Make Some Microbe Friends

It’s the coolest story I’ve seen in the past few days: The New York Times reported how an Italian  museum cleaned its priceless Michelangelo sculptures with an army of bacteria.  As Jason Horowitz wrote, “restorers and scientists quietly unleashed microbes with good taste and an enormous appetite on the marbles, intentionally turning the chapel into a bacterial smorgasbord.”

And you just want to kill them all with your hand sanitizers and anti-bacterial soaps. 

The Medici Chapel in Florence had the good fortune to be blessed with an abundance of works by Michelangelo, but the bad fortune to have had centuries of various kinds of grime building up on them.  In particular, over time the corpse of one Medici “…seeped into Michelangelo’s marble, the chapel’s experts said, creating deep stains, button-shaped deformations…”

This is, I assume, why they tell you not to touch the art.

Scientists picked a bacteria -- Serratia ficaria SH7, in case you’re taking notes – that ate the undesired grime without also eating the underlying marble.   It wasn’t hazardous to humans either and didn’t create spores that might go elsewhere.  “It’s better for our health,” one of the art restorers told NYT.  “For the environment, and the works of art.”

Medici Chapel after bacteria. 
Credit: Gianni Cipriano for NYT

The technique was a success, allowing the sculptures to look like they did centuries ago. 

Using such bacteria to clean art has been around for at a decade, and not just for sculptures.  Perhaps more surprising is bacteria isn’t just cleaning art, it’s also creating it; the American Society for Microbiology hosts an annual Agar Art Contest. 

If you’re impressed by that, researchers are teaching bacteria to read, or at least to recognize letters.  That’s not all they might learn to do.  “For example, the framework and algorithm in our study can be used to facilitate the design of living therapeutics, such as targeted drug release systems based on engineered probiotic bacteria systems,” the researchers say.    

The thing is, we not only don’t know what microbes do, or could do, but we have only a vague understanding how they surround us.  That’s starting to change.  We’ve known for some time that each of us has a unique microbiome (including mycobiome!).  What we didn’t realize until recently was that each urban area has its own microbiome as well. 

Summary of study.  Credit: Danko, et. alia

A new study took samples from the subway systems in 60 cities around the world, and found thousands of previously unknown viruses and bacteria.  There was a “core urban microbiome” that almost all the cities shared, but each city had its unique microbiome. 

The authors conclude:

…these data suggest that urban microbiomes should be treated as ecologically distinct from both surrounding soil microbiomes and human commensal microbiomes. Though these microbiomes undoubtedly interact, they nonetheless represent distinct ecological niches with different genetic profiles.

"Every city has its own 'molecular echo' of the microbes that define it," said senior author Christopher Mason, a professor at Weill Cornell Medicine (WCM). "If you gave me your shoe, I could tell you with about 90% accuracy the city in the world from which you came."

There may be, Dr. Mason thinks, as much biodiversity on a subway railing as in rainforest (which, if you’ve ridden any U.S. subways, probably does not come as a surprise).  He marvels: “I think it’s a wonderful affirmation of how much left we have to discover about the world.”

“The amount of microbial diversity is just incomprehensibly vast,” Erica Hartmann, a microbiologist who was not involved in the study told The New York Times.  “There’s so much out there that we just don’t really understand, and there could be all kinds of nifty biotechnologies and all kinds of fun chemistries that we’re not aware of yet.”

The researchers were able to identify “antimicrobial resistance genes” that indicated resistance to antibiotics and other antimicrobial agents.  Lead author David Danko speculated:

Can we give some kind of heads-up about what to look for? Can we track the spread of bacteria or genes that will make bacteria resistant to antibiotics in the future? Can we use this as a way to inform public health departments in the use of antibiotics going forward?

The team is creating a “global metagenomic map” of the organisms, and plans to keep swabbing to collect more sample.  A companion paper looked at the “air microbiome” of the subways systems, finding a similar “geographic specificity.” 

