Virtual Care, Real Challenges

2020 has been much worse than anyone expected - and I don't think people expected much. I take some comfort that, when things were getting cataclysmically bad in New York City, in March and early April, our virtual urgent care staffed up, met the demand, and was able to help some patients. This is the story of Mount Sinai Now and COVID-19.

Enter the Informaticist

The Meaningful Use program to incentivize adoption of EHRs was announced right as I was wrapping up residency, and planning to embark on subspecialty training in Clinical Informatics. My first real articles for EPMonthly were about Meaningful Use.

Ten years later seemed like a good opportunity for me to reflect on the program's success (almost all of us are, finally, using electronic records for patient care) and failures (the systems are more limited and frustrating than they ought to be). The two-part article is available here and here.

Academic deliverables

While the job I trained the most for is Emergency Medicine, the job I spend more time on these days is clinical informatics. And that job is further subdivided: mostly supporting our ED's electronic record system, but increasingly, helping to study, operationalize and guide adoption of medical apps and wearable devices. It's honestly the most exciting part of my job, because it seems like we're helping to bring about the future.

Two documents that summarize a lot of my recent thoughts and efforts these on these topics are available online. The first (pdf) is a deep-dive into mHealth apps in Emergency Medicine - the potential and the peril. The second document is our case report of pulling a patient's Asthma Health app data into a pulmonologist's EHR. Sounds simple (and sort of is, with the new FHIR standard) but this involved a lot of data-sharing steps and permission settings, from both the patient and doctor (and a lot of steps from us, the clinician-scientists that saw this process through).

One downside to this sort of work is that it's quickly obsolete. But hey, so are blogs. Hopefully, at least, these links endure.

The Last Social Network

We could have prevented a lot of damage and waste, with the "new" "social network" called Binky. Binky that dispenses with illusion that social networks give us useful information that we need to check frequently; Binky exists solely to pacify. But Binky's designed to never disappoint or enrage its users - and all your likes and comments disappear into the ether.
Binky is a social network app with no network and no socializing. And yet, Binky is not just as satisfying as “real” social apps like Twitter or Instagram, but even more satisfying than those services. Its posts are innocuous: competent but aesthetically unambitious photos of ordinary things and people. Should binkers feel the urge to express disgust at Linus Paulding or Lederhosen, they can swipe left, and Binky accommodates without consequence. And the app doesn’t court obsession by counting followers or likes or re-binks. 
There’s a use of cigarettes beyond their chemical effects. Smoking gives people something to hold and something to do with their hands. McLuhan called it poise. And smartphones offer something similar. At the bus stop, in the elevator, in front of the television, on the toilet, the smartphone offers purpose to idle fingers. To use one is more like knitting or doodling than it is like work or play. It is an activity whose ends are irrelevant. One that is conducted solely to extract nervous attention and to process it into exhaust.

Social media is a little like smoking - it started with the elites and spread everywhere, then the elites got wise. Maybe that's what's happening now with social media too. The elites are now (belatedly) treating social media like a cesspool, but the masses are adopting it wholeheartedly. Perhaps Binky will be the Nicorette or e-cig that weans people off their destructive addiction. 

Paul Ford's not sentimental

Well, when I was thinking up and writing my last post, Paul Ford was writing this, on the occasion of 20 years of blogging:

I took it very seriously for many years and it earned me thousands of readers, thousands of emails, and tons of opportunity. It was better at generating opportunity than money. I drifted away for all the regular reasons. 
I had many thoughts about how to mark this moment and all of them were self-indulgent and exhausting. What I do is completely relevant and alive, thank you, and what was lost was lost. People keep expecting me to be wistful and nostalgic. But there was no innocence or purity. Not ideologically, politically, textually, technologically, sexually, or personally. Everything powered by ambition comes with compromise and taint, and is made under ridiculous circumstances. Everything good is transmuted from grudge-fueled self-doubt into something that other people love and criticize, knowing they could do better if given the time and resources.
That's a pretty economical encapsulation, looking back from my mid-career perspective. The ending is also quite a kicker.


