The Expanding Classroom

#healthcare #EHR

Answer by James Fisher:

The questioner asks us Where will they go? And this is the angle I want to explore, because I think the patient portal is taking us down the road to a personal-controlled electronic medical record and this, more generally, to a veritable explosion of personal health care data. This will be, I believe, one of the most important and far-reaching trends in the 21st century.

A Closer Look
To illustrate let me begin with an unlikely source, namely, Simon Cowell. This is from his Rolling Stone interview, April 6, 2006:

INTERVIEWER: What do you want more than anything else in the world?

COWELL: Money. As much money as I can get my hands on. It’s as simple as that.

INTERVIEWER: I read that you’re worth something like $90 million. Not enough?


INTERVIEWER: If you could perform one miracle, what would that miracle be?

COWELL: That tricky. Do suit others of do I suit myself? If I’m being honest with you, I’d probably be to have 1 billion pounds put in my bank account, and then I’d ask the bank statement to magically appear on my desk so I could stare at it from all angles.

INTERVIEWER: Do you think you’re shallow?

COWELL: Yes, I do.

The thing that captures my fascination with this conversation is the evocation of Simon’s gaze, intently focusing on bank balance “from all angles.” Because, really, what’s more interesting than information about ourselves? Maybe financial information now, but one day—very soon—it will be personal health data.

Finance as Analogy
The patient portal is roughly analogous to the electronic financial portal we have into our primary financial institution. You interested at all in that? Check it often? From different devices? Maybe even from all angles?

Of course this financial portal is convenient, and now with more capabilities being introduced (e.g., paying bills, cashing checks, moving money) it’s becoming increasingly useful. But as a full picture of, say, our financial health, it’s incomplete, a myopic or one-dimensional view. Maybe we relate to other financial institution, maybe we have a brokerage account, a retirement fund, credit cards, loans, assets, etc.

Enter a data integration application like Mint or one of its competitors and you start to get a fuller picture: a view of you assets and liabilities, your overall cash position, maybe a summary of your spending and your budget variances. But wait, there’s more: Mint will alert you to upcoming bills, maybe advise you to consider a financial product suited to your lifestyle and its corresponding habit. Maybe it will suggest you consider re-financing your house or a college fund for the kids. You get the picture. Data are aggregated, presented in an accessible and pleasing UI/UX; these same data are analyzed and interpreted and then delivered in the form of financial prescriptions that could, quite possibly, improve your economic well-being.

This integration layer and the overall information sophistication of financial services are pretty decent. The healthcare industry, by contrast, is a much earlier stage of evolution. The patient portal is an important, albeit partial, step.

Patient Portals Are Not all the Same
At present, patient portals are essentially online applications that allow patient to interact, transact and communicate with their healthcare providers. Thus the core functionality (potential benefit) delivered by the patient portal is to enable patients to interact with their medical information via electronic means. Additionally, as functionality gets established and use cases extend, these patient portals will potentially yield an impressive array of services, but we’re nowhere close to that now.

In fact, there is a great deal of variation among patient portal at present (2013).  Some patient portal applications exist as stand-alone websites. Some of these stand-alone websites may be linked to or otherwise affiliated with a sponsor, for example, an employer or a wellness program.

Further distinctions get made about the connectedness or control of these portals. Some may be entirely or largely under the patient or individual’s direct control and considered, therefore, to be untethered. Other patient portals are integrated into the existing website of a healthcare provider, say, a physician or practice group or hospital. These are typically considered tethered.

In a similar vein, some patient portals exist as an add-on module to an existing electronic medical record. And some vendors, like Epic, will offer both a patient portal module to its EHR (MyChart) as well as a personal health record (Lucy).

Though patient portals are frequently conceived of as a module to the EHR (as illustrated in the previous example with Epic), it is just as valid and useful to conceptualize patient portals along the dimension of functionality. Some have this function, some have that; some have more, some have less.

Patient Portals and Healthcare Apps
These facts on the grounds would seem to auger the rapid development and widespread availability of health care apps (available on the Web and on mobile devices) that focus on a specific use or on a more narrow range of uses.

