What we can learn from TCP/IP

"I sent you an SMS to let you know I can't do it"

"I didnt get the message"

Time and again we see this common issue arise; sometimes simply as an excuse, but many a time, because the message is locked up in some digital chakravyuh, fighting hard to come out and reach the recipient, but not being allowed to move further due to various types of bandwidth bottlenecks, or because the receipient mobile is not available for that very instant.

Whatever the reason may be, it often leads to misunderstandings, conflict, trust issues and many a time a business loss.

Given that, what I find surprising, is that in typical SMS or eMail communications, how we shy away from responding to the original sender. "THANKS ...MESSAGE RECEIVED" ...

Thats something we must learn from our friend TCP ... the TCP of the TCP/IP fame...the protocol which is responsible for the internet... TCP or the Transmission Control Protocol provides reliable transmission of messages between programs running on 2 different computers. It is the protocol that major Internet applications such as the World Wide Web, email, remote administration and file transfer rely on. And the basic concept behind its reliability is simple ... "Acknowledgment of communication is the key to reliability" ....

On the right is an image showcasing "The 3 way handshake in TCP"


Imagine if we each of us simply responded with an 'OK' to the sender.

It would give us the freedom to believe that if an acknowledgement of some sort is not received, my message was not communicated. Saving us so many misunderstandings, conflicts and losses.

Information Therapy via Technology

My presentation at the 2nd Annual Conference on "Putting Patients First". I alongwith my good friend Aditya, contributed a chapter to the book USING INFORMATION THERAPY TO PUT PATIENTS FIRST. This presentation touches upon some of the ideas from that chapter.

Information Therapy via Technology

View more presentations from Nrip Nihalani.

Happy Teachers Day

 

This is to every teacher I know, man, woman and experience.  

Some gave me long discourses, 

Some created sparks, 

Some provided  clarifications, 

and Some made me learn things new....

but I am what I am due to you. 

Thanks for having taught me everything I know; 

I wish everyone gets to learn from teachers like you... 

N.B. 5th of September is celebrated as Teachers Day in India.

Here is a beautiful letter from Abraham Lincoln to the principal of son's school.

He will have to learn, I know,

that all men are not just,

all men are not true.

But teach him also that

for every scoundrel there is a hero;

that for every selfish Politician,

there is a dedicated leader...

Teach him for every enemy there is a

friend,

Steer him away from envy,

if you can,

teach him the secret of

quiet laughter.

Let him learn early that

the bullies are the easiest to lick... Teach him, if you can,

the wonder of books...

But also give him quiet time

to ponder the eternal mystery of birds in the sky,

bees in the sun,

and the flowers on a green hillside.

In the school teach him

it is far honourable to fail

than to cheat...

Teach him to have faith

in his own ideas,

even if everyone tells him

they are wrong...

Teach him to be gentle

with gentle people,

and tough with the tough.

Try to give my son

the strength not to follow the crowd

when everyone is getting on the band wagon...

Teach him to listen to all men...

but teach him also to filter

all he hears on a screen of truth,

and take only the good

that comes through.

Teach him if you can,

how to laugh when he is sad...

Teach him there is no shame in tears,

Teach him to scoff at cynics

and to beware of too much sweetness...

Teach him to sell his brawn

and brain to the highest bidders

but never to put a price-tag

on his heart and soul.

Teach him to close his ears

to a howling mob

and to stand and fight

if he thinks he's right.

Treat him gently,

but do not cuddle him,

because only the test

of fire makes fine steel.

Let him have the courage

to be impatient...

let him have the patience to be brave.

Teach him always

to have sublime faith in himself,

because then he will have

sublime faith in mankind.

This is a big order,

but see what you can do...

He is such a fine fellow,

my son!

Why use experts for a Medical Practice Website?

I believe in Information Therapy and a Medical Website is a very powerful tool to facilitate it. But to effectively impart information therapy, requires more than putting up 5 pages of text with some fancy images. Its important to use medical web experts to help create a site which is visually appealing, medically correct and patient friendly. I see tons of bad sites, and to be frank a few years back my own firm provided what I regard as medical websites which were not up to the mark to a couple of its clients. Thankfully, these sites were upgraded for free when our team learnt all about "What makes a Good Medical Website".