They’re all around us.  They’re in us.  We live in a microbial world.  Some argue that our microbiome should be considered another organ, although it may be more accurate to view it as a colony that tries to tolerate us.  However you view microbes, they’re not going away; if they did, we would as well.

You remember

The pandemic has caused all of us to fear the coronavirus, and to take measures to kill it.  We all desperately sought Clorox wipes, stayed away from other people and their viruses, and tried things like UV sterilization.  Scientists worry all these efforts may have unintended consequences.  “We’re starting to realize that there’s collateral damage when we get rid of good microbes, and that has major consequences for our health,” said B. Brett Finlay, first author of a paper on the topic in PNAS.

As Dr. Finley told James Hamblin for The Atlantic. “The microbes we carry around are involved in many of the fundamental processes of Homo sapiens.”  Brendan Bohannan, a professor at the University of Oregon, agreed, telling The New York Times: “The more we learn about our relationships with the microbial world, the clearer it is that we are connected to them and to the rest of the natural world.” 

Mr. Hamblin concluded: “The ongoing challenge is to avoid binary thinking about microbes: They are not simply good or bad, any more than people are, and neither is Purell.”

Last year I argued that modern medicine was reaching the kind of limits that classical physics did at the beginning of the 21^st century, when quantum effects were starting to become known.  It required an entirely new approach to physics – quantum physics – to deal with them, and that ended up revolutionizing physics and our understanding of the world. 

Medicine needs that kind of “quantum” revolution, particularly in regards to understanding, accepting, and benefiting more from our coexistence with the microbial world.  If we can co-opt microbes to clean art, who knows what we can “convince” them to do for our health? 

Holograms to the Rescue

Google is getting much (deserved) publicity for its Project Starline, announced at last week’s I/O conference.  Project Starline is a new 3D video chat capability that promises to make your Zoom experience seem even more tedious.  That’s great, but I’m expecting much more from holograms – or even better technologies.  Fortunately, there are several such candidates.

Project Starline.  Credit: Google

For anyone who has been excited about advances in telehealth, you haven’t seen anything yet.

If you missed Google’s announcement, Project Starline was described thusly:

Imagine looking through a sort of magic window, and through that window, you see another person, life-size and in three dimensions. You can talk naturally, gesture and make eye contact.

Google says: “We believe this is where person-to-person communication technology can and should go,” because: “The effect is the feeling of a person sitting just across from you, like they are right there.” 

Sounds pretty cool.  The thing, though, is that you’re still looking at the images through a screen.  Google can call it a “magic window” if it wants, but there’s still a screen between you and what you’re seeing.

Not so with Optical Trap Displays (OTDs).  These were pioneered by the BYU holography research group three years ago, and, in their latest advance, they’ve created – what else? – floating lightsabers that emit actual beams:

Optical trap displays are not, strictly speaking, holograms.  They use a laser beam to trap a particle in the air and then push it around, leaving a luminated, floating path.  As the researchers describe it, it’s like “a 3D printer for light.”

The authors explain:

The particle moves through every point in the image several times a second, creating an image by persistence of vision.  The higher the resolution and the refresh rate of the system, the more convincing this effect can be made, where the user will not be able to perceive updates to the imagery displayed to them, and at sufficient resolution will have difficulty distinguishing display image points from real-world image points.

Lead researcher Dan Smalley notes:

Most 3D displays require you to look at a screen, but our technology allows us to create images floating in space — and they’re physical; not some mirage.  This technology can make it possible to create vibrant animated content that orbits around or crawls on or explodes out of every day physical objects.

Co-author Wesley Rogers adds: “We can play some fancy tricks with motion parallax and we can make the display look a lot bigger than it physically is.  This methodology would allow us to create the illusion of a much deeper display up to theoretically an infinite size display.”

Indeed, their paper in Nature speculates: “This result leads us to contemplate the possibility of immersive OTD environments that not only include real images capable of wrapping around physical objects (or the user themselves), but that also provide simulated virtual windows into expansive exterior spaces.”