Six (!) years ago I collected a lot of my writing from EPMonthly and Medscape, in links on Tumblr. I thought it looked pretty spiffy, and that I was establishing a beachhead on the next big platform. That didn't exactly work out. I had a splash page to organize my online web presences, but they closed down.

I set up a Medium account a while back, but haven't done a great job of maintaining that, either. This morning I cross-posted a few of my recent articles for EPMonthly and Telemedicine Magazine to Medium - they make it easy to import, and I like how the retrospective on pagers turned out. Maybe it'll get some claps.

Why not use Blogger more? I was thinking about this the other day, as I set up yet another health app blog. When I dashed off the first entry and clicked Publish, Blogger yielded to Google Plus, and I was prompted to share my writing amongst my Circles. I audibly groaned.

First, those Circles haven't been updated since 2012 or so. But most importantly, this latest post was intended for a finely-tuned audience of health app users; not my circle of high school friends or workplace acquaintances. The folks in these Circles, in fact, have never been the audience for this blogging.

An under-appreciated aspect of the blogging scene of the 00's was that we were essentially writing in the dark. The audience might show up, or might not. You could register with Technorati and other indices to popularize your stuff, or try to find an audience with Grand Rounds or other carnivals. But if you didn't want to, that was ok too.

I guess I got used to that environment - because the idea of putting each new blog post in front of old friends and acquaintances, like Google Plus suggests, seems pretty abhorrent. It's probably discouraged my blogging, over the years - certainly on this platform. Imagine if, at the end of each day, a publisher took the output from an aspiring novelist and asked, "are you ready to share this with your family and high school friends?"

Maybe it's time for (sigh) yet another platform. Fortunately, I have a home at EPMonthly (and Telemed Mag) that will continue to inspire and encourage my writing.

The shape of things to come

What's Apple going to do in a few years, when smartphone technology plateaus, and people don't spring for an upgrade every 2-3 years? There's been speculation about a car, but I think the world's most profitable company isn't going to add much to its profits by selling something out of the reach of most of the world (and those that can buy an Apple car probably won't do it as often as they buy an iPhone).

Instead, I think the answer is now apparent, with the new product introductions of the Tim Cook era - Apple Watch, AirPods, and the forthcoming HomePod. These interconnected "smart" devices are all relatively inexpensive (as far as Apple products go). Interactions are largely through voice, or a few taps. You forget you're wearing the Watch or AirPods, and the HomePod looks pretty unobtrusive.

A smartphone is pretty much required to use any of these devices today, but you can imagine that won't always be the case (recall the iPhone required a Mac or PC running iTunes, in its early years).

While none of these devices are essential now, when you need them they're really nice to have handy. They're definite improvements on dumb watches, dumb speakers and regular headphones. I already use my Watch to pay for coffee and taxis, respond to texts, and in the years to come it will probably assume more of my phone's role. The HomePod right now is limited to music, HomeKit, and simple cloud queries, but it seems a safe bet that in the years to come its capabilities will grow (merging with or running Apple TV, serving as a phone, sending and relaying messages to contacts, etc).

Macs will continue to be around, for "serious" work (though they've made up a tiny fraction of Apple's revenue and profits and that seems unlikely to change). Other screened devices, like iPads and TVs, will be around for play, photos and short written notes. If there's one element missing it might be a standalone TouchID keyboard. But more of our future, I think, has come into view this week - and it's mostly screenless, distributed between wearables and innocuous furnishings like the HomePod.

Health IT, under attack

With the recent news of the WannaCry ransomware attack and how it particularly hurt UK hospitals, I figured it was appropriate to link to our writeup of An Academic Medical Center's Response to Widespread Computer Failure (PubMed / ResearchGate). This was our experience in the hours and days following a botched 2010 McAfee's antivirus update, which began attacking a core component of Windows, and rendering PCs unusable. While accidental, in many ways it resembled a cyberattack.

