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Technology in Healthcare

I haven’t posted in a while, but I’m eager to jump back in with a vengeance.

Good article by Megan Mcardle on using technology to improve health care.

She writes:

Eventually, such systems [that unite data from multiple silos] might transform not just diagnosis, but the whole medical system. If we could develop more-comprehensive medical records, and collect that data in some central location, data mining might detect patterns in disease and treatment that we now discover only through painful trial and error. More than that, it could finally allow us to reach the holy grail of health-care wonks: paying for wellness rather than for doctors’ visits and procedures.

She concludes, as many conclude, that resistance from multiple sectors - skepticism regarding an unproven technology, reluctance to modify existing practices, and fear of new costs –  collude to prevent the new technology from being deployed.  While those issues surely contribute, I think that it underestimates the challenge of designing interfaces that allow doctors to interact with patients and simultaneously record data.  The inability to use these systems as easily and seamlessly as a clipboard is the biggest barrier to the adoption of an electronic medical record.

Doctors are as eager – and as reticent – to adopt new technologies as other professions.  Lasik surgery, medical imaging, fiber-optic procedures rely on advanced technologies.  Poor interface design and an uncertain return on investment contribute as much as the lack of regulatory and financial incentives.

Saturday is a work day in Juba, but it’s also a day (the only day) when we have reliable internet because we’re not at the Ministries. Taking advantage of this improved access, I wanted to post some of the articles that I managed to read during the week and thought that other people might find interesting.

Technology will Set You Free. Ethan Zuckerman jumps off Clinton’s Internet Freedoms speech to talk using internet circumvention to provide information to people living in closed societies. He concludes that while the State Department should fund circumvention efforts in the short-term, it isn’t the long-term answer (too expensive, only provides access to international content, and doesn’t protect publishers from cyber-attacks). He also highlights three theories of how access to information can drive change and argues that theory we adopt should influence our policy decisions. I liked: that he tied the policy and the technology together. I wished: that he didn’t imply that his three theories for change as mutually exclusive. State should be pursuing policies to support access to external information, tools for internal organization, and forums for debate that connect a countries citizens to those living in the diaspora.

Bureaucrats are Unhappy. The Buearocratics, a series of beautiful portraits by Jan Branning of bureaucrats around the world in their offices was worth struggling with Juba internet. I liked: the way that common themes connected government employees throughout the world. I also liked that my office in the Ministry of Public Services is nicer than any of the offices in the photographs (albeit with less character). I wished: that more of the bureaucrats smiled.

Senator Brownback is on the Case. Senator Brownback suggested to Secretary Clinton that having a South-Sudanese basketball team tour around the United States might help resolve the crisis in Sudan. I liked: that the Senator from Kansas knows that the Dinka are tall. I wished: that the Senator was as keen to remember that 4 million people are at risk of starvation as he is to recall that Manute Bol can dunk.

Cool Product of the Week: Bloom Energy Server is a fuel-cell that uses natural gas produces 100 kilowatts of power for about $800,000. With incentives, that’s about $.09 a kilowatt. (In DC we pay approximately $.20 a kilowatt and it’s powered by coal.) It’s cleaner and cheaper. The current version is geared to large companies, but they plan on building a consumer version for $3,000 that will recycle the carbon-dioxide to produce more power (and have zero emissions).

In my last post I listed the argument for using Excel as a development platform in developing countries and the many arguments against it. Then, a couple of nights ago, I was discussing how to deploy a solution in a low-bandwidth, low-capacity environment and everyone kept circling around to Excel. The consensus was that it wasn’t the best solution – or even a good one – but Excel and its cousin Access were the ideas that came fastest to everyone’s mind.

Consider this an open appeal for better options. I’m looking for COTS solutions that can store information and support common government functions such as Human Resources and Financial Management. There are zillions of COTS solutions that satisfy those generic needs, but I’m looking for tools with the following characteristics:

  • Incorporate common desktop software. Installing remote clients on desktops and laptops that are scattered throughout rural environments dramatically increases the complexity of any deployment. Beyond the initial installation, it results in reoccurring maintenance requirements and additional license fees. While the proliferation of Microsoft Office promises one solution to this problem, modern browsers such as Google Chrome that store data locally and employ fast JavaScript engines offer another, intriguing, approach.
  • Works offline and online. Low-Bandwidth does not mean zero-bandwidth. Solutions should connect to a centralized server or cloud-based data store whenever possible and gracefully devolve capabilities to a local store when necessary. In the US, developers think of offline capabilities as solving the airplane-scenario when the user doesn’t have any internet connection. In South Sudan, it’s more common to have a connection that fades in and out depending on the weather, the electricity, and the number of users. The solution should not break – and users should not lose their work – when the connection disappears. The Gmail flaky-connection mode and Outlook Send/Receive are models of how this could work.
  • Consumes and conveys data in standard formats. EGovernment solutions must be interoperable. Just as the actions of one ministry impact the rest of the government, data that resides in one ministry’s solution supports the policy objectives of other agencies. Out of the box, the solution must be able to output data in standard formats that can be uploaded to adjacent systems. Likewise, it should be able to accept files that are shared via CDSs and flash-drives as a backup scenario when remote systems are not able to synchronize with the central database

