name and strong direct-to-consumer sales channels that may woo mid-tier smartphone buyers.... It also should not be difficult for Dell to create or outsource the design of an attractive Android-based handset. Additionally, Dell may not want to compete against the BlackBerry in the corporate realm because Android is not yet enterprise-friendly, although that is expected to change with future software updates.

The interest on the part of Dell in the smartphone market is additional evidence that these devices are rapidly becoming the new PCs. Partnering with Google, the developer of the Android smartphone operating system, also makes sense. I am not surprised at the statement above that "Android is not yet enterprise-friendly." The Google approach to software has always been to release early versions and then improve it based on the input from users and experience in the field. Probably only Google could get away with such a strategy because of its strong relationship with the user-community and the fact that most Google products have generally been free. Dell's well known strength is its understanding of the needs of corporate users and, as noted above, its target of mid-tier buyers. This is in sharp contrast to Apple and its iPhone with its appeal to the hip twenty-somethings who are willing to pay a premium price for Apple products. The problem for Dell with such a strategy, also as noted above, is that both BlackBerry and the Palm Pre are strong players in this same space.

Forbes.com Puts Some Numbers to the Epic Systems Success Story

I have a special and continuing interest in the corporate culture of Epic Systems, one of the most successful hospital EMR companies. Because its founder and CEO, Judith Faulkner, does not allow interviews and the company is privately held, hard facts about it can be hard to acquire. However, a recent story in Forbes.com about Epic (see; Wired Medicine's Silent Giant) provides much new information and analysis, all of which rings true to me. Below is an excerpt from it:

...[T]he hottest company in the electronic medical records industry is a secretive Wisconsin outfit called Epic Systems. It does little marketing or advertising, shuns acquisitions, never issues press releases and tries to stay out of the headlines....Yet with a reputation for customer service and software that is more user-friendly than most, Epic has snagged contracts with famous places like the Cleveland Clinic and University of Chicago Medical Center, the big HMO Kaiser Permanente and Group Health Cooperative in Seattle. Epic has recently been winning about 40% of the new contracts for electronic records systems at major hospitals--far ahead of its competitors....In 2008, Epic won 24 big-hospital contracts, versus 12 for McKesson ... and 10 for Siemens....A contract to install medical records software at a 400-bed hospital might be worth $20 to $30 million over several years....Epic had $600 million in revenue last year, up from $500 million in 2007. It does not disclose its profits. The company focuses exclusively on larger hospitals and health systems--it has just 180 customers--allowing it to get business by word of mouth without much marketing....Computer programmer Judith Faulkner founded Epic in 1979 with three part-time employees and is still chief executive....[S]he is known for her liberal politics and buying quirky artwork for headquarters, according to local newspaper reports....Epic has a reputation for relatively high prices and high levels of service to ensure software is installed on time with as few snafus as possible...The fact that Epic is private is also viewed as an advantage by some hospitals....Installing medical records can take a year or more, and hospitals don't want a vendor that will be distracted every three months with earnings reports. Drexel University medical computing expert Scot Silverstein is a harsh critic of most medical records systems, which he says are confusing, glitch-prone and hard to use. But he gives Epic some grudging respect. "It is not terrible. Epic has the advantage of having been around for a long time, and they have been steadily improving the quality of their product. It is much simpler in its appearance to end users than some of the competing products. The user is not presented with a massively complex set of screens." ....Epic, of course, was unavailable for comment [on this article].

I found it interesting that Epic's privately-held status is put forth in the article as an advantage by health system clients because the company does not need to "dress up' quarterly earnings or court financial analysts. It would be more worrisome for me, as in the case of Kaiser Permanente, to have spent a king's ransom ("The Kaiser project will cost $4.2 billion by the time the final updates are completed in 2013.") on an EMR provided by a company micro-managed on a daily basis by a single individual. Perhaps plans have been made for Judith Faulkner's succession and the hospitals hold the system source code to ostensibly protect their institutions, but I very much doubt it.

