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Even as they have drawn more people closer together, technologies like email, texting and social networking have in many ways depersonalized communication. A new wave of software known as emotional networking technology seeks to harness the power of electronic communication without losing the human element of face-to-face contact.

"Communication often has practical considerations--I have a reason and need to talk to you, so I'll pick up the phone or email you," Paul To, CEO and founder of Emota.net, a Menlo Park, Calif.-based technology company, tells Advance for Health Information Executives. "But the kind of communications that carry more emotional values are often more subtle and peripheral in nature. In the past, if you were thinking of someone, you might walk over to their house and drop a basket of flowers on their doorstep. That kind of subtle gesture helped people feel emotionally connected," To explains.

Emota.net is part of a new generation of companies building technology on the principle that emotional connections can have a positive impact on physical health, particularly among the elderly. Such technology could underpin efforts to create patient-centered medical homes and humanize the experience of long-term care. One example is a tree changing color on a computer screen to signify to an elderly person that a family member has sat down near a connected device or another tree waving in the wind as a reminder to call the doctor back.

"We know there is direct correlation between loneliness and healthcare cost," To adds. "Older adults with loneliness-related issues visit [the] doctor and emergency room more often, use more medications, incur higher outpatient charges and stay in [the] hospital longer."

To learn more about this technology:
- read this Advance for Health Information Executives feature

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In the first case of a state attorney general enforcing general HIPAA regulations under the American Recovery and Reinvestment Act, Connecticut Attorney General Richard Blumenthal last week sued Health Net of Connecticut for misplacing the medical and financial information of nearly 450,000 enrollees and failing to notify those affected in a timely manner. The lawsuit comes nearly eight months after the insurer discovered that a portable computer disk drive with unencrypted information disappeared from Health Net's Shelton office. Although the missing data included protected health information and Social Security and bank account numbers, it took Health Net six months to notify appropriate authorities and the affected enrollees, Blumenthal said. FierceHealthcare

University Hospitals of Morecambe Bay NHS Trust is yet to go-live with Lorenzo Release 1 at the Lancaster Royal Infirmary, more than a year after it originally planned to do so.

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… the United Kingdom. Following up on the question I posed last week, asking readers to guess the percentage of U.S. blog readership and the country that’s #2 in the list. Click on the map for a complete view and click on that for a larger image.

I also asked, in quiz form, what percentage of readers you thought were from the U.S.  The wisdom of the crowd was nearly right. 18 of you guessed 75% and 18 guessed 60%. It’s actually closer to 60% from the U.S. It fluctuates from 60 to 68% depending on the time frame, and my web stats count multiple days before rolling over. Google Analytics (my secondary source) says 63% U.S. readership. Smaller numbers guessed 90% or 45%.

It’s great to see how interest in Lean is worldwide and it’s an honor that people would visit my site from all of these places around the world. There are similar trends for the website for my book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction, where actually only 52% of site visitors come from the U.S.

The list of the top visiting countries (not the complete list) is below. From the comments on the blog or the poll site, eight of you guessed “UK.” See below for the winner.

Of the eight who guessed the UK, I put you all in a spreadsheet and set up a random number function in Excel (nerdy, I know):

?Since the random # was 0.67, that means Jan is the winner. Jan, please email me. If I don’t hear from Jan in two weeks, I’ll choose another winner.

?Thanks to all who entered and to all of you read the Lean Blog!

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One of my goals for the next few weeks is to catch up on blogging about some great speakers I’ve seen recently. Coming soon, a post about seeing Dr. Atul Gawande (“The Checklist Manifesto“) and Daniel Pink (“Drive“) in the same week. I’m reading both books and, about 2/3 of the way through each, they are highly recommended.

Today’s post will be about a talk given back in November, at MIT, given by Eric Ries, a blogger and speaker (and soon-to-be author) on the topic of “Lean Startups.” I know, it might sound like an exercise in buzzword-ery, but it’s not. His talk was awesome and I’ll do my best to summarize key points.Even better than reading my key points, you can watch his entire talk here (or at least listen since the video quality is poor), thanks to one of the event sponsors. You can also see this video that I blogged about last September.