In short, I want a solution architecture that is more nuanced. I want something that finds the sweet spot between desktop-centric Office customizations and client-server structured solutions. Can someone point me in the right direction?

Saturday is a work day in Juba, but it’s also a day (the only day) when we have reliable internet because we’re not at the Ministries.  Taking advantage of this improved access, I wanted to post some of the articles that I managed to read during the week and thought that other people might find interesting.

  • It’s TED talk season.  In this November 2009 TED talk, Peter Eigen, the former head of the World Bank for East Africa and founder of Transparency International, talks about how the global economy contributes to corruption and poor governance in emerging markets.  I liked: that every company I have worked for requires all employees to take training on the Foreign Corrupt Practices Act which prohibits payments by US companies to foreign officials.  Eigen talks about the lack of laws preventing bribery of Foreign Officials in Germany, France and the UK and it’s nice to remember that the US has had a law on its books since 1977.  I wished: that his discussion of civil society also addressed tools to expose foreign companies that use bribes to achieve their business objectives.
  • The New York Times At War blog describes the surreal experience of visiting a USAID compound from the 1960s in the Helmand Valley that had since been occupied by the Taliban and is now a police station for the Afghan police.  I liked: the ballsy reporting.  I wished: that it didn’t make me think of the reserved parking space for the SPLA at our camp in Juba.
  •  AidWatch summarizes a counter-intuitive paper by William Easterly and Yaw Nyarko about the benefits of educated Africans living outside of their home country.  I liked: that it added nuance to the debate over the challenges of building capacity in emerging markets by showing that there is benefit to training and education even if someone doesn’t stick around.  If this applies to migration out of a country, it certainly applies to someone switching jobs within a country. I wished: that it had also mentioned the costs of migration by the educated workforce (such as too few health workers).  While the economic benefits of someone living overseas may outweigh the costs of training, there are other ramifications that aren’t captured by looking solely at inflows and outflows.
  •  Friends at Roving Bandit (the best Economics blog in Southern Sudan) argue that more aid should be direct cash transfers and less spent on expensive US-based consultants (like me).  I liked: that it presents an interesting alternative to the traditional aid model (which doesn’t always work).  I wished: that it had mentioned that 51% of the GoSS budget is already spent on salaries and 59% of 2009 USAID funding for Sudan was spent on food.

This week’s cool product:  Google Goggles.  You take a picture of painting, a monument, a strange-looking meal, a bottle of wine, or anything else and Google looks it up and tells you more about the object (the name of the artist, the history of the monument, the ingredients, the Wine Spectator score, whatever).  It’s search by picture as opposed to by text.

This week’s bonus cool product: A machine that can print organs.

Excel is Bad Aid

My project is currently debating the usefulness of Excel in eGovernment projects for Emerging Markets.  It’s not much of a debate; everyone agrees that Excel is not an appropriate platform for a sovereign (or even a semi-autonomous) region to use to manage anything.

Yet, its siren call remains.  Excel seduces because there is limited connectivity.  Its omnipresence – and the sunk cost of the license fee – beckons.  Developers and users are comforted by its familiarity.  Implementors tell donors that it’s just a fling, a temporary solution.  The affair begins, but next thing they know, they are crashing against the rocks.

I advocate for prototypes to gather data, set up business processes, and define functional requirements, so I am not blind to Excel’s appeal.  (To kill the metaphor, imagine me blindfolded and thrashed to the mast of Ulysses’ ship as it drifts to an enchanted Microsoft island.)  But even for prototypes, I think that costs of implementing an Excel-based solution far outweigh the benefits.  In the final reckoning, there is one good argument for Excel, two arguments against Excel, and four bogus arguments that are just myths.

Before I go through each of these arguments, I want to establish a few assumptions.  First, we’re assuming that an experienced VBA developer creates the Excel solution.  The solution catches errors, is flexible, and runs quickly.  This is not always the case, but I want to give the benefit of the doubt.  Second, there is zero connectivity.  Once again, this is not always the case (most places have some limited, occasional bandwidth through V-Sats), but I didn’t want to split hairs.  Third, the implementing partner has access to developers who have skills beyond VBA.  I suspect that Excel is often adopted out of ignorance of other solutions, but I want to assume that everyone has the resources to do what is right and not just what is expedient.