For me, here's one of the paradoxes of the Epic success story. As noted above, Epic only sells to large health systems. These, of course, are the very organizations with the largest numbers of talented IT professionals. One of the secrets of the Epic success is that the company has a "take it or leave it" approach to its software products. In other words, the company does not allow local hospital IT personnel to modify the product -- only install and maintain it. The result of this arrangement is a "not terrible" EMR product, referred to by me in a previous note in a more charitable way as vanilla (see: Some Additional Insights into the Epic Corporate Culture). There are probably few other segments of the global IT industry where the most successful company in an industry would provide a product requiring a multi-billion dollar investment that is described as "not terrible."

Microsoft Opens Chicago and Dublin Datacenters; Scale of Operations Remarkable

I believe that healthcare computing, and particularly lab/digital pathology computing, will eventually migrate to remote data centers operating under the cloud-computing model (see, for example: Xerox Follows Lead of Others, Purchases Computer Services Company). The scale of operations of these centers, often referred to in the past as server farms, gets little coverage outside the hard-core IT press. A recent article provides provides some insights into where cloud-computing is headed from both a physical plant as well as a software perspective (see: Microsoft opens Chicago and Dublin datacenters; preps for more hosted offerings). Below is an excerpt from it:

Just a week after celebrating the opening its “chiller-free” Dublin datacenter, Microsoft is turning on its $500 million, 700,000-square-foot Chicago one....The Chicago datacenter is one of the largest datacenters in the world to make use of shipping containers, according to the company. Each of these containers holds 1,800 to 2,500 servers, which Microsoft officials have said enables the company to better conserve energy and take advantages of new power-efficiency mechanisms....The Chicago center Chicago also is focused on “water-side economization, which enables us to cool the facility without requiring the high levels of electricity typically needed to power large chillers,” according to [a spokesperson]. Dublin, which is aimed primarily at fulfilling the cloud-service needs of Microsoft customers in Europe, the Middle East and Africa, officially began operations on July 1. According to Microsoft, it covers 303,000 square feet, and currently is providing 5.4 mega watts of critical power. It can expand to a total of 22.2 mega watts of critical power.

Note the reference above to "shipping containers." Each of them is packed with thousands of servers, operates semi-autonomously, and can be bolted onto the data center infrastructure as additional computing power is required from the center. This article also contains a link to a Powerpoint deck of  a lecture by David Gristwood, a Microsoft application architect, describing both the data centers and Azure. Azure is the project name for the Microsoft cloud computing architecture (see: Steve Ballmer on the Future of Computing: Three Screens and the Cloud). Here is a summary of current activity levels of the Microsoft data centers copied from slide 10 of the Gristwood presentation:

• 30B live ID authentications/month.
• 2B Bing queries/month.
• 10B MSN page views/month.
• 240B Messenger messages/month.

As you may recall, Bing is the new and very successful Microsoft search engine competing with Yahoo and Google. These activity levels relate to proprietary MS applications. However, a company does not build to a scale like this for its data centers without the intention of capturing much of the world's cloud-computing business. I believe that we are witnessing the end of the PC-Windows era and the emergence of the cloud-computing era. Microsoft obviously intends to be a major player as the "computer service" industry takes hold of business and personal computing on a global scale.

Are We Turning into Informavores?

Although the word imformavore was new to me when I ran across it on the web recently, it turns out that I myself have always had these tendencies. Here's a definition of the term:

The term informavore ... characterizes an organism that consumes information. It is meant to be a description of human behavior in modern information society, in comparison to omnivore, as a description of humans consuming food. George A. Miller...coined the term in 1983 as an analogy to how organisms survive by consuming negative entropy ...."Just as the body survives by ingesting negative entropy, so the mind survives by ingesting information. In a very general sense, all higher organisms are informavores." (see: Wikepedia)

Until the emergence of the web, I have always considered libraries as my second home and was quite content to wander through the shelves, pulling books at random, and briefly scanning the titles and a few pages for bits of information. Information grazing if you will. The idea of the informavore calls to mind the discussion in recent months on the web about whether the web search engine Google was making us stupid. All of this angst was precipitated by Nick Carr who blogs over at Rough Type. The underlying idea is that web search has now been made so efficient and painless that we seek out snippets of information the same way that squirrels search for nuts. Some conclude pessimistically that we have lost our capability to leisurely consume the linear content of printed books.

