3D Printer Out-of-Box Experience Recorded as Google Glass Video

My 3D printer arrived! I shot its Out-Of-The-Box Experience using my Google Glass. It’s ten minutes long! That’s because it’s a kit I have to assemble.

By the way, in the video I mention I read it took three Ph.D. scientists and two engineers eight hours to assemble the printer. To be fair, I read numerous other places it only takes one person four to eight hours.

3D printing promises to revolutionize many industries in the same way the Internet did. Only, instead of manipulating just measly little ‘ol electrons, we’re talking whole frickin’ atoms! Download a 3D design off the Internet, tweak it to your purposes (size, add/subtract features, add your own branding), and presto! I don’t know how soon we’ll be printing pizzas like Star Trek’s replicator, but look at this list of cool medically-related stuff that’s already happening.

If you’re interested in 3D printing in medicine, check out these links!

  1. Trends in 3D Printing of Customized Medical Devices
  2. 3D printing is new face of medicine
  3. How 3D Printers Are Reshaping Medicine
  4. The Five Most Promising Uses Of 3D Printing In Medicine
  5. 3D printing of blood vessels goes to clinical trials

Workflow + EHR + Activity-Based Knowledge Management

From Matthew Loxton’s (@MLoxton) Knowledge Management and Organizational Learning Blog … enjoy!

[The Emergency Room] is a compression zone in the flow of patients, since many routes lead into ER, and frequently the wisest course when in doubt over severity and acuity of a condition, is to process them through the ER just in case the quietly seated patient quietly dies because nobody took a really good look with the right level of technology and expertise.

All clinician roles are stressful; let that be said before I draw the ire of opticians, dentists, and dermatologists. ER clinicians however are right up there with the highest stress roles in healthcare. Although it must be admitted that ER clinicians generally get to see better outcomes than some specialties, ER clinicians are usually presented with life in its raw state. Torn flesh, broken bones, and mangled people, some still with the smell of gasoline and tire rubber on their bodies, the smudges of nitrocellulose propellant from gunshot wounds on their skin, and lots of vomit, blood, and tears. ER departments are not restful, tranquil, or serene, and no amount of feng shui, fragrance sticks, or furnishings can change that. ER departments have to sort people rapidly into categories and actions to be taken, often in exact opposite order to instinct. Quiet and blue takes precedence over bleeding and screaming, necks take precedence over hands, clear fluids over blood in the ear.

As a result, ER departments have an urgent need to have supporting technologies such as ED Patient Tracking Systems and Electronic Health Records (EHR), that can remember and track patients that might easily get lost or forgotten, and whose history will be collected accurately and quickly as they transition from the ambulance to the first-look nurse, then triage team, the nurse, perhaps more than a few doctors, specialty care, radiology, laboratory, and yes, accounts. Have they seen this patient before, are there allergies or prior conditions to consider, are they already taking any medications?
However just having an EHR system does nothing unless there is an underlying workflow, and the EHR integrates perfectly with that workflow.

ER workflow is both physical and virtual, and it comprises rules, procedures, activities, equipment, spaces, places, and people. Although some of the people can switch roles in an instant, they are deployed according to a process, licensure, and how the ER facility is physically structured. The very first person must rapidly assess where the patient most needs to go at that instant in order to get them to the right level of care the fastest, and to maximize the use of the very expensive and scarce resources available. The resuscitation team should receive the person with the cardiac arrest; the trauma team gets the one with the bones coming out of the wound, and so on. No sense in blocking the resuscitation bed with the patient with the broken arm. The workflow has priorities, and activities that have primary and secondary actors, and various technologies including equipment, medical gases and fluids, medications, and consumables such as needles, gloves, and dressings.

In figure 1 the fundamental structures of activities within a workflow are shown for typical industrial or business settings (2), but these map directly to their medical counterparts. Tools relate to equipment and instruments, materials to medications, fluids, and consumables, while utilities relate to medical gases, suction, irrigation, and electrical power.


Figure 1. Workflow activity substructures

The implication of workflow is that knowledge is applied to the activities by actors in relation to the tasks they carry out and the requisites they use in doing so. As such to have a functional workflow that is supported by an EHR, the ER also needs to consider who knows what and how they will best come by this knowledge in order to apply it effectively at the point of care. The application of knowledge management principles to ER workflow expands this as illustrated in figure 2.


