Microsoft HUG Tech Forum 2008 - Day 2

The Transformative Power of Technology, at the Intersection of Physicians and Patients (Opening Keynote)
Steve Shihadeh, VP, Health Solutions Group, Microsoft Corp.
Clyde Wesp, MD, FAAP, CMO, St. Joseph Health System

Today's Steve, like yesterday's Steve, compared HealthVault to PayPay, in the sense that "no one goes to the PayPal website...they go to eBay or Barnes and Noble..." I'm not sure that's quite accurate--PayPal was, in the early days, just a way to send money to send money to friends and family, and perhaps eBay sellers, instead of mailing a check. Once that business model was successful, online merchants jumped on the bandwagon.

In the case of HealthVault, Microsoft is hoping that vendors, hospitals, and insurance carriers jump on the bandwagon in a leap of faith that other vendors, hospitals and insurance carriers will follow suit.

As I've mentioned before, Google is taking more of a consumer-focused approach, much closer to PayPal's approach than HealthVault's.

Also, PayPal generates its revenue from transation fees. Microsoft claims that theirs is an advertising-based revenue model.

Another difference is that, for the most part, PayPal isn't a central storage facility for...well, anything. They do offer the ability to store cash in a money market account and then use that cash for future transactions, but many PayPal users (myself included) never store any cash in their PayPal accounts. Transactions pull money directly from the user's checking account or credit card to the merchant's account.

But I see what the Steves are saying. There is a need for a central clearinghouse for healthcare information, and it makes perfect sense that the patient should have control over the distribution of his/her information...even if (or especially if) they aren't fully aware of the control that they have (like they would if they were carrying around a PHR on a smart card or flash drive).

Click here for full presentation

One participant suggested that HealthVault would be useful to scientists as a source of participants in clinical trials and in other ways. Steve's response was that Microsoft made a hard choice early on that HealthVault would NOT be used in that way, because they worried that going down that road might inhibit adoption of the platform. Consequently, their position is very firm that they are going to err on the side of security and privacy, potentially at the expense of the life sciences side.

Great Healthcare via Unified Communications: A Developer's Perspective (Developer Track)
Chris D. Mayo, Technology Evangelist for the Unified Communications Platform, Microsoft Corp.


It should be news to no one that Microsoft would like to have all of their products fully entrenched in every company in the world. That's obviously not going to happen, since different IT shops have different platform expertise. But for companies that are already on the Microsoft bandwagon, it makes sense to at least explore Microsoft's offerings and, in the case of communications, consider Microsoft's Unified Communications platform as a replacement for traditional PBXs (or even newer IP-based telephony systems).

From a software engineering perspective, Microsoft has provided a wealth of tools (Web services, drag-and-drop WFC controls, etc.) to make it really easy to build UC features into apps.

Cross Enterprise Document Sharing (XDS.b) Reference Implementation (Developer Track)
Mark Simmons, Health Consultant, SIMPL
Wagner Silveira, Microsoft Technical Architect, Microsoft Corp.

This was an interesting discussion of the SIMPL/Microsoft approach to IHE...not highly relevant to AdvancedMD right now, because we're not pursuing IHE implementation at this point. Another opportunity to catch up on e-mails.

Better User Experience in Clinical Applications (Developer Track)
Anand Gaddum, Director, Healthcare Practice, iLink Systems
William Hughes, Director, Product Innovation, GE Heatlhcare Enterprise IT Solutions Division

Anand and William demo'd a prototype application built on Silverlight. It was very impressive, and only took a team of 5 full- and part-time engineers about 2 1/2 months to build...but it clearly wasn't ready for prime-time.

Still, it reinforces my believe that Silverlight will be a powerful development platform as it matures, and as the runtime becomes more ubiquitous.

In particular, as we try to encourage doctors to adopt new technology, Silverlight provides UI "eye candy" that might help pique their interest.

Building Safer Healthcare Applications in WPF and Silverlight with the Microsoft Health Common User Interface (Developer Track)
Andrew Kirby, Director in Microsoft Services UK, Microsoft Corp.

