Dana Blankenhorn

The Health Internet

Think of this as Volume 11, Number 47 of A-Clue.com, the online newsletter I've written since 1997. Enjoy.

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In looking at health care reform I am reminded of an old New Yorker cartoon by Stanley Harris (right).

A scientist stands before a blackboard filled with equations, but with a giant gap in the middle. "Then," he has written, "a miracle occurs."

We're very much in that position regarding health care reform. Advocates across the political spectrum insist that by automating the industry we can save tens of billions of dollars. Both John McCain and Barack Obama had this in their platforms.

Yet no one in the industry believes it possible.

Over the last 13 years many, many industries have succumbed under the World Wide Web. Where we once went to travel agents we now go to airlines' Web sites, or (for complex trips) a site like Expedia.com. Where we once went to book stores and record stores we routinely go to Amazon and similar sites. Instead of the library we ask The Google.

Almost as soon as the Web was spun, the rush was on to create special tags to deal with the problems of vertical industries. That's what XML is. It's an agreement between market participants as to what customized HTML-like tags will mean, in the context of their business. So we have special XML subsets for the advertising industry and for many others.

But not for medicine.

When I went to the annual HIMSS show in Orlando last spring I felt transported back in time. It looked like a 20-year old Comdex. Each major vendor - Cerner, McKesson, Microsoft -- had the equivalent of their own operating system. Each product vendor -- and an MRI machine in this case is just a fancy printer -- required multiple sets of drivers to move files into any one of these systems. And since you could not be certain that the equipment you bought would include drivers for the computer system you might want to buy, doctors and hospitals remained in statis. Because paper worked.

To break this bottleneck requires a set of standards as universal as paper, defining all sorts of medical conditions and procedures, across all vendor systems and equipment types, so that the whole can interoperate.

Easy to say. Very, very tough to do.

There are groups that are trying to create such standards. Health Level 7 is the most prominent. They require agreement on what to call procedures, on how to define medical processes, an enormous, ever-changing schema that is flexible enough to accommodate the change we know is coming to medicine as our knowledge advances.

It is an enormous undertaking.

Acceptance of this grand scheme is at the heart of Electronic Medical Record (EMR) systems (there are over 200 of them) sold to professionals and Personal Health Record (PHR) systems like Google Health and Microsoft Healthvault, which patients will control.

On top of the former are layered a host of regulations like the HIPAA law, which aims mainly to protect us from abuse by our "health vendors," and it's partly in implementing laws like this that EMR vendors have created the proprietary tweaks that make it so hard to create PHRs under patient control.

Note here that HIPAA does not really provide security, just bureaucratic control. And security, or the lack of it, is both the biggest fear and the biggest impediment to computerizing. The fear is real.

Now, having described the intractability of this problem, let me offer your Clue.

The problem can be solved.

An Open Source Christmas Letter

I have been sending out Christmas letters for many years.

I got the idea from Lamont Wood, a writer and friend whose annual reports of Conglomerated Woodco are always filled with fun, and details of his family's life in Texas.

Lamont and I co-wrote a book early in the 1990s, called "Bulletin Board Systems for Business." It described the online tools of the period, and suggested that people harness them. Unfortunately it came out two years before the Web was spun.

Since then Lamont has gone on to write many books, on a wide variety of subjects. He is a brilliant writer and a very good man. Merry Christmas, Lamont. To the right is your Christmas present. I found it on the Web. It's a park in Australia. I hope you can take your family there some day.

My own attempts to create something like the Woodco report have been frustrated by talent and, more important, by technology. I wanted to do it in HTML, but found it never worked. The editors I used couldn't translate to a Web page, and were a disaster in print. For a long time I used Microsoft Word and printed the results. But copies, at $1 and more for color, were prohibitively expensive.

A year ago, as part of my work at ZDNet, I got OpenOffice. It didn't work either. Then, this fall, I downloaded another version, Version 2.3.1.

