Continuous Tool Improvement

I was reviewing the feeds I subscribe to in elfeed this evening when it occurred to me that a lot of my feeds have to do with Emacs. I will often blow through updates on feeds, making sure to only pickup things that are truly useful. But I discovered an amazingly high signal to noise ratio regarding tips for using Emacs more effectively. This got me thinking about how I couldn’t possible remember all this stuff, so I tossed some of the things I was learning in my learnings.org file to review later. At that point, it dawned on my how important tool choice is, and how important it is to learn how to use your tools effectively and be receptive to learning new things about them.

This could apply equally to any well made tool for any discipline (woodworking, drawing, research), but for me that means Emacs. Not everyone is going to ever need to touch Emacs. For me, I can’t imagine not having it, and everytime I learn something new, I get a little more effective with it.

For reference, tonight I learned how to make all URLs, regardless of buffer, clickable. I also learned how to break an org-mode block in two with a single keystroke to insert a comment.

Reading Lists

Oh Goodreads. Your website is a cluttered mess. Your UX hasn’t been improved in years. The only value I derive from keeping my reading list on you is that my friends can see what I’m reading. Which is a neat trick, but since I’ve mostly given up on Facebook too, it not really enough to keep me.

I was an early adopter of Goodreads, but my life has taken a turn towards the personal and the text-based. I use Emacs (via spacemacs) as much as I can. Org-mode might be the single most impressive IDEA rendered into software I’ve ever seen. It simply makes the things I use on a regular basis more powerful and expressive, which is not something I can say for Word, Twitter, or Chrome. Those are merely tools. They don’t amplify my ability to document and create.

Really the post Leaving Goodreads is what convinced me to go, one more time, back to my reading list in org mode. But the killer feature this time around was ox-hugo, which allows me to easily dump Org-mode subtrees into a hugo-powered blog directory. A simple rsync later and I can publish random subtrees, including book reviews!

The whole thing is so elegant, I couldn’t have dreamed up the process if I had tried. The whole thing was truly an evolution of tools, and one that was only possible because each tool, Emacs, spacemacs, org-mode, hugo, ox-hugo, does it’s job so elegantly.

Hacking Healthcare

Table of Contents

Summary

I wouldn’t recommend this for beach reading, but that’s hardly the point. Hacking Healthcare provides a really concise, if slightly outdated look at what it means to work in IT with health data. Unfortunately, I’ve come away pretty underwhelmed at the impact that open source software has had in healthcare. While many industries seem to be going full bore into software built by collaboration, with support provided by for-pay companies, healthcare still seems dominated by proprietary software. What this book shows, is largely why that is so.

Between ontologies (specific words coded for reference), HIPPA-compliance, and the general un-sexiness of health care data, it is amazing anyone at all spends their time trying to make doctor’s lives easier. And even more challenging, a high percentage of docs are well-educated and just technical enough to think they know the best way to solve a problem. That leads to very inflexible ways of thinking, for better or worse.

There’s also the reality that paper really does work very well for healthcare. Before you replace something, you have to understand the value of it, and the value of a patient chart is huge. Doctors and nurses have shorthand; they can scribble in text when checkboxes don’t provide the context they need; they can write down three different possible ways to diagnosis someone and come back later to review their notes, to ensure codes in bills match patient conditions. It should come as no surprise then, that computer-aided solutions often fall flat.

Recently I spent an afternoon in the ER. The RN on duty was quietly cursing under her breath as she struggled with an electronic health record input that required her to code everything. Going back to ontologies, that means that when she used rubbing alcohol to clean off my scrapes, that required her to lookup and specify ICD10 diagnosis code S40.212A, “Abrasion of left shoulder, initial encounter.” What the fuck? No wonder she was frustrated. Nevermind if it turned out to be my right shoulder but she was tired from being on the end of a ten hour shift.

And of course, this doesn’t even get into the politics of ontology. The AMA maintains it’s own list of DX codes, but they charge money for access to them. Meanwhile, there’s also LOINC, a free standard, but which is not accepted by all insurers. And of course, Medicare and Medicaid have their own standard which maps, roughly, to ICD10 and LOINC. BUt don’t forget Snowmed … sigh.