Of course, there's been great coverage of the attack and its implications. Halamka was quoted:

“By prioritizing clinical functionality and uptime, healthcare organizations may not always have the most up-to-date software. Thus, healthcare, in general, may be more vulnerable than other industries to cyberattacks, and the scope of the impact to the NHS in the U.K. illustrates the problem." 
He said that some mission-critical systems were built years ago and never migrated to today’s modern platforms. In 2017, there are still commercial products that require Windows XP for which few patches are available, he said.

Other useful perspectives on healthcare IT's vulnerabilities emphasize HIPAA / business associate concerns when accepting patches. Lessons abound. Hopefully we'll learn them well enough to prevent future episodes.

A year without blogging

It's not I've stopped writing - besides the peer-reviewed stuff there's articles and commentary at EPMonthly and Telemedicine magazine, tweets @nickgenes, and the occasional piece for Medscape.

But coming to blog at this site doesn't just feel like a chore - it's laden with a sense of guilt. I was so very wrong about the potential of blogging and social media.

There were warnings. Back in 2010 I commented on a WSJ blog about our experience implementing electronic medical records in our ED. Another commenter then accused me of practicing "Tuskegee medicine" and experimenting on patients without consent, because EMRs hadn't been shown to be safer and more efficient than paper records in randomized trials. I'd seen trolls before but not for academic discussions like this - and the troll was signing his note with an MD's name (though not someone I could find in US physician databases).

Elevating the status of online discourse is something I've wondered about for years - it's the reason this blog adopted Facebook-authenticated comments. Our research found value even in the web's darkest corners, like YouTube comments. But of course in general, commentary kept getting worse. Last winter I lamented that the media framed stories much like Vegas sets the spread, to ensure maximum pageviews, debate and ultimately, vitriol.

All this was before the 2016 presidential election really heated up. Eventually last year, every news story was quickly put in terms of your team vs the other team. Our team is always noble and wise, but the other team is misguided at best, hypocritical and probably evil, often dumb or short-sighted, and if they're making any gains it's because they're cheating. Interacting with old friends online became a fraught exercise. Even the #FOAMed community began to see polarization and personal attacks.

So blogging and using social media, for me, if it's going to continue, must take the form of record-keeping and journaling - links to useful resources, or snapshots of what I'm up to at a particular point in time. Anything more would be a waste of time.

One week in

I've commented before that politics is increasingly like sport - more and more we're just rooting for our side. Ultimately it means policy and ideas don't matter; only winning does. One side has already made this an explicit part of their strategy; they're playing to win, not respecting "norms," and using every tool at their disposal to keep winning.

A quote from The Economist, on the occasion of President Trump's inauguration:
All populists are at heart conspiracy theorists, who pretend that easy solutions exist to society’s woes and have only not been tried to date because elites are wicked and deaf to the sturdy common-sense of decent, ordinary folk.
 So how can populism be challenged? A lesson from Venezuela:
Your organizing principle is simple: don’t feed polarization, disarm it.
This means leaving the theater of injured decency behind.
The Venezuelan Opposition struggled for years to get this. It wouldn’t stop pontificating about how stupid it all is. Not only to their international friends, but also to the Chavista electoral base itself.
“Really, this guy? Are you nuts? You must be nuts.” We’d say.
Don’t waste your time trying to prove that this ism is better than that ism. Ditch all the big words. Why? Because, again, the problem is not the message but the messenger. It’s not that Trump supporters are too stupid to see right from wrong, it’s that you’re much more valuable to them as an enemy than as a compatriot.
The problem is tribal. Your challenge is to prove that you belong in the same tribe as them: that you are American in exactly the same way they are.
But if you want to be part of the solution, the road ahead is clear: Recognize you’re the enemy they need; show concern, not contempt, for the wounds of those that brought Trump to power; by all means be patient with democracy and struggle relentlessly to free yourself from the shackles of the caricature the populists have drawn of you.
Unfortunately these tactics against Chavez were never truly successful; he was never ousted and died in office. His reputation among the people remains good, even though he didn't do enough strength Venezuela before its economic crisis. 