MSCUI was launched a year ago at the last Tech Forum in Redmond. This session was an overview of MSCUI and a view into how it's been adopted over the past year.

This is a really interesting project, because it isn't a sellable product, or even an initiative that directly results in the sale of Microsoft technology. It's a collection of design guidelines that are totally platform agnostic, as well as a collection of free controls that illustrate the principles of the guidelines using Microsoft technology.

Obviously, one of Microsoft's objectives is to provide enough free controls and other shortcuts using their technology that healthcare organizations will be encouranged to use Microsoft tools to create solutions, so it isn't a purely altruistic endeavor, but it's pretty cool, anyway.

There is a ton of information available at http://www.mscui.net/, so I won't dive in any deeper here.

Surface Technology in Healthcare (Closing Keynote)
Randy Fusco, CTO & Strategist, Microsoft U.S. Healthcare Provider Solutions, Microsoft Corp.

This was a pretty exciting session. Surface started out as an informal collaboration between a couple of departments at Microsoft back in 2001. A few years ago, it was officially funded as a research project by Microsoft, and now it is an actual product.

It's difficult to describe how cool this stuff is without actually seeing it. If you're interested, check out the Microsoft Surface website.

Microsoft HUG Tech Forum 2008 - Day 1

I'm at the Microsoft HUG (not "MS-HUG" any more, according to Michael Clifford's opening remarks) Tech Forum in Redmond today and tomorrow. My primary objective is to gain more exposure to HealthVault so that I can bring that knowledge back to my colleagues, but I'll be posting highlights from all of the sessions that I attend.

Opening Keynote
Steve Aylward, General Manager, Health & Life Sciences, Microsoft

I skate to where the puck is going to be, not where it's been.
- Wayne Gretzky

Steve started his presentation with Microsoft's Health Future Vision video (direct link).
The video has a lot of cool, visionary ideas, but I was especially impressed by the sweet TV in the patient's living room. Being a Tucson native, I liked her low-care landscaping (in contrast to the huge lawns in the Salt Lake City area). I was also happy to see that shopping carts wouldn't change.

In all seriousness, the video demonstrates a vision that Bill Gates has talked about for a long time: The convergence of media, computing, telecom, etc. My favorite part is when the patient uses her cell phone as a TV remote. Having 4 kids, that would change my life. (I'm not sure why the patient's "Digital Wallet" wasn't part of her phone or some other device.)

Microsoft's growth in healthcare market:

2000
63 employees
< $100 million in sales in healthcare market 2008
> 700 dedicated employee
> $1.2 billion in US
> $2 billion in sales world-wide

In 2008, Microsoft invested $8B in R&D. Steve couldn't say how much of that was invested in healthcare, but indicated that it was a large percentage.

Aside from core initiatives like Office, Windows, BizTalk, etc., healthcare is among Microsoft's largest areas of investments.

Other notes:

• Amalga HIS is for emerging markets, where there isn't already a lot of infrastructure in place.
• Amalga Unified Intelligence System: I don't know what this is.
• HealthRamp: "Internet health platform that enables third-parties to create valuable health-related services." That description (pulled from one of Steve's slides) confirms my earlier assessment that Microsoft is taking a more vendor-based approach than Google.

Unified Communications in Health Care (Developer Track)
Dr. Albert R. R. Kooiman
Bill Crounse, MD

Unification (via Office 2007) of:
- E-mail and unified messaging
- Instant messaging
- Enterprise telephony
- Conferencing

Dr. Kooiman opened with a demo of Outlook: He selected an e-mail message, then clicked a button to open an IM window with the sender. With another click, he called the sender on the phone. Presumably, another click or two would allow him to conference in another participant to the conversation.

The "Call to Action" for this session was to encourage developers to use Office 2007 as a platform to integrate unified communications into their applications.

Dr. Crouse introduced this video on unified communications on his HealthBlog, and showed it during this presentation. To be honest, I find UC to be more applicable to hospitals than ambulatory clinics, but perhaps there is a more relevant application for larger clinics.