Here is a 7 step rule which serves as the basic rule set of a Good Medical Website.
1. Ensure Simple Navigation. Follow Jakob Nielsen's rules.
2. Make text readable; on different devices.
3. Use Images and Audio Visual Aids to communicate and explain Diseases and Conditions
4. Provide contact forms and let patients and peers email you.
5. Keep the content fresh and updated.
6. Ensure that every paper one may have to read or fill in when visiting your practice is available for download and easy to locate in either a Doc or a PDF format on the website
7. Provide visitors/patients with easy to use tools such as medical calculators. Let patients have the option of sharing the results displayed by these calculators with you directly via the website.

Why Use Experts for Your Medical Practice Website Design

View more presentations from Nrip Nihalani

Why are there no Mac’s in the clinic?

The Macs (Apple Macintosh) and most of what has come out from the Apple Factory of Kick Ass Design have been an inspiration to Product Designers and Solution Architects. That inspiration alone has helped todays Software products get Richer in User Experience

In the Health Care industry though, EMR’s, Practice Management Software’s and other Clinical Productivity Tools are primarily built for the ubiquitously available Windows platforms. A huge number are also available for linux, most of these Open Source, and a very small number for the Macs.

In the United States, where the EMR business is filled in with over 300 major vendors, there are apparently only 8 offering EMR’s which are natively built for the Mac.  Read this report by Houston from Software Advice to see these 8 vendors and a fantastic comparison of their features.
Very few vendors actually support the Mac, although a number of them do keep posting news and press releases that they are making one or launching one soon.

This may be a reason why many doctors over the years would want a Mac, but would’nt get one due to the lack of Medical Softwares for it.

In the interest of the majority of doctors reading this, lets ask the questions: “What does one mean when they say that their EMR is natively supported on a Mac? What exactly does it take for an EMR to be supported on a Mac ? What is this native thing I’m talking about”

For an EMR to be natively supported on a Mac, it must be able to be used by a Mac User while the program is running ON the Mac. The program’s code must be understood by the Mac –> The program’s code must speak the Mac’s language and follow the Mac’s set of rules. Windows has its own set of rules and they are different from a Mac. So a program made for Windows unfortunately may not run on a  Mac.

The Mac and the Windows are inherently different, and a software program built for one may not run on the other as the other operating system might not understand what the program is trying to say/do

For an EMR to natively run on a Mac, its underlying code must be understood by the Mac, and it must be following the rules of the Mac.

Smart question asked by Dr Vivek Patkar when I was explaining this above concept to him: Nrip, does this mean that if I have a software made for the Mac, and I can make Windows understand it, then it will run on Windows.
 
This is true and is the underlying reason why the virtualization industry is a boon and is bomming.  A Virtual Machine is a type of software used to create a Virtual Environment, which is referred to as Virtualization. Virtualization may be used to run multiple operating systems at the same time on one Physical Machine. Through the help of a virtual machine, the user can operate software built for one Platform (Or Operating System) on another.

This brings us to a Grand Realization. A SOFTWARE NEED NOT BE NATIVELY SUPPORTED ON A PLATFORM TO BE USED BY IT ANY MORE, AS LONG AS YOU CAN USE A VIRTUAL MACHINE WHICH ALLOWS YOU TO USE IT ON THE INCOMPATIBLE PLATFORM.

Here is a link to 2 fantastic Virtual Machines for the interested. As always, feel free to drop me a line at n.nihalani AT plus91.in for any help.

Virtualbox

VMWare Fusion

In recent times, whether it is due to Apple’s advertising or the Word of Mouth spread that works with Doctors, a Number of Indian Doctors have told us that they are buying a Mac; and if the Clinkare EMR would be supported on it. Yes of Course! Both the desktop version and the SaaS version are supported on the Macs.

