The Risk Factor

The controversy over the drug-resistant TB patient Mr. Andrew Speaker who flew back to the US from Europe over his doctors’ objections, and his ability to enter the US even though he was on a travelers’ watch list, illustrates the very old IS&T designer admonition to users that, “It may be the system design you specified, but it isn’t what you wanted or needed.”

As you may recall, Mr. Speaker flew to Montreal from Prague and then drove into the US at the Champlain, New York border as a deliberate means to by-pass the likelihood that would be kept from flying directly back to the US from Europe because he would be on the US “no fly list.” Although the US Customs and Border Protection inspector saw that there was an alert on Mr. Speaker stating that if he should try to re-enter the US, Speaker should be detained and isolated, and public health officials immediately contacted. Instead, the inspector ignored the warning and waved Speaker through because, according to reports, “he didn’t look sick.”

As additionally described in a Washington Post story, US Custom and Border Protection “ … officials testified that they caught the inspector's error only by a mix of caution and luck, because starting May 22 they had ordered a special, twice-a-day check of a database of airline reservations to see if Speaker had changed his expected June 5 return to the United States.

As it turns out, the database is linked to records that also show when a passport flagged by authorities has been swiped at a border crossing, as Speaker's did when he reentered at 6:18 p.m. on May 24.”

The Post story goes on to quote US Customs and Border Protection Commissioner W. Ralph Basham, as saying, “I'm not going to sit here and say the system worked. It may have worked the way it was designed, but it was not good enough.” No kidding.

To reduce the possibility of something like this happening again, US Custom and Border Protection officials are now saying they are putting new procedures in place. Of course, this won’t keep highly infectious and multi drug-resistant TB out of the US, which Nils Daulaire, president of the Global Health Council argues, requires a more active risk management approach to attack TB at its source.

To me, the risk of a single point of failure like a Border official ignoring a warning is symptomatic of what happens in many information system designs. Few IT systems are ever examined in depth after they are deployed for their operational limitations until after an incident like the one occurs. And in my experience, most limits turn out to be, as described by Harvard Business School professor Max H. Bazerman and INSEAD professor Michael D. Watkins, “predictable surprises.”

I'll be interested in seeing whether this event will trigger a wider review of the limitations of the Custom and Border system as well as its systemic role in being able to manage the risks of travelers having infectious diseases, but my expectations are not high for this happening any time soon.

I don't know how I missed it, but the Humane Society of the United Sates has been extremely successful at getting states, and now it looks like the Federal government, to outlaw Internet hunting via H.R. 2711, the Computer-Assisted Remote Hunting Act.

According to a recent story in the Wall Street Journal (subscription may be required), the Humane Society has been mailing people "an urgent message, underlined and in bold type":

Such horrific cruelty must stop and stop now.

No debate there - except, as the WSJ article points out, no one is actually hunting using the Net, even though the Humane Society's site implies that it is rampant.

Better safe than sorry, I guess.

USA Today ran a small story last week on Nissan Motors plans to equip all of its cars and trucks with a dashboard gauge showing the fuel-efficiency of one's driving. The gauge displays your instantaneously computed miles per gallon as a bar graph - the more fuel efficient you drive, the longer the bar displayed.

Nissan claims that based on its in-house testing drivers will cut their fuel by 10%.

I bet if the price per gallon of gasoline was also displayed, or maybe the IRS standard cost per mile reimbursement rate (currently 48.5 cents per mile) used instead, people would drive even less. Seeing that the drive to the local store ten miles away cost you $9.70 might give you incentive to do it less.

Maybe Nissan will add in a costing feature as well in the future. The average cost per gallon gasoline or a total cost of driving per mile could be broadcast over a preset radio frequency, which then could be used to compute the cost per trip.

Given that Nissan's gauge looks software driven, this shouldn't be too difficult too add.

" ... the technology road is bumpy... This is life in the technology lane"

And it is full of pot holes. No, that wasn't in Steve Jobs open letter to early adopters of Apple's iPhone, but it was at least implied.

Mr. Jobs had to issue the apology after thoroughly irritating customers who shelled out $599 a few months ago for their new iPhone only to learn that Apple was cutting its price by $200 to try to gain a strategic if not insurmountable market share during upcoming Christmas season.

Jobs appears to be following former HP Chairman and CEO Lewis Platt's old dictum, “We have to be willing to cannibalize what we’re doing today in order to ensure our leadership in the future. It’s counter to human nature, but you have to kill your business while it is still working.”

Investors didn't take to kindly to Jobs announcement, as they viewed it as Apple cannibalizing its earnings too soon and therefore their investments. Apple also didn't help matter much by announcing a new iPod which appears a lot like an iPhone without the calling features. Apple's stock dropped about 5% in all this week.