I don’t know what all of that means, but it sounds awfully impressive.

The BYU researchers believe: "Unlike OTDs, holograms are extremely computationally intensive and their computational complexity scales rapidly with display size.  Neither is true for OTD displays.”  They need to meet Liang Shi, a Ph.D. student at MIT who is leading a team developing “tensor holography.” 

Before anyone with mathemaphobia freaks out about the “tensor,” let’s just say that it is a way to produce holograms almost instantly. 

The work was published in Nature last March.  The technique uses deep neural networks to generate 3D holograms in near real time. I’ll skip the technical details of how this all works, but you can watch their video:

Their approach doesn’t require supercomputers or long calculations, instead allowing neural networks to teach themselves how to generate the holograms. Amazingly, the “compact tensor network” requires less than 1 MB of memory.  The images can be calculated from a multi-camera setup or LiDAR sensor, which are becoming standard on smartphones.

“People previously thought that with existing consumer-grade hardware, it was impossible to do real-time 3D holography computations,” Mr. Shi says.

Joel Kollin, a Microsoft researcher who was not involved in the research, told MIT News that the research “shows that true 3D holographic displays are practical with only moderate computational requirements.” 

All of the efforts are already thinking about healthcare.  Google is currently testing Project Starline in a few of its offices, but is betting big on its future.  It has explicitly picked healthcare as one of the first industries it is working with, aiming for trial demos later this year.

The BYU researchers see medicine as a good use for OTDs, helping doctors plan complicated surgeries: “a high-resolution MRI with an optical-trap display could show, in three dimensions, the specific issues they are likely to encounter. Like a real-life game of Operation, surgical teams will be able to plan how to navigate delicate aspects of their upcoming procedures.”

The MIT researchers believe the approach offers much promise for VR, volumetric 3D printing, microscopy, visualization of medical data, and the design of surfaces with unique optical properties. 

If you don’t know what “volumetric 3D printing” is (and I didn’t), it’s been described as like an MRI in reverse: “the form of the object is projected to form the model instead of scanning the object.”  It could revolutionize 3D printing, and, for healthcare specifically, “Being able to 3D print from all spatial dimensions at the same time could be instrumental in producing complex organs…This would enable better and more functional vascularity and multi-cellular-material structures.”

OSU shoulder surgery. 
Credit: Wexner Medical Center

As for “visualization of medical data,” for example, surgeons at The Ohio State University Wexner Medical Center are already using “mixed reality 3D holograms” to assist in shoulder surgery.  Holograms have also been used for cardiac, liver, and spine surgeries, among others, as well as in imaging.    

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2020 was, in essence, a coming out party for video conferencing in general and for telehealth in particular.  The capabilities had been around, but it wasn’t until we were locked down and reluctant to be around others that we started to experience its possibilities.  Still, though, we should be thinking of it as version 1.0.

Versions 2.0 and beyond are going to be more realistic, more interactive, and less constrained by screens.  They might be holograms, tensor holograms, optical trap displays, or other technologies I’ve not aware of.  I just hope it doesn’t take another pandemic for us to realize their potential.     

Death, Taxes -- and Paperwork

Today, in case you missed is, is the deadline for filing your 2020 federal taxes (it was postponed  from its usual April 15 date due to “the unusual circumstances related to the pandemic”).  Nothing, Benjamin Franklin famously said, is certain but death and taxes, but if you live in the United States, you might add the inevitability of paperwork involved with both (and with healthcare in general). 

The question is, does it have to be as bad as it is? 

A Washington Post op-ed by Helaine Olen argues that tax filing could, and should, be much simpler.  A March article in The Conversation by Beverly Moran, a tax expert at Vanderbilt, agrees.  Both make the point that, for most of us, the IRS could do the work for us. 

Ms. Olen asserts:

The thing is, filing taxes just doesn’t have to be this hard. In 36 countries, the nation’s tax agency sends eligible residents a pre-filled return, and asks them to sign if they agree with the amount that’s indicated is owed or should be credited to them. Japan does this. So do Sweden, the Netherlands, Spain and others.