Solving the Difficult Problems of Healthcare and Life Sciences with the Latest Generation of Microsoft Technologies (Developer Track)
Tim Huckaby, CEO, InterKnowlogy

Tim was invited to present because his company has done a lot of cool projects for healthcare organizations using Microsoft technologies. Also, Microsoft is IngerKnowlogy's largest client.

Tim demo'd a WPF application built on top of SharePoint Web services for Scripps research. Visually, the data is represented as complex, hyperlinked, rotatable 3D images, but they're stored as large text files in SharePoint. The graphical performance of WPF is impressive, and the rendering code was written by one developer in one week (although InterKnowlogy had invested heavily in WPF prior to embarking on this project).

Why hasn't WPF been widely adopted?
- It is huge: Larger than ASP and WinForms combined.
- It's a thick client, and thin clients are the current rage.

WPF is built on top of DirectX, and it makes sophisticated graphics much easier to deal with.

Silverlight only contains about 18-20% of the classes available in the full WPF framework.

InterKnowlogy has some some cool Silverlight demo apps.

Microsoft HealthVault Architecture Overview (Developer Track)
Sean Nolan, Chief Architect, Microsoft Corp.

Our bet: Patients as the hub of of communication.
- Sean Nolan's HealthVault presentation

Reasons to Integrate with HealthVault

• Private and Secure Storage
• Authenticate Users, Manage People Relationships
• Share Securely, Authorize Data Access
• Application Interoperability
• Device Connectivity
• Application and Device Discovery
• Developer Assistance

How does Microsoft monetize HealthRamp? (There are no fees or charges to use the platform.) They see healthcare being like travel - opportunities for advertising in the future.

HealthVault can be used in "Native" or "Copy" model:

• Native: Healthvault replaces traditional database and authentication mechanisms
• Copy: HealthVault is an external repository, you can pull data out of it or push data into it (import/export, merge, sync)

HealthVault supports both Windows Live ID and Open ID.

Interesting: All access to HV goes through the XML API (Basic XML over -HTTP interface, POST a request and receive a response)...NOT SOAP! (Although SOAP and WSDL will probably come in the future.)

This is interesting to me because we took the same approach with our core (XMLRPC) API 9 years ago. (In our case, SOAP wasn't fully baked, but we continue to believe that our lightweight version of SOAP is better suited for our application.)

Security, authentication, and access control are very important in HealthVault.

HL7 Based Data Warehousing: Fast Build to Data Use (IT Pro Track)
Eric V. Washburn, CTO, Athena Advanced Technologies/HVHS

This was a great opportunity to catch up on e-mail. (Eric did a good job, but his audience was pretty small--few organizations need to do what he did.)

Xbox: Gaming machine or healthcare platform?

If you thought that the Microsoft Xbox 360 was a gaming machine, like I did, you're a couple of years behind the curve.

I've attended 2 sessions at the Microsoft HUG Tech Forum so far, and both of them included slides that included the Xbox 360 in the Microsoft technology stack that is targeted at healthcare. The Xbox? I was intrigued, so I googled "Xbox healthcare". Here's what I found.

Almost 2 1/2 years ago, Dr. Crounse at Microsoft wrote about how the Xbox can be used to "help cure healthcare woes," based on research being done by Dr. Harold Goldberg. A month earlier, an AP article covered the work that Dr. Goldberg had been doing with the Nintendo Game Cube to encourage young people with diabetes to communicate with their doctors and manage their conditions.

It seems unlikely that Nintendo is interested in making heavy investments into healthcare, Wii Fit notwithstanding. So Microsoft, already generating about $2B in revenue from healthcare, is in an excellent position to leverage the Xbox in the healthcare market, particularly among young patients.

At CES in Las Vegas this year, Cerner demo'd their Cerner Care Console (announced in this press release), which is essentially just a customized Xbox 360. It allows hospital patients to play games, of course, but also provides education, a feedback mechanism, maps, information about the patient's doctors and other care providers, etc.