Eric impressed me with a well-thought out, cogent, and intriguing presentation that showed a deep understanding of the lean philosophy — not just a bunch of tools or new buzzwords being applied to startups, in particular software development. His ideas apply mainly to web-based software startups, so I’ll use “startups” as shorthand for that, although some of the ideas would be pretty universal, I think. Eric says these ideas apply best when there’s market risk, as opposed to technological risk. By “market risk,” the question is “should it be built?” not “can it be built?”

Just as many people think lean doesn’t apply to healthcare (“we’re a factory!”), many would also assume that lean is suited for big, established, slow manufacturing companies. But Eric made the case that process <> bureaucracy. Process means discipline, which can be a good thing. For example, his second startup had a “world-class” onboarding process, where new engineers were shipping code the very first day. That sounds like a case where process, “standardized work” even, had benefits for the company.

One of his key themes was that the best startups are those that iterate their code and product rapidly and allow their core business direction to change based on customer needs and what the market is telling them. The point at which a company changes direction based on the market is what Eric calls “The Pivot.” The “iterate rapidly” idea reminds me very much of Steven Spear’s point in his book “Chasing the Rabbit“, that nobody ever designs a perfect system, what matters is how quickly you learn and “PDCA.”

Eric’s first startup was a classic product-out company. They had the perfect idea (so they thought), so they spent a lot of money, took a lot of time — and at the end, had no customers. I’m paraphrasing, but he quipped,

“We could have gotten the same result by just opening a website to take orders before we ever worked on the product.”

At least they would have realized quickly and cheaply that the idea wasn’t going to work. That first startup was using the “one big swing” approach – and they missed. It reminds me of the story Newt Gingrich told about the Smithsonian’s “big bang” approach to trying to build an airplane in an attempt to beat the Wright Brothers. Their one big swing sank in the Potomac when it failed.

With his second startup, IMVU, they took a much more iterative approach and a more market-in approach. They launched their initial product very quickly (just a few months, if I remember right). They had early adopter customers who were, basically, willing to tolerate a bad product that was “more likely to crash your computer than to work properly.” But those early adopters shared the vision and were willing to put up with that pain. The customers gave feedback and interacted with developers in a very public forum (some good transparency). The rapid iteration approach was also a winning strategy for the Wright Brothers, as Newt described. The Wright Brothers succeeded because their plane was tested over land and it was easily repairable (and improve-able) when it crashed and parts broke.

“Iterative” isn’t new to the software world. I’m not an expert in this arena. but I have heard of the “agile” development model (and have lots of Twitter followers who do work with that methodlogy). Eric said “agile” was great for when your problem (customer need) is known and your solution is unknown. This works better than the old “waterfall” approach where it’s assumed the problem and solution are known.

For a startup, the problem AND solution are both unknown. This is why lean and rapid iteration are good strategies.

The iterative cycle is shown in this diagram. You can see some similarities to a Plan-Do-Check-Act cycle (or maybe an OODA loop).

Eric gave examples of using the “5 Whys” problem solving approach for problems like, “Why did the server go down?” He described the PDCA cycle of implementing a new idea quickly and quickly detecting if it was a “good change” from a “bad change,” being able to revert a bad change quickly and “stopping the line,” ala Toyota. With the code line stopped, nobody else checks in new code while there is problem.

As John Shook, of LEI, had blogged about, Eric talked about there’s always a “social problem” behind any “technical problem,” like the server crashing. Lack for training, for example.

When the customer sees the failure, there are two actions, exactly the same as what I teach to hospitals:

1. Fix it
2. Prevent it from happening again

In the controlled experiments approach, Eric said “we’re willing to make any mistake ONE time,” not firing or punishing anybody for that. But the problem would be repeating that mistake a second time, if the organization didn’t learn. People should be allowed to make mistakes, but find them, Eric said. Shorter development cycles allow you to find and fix problems quickly, while slower cycles allow you to hide problems (never a good thing, hiding problems). Making problems is less of an offense than covering a problem up. Reminds me of the Toyota-ism, “No problems is a problem.”

