I maintain C code written by a COBOL programmer. You can tell.

The code is written in a verbose, heavily-commented, yet easy-to-read style, and actually does what it appears that it should?

Do a best-case estimate of the time required, assuming everything goes perfectly and that there are no surprises. Next, double your estimate. And finally, switch to the next highest unit of time measure.

A quarter-hour change will take half of a day. 2 hours becomes 4 days. 3 days becomes 6 weeks. A 6-month project will take 12 quarters, or 4 years.

It's eerie how often that rule of thumb seems to accurately depict the actual calendar time required -- eerily enough that when a so-called "realistic" estimate DOESN'T approach this metric, I find it's usually worth a second look.

Thankfully, at least at my place of work, this rule of thumb seems to break down once the unit of measure hits a year...

On the plus side, I was extremely pleased with the "do this for all" checkbox. In XP all I get is "Yes", "No", "Yes to all" and "Cancel". Where's my "No to all" option???

Shift + "No" == "No to all"

Will this do?

New York Sun, July 2007:

China loses between 100 and 200 million tons of coal a year -- a significant fraction of its production of 2.26 billion tons -- to mine fires, according to Holland's International Institute for Geo-Information Science and Earth Observation. This results in carbon dioxide emissions in a range of between 560 and 1,120 million metric tons, equaling 50% to 100% of all U.S. carbon dioxide emissions from gasoline.

Googling for "coal seam fires" seems to yield enough corroborating evidence to indicate that this isn't just a crackpot talkin'.

With the US government, though, it isn't simply a matter of the government deciding that "all clinics/doctors/hospitals/etc. shall do X, and thus it shall be". Because, if the government MANDATED that all clinics/doctors/hospitals/whatever shall do X, then the government would as a side-effect have to figure out how to ENABLE this mandate to work. Which they can't do right now, because so much of the data in the system is of proprietary origin (drug IDs, care plan information, etc.) By using a carrot-and-stick approach, then they can assert that these requirements are not MANDATES, they're merely "suggestions" that end-users can theoretically determine if they really want to meet -- even if failing to meet the criteria would place the end-user organization under a punitive competitive disadvantage. So, by not being mandates per se, then the government doesn't need to enable/fund/whatever the required effort. So now the end-users get to run around and try to figure out how to meet these requirements on their own, to determine which commercial medical records they feel will be viable in a high-change environment, and to try to pay for all of this technology (software costs of which can easily approach or exceed $5000/year/licensed user, not to mention additional hardware and environmental/logistical requirements), all while attempting to adhere to more stringent HIPAA privacy rules and the upcoming Red Flag reporting requirements. A cakewalk, really.

What we say here in our corner of the medical IT world: "Medicare uses the carrot-and-stick approach. First, they beat you with a stick. And if that doesn't work, they beat you with a carrot."

I haven't seen a BSOD in almost a decade.

OK, here's one to refresh your memory.

No, they haven't changed that much.

I feel your pain. We are a closely-held corporation (it's for-profit, but the docs own the place so they set the priorities), and we're now looking at commercial EMR software costs in the neighborhood of $12,000/physician to license a system, $2400/physician annual maintenance, plus all of the necessary hardware, etc. The hardware cost is a gimme (obviously), as is the implementation effort, but paying a couple million for software plus 400k/year maintenance stings a bit. Especially when you consider that our current home-brewed EMR is working well enough for us to want to limp along for another 5-7 years while letting the commercial EMR scene shake out a bit, but since our EMR misses a few CCHIT checkboxes, it won't qualify for any federal funding (or avoid the upcoming penalties) that HITECH offers. So, after planning for and funding a 10-year commitment to our current EMR, we're looking at being forced to drop it 4-5 years in just to avoid penalties that didn't exist 3 months ago. Bah.

Healthcare is dominated by application vendors who each make their own megaplatform for healthcare records. Cerner, Meditech, Siemens, et al. are all trying to keep as much of their system closed as possible, and aren't particularly interested in opening it up to third party systems. They don't particularly want open interfaces, their goal is to keep their customer locked in as much as possible.

So the healthcare IT companies get what they want, i.e. a bigger push for electronic records, selling the software they already have.

In my experience, you are right on-target with your assertions. In fact, it seems that the "Health Information Technology for Economic and Clinical Health" or HITECH Act (PDF warning) leaves as many questions unanswered as it answers. What we do know: We involved in healthcare have the opportunity to qualify for incentive pay based on "meaningful use" of a "qualified" electronic healtcare record. Unfortunately, what "meaningful use" is, or what "qualifies" an EHR system is conveniently not addressed by the bill. We ASSUME that "qualification" means "certification under specs provided by the Certification Commission for Healthcare Information Technology (CCHIT)"...and that SEEMS to be a fair assumption.

So, what does "certification" under CCHIT consist of? Basically, it seems to be likened to a laundry-list of requirements that are best described as "what the megaplatforms already do". Funny how that works out, until you start looking at the CCHIT decision-makers, e.g. Siemens and NextGen have members on the CCHIT Commission. Allscripts has a member who is a Trustee. And guess what? The Siemens, NextGen and Allscripts products all passed the CCHIT certification without requiring major rework. And other large vendors (e.g. GE, Epic) have representation and input to the CCHIT decision making process. And to add to the pain of trying to avoid one of the "big systems", the CCHIT certification requirements can be punitive for small or one-off vendors...certification costs are start at $35,000 (PDF warning), retesting requires additional payment, and 2-year recertification is mandatory. Not a big problem for a megacorp, but crushing to a small outfit that has written a non-commercial EMR.

