In Defense of Email, Subjects, and Threads

Everyone hates on email. Facebook is trying to kill email by making Facebook chat - a social stream - the primary form of digital communication across all computing devices. They're trying to "reduce complexity" by removing the "clutter". Facebook is adapting the key tenet of its flagship product - the NewsFeed stream - to other communication channels.

I'm going to defend email. Facebook's social stream in no way reflects human thinking and processes, especially when people are collaborating across multiple projects. Facbeook-style streams are useful for fast and immediate communication, but they're terrible at organizing and managing complex information. The more complex and varied the nature of the information, the less effective Facebook is at managing it.

Google's Matias Duarte, Director of User Experience for Android, has recently outlined a company-wide effort to present data to users in cards (Google Now and Google Glass already implement cards). Per Duarte, cards "make very clear the atomic unity of things; they're still flexible while creating a kind of regularity." He is absolutely correct. The human brain perceives and organizes information into "units." Some units are big, others are small. They are all atomic - singular and immediately understandable - in nature:

Yuo cna reed tihs becaseu the rbain recognizes langaueg in antomci "wdor" untis

Conversations that include thousands of words are remembered as a single conversational unit

Emails are organized into threads by subject

Email more accurately models how people think about and manage the disparate information in their lives, if used correctly (please don't respond to my "thank you" email with a totally random request). In our digital age of hyper-everything, email overflow is a real problem, but the basic structure of email as a way to organize and think about information is sound. I'm not suggesting that email is perfect. It's not. Email has many problems, but it's far better than social streams that don't model how humans manage and think about different pieces of information.

Most of email's problems are not inherent to the medium itself, but how it's used. Perhaps the biggest problem with email is that it's abused for every kind of communication - office jokes, to-do lists, email blasts, information feeds, project updates, calendar invites, and more. There are specific applications designed to accommodate each of these scenarios, but most people don't know or don't care to use different applications for different in different contexts. Unfortunately, everyone just falls back on email because it's simple, free, and they already know how to use it.

Perhaps the ideal email client of the future is the one that recognizes all of these distinct use cases, and automatically sorts email accordingly.

A Journey to Peru

I usually don't blog about my daily activities, but I'll make an exception for special trips and international journeys. And here are some pictures.

Saturday May 11th, 2013

I flew out of Austin bright and early to present VersaSuite's full HIS and EHR to a UN hospital in Chiclayo, Peru with our local partner company, El Tumi Peru. After a brief layover in Houston, I took a 6.5 hour flight from Houston to Lima, where I landed at about 10:30PM local time.

I love traveling but hate the act of traveling (read: airports). However, I do appreciate the concentration I'm afforded. I try to capitalize on my lack of an Internet connection by reading long-form books, writing, and watching videos/movies. I read a good chunk of Ayn Rand's The Fountainhead, knocked out my entire short-form reading list, did a lot of Pristine reach out, wrote a few blog posts, and watched James Franco's latest movie, Oz The Great and the Powerful.

Lima's airport is pretty standard: nothing flashy, lots of taxis, ridiculous traffic on a Saturday night, swarms of people with signs for strangers, and of course the obligatory general sense of chaos and disorganization. El Tumi Peru hired a local who picked me up and brought me to my hotel, El Hotel Boulevard, in the beautiful Miraflores district of Lima.

Sunday May 12th, 2013

I woke up and had breakfast on the roof of my hotel, overlooking the hotel pool and small part of Lima. There was an excellent breeze; it was a great way to start the day. I had to wait until 11:00AM to meet Jose from El Tumi Peru, so I did some reading and writing on the roof.

I spoke to Jose for about an hour in the hotel lobby, then headed out to explore the city. I tried to map out my day via limited wifi at the hotel, but quickly gave up on the original plan as I began wandering about without an Internet connection.

The Lima coast is gorgeous, so I walked down it. There are all kinds of playgrounds and outdoor activities going on along the Pacific coast. I walked for 3 Km before I reached an enormous shopping district in front of the flashy Mariott hotel. I ate a superb steak with chimichurri sauce for lunch while getting intoxicated on Pisco Sours. After lunch, I walked around for another hour, then took a drunk nap in the grass along the coast. At some point a police officer woke me up to make sure I was alive, and I was, but then I went right back to sleep.