Eric also advocated looking at the big picture in a company, that you can accept local inefficiency for global efficiency. Measures have to support that global company view, as efficiency shouldn’t be measured in the number of hours of time spent coding, or the number of lines of code written.

Eric’s key metric: how much are you learning? How many experiments can you conduct per dollar?

Great stuff. I feel like I commented on a lot, but there are a lot of other nuggets, especially if you’re interested in startups and entrepreneurship – the real source of job creation in our economy! Check out the video, it is an hour well spent. I will try to get him on for a podcast.

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Saturday’s Wall Street Journal had an article (“11 Minutes of Action“) with analysis that said something my wife noticed a long time ago – there’s a lot of standing around during an NFL football game (or any football game, for that matter). The WSJ analysis, of course, wasn’t done under the mantle of “lean” but I think it illustrates the opportunity for narrow lean thinking to miss the mark in a workplace.

The WSJ analysis wasn’t that creative, you could argue they copied a Boston Globe story from last year that did a similar analysis of a Boston Celtics game (“NVA in the NBA — It’s “Value Added”-tastic?“). Actually, you could argue (call my lawyers!) that the WSJ ripped off my blog post from almost exactly three years ago (“How Much of Football is VA?”) when my reader Chris wrote:

I use this in my orientation to new employees: How much time is value added in a standard three hour football game? 12 minutes.

You read it here first, three years ago. Just kidding about the lawyers, WSJ.

An NFL game, for the uninitiated, has four quarters of 15 minutes each. The clock doesn’t run continuously like the other football (soccer), it stops after certain types of plays (out of bounds, incomplete pass, etc.). So the 60 minutes, with clock stoppages, TV commercials, halftime, etc. can take 3 or 3.5 hours. Of that time, because of calling plays, getting ready between plays, etc. that 60 minutes of game time really only has 11 minutes of action (from the snap of the ball to the time a play is blown dead).

As a football fan, I say “who cares?” Well, OK, I do care that there are a ton of commercials, but three hours for a football game is fine by me. I’m not the type to watch the DirecTV 30-minute condensed versions of a game (potential slogan: “Nothing but Value!” or “Muda-Free Football!”).

So to tie this to lean… who defines “value”? The customer! Is the point of a football game just those 11 minutes? No! What about the time thinking about strategy (especially if you’re watching with friends)… or the lame conversations between announcers. What about the shots of cheerleaders? End zone celebrations (if they allowed them!) can be entertaining to watch. Would we really want the game to be shorter? Maybe not, if you enjoy the whole experience of three hours with friends or just three hours on the couch. The “value” in this context is probably more than the 11 minutes, and it depend on the individual fan.

Our friends at Evolving Excellence had a recent post (“Remember the Perspective of Value“) that illustrated the silliness of micro-analyzing the details of a performance of the Nutcracker and the “waste” that was identified in a way that missed the whole point and the whole context of an artistic performance.

A narrow minded view of value might get you, as a Lean person, in trouble at a hospital. I learned, early, from the nurses I was working with that “value” (in their minds and in the eyes of their customers, the patient) is not just direct diagnosis or treatment activity. Beyond taking vital signs and giving injections, there’s a human caring element to nursing – the time spent talking to a patient, making them feel comfortable or giving them someone to talk to. That can play a major part in their healing. That’s “value.”

That’s why we defined “value” as the nurses observed each other’s work as any time in the patient room. Overly generous? Maybe, but that approach emphasized we were trying to eliminate waste OUTSIDE of the patient room (based on where supplies and equipment were kept, for example) and not by asking the nurses to rush in and out of the rooms. What might have seemed “efficient” in a very narrow sense might have missed the mark completely for that nursing setting.

So be careful how you define value – not from a narrow technical perspective, but from a holistic, customer perspective.

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