Cool Technology of the Week
While in Japan last week, one of my lectures focused on emerging privacy and security issues. I highlighted the fact that increasingly sophisticated malware can breach every defense we put in place and that our best strategy is early detection when prevention fails.
Such an approach works well when the risk for damage is minimal. But what happens when the malware infects a medical device such as a smart pump or pacemaker? The risk of harm is far more dire than data integrity and includes physical harm up to an including death.
Sound far fetched?
This article illustrates that many of the command and control systems used in medical devices have inadequate security protections.
Hacks and malware aren't cool, so my cool technology of the week is a plea to the medical device industry - you need to engineer new devices with hardware level safeguards that impose sanity checks on the commands being given. Use encryption to protect all data transmissions and data at rest. Set limits on the minimum and maximum amounts of insulin that should ever be injected into the patient. Assume that hackers will penetrate and take control of the device.
We need your innovation now and that will be very cool.
Our Lives Together
Monday, August 8 was my 27th wedding anniversary. My wife Kathy and I met at Stanford on September 1, 1980, so we've been together for 31 years. That means that we've spent two-thirds of our lives on this planet together. We've been collaborators, soul mates, homeowners, parents, and friends together. For three decades, our relationship has just worked. Here's why.
My entire life has been math/science/engineering - digital, white and black, linear, orderly, and left-brained.
Kathy's entire life has been the visual arts/humanities/creativity - analog, splashes of color, wabi sabi, Victorian clutter, and right-brained.
Our talents are entirely different, our approaches complementary, and we never compete on any level.
In our 20's we were vigorous hiking partners and built a home together.
In our 30's we focused on raising a young child.
In our 40's we created stability by planning for the future, caring for our parents, and preparing our child to leave the nest.
In our 50's we're likely to travel, create, and tend our garden together.
In our 60's and beyond we're likely to create a Japanese inspired wilderness retreat to serve as a home base between experiences around the world that are part of our work lives, volunteer lives, and personal lives.
We've evolved together and continue to expand and refine our relationship every day.
When I read literature from the scientific and lay press about the "seven year itch", it makes me realize that needs change, people change, and relationships need to change over time if they are going to last.
In your 20's you're likely at the peak of your physical life with more endurance, strength, and biological resilience than any other era. You can climb mountains and if you fall you bounce.
In your 40's, you're likely to be at the peak of your mental life with more experience, intellectual agility, and intuition than any other era. You can climb mountains, but if you fall you break. You're more likely focused on your 401k than your surfboard.
In your 60's you're likely to be at the peak of your financial life with more savings, more earning, and stability than any other area. If you've kept up your workouts and managed your diet, you can climb mountains, but if you fall, you shatter. You're more likely to be focused on supporting your children and aging parents, than thinking about a bleached blonde in a red convertible (unless you're a Congressman…)
If you and your partner are perfect for each other in your 20's, you may not be perfect in your 60's unless you adapt to your changing bodies, changing needs, and changing abilities together.
Kathy and I have been able to do that.
We've always treated each other as equals - there has never been a superior/subordinate aspects to our home lives, work lives, or family lives. Our division of labor is not cast in stone, it remains fluid based on the schedule and needs of each day. We share housework, we share parenting responsibilities, and we support each other's career.
Of course, we've had stress, anxiety, joy, sadness, and conflict along the way, that's life. But we've been able to weather the challenges, relish the successes, and treat each other fairly along the way.
This month we become empty nesters as our daughter begins her college life at Tufts on August 31. The house will seem quieter, the schedules will change, and our roles will need to evolve again as we focus more time on each other and our careers while our daughter becomes increasingly independent. It's another risky time for relationships.
But we'll navigate the transition, overcome the sense of loss, and plan our future together.
Given human life expectancy, we're likely to live another 31 years (I'm using Japan rather than US because our diet and lifestyle are distinctly Japanese). That means that Kathy and I are only halfway through our life together.
Happy Anniversary, Kathy. The second half of our time together will be even better than the first. I love you and always will.