Talking of Saas, this category of SaaS and Web Based EMR’s is exciting. THEY ARE USUALLY PLATFORM INDEPENDENT, UNLESS THERE IS A PC COMPONENT WHICH REQUIRES NATIVE SUPPORT: LIKE A SCREENSHOT PLUGIN, OR A VOIP COMPONENT, OR A DICTATION COMPONENT;

In this article on MAC EMR Software, Houston from Software Advice states “Web-based EMRs are the best long-term investment for doctors using Macs. Unlike their on-premise counterparts, vendors offering web-based software won’t have to support two versions of their software (i.e. one for Windows, one for Mac) in the long run ”

One can’t agree more. Every Web Based EMR vendor, knows that their EMR can be used using a Windows , a Mac, a Ubuntu; Users can even use the EMR’s on Tablet PC’s as well as Low Cost Netbooks.

There has been a surge in the adoption of the iPads in many health care institutions(pictures below), here in India, and as reported in the United States, United Kingdom and Singapore. iPads with their form factor well suited for use by On Round Doctors in In-Patient Wards, Nurses while taking down Vitals in Charts and even Assistants in OT’s for Managing Checklists are a hit. 

LabC: Pathology EMR on the iPad

Dr Bhosale trying the Clinkare EMR on her iPad

        
With Virtualization being available and Web Based EMR’s being the popular flavor with vendors, there are now choices available to Physicians and Clinics for Medical Software which can be used with their Mac’s.

If you are in the United States, you may want to use this comparison to help you select the Web based EMR which works best for you

If in India, you really should give the Clinkare Physician EMR a try ...

Want to acquire an EMR Vendor: Look out for these points:

Considering the Electronic Medical Records space is heating up across the globe, and in India too in the coming 5 years there should be some Big Groups like Reliance entering it, lets look at what a Corporate Biggie looking at entering the EMR space via an acquisition should look for in an EMR Product.

The guys at Software Advice linked me to this very interesting article on their site by Austin on Intuit and a possible acquisition by them in the Health IT segment and requested a few added opinions on the same. http://www.softwareadvice.com/articles/medical/intuit-health-1042511/

Since Austin has done a fantastic job at listing the qualities Intuit should be looking at in an EMR Product for acquisition, lets list them out before going further:

• Low price point product -
• Dead-simple UI -
• Friendliness for cash-based practices -
• Web-based deployment -
• Large market share / brand name -

In case the strategy is to go after Physicians and 1-3 Member clinics as mentioned in the article, most of these points are a given. The price point being low should not be an important factor in case there is a substantial subscriber base of Physicians - the eventual target market.

I'll look more at things to cover which if not looked at can and will lead to issues in the future:

1. Is it just an EMR or does it also help a physician do his job better? 

There must be enough reason for a Phsyician to use this EMR as against pure digitization of records. Here is a list of a few features that help Doctors run their practice more efficiently:

• What Patient Safety features are provided?
• Are there Medico Legal Safety features to protect doctors against suits?
• Does it allow operation for patients as an EHR ?
• Does it allow Physcians to export Clinical Statistics and Trends which can be used in Presentations, Research papers or simply better planning.
• Does it offer Administrative advice like a Hospital Information System does?
• Can it generate Email and Text Messages alerts, Birthday and Anniversary Reminders, have some CRM functionality.
• Can the doctors, nurses and staff have Intra-Team chats via the product.

(This list is compiled from requests by doctors who have been using an EMR for a minimum of 2 years)
One point which I'd also like to add is Does it interface with 3rd party PHR's or Patient Portals?
 

2. How does the EMR vendor provide training and after sales support? This is an important factor which directly influences the percentage of Physicians which will stay on with an EMR vendor in the long term. 

• Does the EMR vendor have a ticketing system?
• Does the EMR vendor allow issues to be reported via the Phone to a person?
• Does the EMR vendor provide Live and Online Support?
• Can the EMR user simply email the issue with possibility of attaching a screen shot?
• Does the EMR vendor have a Dedicated Training and Help portal with html and audio visual Training Aids?
  
• Does the EMR vendor provide a DVD with audio visual aids for Training?

3. How does the EMR vendor collect feedback and feature requests. Health Care IT is still a nascent idea irrespective of the billions being pumped into it. As the user base grows, the improvements and feature ideas that this increasing mass of users provide will change how EMRs are built and function over time. If the EMR vendor you pick does not do it, some one else will.