In my role as Chief Architect at AdvancedMD, it may become important that I get one of these in my office...for research purposes. That realization alone justifies my trip to the Tech Forum!

ICD-10 and ANSI X12 Version 5010: October 2011?

The Department of Health and Human Services (HHS) is working towards switching from the current set of healthcare EDI transaction standards (ANSI X12 Version 4010) to Version 5010 on October 1, 2011. That switch is partially driven by a need (or strong desire) to switch from ICD-9 to ICD-10 code sets, which are already in use in most of the world.

As promised, the recent announcement of this switch gives providers, insurance carriers, clearinghouses, and vendors 2 years to retool our systems to accommodate the new standards. For most of us, that won't be a huge problem (although we've got a lot of work ahead of us). We'll have to wait and see how well the state payers do...

In any case, it will be interesting to see how these changes ultimately affect AdvancedMD and our customers. Certainly the cost of migration will be significant (more for our customers than for us, I would imagine), but maybe we can hope for some benefits.

For years we've complained about the oxymoronic nature of the term "healthcare standards". The ANSI 837 (claim) and 835 (ERA) transactions were supposed to standardize communication between healthcare providers and insurance companies. In some ways they were successful, but, apparently, some carriers (mostly Medicaids) decided that the standards were inadequate. They ended up finding hundreds of creative ways to violate HIPAA and stick weird data all over the place.

Maybe if we're really, really lucky, Version 5010 will accommodate these carriers' requirements without the need for a bunch of "companion guides". Or maybe the switch to Version 5010 will encourage payers with antiquated adjudication systems to upgrade them so that they can obey the rules.

Hey, it doesn't hurt to hope, right?

Whatever the payers do, we'll soon be embarking on projects to accommodate these new standards so that we can be way ahead of the curve if and when they go into effect in 2011.

I "Wordled" my blog...

I love creative visual representations of boring data, so I was intrigued by Wordle. From the Wordle website:

Wordle is a toy for generating “word clouds” from text that you provide. The clouds give greater prominence to words that appear more frequently in the source text.

Cool! Here's the word cloud for this blog:

I've spent a few minutes staring at the word cloud, trying to figure out why some words (e.g. "Alistair") appear more frequently than others (like "data").

Oh, great--I just gave "Alistair" more importance! If I keep talking about "Alistair", eventually he's going to dominate the whole word cloud! What if Alistair himself gets annoyed by my repeated use of his name, and posts a comment, signing it "Alistair"?

Okay, that's enough...I'm off to post this entry, and see what the new word cloud looks like...

Living in the hotbed of Agile Software Development

I was reminded today how fortunate I am to be here in Utah, where Agile was born and continues to thrive.

(The Agile Manifesto was conceived at The Lodge at Snowbird, not half an hour from my house. One of the authors, Alistair Cockburn, lives in Salt Lake City, as do other powerful Agile advocates, like Jeff Patton.)

[Humorous likenesses of Alistair and Jeff used without permission, and, most likely, at risk of serious retribution.]

I was asked by Jonathan Rayback, another local Agile mover and shaker, to talk today in our local Agile in Management meeting about our first experience with the Walking Skeleton concept (conceived and named by Alistair over 10 years ago). I didn't have much time to work on it (due to vacations and a pressing work schedule), but I threw together some thoughts and slides and drove to the meeting, feeling a little nervous, but confident that I had some useful experience to share.

What I didn't know was that Alistair himself would be there. Right! I'm supposed to explain the Walking Skeleton concept to the guy who created it!

Within my little world, this was akin to a physicist explaining the Theory of Relativity to Albert Einstein, or a political scientist explaining the Monroe Doctrine to...well, James Monroe!

Of course, Alistair was extremely gracious and helped me feel at ease from the very beginning. More importantly, he critiqued my presentation very gently, yet honestly. I walked away feeling that I could make the same presentation to a different group in full confidence that I was representing his concept accurately and effectively.

What a great opportunity, though, to rub shoulders with some of the "great ones" of the Agile movement. I've never been in a room with Alistair when I didn't learn something.