My entire life has been math/science/engineering - digital, white and black, linear, orderly, and left-brained.
Kathy's entire life has been the visual arts/humanities/creativity - analog, splashes of color, wabi sabi, Victorian clutter, and right-brained.
Our talents are entirely different, our approaches complementary, and we never compete on any level.
In our 20's we were vigorous hiking partners and built a home together.
In our 30's we focused on raising a young child.
In our 40's we created stability by planning for the future, caring for our parents, and preparing our child to leave the nest.
In our 50's we're likely to travel, create, and tend our garden together.
In our 60's and beyond we're likely to create a Japanese inspired wilderness retreat to serve as a home base between experiences around the world that are part of our work lives, volunteer lives, and personal lives.
We've evolved together and continue to expand and refine our relationship every day.
When I read literature from the scientific and lay press about the "seven year itch", it makes me realize that needs change, people change, and relationships need to change over time if they are going to last.
In your 20's you're likely at the peak of your physical life with more endurance, strength, and biological resilience than any other era. You can climb mountains and if you fall you bounce.
In your 40's, you're likely to be at the peak of your mental life with more experience, intellectual agility, and intuition than any other era. You can climb mountains, but if you fall you break. You're more likely focused on your 401k than your surfboard.
In your 60's you're likely to be at the peak of your financial life with more savings, more earning, and stability than any other area. If you've kept up your workouts and managed your diet, you can climb mountains, but if you fall, you shatter. You're more likely to be focused on supporting your children and aging parents, than thinking about a bleached blonde in a red convertible (unless you're a Congressman…)
If you and your partner are perfect for each other in your 20's, you may not be perfect in your 60's unless you adapt to your changing bodies, changing needs, and changing abilities together.
Kathy and I have been able to do that.
We've always treated each other as equals - there has never been a superior/subordinate aspects to our home lives, work lives, or family lives. Our division of labor is not cast in stone, it remains fluid based on the schedule and needs of each day. We share housework, we share parenting responsibilities, and we support each other's career.
Of course, we've had stress, anxiety, joy, sadness, and conflict along the way, that's life. But we've been able to weather the challenges, relish the successes, and treat each other fairly along the way.
This month we become empty nesters as our daughter begins her college life at Tufts on August 31. The house will seem quieter, the schedules will change, and our roles will need to evolve again as we focus more time on each other and our careers while our daughter becomes increasingly independent. It's another risky time for relationships.
But we'll navigate the transition, overcome the sense of loss, and plan our future together.
Given human life expectancy, we're likely to live another 31 years (I'm using Japan rather than US because our diet and lifestyle are distinctly Japanese). That means that Kathy and I are only halfway through our life together.
Happy Anniversary, Kathy. The second half of our time together will be even better than the first. I love you and always will.
Healthcare is Different
I'm often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.
Many clinicians say that healthcare is different.
I'm going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.
Here's an inventory of the issues
1. Flow of funds - Hospitals and professionals are seldom paid by their customer. Payment usually comes from an intermediary such as the government or insurance payer. Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.
2. Hiring and training the workforce - Important members of the workforce, the physicians delivering care, are seldom employed by the hospital. This is rare if not non-existent in any other industry. It's as if Toyota built a factory that anyone can use but does not hire or train the workers who build cars. If someone wanted to create a Toyota with wings and an outboard motor, they would have the freedom to do it.
3. Negotiating Price - Reimbursement no longer is based on a price schedule hospitals and professionals can control. It is based on a prospective payment model such as DRGs that someone else designs and dictates. Where else in the US do prices get dictated to a firm?
4. Establishing referral relationships - We cannot market services to those who control our patient flow due to Stark anti-kickback regulations. In other industries, you can build relationships, offer special incentives, and arrange mutually beneficial deals to develop your referral business. In health care, it's illegal even when unilaterally funding an action would make things easier for both parties and the patient.
5. Standardizing the product - In most industries, the product or service can be standardized to improve efficiency and quality. In health care, every person is chemically, structurally, and emotionally unique. What works for one person may or may not work for another. In this environment, it is difficult to standardize and personalize care in parallel.