What is truly galling, though, is a myopic refusal to realize that yes, there is life outside of a monolithic EMR. Example: In the CCHIT requirements for clinical testing, there are requirements that lay out in annoying detail how e.g. Lab tests must be ordered, tracked, commented upon, and displayed directly in the EMR itself. There is no recognition that there is any other way to accomplish this outside of the EMR. However, for decades -- long before we moved our health records to electronic format -- we used our Practice Management (scheduling, billing, etc.) system to order Lab, to check for duplicate orders, to ensure that referrals exist when required, to enforce insurance eligibility requirements, etc. NONE of which qualifies for ANYTHING under the CCHIT rules -- under those rules, your EMR must do the order, the tracking, the duplicate checking, etc. So - in order to make our EMR comply with these CCHIT requirements, we would have to pull these activities out of our Scheduling system, and force them into an EMR system which does not, and can not, handle all of the insurance- and billing-driven requirements that our Practice Management system easily fulfills. Patient satisfaction, and ultimately Quality, will be negatively impacted by such a move. But we have little choice but to do so under these CCHIT "requirements" if we are to qualify for any of the HITECH incentives (or more to the point -- avoid the penalties that kick in later in the project).

Another thing that gripes me is the way that this incentive works -- how it's front-loaded, quickly switches to penalties instead of incentives, and rewards businesses that are already using certain EMR systems to the detriment of businesses that would benefit from installing one. Question: Anyone know how long it takes nowadays to select, install, and implement an EMR in a practice, from the Request For Proposal through the date when the last doctor in the last office goes live? 1 year? 2? The past has shown us that 2 years is a very aggressive timeline, with longer implementations the norm. Unfortunately, the HITECH Act starts its incentive payouts for "meaningful use of a qualified Electronic Health Record" in 2011, with the bulk of the payouts occurring in 2011 and 2012, tapering down to penalties that start after 2015. So: What percentage of organizations that aren't already installing or running "qualified" EMRs today are going to be able to qualify by 2011? Note that the incentives aren't to IMPLEMENT or INSTALL an EMR -- the incentives are to USE a "qualified" EMR, which means that the EMR must already be installed by the time the incentives kick in. If the incentive was to install an EMR or to implement an EMR, that would be "stimulative" to those of us who aren't already running CCHIT-certified EMRs -- we'd start looking now, start installing in 2010, and be completely live sometime in 2012 or 2013. However, that's not what this Act actually does. Basically, this is turning out to be a bit of a cookie for organizations that have already installed one of the "CCHIT approved" EHR systems, and a poke in the eye for any organization that installed an EMR that, for whatever reason, isn't slated to be CCHIT certified in 2011 regardless of how well it works.

I'm with the parent poster -- this isn't a real incentive targeted towards moving healtchare into the digital age. This is an incentive that will steer money towards some big EMR vendors, pay off some early adopters (*IF* they happened to choose the "correct" EMR early in the process, mind you!), and to give lip-service towards healthcare efficiency. In other words...pretty much what we expect from our government, all things considered.

Holy cow! Now the thread which had been responded to by a Norton employee has been deleted!

From a recent post on the Norton forum:

To my limited knowledge, that program is legitmately delivered in a LiveUpdate package.

The topics are deleted because it appears that somebody is abusing this system and some legitimate posts may be the collateral damage associated with dealing with this abuse.

-Reese Anschultz
Sr. SQA Manager
Symantec Corporation

From a recent post on the Norton forum:

To my limited knowledge, that program is legitmately delivered in a LiveUpdate package.

The topics are deleted because it appears that somebody is abusing this system and some legitimate posts may be the collateral damage associated with dealing with this abuse.

-Reese Anschultz
Sr. SQA Manager
Symantec Corporation

Hmmm...and now attempts to view the Norton forums either fail, or serve a "down for maintenance" screen. How...convenient.

And now it's back up. Seems to be missing a few threads, though...funny, that.

Hmmm...and now attempts to view the Norton forums either fail, or serve a "down for maintenance" screen. How...convenient.

Sounds like MUMPS (err..ummm...Cache?) to me....

  S MYNODE=^SOMEGLOBAL(INDEX1,INDEX2)
  S MYVAR=$P(MYNODE,"^",1)
  S MYVAR=MYVAR+" BET YOU THOUGHT THIS WAS GOING TO BE MATH, DIDN'T YOU?"
  S $P(MYNODE,"^",1)=MYVAR
  S ^SOMEGLOBAL(INDEX1,INDEX2)=MYNODE

Wow...we never opened OR closed a file, but the next time I reference ^SOMEGLOBAL referenced by INDEX1, INDEX2, darned if the first up-arrow delimited piece of the returned value doesn't have the string "BET YOU THOUGHT..." appended to it. MUMPS (err...ummm...Cache...) must be a really advanced language if it's already doing this "Phantom" stuff already.

(In reference to the above: Slashdot really needs a "sarcasm" tag...)

Ahhh...but they can't make money CHARGING you for that, can they?