The Black Liszt

How to Avoid Cutting off Breasts by Mistake

I think we can all agree that if a breast is not diseased, it should not be removed. High on the list of modest, achievable healthcare goals should be avoiding misdiagnosing breast cancer, and avoiding cutting off healthy breasts.

There are widely known methods and proven technologies that are available for achieving this goal. Instead of applying them, the leading minds in the healthcare technology field ignore them, and instead invest billions of dollars in exotic, cool-sounding AI software that may deliver benefits sometime in the future. Something is deeply wrong here.

Yes, breasts are cut off by mistake

Perhaps you think I'm exaggerating? Here is a recent cover from the NY Post:

The woman felt a lump and had a biopsy. The diagnosis was cancer. She was sent to another hospital for surgery.

Makes, sense, right? Someone should double-check. The rule in carpentry is "measure twice, cut once." When breasts are involved? Double-check should be the minimum; triple-check would be nice.

Checklists

Wait, hasn't someone gone into this already? For healthcare, specifically? Oh, yeah, there's that book written by that famous doctor on this very subject, Atul Gawande:

He dives real deep into checklists in many fields, medicine in particular. Here's a partial summary by Malcolm Gladwell he puts on his site:

The hospital at which the healthy breast was removed knew about checking.They wrote a procedure for it!

What was the procedure? More paperwork. Another in the long list of things doctors have to plow through before they can do their jobs. If doctors actually took all the paperwork seriously, they'd get nothing done. In other words, the "procedure" was just paperwork created by lawyers and bureaucrats that makes life harder and helps nothing. As usual.

Effective, automated workflow checklists

What the healthy-breast-removing hospital did was not what Gawande had in mind, of course. He was thinking group meetings at which everyone goes through each step and signs off. Something meaningful. But that doesn't exactly apply here, since the double-check pathology exam should have taken place before surgery was scheduled. Thinking about it, there are many similar situations in which the checklists are spread out.

There's a concept and proven technology that applies here: workflow. Think of a flowchart with worksteps, lines and conditional branches. Here's a trivial example:

Think of the workflow as being driven not by paper diagrams like this, but implemented in software that interacts with EMR's and people, and tells them what to do.

In this case, when the patient was referred for breast surgery, a proper workflow would have scheduled the pathologist to examine the cancer biopsy data before anything else happened. If the results were negative, as they would have been, the patient would have been notified and that would be the end of it. Only if the results were positive would the system allow breast surgery to be scheduled.

Workflow systems assure that all the work that should be done is done. They eliminate paperwork by putting the checking and doctor sign-offs into the system. No lawyers. No bureaucrats. Near-zero errors. Corrections and enhancements can be made to the workflow without massive re-training and human error. Workflow is like a system-wide, automated checklist, with all the checklist benefits and more.

Let's do AI instead!

Workflow software exists. It's implemented in many industries, even sometimes in healthcare. It works. It reduces human labor and improves outcomes. Why isn't it ubiquitous in healthcare?

Workflow works, solves problems and is understandable. AI, by contrast, is cool, the coming thing and few of the people yakking about it understand it. AI is exploding:

I see a recurring pattern here: people jumping on the new trend, the leading edge, the cool new stuff that "everyone says" is the coming thing, that none of them really understands. And ignoring relatively prosaic technology that works and can provide real benefits today.

Conclusion

Cutting off healthy breasts tells us everything we need to know about exotic new AI, which is at the far end of the innovation spectrum I've described for healthcare here, and illustrated here. Workflow is at the simple end of the spectrum: proven, works, understandable and understood, delivers immediate benefits. I guess that's why the leading thinkers ignore it and all the "smart money" avoids it. 

Government Cyber-Security tops the Oxymoron List

Some cynics keep an ordered list of the "top" oxymorons. Long-term members of the list include "business ethics," "military intelligence," "northern hospitality" and "southern efficiency." While "government efficiency" has a permanent hold in the top ten, "government cyber-security" has leaped to the top.

Cyber-security is a huge problem for large organizations in general, for deep systemic reasons, as I explain here. The US federal government is making a big effort to get ahead of the problem. By doing so, it is embarrassing itself and making things worse.

The government is engaged in a giant effort to systematize cyber-security and train professionals in how to do it. Various claims are made about salaries over $100,000 and a need for over a million qualified people. I first encountered this effort in an article about a local community college that had received certification for their program:

This sounds prestigious: both the NSA and DHS are jointly behind it! This must represent the best training there is!

So I looked into it a bit. Here is what the NSA has to say:

Here is what the DHS has to say:

I noticed a couple things:

• Each organization has its own page to describe the joint program. Of course.
• Each organization lists itself first in the description. At the NSA, the program was created by the NSA and DHS, while at the DHS, DHS is listed first. Of course.
• Each describes the programs and its goals differently. Of course.

This is bureaucracy as usual.

Then I decided to find out about the program itself, so I clicked on the link at the bottom of the NSA site. Here's what I got:

No kidding! That's why in the image above, I clipped to the top of my browser, so you could see the URL and see that I wasn't fooling around. This is exactly what I got by clicking on the NSA site shown above! Maybe it's just the NSA that's screwed up. DHS probably has a better link, since their website was updated less than two months ago. Nope! Same result!