P.S. Plus91 runs a Pain Point Analysis program for Physicians in India and we get almost half a dozen ideas each month. Every 6 months we go through that list of ideas to evaluate which of them should be the next feature to put in. This program lets us "Help Doctors Help Us Help Them". Look for an EMR vendor who has been listening to the users and has a dedicated process to solicit and collect feature feedback and requests.

4. How consistent is the EMR firm with regards their Business Model?
Different EMR firms have different Business Models. Comparing Practice Fusion vs AdvancedMD on a parameter like Subscriber Base doesn't make sense. Some have short terms models directed at Sales, other look at Recurring Revenue via SaaS and Value Added Offerings, while others look at real long term offerings based on Data Mining and Trend Analysis. Whatever be the model, consistency is important.

5. How future proof is it: The EMR and the Vendor? 
Its important to look for an EMR company which is thinking ahead and is building its products influenced by the future. Look for mobile friendliness and features for a smart phone offered by the EMR, Does it have a smart way of integrating Social Media while following privacy norms.

6. Flexibility ???:  Flexibility may mean ability to modify the UI, enhance the product features, add newer modules. Physicians and small practices usually don't have their requirements clear and these do end up varying over time. A flexible EMR permits additions and modifications to be made quickly in the future. Look for an EMR product which is flexible, modular and offers the scope for improvement. Note, that this is a very tough ask in spite of how simple it sounds. Too much focus on flexibility can easily lead to a non-product.

Useful Links:

Technology For Doctors

Physician barriers to EMR Acceptance 

A Blog on EMR and EHR

Slideshare Love & Some Social Media for Doctors

I woke up this morning to the familiar buzz of the phone alarm, and as always, on dismissing it went to check what emails awaited me at the start of the day. I saw a plethora of emails with Slideshare in the subject message. One of my presentations “Facebook for Doctors and Medical Practices” was featured today on Slideshare. :)

An educative presentation which is also available on Wirelysis, it focuses on explaining “the Why and the How” of using Facebook Pages by Medical Practioneers.  I am happy to see that Slideshare’s editors have liked it and they have found the material beneficial for others. Lately there has been a surge in the number of Articles and Presentations being written and shared on topics related to “Using Social Media in Health Care”. Hence I am happy that my 3 month old midnight piece got featured.  

Social media is for everyone. It’s about all people, networking on things they like, whether they are videos, conversations or information.  Doctors are also a subset of this highly engaged group of people.  Tons of them participate in social media; personally, professionally or both.  And as always they have a lot to say

Using Social Media in Health Care has several advantages. It’s a cost effective way to use something you do for fun to help out your patients, by spreading information, providing support as well as in a providing a quick piece of advice.  It’s also a great way to get feedback.  

But take this next bit with a pinch of salt. If you do plan to bring in a professional aspect to your Social Media life, understand that you are now in the public domain. While you will gain publicity, you are now also exposed to being more abused. Don’t be oblivious to the fact that we have a Wall Feed where we will enjoy reading what you post.  With great power, come great responsibilities.  Be responsible and don’t do things which you wouldn’t do in public at a party.

A number of doctors had emailed me today asking me about Twitter and how they can leverage it for themselves. My reply: "Get on it, converse and engage: We'll talk more in a week, hopefully on Twitter".  Well, besides the simple gyan on “the Why and How”, I have something cool coming up.  I have been researching practically and building algorithms and processes related to Twitter as well as other aspects of Social Media, on how they can be leveraged effectively by the Health Care industry. The main onus being on how Social Media can be used to:

• Help provide accurate information faster
• Help patients interpret information more effectively
• How physicians and hospitals can leverage these algorithms to improve patient care, patient safety and patient comfort
• How physicians and hospitals can bring in more patients as a reward for being concerned about them

A lot of my work has pointed towards “unique forms” of collaboration and creation of information ecosystems.  I feel I will take a few weeks to share my work in the public domain as some of the results have not been vetted and processes finalized due to constraints on my time and pocket. Within a few weeks I should be putting out an effective guide on Twitter use for both Physicians as well as Hospitals. In the meantime, I will recommend this simple yet beautiful post by one of my favorite blog authors Scott Hanselman titled  Subtle but Very Important Twitter Tips and Techniques You Should Know (cause no one will tell you)