Professor Moran has slightly different numbers, but makes the same point.  She adds that our tax system is 10 times more expensive than in other major economies.  This should not be a surprise; collectively, we spend close to $200b annually on IRS paperwork, taking some 6 billion hours of our time along the way. 

You’d think that all this time and money spent on tax filing would at least give us an efficient tax system, but the opposite is true.  The last time the IRS took a look, for tax years 2011-2013, the “tax gap” – the estimate between taxes owed and taxes paid – was $441b annually, some 16% of tax liability.  IRS Commissioner Charles Rettig told Congress last month that the number might actually be over $1 trillion annually now, due to new kinds of wealth creation and more sophisticated tax avoidance. 

It’s kind of crazy, because, as both note, it doesn’t have to be this way.  Professor Moran points out:  “Furthermore, 95% of American taxpayers receive more than 30 types of information returns that let the government know their exact income. These information returns give the government everything it needs in order to fill out most taxpayers’ returns.”

Let the IRS do the work.

Congress has been well aware of both the problem and the easy solution for decades, but, both authors agree, the tax preparation industry has better lobbyists than we do.  Ms. Olen says: “Much as the medical industrial complex spends huge sums to stymie effective health-care reform, the tax-preparation industry showers largesse on Capitol Hill.” Professor Moran is equally blunt: “I see America’s costly and time-consuming tax reporting system as a consequence of its relationship with the commercial tax preparation industry, which lobbies Congress to maintain the status quo.” 

We could, of course, just have a much simpler tax system, with fewer deductions and special provisions (a.k.a, “loopholes”), but, well, getting those enacted are how lobbyists earn their money. 

But if there is anything even more confusing and more frustrating than taxes, it just might be healthcare, such as with billing.  We’ve all got our stories about not knowing the cost of health care services before we get them, getting bills from healthcare organizations that we don’t understand and that can’t easily reconcile with our health insurance explanations of benefits for those same services.

The Center for American Progress estimates that healthcare “billing and insurance-related (BIR) costs” amount to some $486b annually, at least half of which they deem unnecessary.  We’ve just got too many health plans, each negotiating different payment rates with health care organizations and clinicians, almost all of whom have byzantine charge structures that vary wildly based on who is paying. 

As Bird Blitch (who, not coincidentally, runs Patienco, “a next-generation patient payment technology company”) writes in Forbes, these “are leading sources of frustration and anxiety for patients, whether they are managing a chronic illness or caring for routine medical needs. This frustrating experience translates to dissatisfied patients and unpaid medical bills.”  Mr. Birch advocates that we “centralize financial information for patients” – presumably using Patientco – to achieve a “personalized billing and payment experience.” 

Similarly, Cedar, a start-up that has focused on assisting with patient billing for health care organizations, announced it would acquire OODA Health, which has focused on payers, in order to “revolutionize the consumer financial experience in healthcare.”  Florian Otto, Cedar CEO and co-founder, said: “we believe that by bringing our companies together, we can identify new opportunities to help consumers — as well as payers and providers — navigate an increasingly complicated healthcare system, leading to better outcomes for all parties involved.” 

Well, good luck to both of them.  They’ll need it.

But, of course, billing is not the only excessive “paperwork” in healthcare.  We’ve all had to fill out countless versions of our health history; recapitulate our prescription drug list; repeat our name, address, D.O.B., telephone number(s), and emergency contacts; recopy our various ID cards; reattach any living wills or health power of attorney.  It’s as though we’ve always starting de novo whenever we engage the healthcare system.

EHRs help, but don’t solve, the problem.  They still don’t communicate well with other EHR platforms, nor do they stop us from often having to repeat information over and over even within the same system.  Similarly electronic claim submission has greatly reduced the amount of actual paperwork involved in filing claims -- for patients, clinicians, and payers -- but none seems any happier about the process.