I woke up at 6:15PM, and rushed back to my hotel to meet the folks from El Tumi Peru at 7:00PM. I'm surprised I was able to find my hotel so quickly. They picked me up and took me to the airport to fly to Chiclayo. We blew through security and took a quick 1-hour flight. The hotel at Chiclayo wasn't nearly as nice as the one in Lima, but that was to be expected.

Monday May 13th, 2013

Jose, his mother Carola and I had breakfast at the hotel in Chiclayo. Like the day before, I demolished a platter of fresh delicious Peruvian fruit. On Monday it was primarily pineapple, watermelon, and papaya. We left to the hospital after breakfast.

The hospital looks much better than it did last time I came to Peru in July 2012. Then, it was clear that significant portions of the building were under construction. At the time, they were only using the building for outpatient functions, i.e. lab, radiology, pharmacy. They're still doing gardening work, but the building appears to be finished. They are now taking care of patients overnight in beds too. The hospital is licensed for 160 beds, though I'm not sure how many are being actively used.

My presentation went very well. It was brief, only about 1.5 hours, but the staff got to ask their questions and seemed engaged and interested. However, I do have major concerns about organizational readiness to take on an HIS+EHR project in Peru. I don't think anyone in the country understands the magnitude of an HIS+EHR project.

After the presentation, I asked to see some of the inpatient wings to assess EHR readiness. The hallways are narrow. So are the elevators. The proliferation of computer on wheels (CoWs) will create major ergonomic problems. The physicians are uncontrollable. They have no structure what so ever. They don't fill out any standardized forms for anything. They just scribble whatever they want in a large free-text progress note. It's up to the nurses to decipher the scribble to understand what orders need to be executed. Structured EHR and CPOE will are going to be jarring to the physicians.

After we left the hospital, we had lunch at a nice cafe. I didn't realize that soups here are entire meals; I thought they were just appetizers. So I had a double lunch - a delightful mixed seafood ceviche, and a rich Criolla soup. I also had two distinctly flavored Pisco Sours. The first was cinnamon flavored and not very good, but the second was passion fruit flavored and absolutely delicious. After lunch, we went back to the Chiclayo airport, where we hung out for a few hours with surprisingly decent wifi before taking off in the evening back to Lima.

Tuesday May 14th, 2013

I woke up bright and early at 7AM on Tuesday. After a quick shower, I went up to the roof of Hotel Boulevard and had a plate of fruit for breakfast. Then I spent 2 hours reading, writing, and taking care of some Pristine stuff until Jose and Carola from El Tumi Peru picked me up at 11AM. We went to a hospital in the poorest district of Lima and talked to the head of IT and the chief MD for about an hour. They weren't particularly interested in the screens, they just wanted me to verbally tell them what the software could do. Clearly, these people haven't been duped by that many software vendors before.

We drove back to the Miraflores coast. The entirety of the parks, hotels, and shopping districts along the coast are atop a 150 foot cliff. There's a narrow strip probably 200 feet wide at the bottom of the cliff before the water (see pictures below). That strip is primarily highway. There are a few peers going out into the Pacific. I had lunch with Jose, Carola, and the big boss, Felix, at La Rosa Nautica on one of the peers. I had Peruvian pork. In retrospect, I should have ordered steak, but the pork wasn't bad. Thanks again to the El Tumi Peru family for hosting me.

After lunch, I went back to El Tumi Peru's office, which is also in Miraflores. We chatted for a few hours about next steps. I really opened Felix's eyes as to what EHR and HIS implementations entail. El Tumi Peru most certainly didn't understand, and neither do the hospitals themselves.

The same driver that picked me up from the Lima airport when I landed a few days earlier took me to a bazaar where I did some shopping for friends and family. Then he dropped me off at the Lima airport to fly back to the US. The wifi was intermittent. To conclude my time in Peru, I bought 3 bottles of Pisco from the duty free store.

Wednesday May 15th, 2013

My United Airlines flight left on time at 11:50PM Tuesday night. Shortly after takeoff, the captain came on the PA system and told everyone that we had to turn the plane around because there was something wrong with the plane door.

After landing, we spent 30 minutes in the plane on the ground hoping that the issue would be fixed quickly so that we could take back off with only a slight delay. The issue was unfixable within a short time span, so everyone starting deplaning immediately. Unfortunately, they had to collect everyone's passport to cancel the immigration stamp as they deplaned. I was at the very end of the line and saw the enormous stack of passports. I refused to part with mine. I told the lady I would follow her wherever she had to go so that I could keep an eye on my passport at all times.