6. Choosing the customer - In most other industries, you can chose with whom you do business. Not so in health care. If you have an emergency department, you must provide treatment even if the customer has no means to pay.
7. Compliance - Data flows in healthcare in increasingly regulated. What other business, including the IRS, is required to produce, on-demand, a three year look back of everyone who accessed your information within their firm.
As I noted in my recent post about the Burden of Compliance "the more complex a health system becomes, the more difficult it becomes to find any system design that has a higher fitness."
We are successfully automating healthcare workflows, motivated by HITECH incentives and the requirements of healthcare reform. The 7 characteristics above have required vendors to create full featured software applications and organizations to create complex rollout/funding models that take time. By 2015 we will be there and I will be proud of all we've accomplished, given that the constraints on the healthcare industry are truly different than industries which have been earlier adopters of technology.
Many clinicians say that healthcare is different.
I'm going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.
Here's an inventory of the issues
1. Flow of funds - Hospitals and professionals are seldom paid by their customer. Payment usually comes from an intermediary such as the government or insurance payer. Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.
2. Hiring and training the workforce - Important members of the workforce, the physicians delivering care, are seldom employed by the hospital. This is rare if not non-existent in any other industry. It's as if Toyota built a factory that anyone can use but does not hire or train the workers who build cars. If someone wanted to create a Toyota with wings and an outboard motor, they would have the freedom to do it.
3. Negotiating Price - Reimbursement no longer is based on a price schedule hospitals and professionals can control. It is based on a prospective payment model such as DRGs that someone else designs and dictates. Where else in the US do prices get dictated to a firm?
4. Establishing referral relationships - We cannot market services to those who control our patient flow due to Stark anti-kickback regulations. In other industries, you can build relationships, offer special incentives, and arrange mutually beneficial deals to develop your referral business. In health care, it's illegal even when unilaterally funding an action would make things easier for both parties and the patient.
5. Standardizing the product - In most industries, the product or service can be standardized to improve efficiency and quality. In health care, every person is chemically, structurally, and emotionally unique. What works for one person may or may not work for another. In this environment, it is difficult to standardize and personalize care in parallel.
6. Choosing the customer - In most other industries, you can chose with whom you do business. Not so in health care. If you have an emergency department, you must provide treatment even if the customer has no means to pay.
7. Compliance - Data flows in healthcare in increasingly regulated. What other business, including the IRS, is required to produce, on-demand, a three year look back of everyone who accessed your information within their firm.
As I noted in my recent post about the Burden of Compliance "the more complex a health system becomes, the more difficult it becomes to find any system design that has a higher fitness."
We are successfully automating healthcare workflows, motivated by HITECH incentives and the requirements of healthcare reform. The 7 characteristics above have required vendors to create full featured software applications and organizations to create complex rollout/funding models that take time. By 2015 we will be there and I will be proud of all we've accomplished, given that the constraints on the healthcare industry are truly different than industries which have been earlier adopters of technology.
A Tale of Telecom Woe
My wife and her business partner have tried for weeks to get a large telecom provider to reactivate an existing DSL connection to their art gallery. However, they will not do it per an official letter which states that my wife has an outstanding balance of ZERO and until that balance is paid, no further work can be done.
As Joseph Heller would have written - you do not have an account and you owe nothing. Until you pay us nothing on an account you do not have, we cannot give you an account.
Numerous phone calls to the telecom's service centers have been answered by people who will not give their full names or contact information.
No one seems empowered to solve the problem, there is no accountability, and no possible escalation.
How can a company with such great technology have such onerous customer service? I'm a CIO so I understand the challenges of running a large organization. I accept variability in individual employee behavior. What I cannot tolerate is weeks of effort across many employees that demonstrates this telecom provider has lost control of its own business processes.
Here's my wife's account of the struggle thus far.
"We would simply like to contract for internet and phone in a commercial building. We are a registered LLC with a 4 year lease, in the second year of operations with this landlord.
