Maurice A. Ramirez, DO, CNS, CMRO

xBox Education and PlayStation Process Enhancement

Futurist and technology guru Dan Burres once observed that to play the average video game such as Halo or Sonic the Hedgehog, a child must learn and master no less than 70 new rules or skills. These 70 skills do not increase the player’s likelihood of success in the game, rather these 70 skills are the bare minimum to negotiate the first level of the game.

Dan also noted that in this virtual reality or immersion simulation environment, the child is monitoring no fewer than 100 individual incoming streams of data from 360 degrees in all three planes of three-dimensional space (X, Y, and Z axis).  In addition, the most recent generations of these game systems provide text, audio, and video conferencing, allowing players to collaborate in real time with individuals not only within their country but across the internet in other countries.

These collaborations are not bounded by language differences. As a result, to work collaboratively within a given group and have that group work collaboratively against other groups, the players must learn a new language either one unique to the game or one utilized in common by all players within their team.

xBox Education:
But what does this have to do with education or business process enhancement? 

What would happen if the much ballyhooed No Child Left Behind curriculum handed over to video game programmers and utilized as the rules, processes and systems of a series of role playing adventure video games?

What if the same level of mastery of scholastic skills were required achieve success within the various levels of these games?

It is estimated that the entire K through 8 educational curriculum would be learned and mastered within a short two and a half years!

Further, the remaining four years of high school would be completed within 18 months. Given that this sophistication of video games require a certain level reading and fine motor skills, students would not be ready to begin such a program until age seven or eight (third grade). These students would therefore complete high school by the end of seventh grade.

Military and civilian applications of immersion simulation and virtual reality training have found that application and retention of information and skills learned maintain greater than 90% recall and greater than 90% proficiency in real world application. This means that students learning in an immersion simulation / virtual reality environment would not only master their K through 12 education, but would recall it with over 90% accuracy and apply it with over 90% proficiency.  This exceeds even the best educational programs anywhere in the world by over a two to one margin. 

Given this level of retention and proficiency, these seventh graders would be able to augment their education with the first two years of college (Liberal Arts studies) which they would again complete within a year.  A well-rounded education could be further augmented with Music and Literature, which of course would be part of the immersion simulation rather than separate courses, lending little or no additional time to the program. 

In such a technology augmented education, by the time an average child graduates from middle school and enter their adolescent years, they would have completed the equivalent of two years of college in a Liberal Arts program, again with a mastery level greater than 90% or in collegiate terms, a Magna Cum Laude level of expertise.

Toaster or Technology:
The problem with the application of such a model within our current educational system is that for a preadolescent or adolescent, the xBox 360, PlayStation 3, or similar device is not technology, rather it is a tool not unlike a toaster.  To those of us who provide education, either in the postgraduate or in the secondary school environment however, this self same device still represents significant technology with “cutting edge graphics” and “blazing speed.”  For those of us raised in the Pong and Atari generation, the xBox 360 and PlayStation 3 were not only unimaginable, but had they existed in our adolescence, they would have cost tens of millions of dollars and been referred to as “super computers”.

The cultural clash between today’s educators and the educational technology represented by the xBox 360 and PlayStation 3 is a chasm almost too wide to forge.

Business Can Lead the Way:
Perhaps the trickle down of effect would be more readily accepted.  Instead of revamping the modern classroom into an educational video arcade, what would happen if currently available technologies such as the xBox 360, PlayStation 3 or even Second Life were applied to immersion simulation training of employees? 

Role-playing games designed around literary works, movies, or even fantasy could be modified or even built from the ground up to incorporate the new skills and processes needed in the business environment or even a manufactured environment.  Fire safety, workplace safety, disaster preparedness, disaster response, or even such mundane activities as packing for trips, preparing for a doctor’s visit, or maintaining your own health could be incorporated into the mythical world of virtual reality role-playing games.

Modern-day Dungeon Masters could tap into the vast bodies of knowledge and work cooperatively with professional organizations and trainers, academic institutions, and advocacy groups to ensure that evidence-based processes were incorporated into the games allowing the games not only to maintain the laws of physics but the laws of business, Medicine, and even real world legal considerations.

Imagine entering Second Life online and “volunteering” at a hospital that is responding to an earthquake (or the attack of Godzilla).  Nurses, doctors, administrators, laboratory technicians, x-ray technologists, healthcare providers, and professionals of every ilk could practice their cooperation, collaboration, policies, and even procedures in this virtual space until these skills became second nature in Second Life.

When a real event occurred, the self same individuals who trained in the immersion simulation / virtual reality environment would find that they apply these new skills with military precision and virtual reality realism.  Life will truly imitate art.