I suspect, like Chavez, Trump's reputation will remain strong with his core supporters, no matter what messages the opposition adopts. Like anti-vaxxers and climate deniers, too many people are just too isolated from the consequences of their beliefs; there's not enough pain or suffering to make them doubt the messages they're hearing. Unless we have a similarly bad economic crisis while Trump is in power, or another 9/11 or Katrina-style catastrophe that he obviously mishandles, this will continue. 

#SAEM16 panels

SAEM's Annual Meeting is in New Orleans this year. While a lot has changed since San Diego, I'm fortunate to again be participating in several didactic sessions this week. The program is available online - links to slides are forthcoming. 
  • Tuesday @ 1:45pm or so in Napoleon Ballroom C2 (3rd floor): As part of the Social Media Bootcamp, I'll be talking with Megan Ranney about using Social Media for research - slides

  • Thursday @ 8am in Napoleon Ballroom B2 (3rd floor): DS-22: I'll speak about conducting EM research using social media tools, in a panel with Megan Ranney & Austin Kilaru - slides & references

  • Thursday @ 9am in Napoleon Ballroom B2 (3rd floor): DS-28: Nidhi Garg moderates a panel featuring me, Esther Choo and Megan Ranney on disseminating research through Social Media - slides & references
If you're interested in any of these topics, and at SAEM, you probably also want to attend the Social Media committee meeting Wednesday at 1pm in Evergreen (4th floor). Also on Friday morning Ken Milne talks about knowledge translation through social media, in DS-58 (Grand Ballroom E, 5th floor).  In the same room, right after, Rob Cooney and others talk about social media as an adjunct to resident conference (DS-62).

So, four social media-related didactic sessions, plus a bootcamp. Meanwhile, I can't help but notice the typical informatics panels (some of which I'd participated in, last year) aren't present this year. I don't even see an Informatics Interest Group meeting. Not sure if anything can be read into this shift, but at the very least there's an opportunity to reintroduce an important topic to SAEM, next year. 

mHealth Toolbox at #ICEM16: Cape Town, April 16&17

I'm honored to be participating in the mHealth Toolbox next month. The two-day event is taking shape with a terrific lineup of physicians, entrepreneurs, technology enthusiasts, and many, many gadgets. Check back for links to presentations and resources.


Another bit about software - iOS mail clients.

Federico tweeted that iOS mail clients are today what Twitter clients were a few years back. Sure, but I never cared so much about reading and writing tweets because my job(s) didn't depend on it. E-mail is mission critical.

I loved Mailbox but it never did Outlook. Acompli was a leap forward, flawlessly blending Outlook and Gmail; I even liked its built-in calendar and recent files feature. I thought it was good that Microsoft bought it - but then innovation stalled and they removed the one feature I was really enamored with - programmable long swipes. Yeah, this may have been a power user feature that confused newbies, but this power user was waiting for someone to re-implement this helpful feature.

Then came Airmail, the most customizable iOS mail client yet. Sure, the new app has a few rough edges, but I'm happy to struggle through a few rough edges, because it has long swipes! And, easy integration with organizational apps like Todoist (you can swipe to Todoist, which almost makes me look forward to emails).

The Big To-Do

So, I've become one of those people that blogs about organizational software. I'm sorry. Just writing this post will probably squander every extra minute I'd have ever saved by using such software. 

For years I've been using OmniFocus, and it's been pretty good. Before that I was using Apple's own Reminders solution (I was a big fan of the Siri integration, which Omnifocus also takes advantage of). Before Reminders, I used Remember the Milk and Wunderlist. 

I've been on Todoist for a few weeks, and it's pretty great. 

The spread

It's been more than fifteen years since hanging chads dominated discourse, but they made a big impression on me.

No one had any idea what hanging chads were, or how they should be interpreted, before the 2000 Presidential election - but as soon as it became clear which interpretation favored Bush, and which interpretation helped Gore, pundits assorted themselves along established party lines. It really showed me there was no over-arching ideology behind what columnists and talking heads were saying - everyone was just supporting their team.