Finally, success. I was able to edit pictures to size using The Gimp, another open source product, and the result printed quite nicely.

Transferring it to the Web, where it appears as the extended body to this post, took several minutes. The pictures didn't follow the HTML code, and had to be manually inserted. Not a problem because they had already been sized. But since the original code had left room for them, the original code for the pictures had to be edited, and the pictures inserted manually. This sounds harder than it was. It took me all of five minutes.

So, finally, with great humility and joy after 13 years of hard work on the Web, our family's first Web Christmas letter:

The Media War

A hallmark of every generational crisis is a conflict between media, with one medium rising while another fights back.

A generation ago TV was the rising medium. Newspapers thought they were serious competitors in terms of political coverage. The decade began with Nixon's loss of the 1960 debate to Kennedy (radio listeners thought he won) and ended with Nixon triumphant, having learned TV stage management from Bob Haldeman.

We're now going through a similar period, only this time TV is on the defensive. And there are many ways in which that medium is fighting back against the Internet onslaught:

• Denial -- Howard Kurtz's new book Reality Show, and the accompanying interview tour, is a great example. He actually claims that people turned against the Iraq War because of the reporting by TV newscasts. Really.
• Advertising -- This is the method favored by incumbent industries, especially the telecom and oil oligarchs. Run a bunch of ads claiming "it's the network" (while seeking a monopoly on the Internet that will let the telecomms close off "selected" sites) or claiming that oil is green (only if it's made from people, Conoco) in such tight rotation that the TV news can't challenge you and people come to believe up is down, right left, and Eurasia has always been at war with Oceania.
• Strangulation -- Cable and telephone networks are deliberately strangling Internet bandwidth, defining "TV" and "voice" as separate services, which they're not, and charging out the wazoo for the few bits that are left. What will happen is people will pay until they realize the depth of the rip-off. And that will be the end of the cable and phone networks. The Internet itself will go blithely on.
• Goons -- From silly strategery to paid goons, corporations continue to treat blogs as something that can be managed and overcome. They can't. You have to deal with them, and accept their values, or you're the enemy.
• Competition -- This has been the most effective tack, turning journalists and columnists into bloggers. The New York Times kept Paul Krugman in a cage for two years, then suddenly unleashed him as a paid blogger. This makes some objective sense, since publishers know how to monetize pages in ways regular people can't (Blogads is dead), but some can make the transition and others can't.

Some thoughts follow

The Corruption of Technology

Of all the corruptions during this decade, it's the Bush Administration corruption of technology that hit me the hardest.

When I use the word corruption, I am describing a deliberate policy of politicizing the development of technology, tearing at the process of change in order to put control into as few hands as possible, so as to control those hands.

This has been the pattern everywhere. The Bush Administration much prefers monopoly, or oligopoly, to real competition. Once such a goal is achieved, the few at the top can easily be manipulated, bribed, cajoled, or threatened into absolute support of the leadership.

I take the subject of technology personally, and have real-world experience with it. For nearly two decades, prior to this Administration, I watched technology change play itself out in successive waves.  No lead was safe. Those who were Clueless, or became so, went under practically before I could proclaim the word upon them. It was Darwinian, it was brutally competitive. It was also wonderful, and highly profitable. The raw capitalism of the 80s and 90s brought the U.S. economy to the very pinnacle of success, producing nearly a third of the world's products and services by the end of the last decade.

Now those days are gone. What we have instead is nothing less than state-directed corporate welfare. Moore's Law has been overturned by the War On Terror.

This Week's Clue: Consensus vs. Conflict

Following is the essay you can designate as Volume 10, Number 21  of This Week's Clue, based on the e-mail newsletter I have produced since March, 1997. It would be the issue of May 21.

Enjoy.

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The great crisis of our time is a dispute over two ways of resolving tensions, conflict and consensus.

How can consensus overrule conflict?  The same way the Internet does. By routing around it, pretending it doesn't exist, and turning the other cheek. The more conflict gets up in your grill, and the more you're able to avoid it, the less powerful conflict becomes, and eventually it gives up. We're not talking Gandhi-ism here, but the old Rope-a-Dope.