Let the Games Begin:
So what would it take to move theory into practice? 

The will to do it! 

The technology exists.  The programming algorithms exist.  The procedures and best practices in each industry that could benefit from immersion simulation / virtual reality training exist.  The only thing that is lacking is a simple collaboration between programmers who are masters of this new world and professionals who are masters of both the new and the old knowledge.

Perhaps like in the video game Cameo, these modern-day digital alchemists can come together with the wizards of ancient wisdom and forge a new world for all.

The Race to a Paperless Society

It is amazing how once you notice something, you begin to pay attention and in paying attention you discover a whole new world.

Several weeks ago I wrote an article on portable medical records and the possible uses of technology to bring part of the medical records from novelty status to a mainstream medical device.  A few weeks later I was introduced to a new generation of portable medical records that were capable of synchronizing with the electronic medical records at a physician's office or at a hospital.

For those of you who are not familiar with portable medical records allow me a moment to give some definitions.  A portable medical record is a USB drive device such as a Thumb Drive, a USB wristband, a USB flash drive wristwatch, pendant, or other portable mass storage that can be worn on the body attached to a belt or keys and holds basic medical information in a database form.  Almost all these devices now are password protected and offer varying levels of functionality.

A personal health record is the online equivalent of the portable medical record.  This software exists on the Internet with storage maintained at a third-party site.  The information is again password protected and in an emergency can be accessed by the healthcare provider with an Internet connection and that password.

An electronic medical record is a software package utilized by hospital healthcare facility physicians that replaces the paper patient chart.  This is an official document and subject to significant government regulation.  By 2008 every healthcare provider in the United States must be executing concrete plans to transition from paper to electronic records and by 2014 all paper must be gone.

With that in mind let's turn now back to the portable medical records.  This is a market that is exploding.  A few short weeks ago I wrote an article, my second in this arena, that described nine products of this type.  Two days ago I did a new Google search on this topic (okay, I was desperate for an article topic) and I found no fewer than 24 companies now offering these devices in the United States, Canada and England.  Many of these devices are now being made in Taiwan and China and installed directly on the flash drives.  They are coming in every shape, size and form but unfortunately with little or no functionality.

Yes, they all have some form of password protection and an emergency screen where basic information can be seen without the use of the password.  They hold information such as living wills, organ donor cards, healthcare surrogate contracts, past medical histories, allergies, medications and a few hold greater levels of data.  Two of them integrate with online personal health records but only one can import and export to electronic medical records.

None of these systems however have one basic piece that is required for credibility in the medical world.  It is called change tracking and it is the ability for the healthcare professional reading the portable medical record to look at what changes have been made in the portable medical record and what existed in the record before the change was made.  Change tracking is an internal audit of the system and ensures that there has been no tampering that could threaten a patient's life.

At least there was not such a system until this week.  This week www.theoriginalmymedicalrecords.com announced the prototype release of Version 1.2, a portable medical record with change tracking, high-level encryption and password protection.

This is truly something new and represents a second generation of portable medical record.

Where will this new medical device find a home? 

As the water resistant or splash resistant USB devices these units are already finding a home on the wrists of scuba divers, sky divers, mountain bikers and others who enjoy high fun/ high risk sports.
      
But I envision a larger market.  I envision a day when rather than receiving a flimsy paper wristband at the hospital or nursing home a patient has a portable medical record in a waterproof band around their wrist.  When the nurse comes by with their wireless Tablet computer to chart she simply plugs the patient record band in and the records are immediately synchronized.  The patient goes nowhere without their chart on their wrist.
      
When they go home the patient takes the band with them carrying the entire chart in miniature form.  The hospital has its copy.  The patient has their copy and their copy goes back to the doctor's office.
      
In the event of an emergency the patient's band is on their wrist and it does not matter what emergency room they go into, what EMS service picks them up all the important information is at the fingertips of those there to save their life.
      
I envision a day when my disaster medical assistance team (MDMS/DMAT-FL3) provides care in a Katrina like event after a natural disaster with subsequent flooding and places a USB flash drive wristband around the wrist of every evacuee.  Information on federal assistance, registration for finding lost family members, their own personal information as well as a health record will travel with them from the moment of rescue until their final destination.  If they already had a personal medical record on their wrist or in their pocket or around their neck as an independent we in the MDMS/DMAT-FL3 would be able to plug their device into our computers and upload the important information to help them recover their lives and help us treat their injuries.
      
This second generation of flash drive device holds tremendous promise not only for the transfer of information but even the prevention of medical errors by ensuring that the most basic information is in the hands of those who are making the most important decisions.