Development strategies may, therefore, bifurcate between organizations (e.g., hospital systems, medical practices, pop-up clinics, employers, wellness programs, insurers) that offers a range of what it anticipates will be popular or useful functions and use cases and the development community that focuses of very specific and targeted applications that the health care providers and consumers qua patients would select from an app store.

With all these distinctions to be made, it is not surprisingly that the meaningful differences among portals, applications, electronic medical records, personal health records and even health information exchanges are starting to blur or otherwise cause confusion.

At same time, each stakeholder in the healthcare system (e.g., patients, physicians, practices, hospitals, insurers) relies on the portal effectively serving the needs of other stakeholders. Better health outcomes—sought by insurers and healthcare providers—are unlikely to be forthcoming without patient engagement and utilization of the portal. Personal control sought by patients similarly depends on access to relevant data (and data originating from a variety of sources) and participation by those in the larger health ecosystem if the locus of control is to be sufficiently broad and meaningful.

Whither Patient Portals?
So these musing provide the basis for some preliminary conclusions about the patient portal and its future:

  1. Data richness is a key driver of the ultimate utility derived from of a patient portal. So, too, is access to the data and the capacity to add or write appropriately to it.
  2. Context counts. Utility of patient portals will also be shaped by their functionality and the context in which they are used. This utility can be captured in different ways by different stakeholders at different stages in the healthcare delivery process.
  3. User interface and user experience will separate the winners from the losers. Delivery of best experience yields a host of advantages, including patient engagement, utilization rates and improved outcomes,

The Big Picture
So the patient portal really opens the door to a world in which personal health data gets big, gets shared and applied and then, ultimately, gets results.

More specifically, I think we will see a proliferation of medical devices—most of them miniature or otherwise unobtrusive—and these will start to contribute or write to our medical records.  Just think how much more utility this personalized health data will have as we start to get real-time data instead of the static measures that get taken at the doctor’s office or at the patient’s bedside. Devices like FitBit and Nike’s Fuelband are now getting dramatic uptake in the fitness market.  I wouldn’t be surprised to see these devices or ones like them starting to attach or to write to personalized health records—perhaps through the patient portal.

So personal health data will get big and get big fast. As it does it will get tapped in valuable ways. Build these data, make them accessible and the developers will come. Patients—maybe we should just call them consumers—will become empowered as they capture the data and find novel ways to apply it. Data will be shared more widely. Privacy concerns notwithstanding, personal healthcare data will get exchanged much faster, more productively within the healthcare system and beyond. The fitness and personal training market will gain deeper insights and greater relevance as they assume more data-driven approaches. Social media will similarly have its role in this data-enriched environment, connecting people to valuable resources, keeping them on track with their respective health agenda and gamifying efforts to get fit and stay well. Personal health will be less a medical monopoly as a wider network gets applied. Algorithms and artificial intelligence will have a role in screening populations, alerting people at risk and preventing potential health crises.

The patient portal is a catalyst for much of this, an organizing principle for both the collection of data and the dissemination of information services and, most certainly, behavioral modification. At present, patient portals are fairly sterile conduits of limited medical information and thus probably not attracting many eyeballs, but as the data are enriched, as the UI/UX experience gets elevated, and as the data get shared and applied in engaging and helpful ways they will draw users seeking a host of benefits and, who knows, wanting to stare at it from all angles.

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As a young graduate student (well, relatively speaking) I became interested in social class and its measurement. I revisited the topic on Quora by showcasing one of the more interesting and robust social class yardsticks: The Living Room Scale. Was interested to see that it has been revised a couple times: once by Paul Fussell and then more recently by fellow St. Louis academician, Robert Keel.

Answer by James Fisher:

If you must know, then apply the highly reliable and largely valid Living Room Scale.