Companies like Patienco and Cedar/OODA Health are trying to be helpful, but they’re putting a band-aid on a very dysfunctional system.  It’s more like using TurboTax than having the IRS do your tax filing; yes, it’s easier, but, no, it doesn’t address the underlying problems. 

There’s no good reason our tax system needs to be so convoluted, or for our tax filing process to be so burdensome.  Similarly, there’s no good reason for our healthcare system to be so complicated.  It should remember us; it should act as though it was talking to us rather than to other insiders within it. 

Instead, the “medical industrial complex,” as Ms. Olen described it, adds layer upon layer, complexity upon complexity, cost upon cost, because doing so helps its revenue.  If you think the tax code is complicated, try making sense of ICD-10 codes. 

Perhaps once Ms. Olen and Professor Moran whip the IRS into shape they can take on healthcare. 

A Timex Healthcare System

Those of us of a certain age remember the Timex slogan that bragged about its watches’ durability: “It takes a licking and keeps on ticking.”  A recent article about our military, of all things, made me wish we had a healthcare system that prized that kind of durability. 

Credit: Zazzle

I can never resist analogies between the U.S. healthcare system and the U.S. military system.  They’re both huge, they’re both wildly expensive, they both rely on a combination of high tech and front-line people, and they both protect us from threats.  In some ways, both are the best in the world, and, in other ways, both have weaknesses that are embarrassing. And, as I wrote last year, both are often still fighting the wrong wars. 

The article is by national security expert JC Herz on the Atlantic Council’s website: A plea to the Pentagon: Don’t sacrifice resilience on the altar of innovation.   Boy, that sure applies to healthcare too. 

Innovation versus resilience. Credit: Stanford Social Innovation Review

Ms. Herz notes how Americans love innovation, but:

This mythos informs a narrative that what is valuable is The New—the upgrade to something bigger, badder, and sexier…What the United States needs to reinvigorate its defense base, compete with China, and win the global economy must be more innovation.

Except the United States does not suffer from a lack of innovation; it suffers from a lack of resilience.

That deserves some thought, especially to a healthcare system that has been shaken to its core by the recent pandemic, and that may never quite be the same again. 

According to a recent Washington Post-Kaiser Family Foundation poll, three-in-ten healthcare workers have weighed leaving the profession; more than half are burned out.  That doesn’t even count the ones whose practices didn’t survive last year’s turmoil.   One physician told them: “You look at staffing, preparedness, what the priorities were for many hospitals during the crisis, and it’s clear the industry is driven by profits rather than well-being of patients or health workers.  It makes you question the whole system.” 

I’d call that a lack of resilience.

You may have read about last weekend’s cyberattack on Colonial Pipeline, one of the nation’s largest fuel pipelines.  Or about the nefarious SolarWinds hack, which went undetected for months and whose breadth, depth, and ultimate impact remain unknown.  Or about any number of ransomware or other cyberattacks on healthcare targets.  Ms. Herz has thoughts that apply to them:

All the defense, critical infrastructure, and commercial systems that have been compromised in the last ten years—and that are still being compromised, surveilled, ransomed, and taken offline—are not easy targets due to lack of innovation. They are vulnerable because they are brittle and unmaintained, and thus not resilient. Military systems and infrastructure, financial institutions, energy grids, healthcare providers, and public safety capabilities—the systems that keep modern society from descending into chaos—are fragile because they are not built to recover from attack.  

It doesn’t have to be “bad actors” that take systems down, and it doesn’t have to be IT systems.  Natural disasters test resilience too.  Hurricane Katrina is widely thought to have spurred awareness of the importance of EHRs, but the February Texas power grid outage still heavily impacted healthcare organizations – even if they had power for those EHRs, they might not have had clean water.  And how many healthcare organizations are truly ready for an earthquake? 

Ms. Herz preaches:

Resilience is what allows systems to take a hit and keep going. Resilient systems are well-maintained, fixed before they break with predictive maintenance, and progressively strengthened at weak points. They have the spare parts needed to keep flying or driving. They are continuously tested and red-teamed as part of a culture in which finding cracks is a badge of honor, not a threat to the organization.