And that’s just ontologies. There’s also the simple matter of what IS a patient chart? Is it just the patient? What happens when a patient changes their name? Should we assign an ID to the patient? But how do we track the ID across the various systems they might travel through when they are referred?

What about billing? Oh my. Let’s not even start with that.

Suffice it to say, reading this book was mostly humbling. I will likely return to it as a reference in the future, as I mostly skim read it this time. But it is a fantastic overview of the state of healthcare IT from 2015.

Notes

The VistA effect, as explained in Longman’s book about the VA, is where the quality healthcare outcomes are continuously measured to enforce higher levels of patient safety and care.

This hinges on “meaningful use” measurements, which include:

  • Demographics
  • medication lists
  • problem lists
  • vital signs

These are trivial for a clinician to understand, but very difficult to model in software.

Given how difficult some of these problems are to reason about (is Fred Trotter and Frederick Trotter the same person?), are there opportunities, as a forward thinking healthcare problem solver to open source certain tools that make expunging HIPPA data easier? Or perhaps to rectify demographic information? Can we, while still making money and not tipping our hand too much, help those who are technical to advance the state of the art in healthcare IT?

Another Engine

Once, I used Jekyll. Then I switched to Pelican. I’m finally here on Hugo, and hoping that this will make it easier to keep things updated. The eternal question when chosing a method to publish a blog is, why publish a blog. I don’t really have an answer for that yet. I wish I did. Honestly, I do. You don’t have to believe me, because I believe in myself, and if this is all one big simulation, you don’t matter anyway.

Incidentally, perhaps the best part of this transition is the ox-hugo plugin, which makes writing new posts and publishing them a dream. Now, instead of some complicated cocktail of adding a new file with the write filename and proper metadata, I can just org-mode capture the thing. The more I use emacs (and specifically spacemacs), the more in love I am.

Roger Williams and the Creation of the American Soul

The Wall of Separation

In January 1636, during a blizzard, in the dead of night, and still nursing an illness, Roger Williams stole out of his own home, leaving his wife and young children, and walked 55 miles through deep snow from Salem to Raynham, Massachusetts. He would depend on the kindness of his friend, Massasoit, Sachem of the Wampanoags for three months while he waited for winter to pass, before he could endeavor to settle land purchased from the Massasoit.

What had Williams done that was so heinous to the Massachusetts Bay fathers? He argued that the Colony had no right to take Indian land without payment, and furthermore charged King James with uttering a “solemn lie” when he claimed to be the first Christian monarch to have discovered the Colony lands. To arrive at these conclusions, Williams had applied English law, but the leaders of the Boston church, at the time an extension of the government, took issue with his political position and took it upon themselves to ensure that he could not preach anywhere in Massachusetts.

As far as I had been taught Rhode Island founder was a religious extremist worse even than the Pligrims themselves in his Christian piety and I had assumed that with their capital named Providence, the whole state was thick with Christian belief. Turns out I couldn’t have been further from the truth. Why had I never heard this part of Roger Williams’ story?

In my sophomore year of high school, I took a world history class from a socialist-minded teacher. The room that Mr. Levy taught in was assembled from thin, temporary walls in tracks. He took delight in explaining how the whole extension we were in was built as an experiment in the 70s. Teachers taught in various corners of one big room, and students could float between them, and learn what they wanted, when they wanted.

The experiment, for some reason, didn’t really fit in with public school educational models, and it only survived one semester. The chronically damp carpet in that extensions would, however, grow mold that survived and ended up making a number of kids (thankfully not me) very sick. But anyhow, Mr. Levy also had a habit of photocopying sections of Howard Zinn’s A People’s History of the United States.

Zinn’s oft criticized and sometimes canonized book portrays a more nuanced walk through the history of our country. By nuanced, I mean socialist. Zinn specifically looks for the people who are left out of orthodox versions of our history. While Mr. Levy delighted in turning history on it’s ear, his primary aim was to encourage us to not look at history as immutable writings scribbled in books. History is a living discipline. In French, the word histoire depending on context can mean history, or story. Indeed, history is the telling a story. A story of where we’ve been, who we think we are, and why we believe what we do.