Take up a position in your living room and start your tally with 100 points. Add or subtract accordingly:

Hardwood floor, add 4

Parquet floor, add 8

Stone floor, add 4

Vinyl floor, subtract 6

Wall-to-wall-carpet, add 2

Working fireplace, add 4

New oriental rug or carpet, subtract 2 (each)

Worn oriental rug or carpet, add 5 (each)

Threadbare rug or carpet, add 8 (each)

Ceiling ten feet high, or higher, add 6

Original paintings by internationally recognized practitioners, add 8 (each)

Original drawings, prints, or lithographs by internationally recognized practitioners, add 5 (each)

Reproductions of any Picasso painting, print or anything, subtract 2 (each)

Original paintings, drawings, or prints by family members, subtract 4 (each)

Windows curtained, rods, and draw cords, add 5

Windows curtained, no rods or draw cord, add 2

Genuine Tiffany lamp, add 3

Reproduction Tiffany lamp, subtract 4

Any work of art depicting cowboys, subtract 3

Transparent plastic covers on furniture, subtract 6

Furniture upholstered with any metallic threads, subtract 3

Cellophane on any lampshade, subtract 4

No ashtrays, subtract 2

Refrigerator, washing machine, or clothes dryer in living room, subtract 6

Motorcycle kept in living room, subtract 10

Periodicals visible, laid out flat:
  National Enquirer, subtract 6
  Popular Mechanics, subtract 5
  Reader’s Digest, subtract 3
  National Geographic, subtract 2
  Smithsonian, subtract 1
  Scientific American, subtract 1
  New Yorker, add 1
  Town and Country, add 2
  New York Review of Books, add 5
  Times Literary Supplement (London), add 5
  Paris Match, add 6
  Hudson Review, add 8

Each family photograph (black-and-white), subtract 2

Each family photograph (color), subtract 3

Each family photograph (black-and-white or color) in sterling-silver frame, add 3

Potted citrus tree with midget fruit growing, add 8

Potted palm tree, add 5

Bowling-ball-carrier, subtract 6

Fishbowl or aquarium, subtract 4

Fringe on any upholstered furniture, subtract 4

Identifiable Naugahyde aping anything customarily made of leather, subtract 3

Any item exhibiting words in an ancient or modern foreign language, add 7

Wooden venetian blinds, subtract 2

Tabletop obelisk of marble, glass, etc., add 9

No periodicals visible, subtract 5

Fewer than five pictures on walls, subtract 5

Each piece of furniture over 50 years old, add 2

Bookcase(s) full of books, add 7

Any leather bindings more than 75 years old, add 6

Bookcases(s) partially full of books, add 5

Overflow books stacked on floor, chairs, etc., add 6

Hutch bookcase ("wall system") displaying plates, pots, porcelain figurines, etc., but no books, subtract 4

Wall unit with built-in TV, stereo, etc., subtract 4

On coffee table, container of matchbooks from funny or anomalous places, add 1

Works of sculpture (original, and not made by householder or any family member), add 4 (each)

Works of sculpture made by householder or any family member, subtract 5 (each)

Each framed certificate, diploma, or testimonial, subtract 2

Each "laminated" ditto, subtract 3

Each item with a ‘tortoiseshell’ finish, if only made of Formica, add 1

Each “Eames chair”, subtract 2

Anything displaying the name or initials of anyone in the household, subtract 4

Curved moldings visible anywhere in the room, add 5

245 and above: upper class
185 to 245: upper middle class
100 to 185: middle class
50 to 100: higher proletariat
Below 50: lower proletariat
The Living Room Scale originated with sociologist F. Stuart Chapin over 75 years ago in his book Contemporary American Institutions (1935). The version provided here is a revision by the late cultural historian, Paul Fussell, in his book Class (1983). My fellow St.Louisan, Robert Keel, himself a sociologist, updated the scale in 1999. You will find it at THE LIVING (

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Answer by James Fisher:

The seeds of the sixties are largely located the swirl of social currents that precipitated shifting social attitudes and sweeping social change. Values, lifestyles and institutions all received special scrutiny and challenge at different times and from different quarters.

Theodore Roszak in his The Making of a Counter Culture (1969) alludes to the historical antecedent of the sixties:

Why and how this generation lost control of the institutions that hold sway over its life is more than we can go into here.  The remembered background of economic collapse in the thirties, the grand distraction and fatigue of the war, the pathetic if understandable search for security and relaxation afterwards, the bedazzlement of the new prosperity (pp. 22-23). 