After waiting another hour in state of raging frustration just inside the duty free zone, they finally cancelled my passport stamp. Then I went to some hidden basement gate where they kept everyone waiting for another hour. Eventually a bus arrived to take us to the baggage claim. At this point, I realized that I needed to be in the front of the line if I wanted a chance at getting to the front of the main airport ticketing line. So I charged to the front of the bus line. I was lucky I didn't let them put my passport in the big stack. Many people still hadn't gotten their passports back by the time the first bus arrived.

When the bus arrived to the baggage claim, I charged straight towards the airport exit. A security guard stopped me. Within a minute, another 50 people showed up behind me asking to exit as well since they didn't have bags either. I heckled the security guard delicately, prompting the other passengers to heckle too. The security guard quickly caved. I burst out the exit, around the entrance and back to the front of the United ticketing line. I got the last seat on the American Airlines 7AM flight to Miami. I spent at least 20 minutes at the ticketing desk as the guy tried to figure out my flights from Miami to Austin. The passengers in line behind me were pissed. They thought I was haggling over vouchers and refunds while they were stuck not knowing how they were getting home.

I caught my flight back to America without any problems. After a few more bits of airline stupidity in the Miami airport, I flew through to Houston, then finally back home to Austin.

Morals of the story

1. Never let your passport leave your direct line of sight. Had I done as instructed by the United staff, I probably wouldn't have been able to be first in line at the ticketing counter, and would have surely been delayed a full 24 hours instead of just 8 hours.

2. Make sure everyone knows that you're pissed off like hell, but do not yell or be rude. The airline staff will treat you as if nothing is wrong unless you make it absolutely clear that you are rightfully pissed off. I was the most tense and frustrated passenger, and I led the charge got myself back to the US before every everyone else.

3. Demand vouchers, reimbursements, cash, and whatever else you can in compensation for the pain the airlines cause. Airlines will not go out of their way to apologize or rectify their mistakes. Extract every last penny from them that you can.

4. McDonald's french fries in the Lima airport at 4AM suck.

5. Fuck United Airlines.

How Do You Improve Upon Perfection?

The 15" Retina Macbook Pro (RMBP) is the first "perfect" PC. Of course Apple and its suppliers will continue to innovate, but the innovations at this point are effectively meaningless because the RMBP has extracted virtually all the value to be had from the laptop/PC form factor:

• It's super thin and light. It could get thinner, but I can comfortably carry the RMBP all day without any problems.
• It's powered by the superfluously fast quad-core laptop grade CPUs Intel offers.
• It can support up to 16GB of RAM, allowing for nearly limitless multi-tasking.
• The logic-board integrated SSD based storage is ridiculously fast. The OS boots up in seconds, and all applications and content load instantly.
• The retina-grade screen is stunning.
• The trackpad with BetterTouchTool is spectacular.
• The keyboard with Alfred is incredible.
• It offers native HDMI-out (finally!).
• It runs the sleek Mac OSX, with options to virtualize any other OS via Parallels Desktop or VMWare Fusion. Modern virtual machines offer performance that rivals that of native installations.
• It can power 9M pixels across 3 monitors without any problems.
• The battery is good enough for all of my mobile requirements.
• All of my content seamlessly syncs to all my devices via iCloud, DropBox, and Gmail/Google Drive.

I use my RMBP all day everyday across 9M pixels and 3 monitors, and I'm always running at least 30 apps. It never slows down under any circumstances. All applications run at full speed at all times (I don't count in-app bugs against the hardware + OS experience).

What more could I ask for? And what comes next?

To answer that question, let's revisit the most basic question of computing: what do computers do? They take input, they process it, perhaps store it, and then may output something that the user can perceive through at least one of the five senses. Note that the processing and storage don't have be done locally, but could be done in the cloud. We have fundamental opportunities to innovate at the HCI input layer, the hardware performance layer, the software layer, and the HCI output layer.