An Innovative Approach to Disaster Preparedness

I have been in the disaster response field for over 20 years and had thought I had seen or at least imagined every possible means of reaching the general public. We have had a "War on Terror," a disaster evacuation back packs sold on infomercials, catalog and Internet sales of every size, shape and description of preparedness tool and resource. Today I was introduced to a new and definitely different approach to the problem of getting the everyday person to be prepared, a multi-level marketing business (MLM).

Don;t worry gentle readers, I am not in the MLM business and there is no pitch coming.

MLM's have been around for over half a century. These highly regulated companies present everything from vitamins and supplements to industrial cleaning supplies,to information systems for MLM marketers. In my remote past, I was a motivational speaker for three different MLM companies, but I never thought I would see an MLM dedicated to disaster preparation products.

My introduction to the concept came as most MLM introductions do, by email from a colleague. She is an "independent representative" (the legal term is "independent distributor") and felt I establish a "business" through my network of disaster professionals, family and audiences. I will admit that the product line appears both reputable and useful. The marketing system will reach a lot of people and most that sign-up for MLM's do so for the networking, not the products so it will be a group otherwise unresponsive to the preparedness message.

The old adage: "There's nothing new under the sun," may be true, but there is always a new use for an old tool.

The Missing Link

The medical profession is being dragged kicking and screaming out of the Nineteenth century and into the Information Age. President Bush has forced this issue by ensuring that physician’s offices, hospitals and healthcare providers of all types must implement fully paperless electronic medical records (EMR’s) by 2014. More imminently, those with these EMR’s must provide off site storage of records in online medical record repositories.

Consumers are already doing this for themselves. Online and at home personal health records (PHR’s) are gaining in popularity. These consumer controlled systems allow patients to store everything from past medical histories to legal documents to MRI images for later recall and review. All of these systems require that the consumer or their physician input the data (online, by keyboard, or by fax/scanner).

Another group of consumer directed products are the portable medial records (PMR’s). These database systems reside on wallet sized CD-ROM’s or USB Flash Drives and allow the consumer to carry their records with them in case of emergency or disaster evacuation. Like the PHR’s, data is entered in the PMR’s by the consumer or their doctor.

Each of these systems has a critical failing. EMR’s are site specific and unless synchronized with the medical record repository, only contains the data generated in that office. Further, these systems are not available to Emergency Rooms and Disaster Medical Professionals when the information is needed most. Further, consumers are uncomfortable with their doctor uploading their medical records to a medical record repository such as the Social Security Administration or other insurance company.

PHR’s address the problem of site specificity, but medical professionals are suspicious of the systems because the consumer has the ability to alter or omit portions of the record. Consumers are like that they control the destination of the records, but PHR’s do not fulfill the current requirement for medical record repository storage of EMR data. Consumers are also suspicious of records stored online that may be accessed without their knowledge.

PMR’s address the problem of access (the data is literally on your person), but what about the problems of repository storage and data alteration/omission?

The missing link between PHR’s and EMR’s is a PMR that synchronizes with the export data stream of the EMR through the USB port and then uploads to a repository and a PHR of the consumer’s choice from the PMR in an unaltered and unalterable state. Such a device would allow consumers to carry records between doctors, shortening the time doctors wait for reports from other doctors. Consumers would retain complete control of where their medical information goes on the internet, what agencies have access to the data and how it is used. In the event of an emergency or disaster evacuation, the consumer would have their medical record with them that, because it is unalterable, would be accepted by medical professionals.

Just a dream? Not any longer. One PMR new to the market promises these functions and more. If this PMR fulfills its promise, the missing link in health informatics wil have been found.

Where’s the Technology?

Where’s the Technology?
The last ten years of medical advance has promised again and again the ability for physicians to remotely examine and even treat their patients.  Federal government states and universities have spent that millions of dollars in the development of examination stations and “robots” to provide stereo two-way voice communication, stereoscopic video and even remote stethoscope capability to patient bedsides in remote hospital communities.  This new science of telemedicine has brought advances to hospital and emergency room based medicine for those remote communities.

But what about the average consumer?  The coming pandemic looms ominously on horizon.  But this ominous shadow may actually be a new dawn for telemedicine. 

The SARS outbreak in Toronto and Singapore proved that quarantine does not work but that “Social Distancing” does.  The message in Toronto was clear and simple.  “Don’t go to hospitals and healthcare institutions unless you want to catch SARS.  That’s where the SARS is.”  In Toronto it worked.  The SARS epidemic fizzled out after only a few short weeks of social distancing. 

But in the United States, emergency rooms, hospitals and urgent care centers are the destination for the treatment of after-hours illnesses and sudden onsets of the flu.  Pandemic flu will strike like a blitzkrieg across the world.  People will fall ill in a matter of hours not days.  Doctors’ offices will be overflowing with the sick and those who are afraid that they will become sick.  The default will be the urgent care centers emergency rooms and hospitals of the nation.  This is where the disease will be concentrated and like with SARS in Toronto this is where it will be most likely that you will become ill.