It's really no different than sports - look at last year's discussions of DeflateGate, or recent commentary when the Yankees signed a closer with pending charges of domestic violence. If you love your team, you'll find a way to rationalize or dismiss disturbing details. There's a small percentage of undecideds, largely indifferent or uninformed - and all the arguments to persuade these folks for or against a position are really just sophisticated cheers for the home team.

In sports, gamblers have come up with a clever way of dividing issues right down the middle: the point spread. For each game, the house sets the point spread such that even if one team is much better than another, you'll still get maximum participation in betting, with approximately 50% siding with the better team (which has to not just win but overcome the spread) and 50% favoring the worse team (these people are essentially betting that their team is bad but not that bad).

Of course it's in the house's interest to set the spread accurately, to maximize the number of bettors - the house takes a percentage of each bet.

The media is now playing the same game, trying to maximize the number of clicks, shares, comments, and eyeballs - because that's largely how they're paid. This is why so many stories are framed so provocatively - to make it seem as much like a game as possible. We're all familiar with simple clickbait ("You'll never believe what happens next") but that's just the equivalent of sports highlights - everyone likes to see a great play.

The media's real bonanza comes when they can frame an issue to evenly divide us. Starbucks going with simple red cups for the holidays isn't noteworthy, but when some fringe character decides it's a sign of the War on Christmas, suddenly every mainstream media outlet is running a story, and people on your Facebook feed are debating a boycott.

The Paris attacks were a huge story to begin with, of course - there will always be a legitimate function for reporters to report facts, and for readers to seek details. But when a story passes from the reporting phase to the commentary, it's often framed as an matter of supporting a team. "Team Civilization vs ISIS" is (fortunately) not very controversial, and wouldn't generate many more clicks - but framing the issue in terms of gun control, or immigration policies, is sure to keep people frothing, clicking and commenting (even if neither issue has much bearing on the attacks).

No part of our discourse is immune to framing issues in terms of teams. In the ad-supported tech press, it's Apple vs. Android, or Silicon Valley VC's vs the rest of the world. In the weather, every storm or unseasonable hot or cold streak is evidence that human-induced climate change is fake, or real.

This goes beyond the journalistic practice of seeking balance for the sake of seeming objective. It's as calculated as setting the point spread to maximize betting - and far more cynical. This practice turns any issue into an opportunity for cheerleading and grandstanding. You're either with your team or against them - there's no room for nuance, learning, seeing merit in both sides.

I used to think that ad-supported media and social networks were both overwhelmingly positive things, that would inform the population and expose us to a diversity of well-reasoned opinion. But now that most every story is shoe-horned into familiar narratives, now that social networks act as echo-chambers to parrot the talking points of entrenched interests, I have to wonder - is anyone still undecided? Is anyone being persuaded by the mountains of comments, of shared stories advocating one side or another? Or is it all just preaching to the choir, or more accurately, pointing to your team and cheering?

Program update

It's an honor to be included among the high-quality EM blogs and podcasts in Brent Thoma's article, in this month's Annals (second line in the figure). But it's also a reminder that content has become sparse. More of my on-the-spot EM (and informatics) opinions are posted at, specifically the Crash Cart series.

#SAEM15 panels

I'm very happy to be in San Diego for SAEM's Annual Meeting - and fortunate to be participating in a few didactic sessions this week. Here are links to the program, slides and references.

Tuesday  1-5:30pm - Nautilus 3: Social Media Bootcamp - led by Brett Rosen - slides

Wednesday 1:30pm - DS-18 Point Loma Ballroom A: I'll speak on clinical decision support projects for residents, as part of Jeff Nielson's panel called "Emergency Informatics Research: Interesting, Approachable Projects for the Resident or Career Scientist" along with Jason Shapiro and Adam Landman - slides - references

Wednesday 2:30 pm - DS-19 Point Loma Ballroom A: I'll speak on research opportunities in Informatics Education, as part of Ryan Radecki's pane "From Clicks and Complaints to an Informatics Curriculum" along with Jim McClay - slides

Friday 4pm - DS-95 -Harbor Island Ballroom 1: I'll speak about conducting EM research using social media tools, in a panel with Megan Ranney & Austin Kilaru - slides