She urges: “System owners in the public and private sectors need to think about building fast-healing, adaptable, durable systems, especially the “boring” ones that people only tend to notice when they break.”

Any of that sound like healthcare to you? 

Our healthcare system suffered widespread shortages of PPE and other vital supplies and equipment, as supply chains were radically disrupted.  Primary care practices floundered as people avoided office visits.  We’re still not using primary care practices appropriately to help combat vaccine hesitancy.  We weren’t prepared for the flood of vaccine misinformation – some organically generated, some maliciously.   

How many of those issues have been fixed?  We may not know until the next crisis.

Meanwhile, investments in digital health are soaring (come on, did you really know what a SPAC was at the start of the pandemic?).  Innovation is sexy; innovation is the future; innovation is what gets you funded.  But, as Ms. Herz says about military spending:

Stellar maintenance and logistics do not get people promoted, and thus are not prioritized among program managers who are more focused on delivering novel, “sexy” capabilities…There is a naïve faith that someone more conscientious and less charismatic, perhaps, will go back and redesign the technology, processes, and procedures to make the sizzle into steak. Except it doesn’t happen, because by the time a qualified systems engineer views the horror show of taped-together, unmaintainable code, it’s too complex to fix and too politically enshrined to critique.

How many of those healthcare SPACs are aimed at “hardening” our healthcare systems and processes?  How many are prioritizing “stellar maintenance and logistics”?  Yeah, I thought not. 

Our healthcare system was once more like a Timex watch: nothing too fancy, but durable.  Over time, it’s changed in the way that the watch business has left Timex behind – more focus on new features, new technologies, more functions – and, of course, more expensive.  Whether those watches – or the changes in our healthcare system -- are really necessary, or how long they’ll survive the punishment we’ll put them to, are not questions we ask enough.

Ms. Herz warns the Pentagon: “Defense acquisitions should be less like the Macy’s Thanksgiving Day Parade and more like NASCAR, where tire-changing speed and pit-crew coordination are recognized as key performance metrics.”  The same should apply to healthcare: less splash, less flash, more emphasis on ensuring it delivers, under all conditions.   

Innovation is necessary, new technologies are exciting, but let’s not forget the importance of simply being able to take a licking and keep on ticking.  Especially in healthcare. 

We Are All Designers

Raise your hand if you had to go through the Hunger Games labyrinth to score a COVID-19 vaccine earlier this year – figuring out which phone number(s)/website(s) to try, navigating it, answering all the questions, searching for available appointments within reasonable distances, and, usually, having to try all over again.  Or, raise your hand if you’ve had trouble figuring out how to use an Electronic Health Record (EHR) or an associated Patient Portal. 

The classic usability problem.  Credit: Gfycat

Maybe you thought it was you.  Maybe you thought you weren’t tech-savvy enough.  But, a trio of usability experts reassure us, it’s not: it’s just bad design.  And we should speak up.

“Everyone everywhere: A distributed and embedded paradigm for usability,” by Professors Michael B. Twidale, David M. Nichols, and Christopher P. Lueg, was published in Journal of the Association for Information Science and Technology (JASIST) in March, but I didn’t see it until the University of Illinois School of Information Sciences (where Dr. Twidale is on faculty) put out a press release a few days ago. 

The authors believe that bad design has costs -- to users and to society -- yet: “The total costs of bad usability over the life of a product are rarely computed. It is almost like we as a society do not want to know how much money has been wasted and how much irritation and misery caused.”

Whatever the numbers are, they’re too high.

As Dr. Twidale said:

Making a computer system easier to use is a tiny fraction of the cost of making the computer system work at all. So why aren't things fixed? Because people put up with bad interfaces and blame themselves. We want to say, 'No, it's not your fault! It is bad design.'

He specifically referenced the vaccine example: “When hard to use software means a vulnerable elderly person cannot book a vaccination, that’s a social justice issue.  If you can't get things to work, it can further exclude you from the benefits that technology is bringing to everyone else.” 