So here are the arguments.  Let’s start with the good news.

The Argument for Excel

I want to be fair and look at both sides of the coin, but after a lot of thought I can only think of one argument that supports using Excel as an eGovernment platform and even that argument comes with caveats.

Excel is Easy. I am a fan of VBA, the programming language that enables custom Excel solutions.  I have developed solutions with it (and continue to develop with it) for over 10 years.   A good developer can develop a beta-application in hours, test it over days, and deploy it over weeks.  VBA in Excel is easy to modify and while it is optimized for calculations, you can create acceptable user forms and interfaces.    In a short amount of time, Excel workbook can become a prototype and test a solution to support business processes.

If, however, the (experienced) developer has struggled to fix an error prone solution for months, it probably means that Excel is not the right tool to solve the problem.   Excel isn’t the right software for many problems (writing reports, drawing pictures, sending emails).  Excel is useful for financial models, some types of data entry, and data manipulation.  It should not be used for everything.

The Argument against Excel

Sometimes I fear that these arguments are so obvious that people don’t even mention them.    Nevertheless, they are important reasons not to use Excel.  Let’s get through them quickly.

Excel is not Scalable. Deploying an Excel solution is like putting a male and female bunny in a cage.  Little Excel solutions will be hopping around very soon.   The best argument against Excel is that it creates an operating environment where information lives on desktops and is inaccessible to the entire organization.  It empowers a single user, but does not provide enhanced capabilities to the entire organization.

Excel is not Secure. While it is possible to protect worksheets and prevent a user from ruining a developer’s precious code, it is much more difficult to implement even the most basic security requirements.  There is no (easy, automated) way to enable segregation of duties, where one use enters information and other user approves the data.  There is no (easy, automated) way to track who has viewed or modified the worksheet.  There is no (easy, automated) way to check to see if the person making updates has the authority to make those changes.   Using Excel in a context where people have incentives to be dishonest (such as payroll or financial management) is asking for trouble.

The False Arguments

These are the most interesting – and infuriating – arguments for Excel.  People make claims that Excel solves intractable problems when often Excel makes these problems worse.

Excel is a Low-Bandwidth Solution. This used to be one of the most compelling arguments for Excel, but new web standards have allowed web-browsers to emerge as strong competitor.   Modern web-browsers, which can run JavaScript and have offline data storage, offer a compelling alternative to Excel.  These solutions can run when there isn’t a network connection and can output data in formats such as XML that can easily be transferred.    An added benefit is that when connectivity becomes available, the same interface can synchronize with central data-stores and be used in an online environment.  This solution is much more elegant (albeit harder to develop) than relying on a desktop-based application like Excel.

Excel is Available on Every Computer. According to Forrester Research, 80% of enterprise companies use Microsoft Office for worker collaboration and productivity.  We’ll ignore the 20% that don’t use Office and assume Excel truly is omnipresent.   In theory, since Excel is already installed on the user’s computer, the VBA solution should work without any modifications.  In practice, however, Excel’s security settings prevent VBA code from running by default.  While this prevents malicious code from hacking into a computer, it also make deploying a solution fairly complicated.  In addition, changes between Excel 2003, 2008 and (soon) 2010 complicate testing and deployment.  It’s available, but it isn’t consistent and it still requires manual installation.

Excel is Familiar. Even if people know how to use Excel, they will not know how to use the Excel solution that addresses the eGovernment problem.   Training will be required.  Worse, Excel’s worksheet, row, column, and cell structure constrains developers and offers limited options for creating intuitive interfaces.  For example, there is no easy way to validate an entire record (as opposed to a single cell) before the solution stores the record.  Likewise, creating interfaces that support workflow and approvals is very difficult in Excel.  Ultimately, this results in unintuitive solutions that need more training.

Excel is a Temporary Solution. It’s common to hear people claim that they are building an Excel based solution as an interim fix before they can deploy the solution that will last for all eternity.  Unfortunately, that claim is rarely supported by clear plans – and timelines – to actually design and deploy the sustainable enterprise tool that will replace Excel.  Temporary solutions sans a clear plan for depreciation are permanent solutions.


If you’re debating whether to use Excel to produce an eGovernment solution, ask yourself the following questions:

  • Do I want the solution to support multiple users?
  • Is the information sensitive?  Can modifying the information hide corruption?
  • Do I want this solution to last for more than six months?

If the answer to any of those questions is yes, don’t use Excel as a development platform.  Excel is a great tool for many things, but it isn’t a great tool for everything.   When someone suggests using it for an eGovernment project, be wary of the false arguments.


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