Useful Links:

The Facebook Pages presentation on Slideshare
 

Plus91's Website 

Websites For Doctors  : This is where you must contact to get Social Media profiles made and managed for your self or practice

Follow me on Twitter: @nrip

Follow Plus91 on Twitter: @plus91
 
Note: 

A number of doctors in India and a few from the United States have contributed by either sharing the statistics from their Social Media Data and Profiles with me, while some have done so by actually getting on it and trying out what I’ve been asking them to do. 

Any doctor who wishes to help out may simply contact me via emai or Contact me via Plus91  :)

Prayers for Japan and Learnings for everyone on the benefits of National Health IT Policies

The past few days have involved almost all of us praying for Japan which was ravaged by a severe earthquake and tsunami. Japan's most powerful earthquake in 140 years struck the north-east coast on March 11^th 2011, triggering a massive tsunami leaving behind many homeless and stranded. (Information and Situation Report from WHO)

As we continue praying for hope in Japan, we are also learning all we can about how disasters can impact the way we live and seek to improve. Sadly, Japan now faces severe logistical problems and with the latest news on the mishap at a nuclear reactor, the situation only seems to be getting worse. While Japanese officials have more pressing issues on their hands, a problem that will arise as time progresses will be that those left alive may find themselves without their medical records. Natural disasters wipe out everything — including paper medical records as well as computer and communication networks.You can setup the network again, but you can't bring back the paper.

In this time of national crisis, it would have certainly been helpful for Japan to have a robust Healthcare IT network in place. A collaborative one where it is easy to share data, which is securely backed up redundantly in multiple locations that would leverage geographical diversity as a means of countering nature’s unpredictability: Geographical Division Multiplexing if you please;

While Japan does have a Healthcare IT strategy setup, with benefits and stimulus funds, it is relatively new and yet to mature. Health data digitization and Electronic Record Keeping is still in its infancy. Japan does not boast of large scale Electronic Medical Record coverage.

Wouldn’t any country ride out disasters better with health data sharing in place? This should be taken as a wakeup call as well as a learning lesson by all nations which haven’t yet devoted time and money to setting up Nationwide Health IT Infrastructures.

India for one must be looking at learning from this.  Having a Nationwide Health IT Strategy should be treated as important as a Tsunami Alerting System (TAS).  Purists will argue that a Nationwide Health IT System is not intended for alerting and helping contain situations like the TAS. And they are not completely wrong. 

In many cases it has been observed that long term benefits are eventually forgotten. Instead, this concept of “Long Term benefits” must be replaced with Pre-planned Goals which must be “Sought” on maturity of a model.  Now, any system can provide a set of benefits directly on implementation, and an additional set when it has matured.

Similarly, the use case of using a Nationwide Health IT System for predicting and alerting requires a certain amount of usage at first.  A sophisticated and mature Nationwide Healthcare Network built using technology can identify the emergence of possible pandemics. Trends in symptoms can help identify risk areas, and collaborative diagnosis can help is sharing treatment plans and improving them.

One must understand that if maturity of a network is required for additional goals and since that takes time, one must seek to implement early. 

Links of Interest

WHO Page on Environmental Health in Emergencies

WHO page on Myths and Realities in Disaster Situations

NDNC just got a bit "Smarter"

The National Do Not Call (NDNC) registry is a short sighted solution to the nation's tele-marketing woes. Its strange that in a country built on a pedantic education system, the real life solutions which are implemented never seem to identify educating masses as a possible option. 

Note: to those who implemented the NDNC: your intentions were great; However, its important to look at the impact on Indian business of all types... The fact is that Mass SMS solutions are used not just for Tele Marketing. Since a Bulk SMS plan (primarily for telemarketers) is sold for 5-6 paise per SMS vs a Bulk Priority SMS plan for 50 paise or more per SMS (For Priority SMS which routes around the NDNC), Most Indian firms(primarily SME's) were happily using the former for all their SMS needs: even for critical alerts...Customers usually would demand that decision due to the knowledge that a lower price is possible and most firms would jump at this opportunity to inflate margins; Rashmi Bansal and many others celebrate this spirit and call it "Jugaad"...