Makes perfect sense. The NSA can't keep itself secure. We already knew this from the Edward Snowden problems, and more recently from their role in the world-wide Wannacrypt virus attack. The DHS? Even government investigators have concluded that its cybersecurity efforts are worthless. So why shouldn't their joint website fail the most elementary security test?

I dug and dug, trying to find what was actually taught, and what the cybersecurity standards and practices actually were. In particular, I was curious to find if there was any mention of the NSA's role in supplying the weaponry for the Wannacry attack by means of gross deficient internal cybersecurity. I was also curious to see what level of acknowledgement there might be of their problems.

Result: a couple hours of digging resulted in amazingly little of substance. I'll just end with an interesting comparison.

Remember the world-wide outcry about the guy being dragged off a United airplane? The CEO stepped up quickly and defended his employees. Then he took it back and abjectly apologized, and there followed a stream of discussions about how other airlines did it and specifically how United was going to change to prevent a repetition of the drag event.

Compare this to Wannacry. Not just one guy, but tens of thousands of organizations, including most of the UK's NHS -- resulting in massive patient issues, many of which were far worse than United's dragging event. Who was put on the carpet? Who apologized? Any word from the NSA about their security breach that greatly magnified the problem? Of course not! Don't be silly! This is an august government organization: no one apologizes, no one loses their job, and nothing changes. Got that?

Software Myth-Conceptions: Building Materials

An amazing amount of discussion about software is governed by metaphors. This is not surprising, since software is so abstract, and invisible to most people. So a shared physical metaphor helps everyone communicate.

The trouble comes when the metaphor doesn't match with the reality of software, as it often doesn't. In those cases, what usually seems to happen is that what everyone understands about the metaphor is assumed to be true of the software. Bad things then happen.

One of the most common metaphors for software is a physical building. Buildings normally have architectural plans that are determined before ground is broken, with the architect being in charge. Then some digging happens and a foundation is created. From then on the framing is built, the electrical and mechanicals are installed, and the finishes are applied inside and out. Now the building is ready for use. Something everyone can understand, right? It makes sense that in software we also have architects, carefully planned and laid foundations, workers who fill things out according to plan, and finally finishes applied.

Software is usually built according to the physical building metaphor. Things like Agile methodology don't change things very much -- they just mean that instead of a complete plan of everything from the beginning, things happen in phases. The physical building metaphor for software is unacknowledged, unchallenged ... and pernicious. Ignoring the metaphor is one of the main things that smart software people who follow Wartime Software practices do to beat the competition and win.

Temporary physical buildings

When we think of software in terms of the building metaphor, we nearly always think of "permanent" buildings, ones with poured foundations and all the rest. Of course, you darned well better have it all planned out right -- altering a foundation is no easy job!

What about the technology used to build temporary buildings? These aren't just tents for camping; some of them are extensive. A great example is the Frieze Art Fair, an international art fair held in NYC every year. It's huge; over 200 galleries exhibited last year. Here is a view of the extensive building from the air:

Here's a view of part of the exhibition area on the inside:

There were even a couple of restaurants:

All this was assembled in under a week, used for the time of the fair, and then torn down and carted away. No poured foundations. No big deal!

Architectural programs

Architects use software to do their work today. There are varying levels of programs they can use. I used a semi-professional one to design a house. The program was amazing. It helped me with everything. Here's part of a drawing from my project:

See the steps in the lower left? The software made it easy. I didn't draw every step. There was a staircase module which did most of the work for me. Same thing with roofs, walls, windows, doors, appliances and pretty much everything. At any time, it could generate a list of the building materials required.

In the physical world, I would need those building materials. But what if I were designing a building that existed only in a virtual reality world? I wouldn't have to go farther than the design -- the design itself is all that would be needed! Now let's turn to software. Suppose I'm designing a UI and I want a footer on every page, and a logo on the top right corner. If I'm reasonably competent with software, I don't have to count the pages and place the logo and footer as many times as there are pages -- I do it once, in a page master!

In the plans for the physical house, while it's easy for me to pop 10 identical windows into the drawing, when it gets built, someone has to build and install 10 physical windows. In the software world, the realization is done by more software. In the physical world, if I want a change to all 10 windows after they're installed ... ugh! Go back to all 10 and re-do them. In software world, I go to the footer or logo definition, change what I want, and boom! It's done!

Yes, you can design software that doesn't work this way. Yes, all too many people do it the wrong way. They're stupid. What's important is that software can be designed the smart way, and it's not hard, so often enough, it is.

The building metaphor

So what does this mean? A couple things.

Using the building metaphor encourages software to be built the wrong way. It encourages people to think about it inappropriately. The smarter you are in building software, the farther away from the physical building metaphor you get. The metaphor even gets you to think about roles badly -- the "architect" is someone who does lots of planning but no real work. Lots of workers are needed to build, workers who follow exact instructions. Then checkers who walk around with the plans making sure the workers did their job. All of this is counter-productive! It leads to bad process and bad software.

Let's knock the building metaphor down, bury it and move on.