Perhaps it’s obvious at this point, but Roger Williams story of exile was left out of my early American history lessons. Mr Levy only had us in class for one semester, and Williams was probably too English and white to have warranted much mention in Zinn’s history anyhow. So instead, I was taught that Plymouth and Massachusetts Bay setup successful colonies which over time, and with minor setbacks, eventually led to the complete colonization of North America by white Europeans. This is, of course, absurd, but welcome to American high school curricula circa 1997 (and I’m guessing that’s not far from 2018 either).

Williams exile, however, was more nuanced than I presented it. He had actually preached in Plymouth Colony for a time, drawing admiration from Governor William Bradford and being on good terms with John Winthrop, despite the latter’s disdain for Williams more liberal views. Indeed, Williams was uncomfortable in Plymouth, arguing that the church there was insufficiently separate from the Church of England. Plymouth was also where he began to take issue with colonial charters which did not include legitimate purchase of Indian land.

While Williams could tolerate political corruption, the fact that in both colonies, the church was inextricably linked to that corruption through law greatly disturbed Williams. As he sought out an audience for his ideas, the leaders of Massachusetts decided they had to act. His conviction for sedition and heresy meant he was to be put on the first boat back to England where his best outcome was life in prison, a sentence that in those days did not last very long and usually ended in death.

So Williams escaped, tipped off by his friend Winthrop, and in the spring of 1636 he, and along with his family and a small group of like-minded families setup a new community on the banks of Narragansett Bay, which Williams had purchased from the Womponoags. Under colonial law of the time, his purchase entitled Williams to rule the land and run the court. But he took the unheard of step of creating a community charter and, after securing a small parcel of land for his family, offered up the rest of the purchase to be dolled out from a town common stock, at a fixed rate.

In “Roger Williams and the Creation of the American Soul,” author John Barry goes to great length to point out how radical a government with power drawn purely from the people goverened and not at all by God was in an English community in the 17th century. With Williams’ explicitly leaving God out of Providence’s government, the community quickly became known amongst the regligiously persecuted. Jews and athiests lived next door to people like Samuel Groton, who was indeed Christian but seemed to refuse to be held to the same standard as the church fathers in Massachusetts and so was difficult to govern. Williams’ community also became a home for Quakers, a persecuted religious group who plagued Plymouth and Massachusetts Bay with their belief that God channeled his communication directly through lay people, frequently being charged “causing a disturbance.” Williams believed that so long as the beliefs of these groups did not interfere with civil governance, the Rhode Island government should have no say in what they do.

As radical as his property rights position was, his declaration that the new colony would “still to hold forth liberty of conscience,” would go on to influence similar declarations one hundred years later, as the United States formally established its own government. Indeed, the future Rhode Island and Providence Plantation colonial charter would be the first place in the history of European colonialism where citizenship did not depend on church membership. The actual compact establishing Providence Plantation in fact made no mention of God at all.

Williams convictions, born from ideas he developed over decades, were given life in Providence out of the crucible of injustice by the hands of men who claimed to be acting for God. “When they have opened a gap in the hedge or wall of Separation between the Garden of the Church and the Wilderness of the world, God hathe ever broke down teh wall it selfe, remove the Candlestick &c. and made his Garden a Wildernesse.” Williams soul had been hurt by those he considered friends. In founding Providence and the future Rhode Island on the idea of government power derived from the people, and leaving the Holy out of human concerns, Williams hoped no one would suffer as he had.

Thirty-five years later, Williams would continue to refer to the cold January night he escaped Massachusetts and the “snow wch I feele yet.” This was a wounded man. This was a brilliant man. And this was a virtuous and pious Christian, who was hurt by those he thought himself in religious communion with. Williams “Wall of Separation” was not to keep belief out of government, it was to keep government out of belief.