The job of conflict in this case is to be essential, to force itself, to demand the satisfaction of a final confrontation.

Right now, after 40 years in which American politics have been defined by conflict, and 65 years where world affairs have been a non-stop conflict, analysts can't conceive of consensus winning anything. Strangely enough many of these same analysts call themselves Christians.

Rather than talk about Bush, the American elections or the War on Terror, I'd like to illustrate the point by looking at three completely different situations -- Russia,  France and Microsoft.

This Week's Clue: The Open Source Revolution

Following is the essay you can designate as Volume 10, Number 20  of This Week's Clue, based on the e-mail newsletter I have produced since March, 1997. It would be the issue of May 14.

Enjoy.

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When I first started writing about Political Philosophy on this blog, a little over a year ago, I summed up what I was talking about with one word consensus.

Later I described what I was talking about as an €œopen source thesis,€ but no one seemed to understand what I was getting at. So lately I'€™ve switched to calling what I'€™m talking about the Internet Thesis, a political myth based on the values of the Internet.

But I was being more accurate the first time.

Because it'€™s open source that is the real economic revolution of our time. Open source transforms market relationships between vendors and customers, between employer and employee . By placing source code in a commons, it gives the customer the power to walk away from the vendor, and the employee the power to walk away from the employer.

Open source is a decade-old concept which first came to prominence through the publication of €œThe Cathedral and the Bazaar€ by Eric Raymond.

Kos Scales the Intimacy

Back in 2003 Markos Moulitsas told Howard Dean that Dean could become President if he upgraded his Web site, from a blogging platform to a Community Network Service.

I called that "scaling the intimacy."

Dean didn't, Bush was re-elected, but Markos took his own advice. The Daily Kos is now the unofficial Democratic Party clubhouse, with tens of thousands of users, and hundreds of thousands of irregulars.

If I want readers for something I write, if I really care about that, I no longer just post it here. It's suicidal (to my interests) not to post it there as well.

I point this out not to pat Markos on the back, but to point out to all of you that, in any business, standing still is not an option. You grow or you die. And Markos is, above all other things, a businessperson. So he has begun the task of up-scaling yet-again. Kos is going to ditch its present Scoop system and go with Ruby on Rails, an open source Web framework.

Unlike Scoop, which is optimized for discussion, Rails can be optimized in many different directions. It can be used for ecommerce, for file hosting, for asset management, or group chat, or sharing audio files. It can also be used as a blogging platform.

While the media is just now talking about blogging, and some trendsetters are moving toward the CNS space, in other words, Kos is preparing to become a sort of "AOL for Liberals", a service capable of going in many directions, all at once. This also means Kos has many different business models open to him, many different ways in which people can put money into his business and feel they're getting value-for-money.

A Modest Proposal for the New Congress

I know the new Congress is going to be very busy. But if I could make one suggestion, it would be for someone with oversight (like Rep. Ed Markey ) to host some hearings on this topic:

How do we accelerate technology?

For six years the Bush Administration has been claiming that its laissez faire big corporate plan for the technology industry will work. And for six years the pace of change has been decelerating.

This, more than anything else, is responsible for our trade troubles. China can't adapt as fast as we can to technological change. India lacks the infrastructure to adapt. Russia is mainly an oil supplier. Yet all these countries have gained enormous power in the last six years, and America has lost power, because the pace of American innovation has slowed.

When was the last time you were excited about something in the computing field, something really new and different? It's been a long, long time.

Sure, we have better game machines – foreign-made game machines. But our data now moves at a snail's pace compared to what our competitors enjoy. Our software companies have spent their time replicating the past – re-building applications for open source or re-creating a stale, slow, small file version of the online world in the case of cellular.

We keep falling behind.