Well the NDNC was appreciated at first, but as it went along, it started having detractors. The ones who were affected: All the way from Solution providers, eventually to the ones who wouldn't receive Password change alerts, Medical Appointment Alerts, and so on and so forth became critics of the NDNC. A most interesting and worth mentioning example here is of a "Software Security" Institute which would send the password for newly registered  users via an SMS and since half the nation had parked their numbers into the NDNC these guys would wait endlessly for the SMS ... I found it really silly on the part of this Institute: apparently teaching cutting edge IT Security,  they could'nt take the basic effort to update their systems: Instead they put up disclaimers stating that this is not their fault but that of the govt. :).

But what else does one expect. In India, entrepreneurs and  businessmen are driven by profit rather than anything else. Most Indian Business firms start talking RoI on day 1. The usual plan is to create quick and dirty solutions, as long as they work... and move to quick and dirty solution No. 2. Well getting back to the point, a number of cool firms locked in SMS solutions for their effectiveness and also for the coolness factor involved. The day NDNC came in, these guys were on plan 5 and plan 1 got hit. Most didn't care sadly.

Thankfully, the NDNC solution has been modified and made a bit more flexible and smarter. Now it allows mobile subscribers to register into the NDNC; but also specify their options on industry types do they find worth their time.

One simply has to dial 1909 from the mobile or send an SMS as following:

START [OPTION] and send it to 1909.

There are a number of options to choose from. For example, if you’d like to block all calls and messages, your option code is ‘0’ (ZERO). In this case, you should send an SMS as START 0 to 1909. Other options are:

1. To block all calls and SMS except from Banking/ Insurance/ Financial products/ Credit cards category
2. To block all calls and SMS except from Real estate category
3. Block all calls and SMS except from Education category. Similarly,
4. Allow only health related calls or SMS
5. Allow only consumer goods including automobiles related calls or SMS
6. Allow calls or SMS only from Communication/ broadcast/ Entertainment/ IT related fields
7. Allow calls or SMS only from tourism and Leisure segments.

As an example, to allow calls and SMS's from the Health care Sector and to block everything else

Compose an SMS "START 4" and send to 1909

On an other front, I am happy that more people can benefit from Plus91 's SMS Based Appointment AlertsPrescription Reminders. Further now more patients can take advantage of our Information Therapy Initiatives such as My Fertile Time. 

Facebook for Medical Practices and Doctors

Facebook has seen unprecedented growth in the last 4 years. From a small community site, specific to colleges, it has overtaken Google to become the favored haunt of the webophile. One of the reasons for this has been the number of applications that are built on Facebook, but a bigger reason is that because "Everyone is On Facebook". Lets face it, if you want to know what someone did last Sunday, or last month, Facebook is a bigger help than any friend that you have.  Coming to the point, the last year has seen a serious growth in the number of doctors creating Facebook profiles.

Now I've spent a considerable amount of time helping doctors embrace technology for different reasons. Some want technology to help manage their clinic, some to help manage patients also, some simply want to use it to connect to friends and family far away while some other want to use it to see if it can help them learn more. Facebook is a brilliant technology for just keeping in touch, and to make regular announcements. Not too regular mind you.

The presentation below delves into the Why's and How To's of setting up a Facebook Page for a Medical Practice. It also provides some examples and contains a video showcasing samples of very effective techniques.

Facebook Pages For Doctors and Medical Practices

View more presentations from nrip.

Note:
As with all professions, Medical Professionals have started slowly empowering themselves using the benefits of technology. Over the years, I have analysed how each medium would benefit a doctor given his specific needs, and of course had to reason on factors such as the learning curve, investments on time  and mindsets.   Social Media is one such medium. This article is part of a series of 4 where I delve into how Doctors can use different Social Media avenues for different purposes.

You may wish to check out Websites for Doctors to start off with creating a digital Identity for yourself. By my calculation, its the largest provider of Medical Websites in Asia