Business partner Natacha Sochat is so frustrated that we will need to start reviewing our alternative options. We have been operating our business without phone and internet since May 3 and need to start service as soon as possible.
NK Gallery LLC (Massachusetts) was established January 2010 by business partners Natacha Sochat and Kathy Halamka. Our initial location beginning February 2010 was 460 Harrison Ave #17, Boston, MA 02118.
On May 1, 2011, we relocated to a larger space at 450 Harrison Ave #61, Boston MA 02118 (current lease runs to November 2014). The landlord/property manager is the same in both locations - GTI Properties.
The 450 Harrison building space #61 has preexisting writing, so we wish to purchase your phone and internet service.
On May 3, 2011, Natacha initiated contact. Your business services informed Natacha they would not proceed with our application until we updated the lease to prove we were a real business in the 450 Harrison #61 location.
On May 20, we obtained a finalized signed lease from the landlord. The lease includes our personal names, Kathy Halamka and Natacha Sochat, as this is the standard policy of the landlord, consistent with our prior lease in the 460 Harrison building.
On May 23, Natacha devoted the entire day to resolving this issue. Natacha visited your website and spoke with Laura. She was helpful and pleasant, but could not navigate your internal business operations.
Natacha called the your Credit Center twice while Laura was on the phone with her.
Four hours later, Natacha received a "denial of lease" fax.
Natacha again called your Credit Center and spoke with a heavily accented woman. The representative said she had no idea why the application was denied but told Natacha it may be because the lease refers to people rather than a corporation as the tenant.
Laura had no insight as why NK Gallery had been tormented, as no one else that day had been required to call your Credit Center, and when Laura called her fellow employees at the Credit Center they would not explain it to her either!
Laura advised Natacha to speak with a supervisor at your Credit Center. Natacha spoke with a supervisor and he would only tell Natacha his first name, Travis. He refused to provide any further contact information. He was very challenging to understand and requested many additional documents. (IRS, Fed ID documents etc). Natacha asked him to send her an email with a list of the documents he needed. She asked him if she could respond via e-mail instead of fax. He said no - the Credit Center cannot print anything, so fax is required.
You then sent a letter refusing to offer services until we paid a ZERO balance on the account that had not yet been created."
So there you have it. We tried desperately to give this telecom the business, but they refused.
As a test, I used my role as CIO and a major purchaser of services to escalate this Catch 22 situation and instantly received numerous offers of help from the telecom's Director and VP level. I chose not to pursue those offers and the gallery purchased services from a competitor. A CIO with a multi-million dollar budget should not be required to get simple DSL service!
There's a point at which companies get too big and lose touch with their customers. This particular telecom is a case study in broken business processes.
As Joseph Heller would have written - you do not have an account and you owe nothing. Until you pay us nothing on an account you do not have, we cannot give you an account.
Numerous phone calls to the telecom's service centers have been answered by people who will not give their full names or contact information.
No one seems empowered to solve the problem, there is no accountability, and no possible escalation.
How can a company with such great technology have such onerous customer service? I'm a CIO so I understand the challenges of running a large organization. I accept variability in individual employee behavior. What I cannot tolerate is weeks of effort across many employees that demonstrates this telecom provider has lost control of its own business processes.
Here's my wife's account of the struggle thus far.
"We would simply like to contract for internet and phone in a commercial building. We are a registered LLC with a 4 year lease, in the second year of operations with this landlord.
Business partner Natacha Sochat is so frustrated that we will need to start reviewing our alternative options. We have been operating our business without phone and internet since May 3 and need to start service as soon as possible.
NK Gallery LLC (Massachusetts) was established January 2010 by business partners Natacha Sochat and Kathy Halamka. Our initial location beginning February 2010 was 460 Harrison Ave #17, Boston, MA 02118.
On May 1, 2011, we relocated to a larger space at 450 Harrison Ave #61, Boston MA 02118 (current lease runs to November 2014). The landlord/property manager is the same in both locations - GTI Properties.