Thus the so-called Generation Gap was one of the root causes. The hippies gave the movement a distinctly anti-establishment character, rejecting certain values they labeled materialistic, business interests they characterized as rapacious and politics they lampooned while protesting and attacking its leaders and practitioners as bellicose and lacking moral authority. In this regard the signal issues of the day–the Vietnam War and civil rights–gave credence to certain aspects of the Hippie indictment of society's institutions. And perhaps those flash-points broadened the appeal of the Hippie movement while also giving it a moral dimension if not exactly depth.

Hippies were non-conformist in their intention and anarchist in their practice, a heady mix of  idealism and rebellion. Clothing, hair and personal hygiene were all outward expressions of an internal and seemingly abrupt about-face on the current establishment. Timothy Leary’s famous advice to turn-on, tune-in and drop-out was but a psychedelic variant of a lifestyle exploration that, for many, combined an inward search with a outward release of pretense. 

Though emphatically non-materialistic, the idealized lifestyle was unabashedly hedonistic:“if it feels good, do it!” was one of the more common mantras of
the sixties and the hippies that embodied so much of its spirit.

I remember. I was there.

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Super Bowl XLVI kicks off today. It’s a quintessential American spectacle, blending competition and commerce seamlessly.

Just yesterday, I taught a marketing class that featured a case on advertising, so we took some time before our case discussion to consider the larger significance of the Super Bowl as a widely observed ritual here in the United State—one that’s increasingly reaching a global audience. It’s a celebration embedded deeply in our culture, having been joined securely at the hip to the institution of advertising.

The Super Bowl is one of a handful of really big shows that can command a truly national audience. With the proliferation of cable, on-demand entertainment and DVRs there are few, if any, occasions for an advertiser to draw anywhere near the audience that a Super Bowl commands. This year well over one hundred million viewers will tune in. I have seen estimates that perhaps half of all Americans will view some part of the Super Bowl. What will you be doing?

The bonanza for advertisers is that many, many viewers are just as interested in the advertising that accompanies the Super Bowl as they are in the action on the field. This interest spills over into the following days as discussions about the Super Bowl ads enliven water-cooler conversations, media accounts and Internet chatter. For a brief respite the advertising mavens escape their subordinate, supporting role as the subsidizers of commercial media. Advertisers take a holiday from their so-called interruption model on Super Sunday. For many, it’s the main event.

So how might advertisers want to take advantage of this special opportunity? Let me count the ways:

1. Get on the consumer’s radar: Awareness is the coin of the realm in mass communications. It’s hard to find a large audience and then when you do it’s often difficult to make an impression. So advertising on the Super Bowl will be enlisted to announce what’s new: new TV shows, new products, new styles and fashions. Over-the-top executions will drive home the impression.

2. Keep a brand’s forward momentum: Strong advertising campaigns can reassert their dominance with a strong Super Bowl presence. So this year, watch for the E*Trade baby, back for something like his fifth year. You’ll recognize other familiar campaigns, icons and, of course, the usual cast of animals: chimps, dogs, Clydesdales, polar bears, etc.

3. Update the viewer: Have you driven a Ford lately? If not, then the Super Bowl is excellent venue to suggest as much. So watch for marketers to tell you what’s new and improved. If an image needs polished or re-positioned then no better stage than the super bowl to do so. Dannon Oikos Greek Yogut is a good example of the stratagem this year.

4. Cement customer loyalty: People always pay closest attention to advertisements for products they already own. So as you eat your Doritos and swill your Bud Light you can likely depend on the corresponding ads to reinforce your behavior.

5. Demonstrate your advertising chops: You go-pro on the Super Bowl. For an up and coming ad agency, this worldwide stage showcases your work like nothing else. Creative, break-through advertising get announced to the gatekeepers and influencers that keep watch over the ad industry. And, of course, potential clients are watching as well.

Kick-off is at 6:30 pm ET. But advertisers will have put points on the board even before the coin toss.