Figure 2. Knowledge Sources

All things being equal, the ER staff, deployed in space and sequence in a carefully monitored and calculated fashion will quickly identify urgency and action to stabilize, treat, and often admit patients with the maximum efficiency, because in illness, time counts.

However, even a perfect ER, operating at 100% efficiency, will swiftly overcrowd unless the patients can be routed to the next appropriate level of care as efficiently. Whether the next point of care is the patient’s home, their local hospital, or Intensive Care (ICU), the time it takes to process the necessary documentation and route them is not infinitely small, and results in backlog and patients piling up in holding areas in and around ER, and people die in these interstices of care.

The workflow thus needs to integrate with care beyond the ER, so that patients can be drawn off to the next point of care at least as fast as they are processed by ER, and this is where the integration of EHR across the institution comes into play. The workflows at the perimeter of ER can only effectively integrate with those of other services and points of care if the EHR enables seamless transition.

An example of this is the bed management system for inpatient registration. An ER patient that requires definitive care as an inpatient can only be transported to a ward if there is an open bed suitable for the level of care required. To achieve this, the ER clerk must be able to see with great reliability which wards have a currently open and clean bed that has the right associated services, technologies, and level of care. A patient requiring 24hr surveillance may require a telemetry bed, patients with mental health conditions may require special services, and fall-risk patients, and infectious patients have still other bed and location requirements. To complicate matters, ward configurations change, policies changes, and new medical norms arise, requiring the systems and the people to adapt smoothly to changes.

Reflecting on figure 2 one can usefully ask how the ER clerk would know what the current policies are with regard to the patient needs and available beds. The answer is that it will be a combination of embedding the knowledge in the EHR, recruiting people with the right prior application and hospital knowledge, training on the EHR and the policies, and job aids that are either embedded in the EHR or available in conjunction with it.

Throughout the process from registration to discharge, the integrity of the patient’s record must track smoothly across transitions and locations of care, including follow-up and outpatient care.


Integration of workflow, EHR, and knowledge management methods can provide significant improvements in patient flow management in a hospital, and this can be seen in what is perhaps the starkest situation- the ER. Workflow ensures that the right things are occurring with the right actors and at the right time, while EHR avoids medical mistakes by tracking the patient and their health throughout the system. Knowledge management asks the important question of how all the actors know how to do what they are expected to do. This applies to all the actors involved, whether they are clinicians, administrative staff, the patients themselves, or those that care for them.

National Mall Google Glass Video Walk Through Snowstorm Janus In Washington DC

Google Glass works great in low 20-degree weather, as I proved today when I walked from the US Capitol to the Washington Monument in Snowstorm Janus. It took about 20 minutes and I encountered tourists, dogs, snowballs, snow angels, reporters, and even a museum alarm (plus a guy running away: exciting). Along the way I talked to myself. About whatever came to mind (including Glass).

I tweeted a lot of photos from Glass. I’ll add them below. But, in the meantime, I wanted to upload, embed, and tweet this video, literally while the snow is still flying. Thank you to everyone who favorited and commented on those tweets, I enjoyed the feedback while I was out and about in the biggest DC snowstorm in three years! (Which is not so big as all, since I grew up in northern Idaho and norther Illinois.)

OMG! Plagiarism In The Health IT Online Community? I’m Delighted!

I’ve heard that “Plagiarism is the greatest form of flattery” and I’ve finally been flattered! I had writer’s block this morning, until a routine search turned up 5 EHR Workflow Flaws To Watch Out For. Fantastic! Wait. Didn’t I just write an article with the same title?


And there it was! Identical ideas and organization, somewhat rewritten, but in many instances copy-and-paste. For example, “EHRs fail to support user-shared mental models of workflow. One of the very few benefits of paper-based workflow is that documents and forms can” is word-for-word identical!

And no link or attribution to me.

Now, I’m the kind of guy who sees an opportunity in every problem. No more writer’s block! I’d write a blog post comparing my and their blog post. Just another way to get important ideas about EHR and health IT workflow and usability in front of as many people as possible. I’ve presented and written about these ideas for years, starting at the 2004 MedInfo meeting in San Francisco.

I’ve bolded the most important concepts and embedded a screenshot at the end of this post.

By the way, here is my own 5 EHR Workflow Flaws To Watch Out For on Medical Practice Insider.