The 450 Harrison building space #61 has preexisting writing, so we wish to purchase your phone and internet service.
On May 3, 2011, Natacha initiated contact. Your business services informed Natacha they would not proceed with our application until we updated the lease to prove we were a real business in the 450 Harrison #61 location.
On May 20, we obtained a finalized signed lease from the landlord. The lease includes our personal names, Kathy Halamka and Natacha Sochat, as this is the standard policy of the landlord, consistent with our prior lease in the 460 Harrison building.
On May 23, Natacha devoted the entire day to resolving this issue. Natacha visited your website and spoke with Laura. She was helpful and pleasant, but could not navigate your internal business operations.
Natacha called the your Credit Center twice while Laura was on the phone with her.
Four hours later, Natacha received a "denial of lease" fax.
Natacha again called your Credit Center and spoke with a heavily accented woman. The representative said she had no idea why the application was denied but told Natacha it may be because the lease refers to people rather than a corporation as the tenant.
Laura had no insight as why NK Gallery had been tormented, as no one else that day had been required to call your Credit Center, and when Laura called her fellow employees at the Credit Center they would not explain it to her either!
Laura advised Natacha to speak with a supervisor at your Credit Center. Natacha spoke with a supervisor and he would only tell Natacha his first name, Travis. He refused to provide any further contact information. He was very challenging to understand and requested many additional documents. (IRS, Fed ID documents etc). Natacha asked him to send her an email with a list of the documents he needed. She asked him if she could respond via e-mail instead of fax. He said no - the Credit Center cannot print anything, so fax is required.
You then sent a letter refusing to offer services until we paid a ZERO balance on the account that had not yet been created."
So there you have it. We tried desperately to give this telecom the business, but they refused.
As a test, I used my role as CIO and a major purchaser of services to escalate this Catch 22 situation and instantly received numerous offers of help from the telecom's Director and VP level. I chose not to pursue those offers and the gallery purchased services from a competitor. A CIO with a multi-million dollar budget should not be required to get simple DSL service!
There's a point at which companies get too big and lose touch with their customers. This particular telecom is a case study in broken business processes.
First Experiences with Mac OSX Lion
Generally, I do not upgrade my operating system until at least the first major service pack is released and the industry has declared the software stable and secure.
However, many people have been asking me about Mac OSX Lion and I installed version 10.7.0 (that's version zero) on my personal Macbook Air so I could answer their questions from personal experience.
Here's an excellent MacWorld overview of its features.
The upgrade for me required a major decision - Harvard Medical School and Beth Israel Deaconess Medical Center have used PGP Whole Disk Encryption (PGP WDE) to support Massachusetts mobile device data encryption regulations and Federal best practices. PGP WDE does not work with Lion. Although PGP has been a great product, it has had issues with Mac OSX upgrades in the past.
Lion now includes native whole disk encryption, FileVault2 as part of the operating system.
I could have decrypted my existing drive and removed PGP WDE (not easy), a process that would have taken hours.
Instead, I simply backed up my files (my digital life is so cloud-based that I keep just a few hundred megabytes of personal files on my laptop), repartitioned and formatted the hard drive, did a fresh install of Snow Leopard, then installed the Lion upgrade.
Apple has chosen to make Lion a $29.99 download from the App Store rather than providing a DVD, so there is no easy way to directly install Lion on a blank hard drive at present - making the Snow Leopard reinstall/download Lion the easiest installation path.
Of interest, the $29.99 download license covers all the Macs in your household. Since each member of my family has a Mac laptop, that's a real deal.
The installation went flawlessly. As soon as it was done, I turned on FileVault and my entire disk was encrypted in the background in about 2 hours. I also turned on the host-based firewall.
I configured Mail/iCal/Addressbook and my entire historical data set synched with BIDMC's exchange servers in about 30 minutes.
The only applications I use other than those which are native to MacOSX are Keynote, Pages, and Numbers - the Office Suite from Apple that is bundled as iWork '09. I installed those applications and the end result was a complete new, fresh Macbook Air with Lion, iWork, my personal files, and a local copy of my email.