One of the interesting things about Alistair is his skepticism of Scrum. Not that he's opposed to it. In fact, whenever Mickey, Sheridan or I tell him how great Scrum is working for us, he expresses his enthusiasm (and shock?) over our successes. It just seems that he's seen a lot of failures in half-hearted or misguided attempts to implement Scrum.

In any case, I think you'd be hard-pressed to find a better place to do Agile than Utah. Now if we could just get Ken Schwaber and Jeff Sutherland to move to Salt Lake City...

Microsoft releases SQL Server 2008

Our long wait is over:

http://www.microsoft.com/Presspass/press/2008/aug08/08-06SQLServer2008PR.mspx

We've been getting along just fine with SQL2K5, but some of the features in this new release are really going to make our lives easier.

One great example is what they call "Transparent Data Encryption". At first blush, this doesn't seem like a particularly useful feature for us, because our database servers are stashed behind so many layers of physical and network security that it would be extremely difficult for anyone malicious to get at them. And hard drives with PHI never, ever leave the data center.

But in spite of all of that security, we have had a couple of requests from our more security-sensitive clients to encrypt their data at rest. To date, the only reasonable approach to that problem is to encrypt the disk volume that the database is on, inevitably impacting performance in a big way.

This new feature of SQL Server will allow us to physically encrypt their data with minimal fuss, and, presumably, without a noticable performance hit.

I'll post in the future about other key SQL2K8 features that we plan to incorporate into our systems.

Microsoft SQL Server: World's most secure RDBMS

Hey, that's a pretty controversial headline for a mild-mannered blog like this one! But I think it's supported by evidence.

In November of 2006, Enterprise Strategy Group released an "Information Security Brief" that makes the following conclusions, based on Common Vulnerabilities and Exposures (CVE) data from the National Vulnerability Database:

• Oracle’s results over the past two years show that much work has to be done to bring the vulnerabilities into line with competing database products from IBM, Microsoft, MySQL and Sybase.
• ESG considers Microsoft to be years ahead of Oracle and MySQL in producing secure and reliable database products.
• Microsoft’s results are almost too good to believe, and thus serve as a model for other database vendors.

During that same month, David Litchfield did a separate study based on a broader set of data and reported:

• It is immediately apparent...that Microsoft SQL Server has a stronger security posture than the Oracle RDBMS.
• The conclusion is clear – if security robustness and a high degree of assurance are concerns when looking to purchase database server software – given these results one should not be looking at Oracle as a serious contender.

Even before those reports were compiled, Cesar Cerrudo of Argeniss put together this presentation in which he provides lists of Oracle security flaws and SQL Server security strengths and asks, in apparent exasperation, "Why do you think [Oracle] is Secure?" And, "Why do you think [Microsoft] is not Secure?"

It's interesting that Microsoft has several pages on its website where you can find articles like these (albeit not these specific ones) touting the security of SQL Server, while I couldn't find anything on Oracles site (and I looked) citing independent analyses that provide evidence that Oracle is more secure than SQL Server...and Oracle has had a couple of years to respond.

OK...so, all of this does NOT mean that SQL Server is better than Oracle. Recent releases of Oracle 11g and related products offer all kinds of features that SQL Server doesn't. I'm certain that there are literally thousands of companies currently using Oracle that would be foolish to consider a switch to SQL Server. There may even be hundreds of companies that should seriously consider switching from SQL Server to Oracle, for any number of valid reasons.

But, c'mon, think about it: Microsoft SQL Server more secure than Oracle??? Are we talking about the same Microsoft and Oracle? Unbreakable Oracle?

And don't forget that ESG found SQL Server to be more secure than MySQL...and MySQL doesn't have a target painted on its back. Hackers exploiting flaws in MySQL would be like animal rights activists vandalizing PETA headquarters. Well, not exactly, but it makes an entertaining simile.

In any case, SQL Server has worked great for us. We're looking forward to using some of the features in SQL Server 2008. I'll try to describe how we end up taking advantage of those features in future posts.