The term informavore apparently refers to someone who acquires information anywhere, whether on the web or the printed page. The Google/stupid dialogue focuses on only web search. I personally acquire information via both the printed page and the web. If I am trying to understand some new idea quickly, however, I always turn to the web. For me, this is a matter of efficiency. Of course, there is a downside to being an informavore -- information fatigue syndrome. The cure for this latter condition is well understood.

Search Engine Users Versus Frequency of Use; Yahoo, Microsoft Compete with Google

The recent agreement between Microsoft and Yahoo has launched speculation about whether this collaboration can dent the dominance of Google in the web search market (see: Behind Microsoft-Yahoo: The Online Economics of Scale). This article refers to the idea of search engine scale or network effect, speculating that the goal behind the Microsoft-Yahoo deal was to increase the number of users. The classic example of the power of scale and the network effect was the fax market -- faxing became more practical and useful as the number of owners of fax machines (i.e, the size of the network) increased. Another recent article speculated on a similar question (see: The Gap Between Google and Rivals May Be Smaller Than You Think) and raised the question of search engine users versus frequency of use:

It’s no secret that even with their recently-announced alliance, Yahoo and Microsoft will lag well behind Google in the hugely profitable search and search advertising business. How far behind? With a combined 28 percent of the American search market, Yahoo and Microsoft could double their usage and still trail Google, which accounts for 65 percent of the market. But by another important measure, the two sides are much closer. Com Score found that for the combined Yahoo-Microsoft, “searcher penetration,” or the percentage of the online population in the United States that uses one of those search engines, is 73 percent. Google’s searcher penetration is higher, but not by that much: at 84 percent. The difference between the two ways of measuring is frequency of use. Users of Yahoo-Microsoft on average searched just under 27 times in a month on those sites, whereas users of Google searched on average 54 times a month, or twice as often. Of course, when it comes to making money from search, it is the number of searches, not penetration, that matters. But the penetration figures suggest that Yahoo-Microsoft could close the gap with Google if they persuade their existing users to use them a bit more often.

To summarize, the number of users of a Yahoo-Microsoft search product (i.e., penetration) is relatively close to that of Google. This measure is analogous to scale and network effect. Google users, however, each perform more searches per day and therefore are presented with more advertisements. It also worth emphasizing in this discussion (see: Do you Yahoo? Probably.) that Yahoo specializes more in content than search and the latter tends to be more profitable. Among the readers of this blog who are referred by a search engine, about 15% use Yahoo and Bing and 5% use Google. 

My own view is that this market competition benefits us all as companies strive to improve the quality of web search. I find web search, in general, extremely useful -- I don't think that I could work without it. However, I also rarely click through any of the search engine advertisements. There is no doubt in my mind that the quality of search can and will be improved in upcoming months and I look forward to this trend.

About One-Half of U.S. Hospitals Save Their Medical Records Forever

Storage of healthcare data in the "cloud" is an important topic to understand. Although the use of this technology for all healthcare data is important, it is particularly relevant for the storage of radiology and pathology imaging data. For additional details about cloud storage, you want to review my past notes on this topic. Last week I signed up for a webinar on this topic sponsored by Iron Mountain, which is in the healthcare data storage and protection business. This lecture is available for your review (see: Leveraging Cloud Storage: Store More and Spend Less for Medical Image Archiving).

All of the material provided by the two speakers was useful and interesting. One of the points that interested me the most was the assertion that about half of all hospitals save all medical records, presumably electronically, forever. The rationale behind such a policy is that the legal storage requirements for various components of the medical record such as clinical lab data or radiology images vary considerably. It is thus easier for hospitals to store all of their data forever rather than researching and complying with the individual patchwork of storage requirements. This makes total sense to me, given the relative ease and cost-effectiveness of computer storage of data and particularly cloud storage. However, keep in mind that Iron Mountain is in the business of selling cloud storage and this statistic comes from them.

This brings me to my last point. The presentation and PowePoint file linked to above certainly has a commercial bias. It''s very good content but it's still a kind of commercial for the company. My preference for webinars sponsored by various companies is for them to be neutral and unbiased in tone. This may turn out to be an irrational hope. I still think that the cloud storage lecture is worth a look but consume it with proper consideration of the source.