Here’s where telemedicine has the advantage, if somebody, anybody can produce a telemedicine technology solution within a reasonable price range for the average consumer to buy.  What would be needed would be a high resolution web camera and a simple handheld stethoscope-like device that could produce high fidelity sound in real time.  A web based portal for physicians would also be needed.  The examination would need to be completable in real time. 

Imagine a simple device with a webcam and a modified microphone similar to that already found on electronic stethoscopes used by physicians coupled with an electronic blood pressure cuff. Now imagine this device providing information in real time to the physician a rudimentary medical examination, a kind of “telemedicine triage.” With this consumer priced equipment, an examination could be performed and basic healthcare decisions such as the need for home healthcare nursing, antiviral medication prescriptions, or simple chicken soup could be made.  This “telemedicine triage” would ensure that only the sickest of the sick would go to the hospital guaranteeing that the spread of the disease was decreased because fewer people would be sent home from the hospital not sick, but now contaminated. 

Of course Medicare, Medicaid and other healthcare insurances would have to begin to actually pay physicians to perform telemedicine services.  While the codes exist reimbursement is slow and difficult.  Telemedicine takes more time than a regular examination and time does have a value.

Will anybody step up to the plate?  That depends on demand for “telemedicine triage” by the public, the demand for a consumer telemedicine product and, unfortunately, the ability of physicians to get paid for what they do. On the other hand, the cost if telemedicine triage does not become is that the future pandemic will rage on.

What a Great Idea!!!

Kevin Freking, of the Associated Press reports on the first major corporate sponsorship of portable electronic medical records. Applied Materials, BP America, Inc., Intel Corp., Pitney Bowes and Wal-Mart will enroll employees in a central database to maintain health records in an effort to eliminate duplication, omission and error.

This is a concept that is supported by President Bush and the National Academy of Science - Institute of Medicine. Not only with the system collect medical record information and reports to a central repository, but individuals will be able to provide personal and family information to augment the record. This type of system is envisioned by the Whitehouse as a national standard by 2014 and is a requirement for implementation by medial providers by 2008. The problem with this on-line repository database is that it is internet dependent and while accessible from any internet portal, it is not truly portable. You cannot carry it self contained in your hand.

But, what if there were a way to carry a copy of such vital data in the palm of your and, or in a watch, wristband, pocket card, etc.?

W. David Stephenson of Stevenson Strategies made a fantastic suggestion in his September 26, 2006 blog entry. He suggested that people carry their medical records on secure U3 enabled USB drives. Such devices are already imbedded in credit card sized wallet drives, wrist watches, necklaces, key rings, pens and every manner of business sundry.

As an Emergency Room physician, I'm not sure I would look for a USB drive in the pockets of a patient in the emergency room, but a USB drive watch, wrist and, pendent or wallet card would be useful. What a wonderful merger of form and function that could now save your life! David ends with the statement:

"This sounds like a real win-win technology that hits my sweet spot: convenient and usable every day (no more lugging laptops home from the office!), and, in a disaster, a literal and figurative lifesaver, because you'd not only have your medical records in hand, but also all of your critical applications and business files as well. It wouldn't be ideal, but, in a worst case, you'd still be able to do limited business if you had access to a shared computer in a shelter -- and, for emergency workers themselves, smart drives are going to be essential supplies."

Currently there are 8 companies selling a solution similar to what David is suggesting. Unfortunately, none of these take advantage of the U3 technology David describes. One of the 8 companies is planning a U3 version in 6 months. Although all 8 companies claim password protection for the user interface, only one of the systems uses encryption to safeguard the data files from direct access by other software.

Also needed is the ability to ensure that the patient does not deliberately or accidentally alter the records, especially if they record includes notes from medical professionals as several of the systems do. Another nice feature would be the ability to synchronize with the electronic medical record (EMR) at the doctor's office. Here, the existence of the type of central repository described in Kevin's report serves not only as a primary data source, but an ideal back-up for the USB data.

There are a few problems that are still to be addressed including ISO-9000/CMS-EMR standards compatibility and linking to the coming central medical records repository, but one company is already cracking that nut too.

All in all, Kevin & David propose a great idea!

Kevin's article can be read at: http://www.wilmingtonstar.com/apps/pbcs.dll/article?AID=/20061207/NEWS/612070357&SearchID=73265339316299

David's complete blog entry can be read through the permalink: http://stephensonstrategies.com/categories/profitableCorporatePreparedness/2006/09/26.html#a9