The RMBP keyboard and trackpad are phenomenal. They're efficient, precise, accurate, comfortable, and elegant. There's not a whole lot of innovation left to be had on the keyboard and trackpad. Microsoft's hardware partners have been offering all-in-one touch screen computers for years, but they haven't been very popular because desktop based touch screens aren't ergonomic. Windows 8's lackluster critical and commercial reception speak to the challenges of making effective use of touch-screen technologies in traditional mouse/trackpad/keyboard form factors. OSX supports global voice dictation, but it's not nearly as useful in the PC form factor as it is in the smartphone form factor. There are opportunities to integrate new HCI mechanisms such as Leap-like technology into PCs, but the use cases for Leap's technology are inherently marginal. Leap presents opportunities for novel apps that may not have been feasible on a keyboard/trackpad, but Leap won't change how we use laptops or desktops. There are still other opportunities to innovate at the HCI layer, such as eye tracking, but it's a decidedly uphill battle. Most of the technology press found the Samsung Galaxy S4's eye tracking to be a marketing gimmick and not particularly useful. It's going to be extremely difficult to meaningfully innovate at the HCI layer in the laptop form factor. Many people have tried and failed.

As I outlined above, the hardware performance layer has passed the point of relevance. Even "breakthrough" technologies such as memresistors will provide marginal performance improvements given how fluid the RMBP is today. I am still waiting for that always-promised-but-never-delivered revolution in battery technology, but the benefits of battery breakthroughs will be far more profound in hyper mobile form factors such as smartphones, watches, and eyeware computers, and in transportation such as cars and planes. Battery breakthroughs won't really change how we use laptops.

We've been iterating desktop OSes for 30 years. Desktop OSes matured some time ago. They are optimized for the HCI input and output mechanisms: the keyboard, trackpad camera, and microphone; and the screen and speakers. If the HCI mechanisms don't change, there's no reason to make any dramatic changes to the OS. Beyond HCI optimization, the dearth of ground breaking new features in PC OSes speaks nice to lack of innovation opportunities left. It was nice to see Apple integrate iCloud directly into OSX to enable seamless file syncing across devices, and to optimize OSX for retina grade displays, but there's just not much left to be done at the desktop software layer. Desktop OSes are gorgeous, functional, always synced to the cloud, are very optimized for their HCI mechanisms, and lightning fast.

We don't have a lot of innovating left to do on desktop computing, other than to reduce the cost of perfection. The 13" RMBP starts at $1500, and the 15" at $2200. Perfection certainly isn't cheap, yet.

Throw Yourself Out There and You'll Find a Soft Landing

“I never allow myself to have an opinion on anything that I don’t know the other side’s argument better than they do.” — Charlie Munger.

Well, I most certainly don't heed that advice. My blog violates that rule in every possible way. Every post has an agenda. I like to think that I know the other side's arguments, and I usually do to some extent, but I rarely know the other side's argument as well as they do.

On the other hand, I have nothing to lose. Charlie Munger has tens of billions of dollars to lose. I should use that to my advantage. I can bet everything without really betting anything. I have nothing to lose, and potentially a great deal to gain.

99% of my assertions my be wrong. Only 1% need to be right. The cost of being wrong is absolutely nothing. In my short time as a blogger, I've already achieved more than I thought I possibly could have when I started just a few months ago. I'm getting paid to write for the most prominent blog in healthcare IT, HIStalk! I couldn't possibly ask for anything more. I've read every HIStalk post in the past 2 years. It means a lot to be part of that.

Throw yourself out there. You'll find a soft landing.

MBAx is What College Should Be - Free and Career Oriented

MBAx is one of those ideas we're going to look back on in 10 years and think to ourselves "duh, why didn't I think of that?" It's perfect in so many ways.

So what does MBAx do? MBAx doesn't create any educational content. They don't do large-scale data analytics like Newton, and they don't create their own educational content like Coursera. They don't sell anything. They curate courses from other esteemed educational resources such as MIT Open Courseware, and organize it by professional discipline. MBAx's CEO describes it well. For example, the sales section lists some of the major sales skills - lead generation, cold calling, using CRMs, negotiating, and closing - and provides links to free high quality courses in each of those areas.

MBAx is invaluable. I'm perusing through 1 lesson per week, just to sharpen up some of my skills. I've always wanted to learn basic photoshop so that I can mock up user interfaces and screen layouts with greater graphical fidelity. I strongly recommend it to anyone looking to learn real world applicable white collar skills.

MBAx is a solution for the hundreds of thousands of recent undergraduates that cannot find work. Most of them, including many of my friends at NYU who spent a fortune on their educations, learned a great deal about liberal arts majors that most employers don't value, such as political science and psychology. Unfortunately, most modern undergraduate programs don't teach students the skills to succeed in the real world. Here's to hoping that MBAx can change that.