Consensus vs. Contracts

One key difference between the Nixon Thesis of Conflict era that we are leaving and the Open Source Thesis era I'm exploring here lies in how political change occurs.

Open source is a model for the process change I'm talking about

Open source itself works based on consensus. If a question becomes closely contested within a project it forks or dies. The niceties of open source licenses are not nearly as important as the general agreement they represent. Violations of norms are dealt with from within a social context. Losing your reputation, having people leave your project, is effectively a death penalty.

It's a little like a church. We have a general agreement on doctrine. We hash out those differences within the faith. Leaving, or being forced out or (in some cases) being shunned is the penalty. Heresy isn't a crime, except inside the church. (Please don't take the analogy too far in the comments -- it's merely a teaching tool.)

The proprietary software world, on the other hand, is based on a contract process. Relationships begin at the time of a purchase, they are defined by a written contract, and violations are handled by lawyers. Obligations that are not spelled out simply don't exist.

We have had political eras based on consensus before. The New Deal Era was held together by consensus. We needed to deal with the Depression, we needed to deal with Hitler and the Japs, we needed to confront the Communists. It was when the consensus broke down that the era ended.

The same was true in the Civil War Era. The consensus of the North defined what happened to the South, both during the War and afterward. The imperative of business, of industrialization, defined what happened in the law, in social structures, and the economy. The consensus for growth and expansion continued until farmers and workers were willing to put their lives on the line in order to object.

Consensus, then conflict (dealt with through negotiation) have been the pendulum defining the process by which Americans have gone about their business. The conflict of the Revolution followed by the consensus of the Constitution. The conflict of 1800, lasting through the War of 1812, became the consensus called the Era of Good Feeling. The conflict era of Andrew Jackson, ending in the Crisis of Civil War, became a consensus for business and expansion. And so on.

This is not seen today because we have lived in conflict for a generation. We don't know any other way to think things through except through conflict, a proprietary process in which power is either held or not held.

The whole Nixon Thesis was based on conflict, on small majorities defining our actions, resulting in incremental changes that looked much like business contracts. The reason Ronald Reagan is revered by so many (despite the inherent contradictions of the 1980s) is because his leadership style was based on consensus – simple goals simply stated. And when his party tried to go beyond that consensus, when his successors chose the Nixon Way, their forward movement slowed and, eventually, stopped.

 

 

 

This Week's Clue: Internet Past, Present and Future

I have been writing my free weekly e-mail newsletter, A-Clue.Com, since 1997. In this week's issue I look at the past 10 years, and speculate on what may be coming.

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When I first began writing A Clue, in 1997, the Internet was quite different than it is today.

It was more primitive. It was portals and push technology. The Dot-Boom was just getting rolling. But it was also more international. Those who had good Internet connections were elites, people with natural curiosity, and in its early years I often received e-mails from very far away.

Today's Internet is bigger, more technically adept, faster but also more local. It's a mass market phenomenon. There is plenty to do, see, and be in your own patch, so international traffic is reduced. And it's no longer an American lake. What can I tell a Korean or Japanese user about Internet commerce, when their connections are 100 times faster than my own?

Yesterday's Internet was in English. Today's is in a myriad of languages. And this is one of the key challenges facing the Internet's future. Internet name spaces in local languages create a natural balkanization. Hardly anyone here will have the language support needed to reach a Chinese or Thai or Arabic namespace, and folks there won't come here, either.

Translation is the key. Google's translation service remains primitive. It is unfortunately the best we have. And it needs to be deployed, now, in all these new namespaces, if people speaking different languages are to have any connection in the future. This starts with applying it systematically to other character namespaces – add a .abc (for the name of the language in English) to the URL coming here, and a .abc (in the other language) going the other way. This will also tell the user that the page is translated.

The main problem is that, in terms of this challenge, groups like ICANN are dirt poor. It's firms like Google which have the technical chops to take this on, but how do you move the work without also moving the business, without privatizing the Internet's operation further? All this at a time when governments are seeking greater control, both of their own networks and what they link to.