They’re serious about the social justice aspect, calling for “Distributed Usability Activism:” promoting “distributed usability through mass awareness leading to usability activism across society.”  They cite how user activism (e.g. Ralph Nadar) led to changes in vehicle safety several decades ago. 

Moral of the story: encourage more complaining.    

Many designers or developers would blanche at that prospect, and many of us users might shrug at the notion that our complaint would make any difference.  However, “usability is too important to be left to usability professionals.”  The authors urge that users be given both concrete examples about how complaints can lead to positive changes, and better venues (including social media) in which to air them. 

Credit: Justinmind

The end result, they suggest, might be a “Usability Kaizen,” likening it to the Japanese factory practice where everyone is encouraged to identify flaws and to voice suggestions.  I.e., “everyone should be involved in usability discussions, including end users.”

There are, they admit, a lot of smart people, in numerous professions. involved in the various products and processes that we use, but “a wider usability movement would remind members of any profession that regardless of their domain and efforts in making the world a better place, bad usability makes everything worse.” They remind us that: “Their complaints are valuable data if only we would listen, and if only people believe that their complaints will be listened to—and acted on.”

The authors believe that what we often view as “user errors” or “human errors” are, in fact, usability problems, asserting: “Hard‐to‐use software should be as unsuccessful as hard‐to‐drive automobiles.”  Indeed, they view the need for training as a tip-off there are design issues:

...it is particularly egregious to first blame the end user for errors, and then to adopt a training regime for these users to conform themselves to a badly designed product….

…the default should be to regard the provision of substantial training as indicative of potential interface design failure.

For example, iPhones are an engineering marvel, with a huge range of functions, but did you ever need training to use your iPhone?  That’s the point.

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Dark patterns.  Credit: Techcrunch

Usability isn’t always bad because of poor design; Greg Bensinger recently wrote in The New York Times, “some things are difficult by design.”  He was referring to so-called dark patterns -- “the techniques that companies use online to get consumers to sign up for things, keep subscriptions they might otherwise cancel or turn over more personal data…Think of them as the digital equivalent of trying to cancel a gym membership.” 

We’ve all encountered them.

Mr. Bensinger fears that such dark patterns “are particularly effective when used against minority groups, the poor, the less educated and the elderly, echoing offline schemes.”  No wonder Professors Twidale, Nichols, and Lueg are calling for activism.  He advocates legislative or regulatory solutions, and some may certainly be warranted, but some distributed usability activism is badly needed as well.

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Healthcare, of course, is replete with both poor design and dark patterns.  Some say that healthcare is “the standard for poor UX/UI,”  despite the fact that “user errors” can literally kill patients, as well as lead to clinician burnout.

Nurses recently rated the usability of EHRs as “F,” and the reaction on Twitter was that there must not have been a lower score available.  Physicians have long felt the same.  Much was made of recent hospital pricing transparency requirements, but hospitals figured out how to use design to thwart consumers actually benefiting from them.  And how many times have you had to input the same information in doctors’ offices or sign forms you didn’t understand/couldn’t read? 

Don’t just accept it: complain, complain, complain. 

Bon Ku, MD

One of my favorite quotes is from Bon Ku, MD: “everything in health care is design.”  Simply put, if the design isn’t making your health better, or, at least your interactions with the healthcare system easier, then it is, at best, poor design and, at worse, a nefarious dark pattern.  Either way, we’ve got to speak up. 

Professors Twidale, Nichols, and Lueg suggest we look at usability equivalents of Fair Trade accreditation or Energy Star rating, and wonder: “Imagine what the impact might be of a Usability Star rating on a library catalogue. Or on a university's application process.”  I’d like to imagine such a star rating on an EHR, a health plan explanation of benefits, a hospital bill, or a prescription drug warning label. 

Insert your own healthcare-related example; I’m sure there is no shortage of candidates.

Let’s all become usability activists.