In our modern view, we often understand the separation of church as state ans chiefly benefiting our government, keeping the specifics of religion from our common law. Yet, as I stand here in a Unitarian Universalist Church in 2018, I say, thank Budda, and the gods of ancient Rome that what I say here today can incur no civil penalty so long as it breaks no civil laws. This a privilege Williams nearly died for, and countless other American patriots certainly have died for. On this independence day, remember why the Wall of Separation is there, and if you are so convicted as Williams, defend

Notes

Chapters 19-20

While I found the build up of Williams’ story a bit dry, especially the bits in England, and the early Planters in New England, these chapters kicked off his banishment from Salem. There’s an almost visceral quality to Barry’s depiction of his leaving, and it’s not an accident I suppose. Williams wanted to stay in Salem, and Barry goes to great ends to explain that he felt betrayed. But beyond Barry’s betrayal, or perhaps with that as a backdrop, we begin to find out just how revolutionary the founding of Providence was, not just for the American plantations, but the development of Western Civilization. Barry explains how devout a man Williams was, and notes just how striking the absence of the Christian God in the founding documents of Providence really was.

I’ll admit to being blindly dismissive of the founding of Rhode Island. I assumed Williams, like the Puritans before him, sought only a different religious individualism, but just as comformist in it’s own way. And yet the story is almost the exact opposite. Providence received it’s name because Williams believed his ability to sneak out of Salem before being sent back to England for torture was a form of divine intervention. And his grant of land from the Narragansetts would look like luck to any unchurched person, but Williams believed differently. And yet. And yet, this religiousity did not inform his new community. Providence was to derive the power of it’s governance NOT from a god, but from the individual rights of it’s inhabitants. Far from yet another religious plantation, Providence proved to be the first experiment in what would eventually become the United States. Silly to restate Barry’s title, but indeed, Williams’ idea birthed the soul of America. Not the Pligrims, not Plymouth, certainly not the industrious Dutch in New Amsterdam. Rhode Island, Providence and Williams, churched in liberty by Coke and religious tolerance by his own treatment in Masschussetts, began a period of Baconian government by scientific method in which we find ourselves today.

I think the most important aspects of Williams idea came from his willingness to put his trust in his whole community, while still acknowledging the importance of structures of governance. His was not a commune of anarchists, or anti-government activists. He simply wanted a place where his beliefs would be free from the tyranny of governance. Where the liberty and equality of governance were not required to poison the well of faith.

These chapters also touched on the tragic consequences of war and alliances. The fall of the mighty Narragansett empire was precipitated by a self-preservation move to ally with the English. Ironically, this alliance’s victory of the Pequot nation gave power to the Mohegan’s in the north who had never much cared for the Narragansetts. Sometimes, it would appear, survival means defeat.

Chapters 20-25

Thinking now about this book from the perspective of writing a sermon, as Margaret asked me about it. I’m struck by how radical Williams’ point about Christianity not involving Earthly government was, and how we still haven’t really gotten there. There are still debates about the morality of our government which fall back to religious arguments because it’s all we have.

Chapters 25-34

Noted this in my journal as well, but Williams’ stand for religious liberty reminded me very much of John Adams (portrayed) stand for legal liberty at the beginning of the HBO mini series. And really, in another turn of phrase, it would be called moral imagination. To provide someone else the respect of not understanding or feeling how they feel or think, but giving them room to do it anyway. Williams was a devout Christian. In these last chapters, Barry makes it clear that he also detested Quakers. And yet, his distaste for their beliefs, had zero impact on their ability to live in community with others. When the governor of Rhode Island was asked to keep the Quakers out of the United Colonies, they rebuffed them by saying they would stop them from violating civil law, but had no business what they believed so long as they respected others.

In 2018 it’s easy to think that’s not that big a deal, but it was a radical notion then, and as regards debates about public education and the role of religion in civil life, still just as important.

It’s also important to remember that Williams did not like the Quakers. He had falling outs with many of the rougher sorts who came to settle in his more-tolerant colony. But his personal distaste for them meant nothing so long as they abided by the laws as decided on by the people being governed. You do no have to like everyone, and you certainly do not have to agree with everyone. But laws should be generated by the people being governed under a framework of providing mutual aid and security. Beyond that, religion has no place in civil society. The use of laws to enforce religious preferences is abhorant, whether they be liberal preferences or conservative.