A few first impressions.
Lion is extremely fast - booting, browsing, and emailing were noticeably faster for me.
The new user interface includes many iOS gesture features and it appears that Apple is converging MacOSX and iOS to make it easy to for customers to use any Apple product without significant retraining.
The major gestural change is that the Macbook trackpad now works just like an iPad. You can zoom/shrink with a pinching movement and scrolling is reversed from previous OSX versions. If you move two fingers up, you push the document up and you see the content that had been offscreen.
Mail/iCal/Addressbook have been significantly upgraded and they are now superior to Outlook in appearance, usability, and functionality. In its standard configuration, Mail works just like gmail and maintains threaded conversations rather than just individual email messages.
In summary, I've now retired PGP Whole Disk Encryption, and use no other software in my digital life other than Mac OSX Lion and iWork '09. All appears fast, stable and secure thus far.
It will take time for IT organizations (including mine) to train internal staff sufficiently to support Lion, but for those early adopters who have the confidence to install and manage Lion for themselves, the experience seems entirely positive.
However, many people have been asking me about Mac OSX Lion and I installed version 10.7.0 (that's version zero) on my personal Macbook Air so I could answer their questions from personal experience.
Here's an excellent MacWorld overview of its features.
The upgrade for me required a major decision - Harvard Medical School and Beth Israel Deaconess Medical Center have used PGP Whole Disk Encryption (PGP WDE) to support Massachusetts mobile device data encryption regulations and Federal best practices. PGP WDE does not work with Lion. Although PGP has been a great product, it has had issues with Mac OSX upgrades in the past.
Lion now includes native whole disk encryption, FileVault2 as part of the operating system.
I could have decrypted my existing drive and removed PGP WDE (not easy), a process that would have taken hours.
Instead, I simply backed up my files (my digital life is so cloud-based that I keep just a few hundred megabytes of personal files on my laptop), repartitioned and formatted the hard drive, did a fresh install of Snow Leopard, then installed the Lion upgrade.
Apple has chosen to make Lion a $29.99 download from the App Store rather than providing a DVD, so there is no easy way to directly install Lion on a blank hard drive at present - making the Snow Leopard reinstall/download Lion the easiest installation path.
Of interest, the $29.99 download license covers all the Macs in your household. Since each member of my family has a Mac laptop, that's a real deal.
The installation went flawlessly. As soon as it was done, I turned on FileVault and my entire disk was encrypted in the background in about 2 hours. I also turned on the host-based firewall.
I configured Mail/iCal/Addressbook and my entire historical data set synched with BIDMC's exchange servers in about 30 minutes.
The only applications I use other than those which are native to MacOSX are Keynote, Pages, and Numbers - the Office Suite from Apple that is bundled as iWork '09. I installed those applications and the end result was a complete new, fresh Macbook Air with Lion, iWork, my personal files, and a local copy of my email.
A few first impressions.
Lion is extremely fast - booting, browsing, and emailing were noticeably faster for me.
The new user interface includes many iOS gesture features and it appears that Apple is converging MacOSX and iOS to make it easy to for customers to use any Apple product without significant retraining.
The major gestural change is that the Macbook trackpad now works just like an iPad. You can zoom/shrink with a pinching movement and scrolling is reversed from previous OSX versions. If you move two fingers up, you push the document up and you see the content that had been offscreen.
Mail/iCal/Addressbook have been significantly upgraded and they are now superior to Outlook in appearance, usability, and functionality. In its standard configuration, Mail works just like gmail and maintains threaded conversations rather than just individual email messages.
In summary, I've now retired PGP Whole Disk Encryption, and use no other software in my digital life other than Mac OSX Lion and iWork '09. All appears fast, stable and secure thus far.
It will take time for IT organizations (including mine) to train internal staff sufficiently to support Lion, but for those early adopters who have the confidence to install and manage Lion for themselves, the experience seems entirely positive.
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