Probably more of an issue is that many folks who bought iPhones now think they were not only out $200, but went from being cool to being uncool. Even my local small town newspaper has an article about how much coolness that $200 bought.

IBM announced this week what they call an Anatomic and Symbolic Mapper Engine (ASME) that allows doctors to visualize patient medical records in 3-D using an avatar. Using a mouse, a doctor can click on a particular part of the avatar's "body" to trigger a search of medical records to retrieve relevant information.

The idea is to be able to display information contained within electronic health records in a way that a doctor can make sense of quickly, and is specific to the ailment a patient is currently complaining about. You can go to the press announcement link above and see a sample illustration.

I will be curious to see how this approach impacts how electronic health records are designed and what information is captured.

I guess soon our electronic medical records will be made up of our own avatars that replicate us down to our genetic code.

WellCare Health Plans Inc. of Connecticut appears to be too busy to fix a software bug that is harming low-income adult and children Medicaid patients, the Hartford Courant is reporting today. During the summer, WellCare and two other insurance companies, Anthem and HealthNet, were discovered "accidentally" sending pharmacists computer messages saying that a prescription was not covered when in fact what should have been sent was that the prescription required prior authorization from the insurer. By law, managed care organizations are required to cover all drugs that are approved by the federal Food and Drug Administration.

Anthem and HealthNet have already fixed the problem, but Wellcare says it can't do so until December 1st. Must be part of a larger WellCare software maintenance build, I guess. It may also be because the FBI, Department of Health and Human Services, and Florida Medicaid Fraud Control Unit raided the company's Tampa, Fla., headquarters last Wednesday.

Wellcare says "to the best of its knowledge" it knows of no one who has been denied coverage, but Connecticut Attorney General Richard Blumenthal said his office has credible and plausible reports that prescriptions have been denied.

Having grown up in New England but now living in Virginia, it has been a mixed week for me in the world of sports. Boston College beat Virginia Tech last Thursday night in Blacksburg, Virginia, coming from 10 points behind in the last four minutes to win and keep their number 2 ranking in college football. Then yesterday afternoon, the New England Patriots crushed the Washington Redskins for their eighth win in a row to keep their perfect season hopes alive. (Oh yes, the Bosox won the World Series again last night - but at least they weren't playing the Washington Nationals.)

Anyway, it must be great to be a sports fan right now in New England, except maybe for some Patriot season ticket holders. You see, last year the Patriots sued StubHub! (which is owned by eBay and enables fans to buy and sell tickets to sporting, concert, theater and other live entertainment events, even those that are otherwise sold out) for its list of people who were using the site to resell their Patriot tickets. The Patriots allow season ticket holders to resell their tickets at face value on the team's website, but prohibit all other resales.

StubHub! fought hard against the lawsuit, claiming it violated customer privacy, was anti-competitive, etc., etc., but the company was recently ordered by a Massachusetts Superior Court judge to turn over to the Patriots the contact information of every person who used StubHub.com to sell, attempt to sell, buy, or attempt to buy a ticket to a Patriots home game from November 2002 to January 2007. It is estimated that 13,000 names have since been turned over.

The Patriots, have remained mum on what exactly they are going to do with the information now that they have it. However, the Massachusetts court judge said that the Patriots intended to use the identities of the purchasers and sellers not only for this case, but also for its own other allegedly legitimate uses, such as canceling season tickets of 'violators' or reporting to authorities those customers that they deem to be in violation of the Massachusetts anti-scalping law.

At this time, the Patriots will most likely make it deep into the NFL play-offs, and, if they continue to play as they have so far this season, they have a decent chance to repeat as Super Bowl champions.

I wonder if the Patriots are going to drop kick some of their season ticket holders before or after the playoffs.

The BBC reported last week that the decision to move forward in 2002 with the UK National Health Service's electronic health record's National Programme for IT (NPfIT) took place after a ten-minute presentation to then Prime Minister Tony Blair. The cost estimate for NPfIT - done basically on the back of an envelop - was for £2.4bn over three years, to which Blair basically said, "Go for it."

Surprise, surprise, NPfIT is currently projected to cost £12.4bn over ten years, and even that estimate is likely severely optimistic. Tony Collins over at ComputerWeekly who has been following the NPfIT situation for years has all the gory details. Collins has been trying to get the minutes of the meeting released, which the government refuses to do, despite being directed to do so by the Information Commissioner.

The NHS has recently stated that regardless of the many problems the NPfIT has faced, it is highly successful, and that it is "so well advanced that the health service 'could no longer function' without it."

This is kind of like Homer Simpson saying,“I think Smithers picked me because of my motivational skills. Everyone says they have to work a lot harder when I’m around.”

Spectrum's Senior Associate Editor Samuel Moore sent me a note on an interesting news release titled, "Design of Patient Tracking Tools May Have Unintended Consequences" about a study by researchers at the University of Buffalo regarding the replacement of dry-erase patient status boards by electronic patient tracking systems. The researchers studied how new electronic patient-status boards were functioning in the emergency departments of two busy, university-affiliated hospitals.

