Waving in eHealth

I’m excited and optimistic about Google Wave. In my mind, its key strength is as a brilliant hybrid medium for complex, small group conversations:

• allowing tightly focused, tree-like threads, through contextual inline replies;
• synchronous & asynchronous collaboration, wherever useful or most appropriate; and
• inclusion of shared resource files.

So, Google Wave in eHealth - how could it be used?

A few thoughts...

1. Health Conversations

• For private use...

For Patient to Patient or Clinician to Clinician conversations, Wave is a great way for individuals to share thoughts and information on any topic, health included, and no matter what the personal or professional purpose. However if the topic IS health, then there also should be a caveat that the Wave doesn’t contain any private health information. It is not unreasonable to assume that sharing health information in Wave is similar to that of using insecure emails – so just don’t do it!

• For use in healthcare provision...

As a vehicle for a dialogue between Clinician and Patient, Wave is great but it is important to keep in mind that this is not just your average chat, but another format of an online consultation, and all the complications that this brings. If Wave is embedded in an appropriately secure environment, such as an existing EHR/PHR platform with appropriate privacy provisions/authorizations etc. and where versioning of the Wave could be recorded to support the medico-legal record, then Wave could be a great tool in eHealth.  Remember that this is a preview and it is a new technology, so there will be hiccups as we all learn to use Wave - there is a significant overhead to using Wave effectively.

One of my first thoughts re the potential clinical use of Wave was how it could have enhanced a Personal Health Record (PHR) that was developed for use by older children and teenagers with Insulin Dependent Diabetes at Royal Children’s Hospital, Melbourne – BetterDiabetes. There is a component within this PHR where the teens can request online assistance and advice from their Diabetes Nurse Educators (DNEs) for management of their diabetes. Armed with appropriate authorization and access permissions, the DNEs can view selected parts of the BetterDiabetes record, including glucose measurements uploaded only minutes beforehand, making informed and making real-time responses back to the teens regarding proposed changes to their care. In the online version of BetterDiabetes the secure messages flowing back and forth are similar to email, but embedded in the PHR – asynchronous, fragmented and clunky. If this was able to be transcended by a Wave-like tool for communication it could be a very useful vehicle for collaborative healthcare provision. The provision of timely information flow in both directions, and including addition of external files to the ‘Wave’ could be extremely valuable.

2. EHRs & EMRs

Wave is NOT appropriate for an EHR/EMR platform. Formal health records should be based on standards such as ISO 18308 – ‘Requirements for an Electronic Health Record Reference Architecture’ and ISO/DTR 20514 – ‘Electronic Health Record Definition, Scope and Context’. Now Wave may be very useful as an interface for communications within that EHR framework, form or structure, but it is definitely not the basis for "…a set of clinical and technical requirements for a record architecture that supports using, sharing, and exchanging electronic health records across different health sectors, different countries, and different models of healthcare delivery." Of some concern, there are some public Waves that are promoting Google Wave as the newest medium for EMRs. One public Wave as an example is: Electronic Medical Records (EMR) and Medical Information Systems: Is Wave the future of electronic medical records? which includes an EMR example.

By all means let's embed the innovative Wave interface for use within a formal EHR/EMR but we need to be careful if we are expecting more from it.

3. Clinical Decision Support

Phil Baumann’s ‘A Clinical Infusion of Google Wave’ blog, featuring Clinybot, is a fascinating, futuristic view of Clinical Decision Support provided for clinicians. Phil states that he assumes all privacy and security aspects are OK when proposing Clinybot - agreed. However, the missing ingredient in Phil’s proposal is not unique to Clinybot but the reason why we have so little Clinical Decision Support in practice. In order for Clinybot to function as described it would have to have a clear semantic handle on the data structure underlying it. Clinical Decision Support can be and is developed on a per EHR/EMR basis, however standardization of clinical content would enable universal applicability of Clinybot across all EHRs and EMRs. The combination of Clinybot and standardised content could be a very powerful potential partnership.

_____

I’m a pragmatist; definitely not a futurist. I’ve seen some predictions and anticipated uses for Wave that I think are very optimistic, maybe even a little far-fetched. Perhaps these things might happen... probably not.

And of course there are issues and drawbacks to Wave. Tech Crunch's Why Google Wave Sucks, And Why You Will Use It Anyway is a pretty good heads up to the reality of Wave at present.