My Original Text Plagiarized Text & Ideas
Unnatural. Unnatural:
Many EHRs do not match healthcare task structure. Most EHRs are built in a way that they do not match practices’ workflow.
Inconsistent. Inconsistent.:
Similar information within an EHR may require completely different workflows to access, depending on which vendor or even which programmer wrote a particular module. If physicians are looking to access similar information within one system, there may be two or more ways to do it based on which module is being used.
Irrelevant. Irrelevant:
At each step in a workflow, only a small subset of the possible data or entry options is relevant, yet users face high-resolution screens thick with tiny checkboxes. In most of the modules, only some information is mandatory while the other ones can be skipped. This results in overwhelming screens with aplenty tiny checkboxes
Unsupportive. Unsupportive:
Many EHRs fail to support user-shared mental models of workflow. Many modern day EHRs fail to support user-shared mental models of workflow.
One of the very few benefits of paper-based workflow is that documents and forms can explicitly and visually represent workflow state. One of the very few benefits of paper-based workflow is that documents and forms can clearly represent a workflow.
Whomever has the documents has the responsibility. Whatever remains to be filled out signals what remains to be done. If something is missing in a chart, it needs to be filled out by the person holding the document.
Instead, workflow state is hidden in database tables and obscure screens. Compare this to EHRs and we find that workflow state is hidden in databases and complex screens.
Inflexible. Inflexible:
Most important of all, much EHR workflow is inflexible. One of the biggest problems EHR users face is the lack of the software ability to be flexible.
The workflows are hardcoded. Users of the system have to make do with the inbuilt workflow or rely on the way it was installed when being deployed.
If the software is unnatural, inconsistent, irrelevant, and unsupportive when installed, it cannot easily be changed to become natural, consistent, relevant, and supportive. They cannot easily be changed to become more flexible, natural, consistent and supportive.


Tweeted Photos From My St. Thomas US Virgin Islands Vacation

I just got back from a fun vacation in St Thomas, in the US Virgin Islands. I tweeted lots of photos. This is just a blog post to collect them in one place so I can send them to folks not on Twitter or who don’t read every one of my tweets. (Is that possible?). 🙂

$100M of Grid Computing vs $34B of Meaningful Use? Distributed EHR Workflow

Meaningful Use creates ‘medical bridges to nowhere’ generated a lot of traffic on Twitter this morning. What I find most interesting is that the $100 million dollar alternative to the $34 billion dollar Meaningful Use program is based on grid computing. And grid computing relies on the workflow management systems technology I write about here and elsewhere every day. Don’t believe me? Take a look a the following section of index from Grid Computing: Infrastructure, Service, and Applications.

I rest my case.

Actually, I don’t, because I’m sure to continue in the same vein.

A grid computing system for healthcare data exchange is exactly what we need in healthcare. And it relies on much of the same technology I’ve argued is missing from most EHRs and health information systems. If you are interested in learning more about this technology, check out my archive of almost 2000 links at the EHR.BZ Report: EMR & EHR Workflow, Usability, Safety, and Productivity. And follow me on Twitter at @wareFLO.

P.S. Here’s a description of a grid computing workflow editor. Note its graphical drag-and-drop nature. Of course, the elements that are drag-and-drop-able are technical and specialized in nature. However, a data scientist does not have to be a programmer to create and/or edit grid computing workflows. Clinicians and other care team member likewise should not have to be programmers to create and/or edit their own workflows.

Doctors? Programmers? Meh! — Maybe Industrial Engineers Ought to Design EHRs!

You may already be familiar with hospital management engineers. Industrial engineering is sometimes called management or health systems engineering (“Cheaper by the Dozen” is based on the lives of the first industrial engineers to study medical workflow. Read myy EHR riff on CbtD!).

An EMR designed and implemented using industrial engineering principles and techniques is a fundamentally different EMR that the traditional EMR. Instead of starting with a user interface that looks like a paper form, the user interface is essentially derived, using scientific and engineering principles, from the human body’s response to physical, physiological, and cognitive workload. Perception, attention, cognition, motor control, memory storage and retrieval all interact with work environment and job demands to result in a body of knowledge about mental workload, vigilance, decision making, skilled performance, human error, human-computer interaction, and training. (This is not dissimilar to the way in which medical knowledge is derived using scientific methods from the structure and function of the human body.)

The resulting EMR should not necessarily look like what has gone before. (In fact, the first use of computer displays in aircraft cockpits mimicked physical dials and switches. Today’s “glass cockpits” do not.) Many EMR designers are seduced by the idea that since users are already familiar with paper forms that the paper form metaphor is a good user interface. It is not. EMRs that try to mimic traditional paper medical records are not well designed for high-usability, high-productivity data and order entry.