What the researchers found was while there were surface similarities between the manual and electronic systems, there were subtle differences in the design of the latter that affected how health-care providers communicated and tracked patient care, sometimes not for the better. As one of the researchers noted,

"The manual whiteboard allows flexibility in tracking patients. For example, maybe the first time the provider sees a patient, she initials the name on the whiteboard, then the next time she circles the initials, then when the patient is discharged, she might put an 'x' in the circle, signals that are a means of communicating with her colleagues in the ER."

"With a computerized system, providers have to find an available computer terminal and log-in. The providers can't just walk up to the whiteboard and make a notation."

Whiteboards also provided immediate visual clues that the electronic tracking system did not, like how busy the emergency room was and how critical resources were allocated.

The researchers note that future electronic patient tracking systems need to investigate workflow and communication issues more carefully, and hope their study will encourage designers to better meet user needs.

Last week, ComputerWorld published a lengthy story about the disruption of the US Department of Veterans Affairs' VistA electronic health record (EHR) system in Northern California last August. According to the story, the outage was caused by "a simple change management procedure that wasn't properly followed."

It turns out that one group of maintainers asked another to make a change to a network port configuration without having the proper authorization to do so, which the second team did. In other words, the system was done in by poor configuration management.

For reasons left better explained by the ComputerWorld article, the VistA back-up systems that were supposed to kick in, didn't.

The outage caused the VistA system to be down for a good part of a day, which caused healthcare workers to revert to paper and pencil. Patient safety was increasingly put at risk, because the VA health system is almost completely electronic. In the VA's words, the outage was "the most significant technological threat to patient safety (the) VA has ever had.” It has taken months to put all the paper-based information created that day back into electronic format.

The VA experience provided a glimpse of what may happen if a major outage and back-up systems fail once EHR systems are fully up and running. System designers of EHR systems need to think a bit harder about what happens when the "unthinkable" does indeed happen.

As first reported yesterday in the Register and then picked up today by ComputerWorld, Microsoft has had to pull the plug on its on-line "artificial-intelligence Santa bot" that was meant to talk to children about what they wanted for Christmas. Seems that the bot, as ComputerWorld put it, "wandered off topic" when certain words - like pizza - were used.

According to ComputerWorld, "Microsoft recently added the artificial Santa as a bot that Windows Live Messenger users could insert into their IM buddy list as northpole@live.com."

You can read about the bot in a Microsoft press release I found from last year titled: For a Jolly Good Time, Chat With Santa on Windows Live Messenger. A line in it is: "Filling Santa in on Christmas wishes and asking all about how the reindeer are doing or what’s new at the North Pole are a few of the things kids can talk to Santa about. Santa can even tell kids where they stand on his list: naughty or nice."

I guess the press release forgot to mention that Santa would be informing the kids about whether he was naughty or nice this year.

Microsoft said in a statement posted on the Register site: "Yesterday we received reports that the automated Santa Claus agent in Windows Live Messenger used inappropriate language. As soon as we were alerted, we took steps to mitigate the issue, including the removal of language from the agent’s automated script."

"We were not completely satisfied with the result of these actions, and have decided to discontinue the automated Santa Claus agent. We apologise for any offence or upset caused by this disturbing incident."

I guess Microsoft tested this year's Santa bot using the same strategy it does on most of its products - let the users find the bugs.

It is being reported that Chysler is expanding the recall of its Jeep Commander SUVs to repair engine stalling caused by a flaw in the automatic transmission software that could, according to the National Highway Traffic Safety Administration (NHTSA) "could cause a crash without warning."

In March, Chrysler recalled 1,338 of the 2008 Jeep Grand Cherokee and Commander SUVs to repair a stalling problem in the vehicles. The NHTSA reported at the time that the “the front control module may have been incorrectly manufactured. This could cause the engine to stall while driving or nor to start.”

This month, Chrysler expanded the recall to include 24,461 Jeep Commanders equipped with the 4.7 liter engine and built before 11 January 2006.

As a point of reference, GM expects its cars to have about 100 million lines of software in them by around 2010. Software reliability issues will undoubtedly increase in cars from sheer numbers if nothing else.

Having bought a new car in the past month, I sometimes feel that it is more computer network on wheels than anything else. I am still climbing the learning curve on how to operate all the gadgets in the car.

Car manufacturers, unfortunately, seem to have taken on the same attitude of many manufacturers in the computer and electronics space - make the operating instructions to their tech toys as confusing and contradictory as possible. Car manufacturers may claim in their automobile commercials that they are spending a lot on the human factors engineering side, but from a software systems perspective, I don't see much value being created for all the money being spent.