For the moment I'm more than happy to explore how the benefits of the complex, small group conversations can be leveraged in healthcare, and particularly my clinical modeling work with openEHR. I will keep an open mind to see how Waving in health develops.

Riding the Google Wave

This morning I posted two tweets: "I'm having some great 'robust' discussions on #GoogleWave. I'm now able to finish @ianmcnicoll's sentences for him... in person & online;-)"

and

"I have a love/hate relationship with #GoogleWave. Getting sick of the "Everything's shiny, Cap'n." message, when clearly everything is NOT".

These two statements posted about an hour apart reflect some of my journey into the world of Google Wave.

My day-to-day work is all about collaboration - relying heavily on Skype and GoToMeeting as online tools to communicate with colleagues and clients distributed around Australia, and overseas; and working with groups of clinicians who are using an online application, the openEHR Clinical Knowledge Manager (CKM) for designing, reviewing and agreeing computable clinical content definitions, known as archetypes, for use in Electronic Health Records.

CKM is a relatively new and unique online application. Powered only by volunteers, it is harnessing the "collective intelligence" of clinicians and informaticians from all over the world to create open source archetypes, which underpin the European and international EHR standard, ISO13606.  Since its April launch, CKM is gaining momentum and has attracted 388 registered users from 49 countries, with 130 individuals actively involved in reviewing and agreeing the current 200+ archetypes - some modest success methinks.

The biggest challenge for me this year has been exploring how to productively engage with these busy clinicians and informaticians who are volunteering their time and expertise.  As a result, it was only early this year that I opened a Facebook account (after swearing I would never do it), and only this week I passed my 1000 tweet mark!  Learning to engage with these social networking tools and communities has certainly given me enormous insight re how we might be able to take CKM forward.

The core CKM team comprises Ian McNicoll (@ianmcnicoll) in Glasgow, Sebastian Garde (@gardes) in Dusseldorf and myself in Melbourne and we meet formally using Skype and GoToMeeting twice a week, which is not always the easiest way to collaborate.  One of the next challenges for CKM  is to nurture the design and initial creation of the archetypes collaboratively - effectively a sandpit or archetype 'nursery'.  Our main question is how to provide an online environment where interested international clinicians could share their time and resources effectively... and then we heard that Google Wave was coming!

Receiving that invitation was very exciting.  This was immediately followed by the let-down phase because, of course, you have to wave with someone!  And then the dilemma of "What to do with it?" I found a number of public waves where there were multitudes of people joining and then... well, nothing.  No-one seemed to have a clue what to do with it!  And the few Waves that were very active seemed to become quite chaotic very quickly, resulting in confusion rather than collaboration.

Once Ian, Sebastian and I all had our Wave accounts, we had an opportunity to play - sending asynchronous messages, using the Piratify and Flippy bots to do silly things to the blips and co-writing in real-time - hence my ability to finish off Ian's sentences for him;-).  More recently, we started to find some real uses for Wave which our usual email, Skype and GoToMeeting couldn't do.  We created a number of separate Waves, each related to a particular CKM requirement that we were trying to thrash out.  In fact, only this morning we managed to come to an agreement on a particularly curly one - an issue that we hadn't been able to resolve through a number of verbal discussions.  The ability to focus on one comment (blip) to get a common understanding has been very useful.

And then there was a recent twitter discussion that I had with @psweetman and @JFahrni about allergies - 3 strangers from UK, US & Australia using Twitter to try to come to a common understanding!  Jerry took the initial tweets (-what is the collective noun for a group of tweets?) and combined them in his blog.  While we could now see them all together, instead of fragmented 140 character snippets, it was still difficult to engage with each other.  So I took the blog and 'Waved' it - created a private Wave in which all 3 of us could participate.  The discussion that ensued was much more effective, building on previous comments and thrashing out specific points. It worked pretty well, including some bonus tips on where to visit next time I go to Las Vegas!

It is this collaborative aspect of Google Wave I'm beginning to love - it is really quite compelling.  Other tools, even used in combination don't cut it. Yet the down side is that Wave is still pretty clunky and I feel that I have seen more than my fair share of the "Everything's Shiny Cap'n" messages as the Wave crashes - hence the frustration evident in my second tweet.

The reality is that you just can't collaborate like this in other media.  Google Wave has enormous potential as it is refined and is extended. I look forward to exploring if and how we can incorporate Wave into our archetype development, especially now with the opportunity to federate Wave servers.  Perhaps it will work, perhaps not - but I have a glass half full kind of view at present.  Will keep you posted...