Since starting my teaching career at Saint Louis University,  I have taught using the case study method.

This means that on any given day if you were to attend one of my classes you would likely find me and my students engaged in a collective discussion of a business case study, which is to say, a story. It has characters, it has plot twists and it has a narrative flow that we commonly recognize as story-telling. A veritable 3-D effect: dialogue, data and drama.

I made the decision to jump into case teaching for largely serendipitous reasons. Long age, I attended an American Marketing Association meeting in Detroit and met a couple Harvard professors (Bob Dolan and Ben Shapiro), who were effective evangelists for the case method. (Harvard is famous–some might say infamous–for its advocacy of the case-study method for graduate management education).

At the same time, I knew that I was headed for Saint Louis University and knew further that I would be largely responsible for teaching MBAs, most of whom would likely be engaged in full-time employment while pursuing their graduate degree on a part-time basis. I imagined that this type of student would have a big appetite for all-things-pragmatic and maybe little taste for the theoretical musings of a freshly minted Ph.D. (Actually my Ph.D would me minted a year or two after I started teaching at SLU.)

At the risk of seeming to offer a post-hoc rationalization for my case-method predilection, I’ll submit that are at least three good reasons for teaching with case studies:

  1. professional: Entry into case-studies simulates managerial decision-making. The best case studies challenge student to ferret out real problems and formulate feasible solutions under conditions of uncertainty and incomplete information–which is more or less the situation we always find ourselves in..
  2. pedagogic: The case study is a form of experiential learning. It engages students in a more active and participative fashion than does lecture-based format. It places a premium on communication, the exchange of ideas and the conflict of opinions. Pretty much what goes on in the world of business and, for that matter, the world at large.
  3. dispositional: Cases offer an inductive styles of learning, which is well suited to how we naturally learn, seeking connections and common threads across many different contexts.  When we learn under the influence of case study, I do believe that that learning is especially practical, deep and persistent.

Here are a few video clips in which I and my colleagues make the case for cases:

I’ve just waded through a lot of exams. A handful of questions on my part, but each one generating in turn twenty to thirty answers. The questions are open-ended and so the students answer with essay-style answers. That’s the essential bargain at semester’s end. They write the examinations. I grade them. The student’s revenge, if you will.

The longer I teach, the more value I attach to good questions. Ask a bad question on a test–and I’ve done that–you pay the price. The answers are all over the board and by the time you work down to the bottom of the pile you find yourself wondering what exactly you were trying to elicit from the students, grasping for a reliable set of criteria to distinguish the informed, reasonable answer from the less knowledgeable one.

I suppose that we ask questions to elicit what people know. This is the set piece that constitutes the exam: ask questions, let students demonstrate that they know the subject matter. But the best questions focus thinking. They push the matter further. They advance the inquiry. So some of the best questions offer a sort of window into how students are actually thinking about certain problems.

This insight stands behind the so-called Socratic method, which depends on questions and questioning as a means of directing and deepening inquiry. This turns our more traditional notions of teaching on its head. We tell students what we think they should know, then follow that up with questions: Were you paying attention? Can you tell me what I just told you? Or, a variation on the theme, can you apply what I just told you?

Socrates seldom provided answers. In fact, he seemed to harbor a deep suspicion of answers–maybe in part because he recognized that our knowledge is typically limited and partial. His preference was to use a precisely targeted question as his point of entry into a particular issue, probing the assumptions and definitions that typically shape our thinking and direct our conclusions. So Socrates is more focused on understanding or living questions than offering definitive or air-tight answers. The question can also offer a kind of road map into the mind of the questioner and Socrates was a master at going down these paths of thought.

Thus Socrates asked questions not so much trying to elicit the “right” answers from his audience as to discover what was good and true, but also largely obscured or buried. A well-aimed question will focus the mind in the right area and, who knows, maybe provoke insight or discovery. Now here’s the catch: questions capable of doing this are not easy to come by. This takes us back to my exam example. Many of the questions we ask just don’t get the job done.

So better teaching (and better testing) requires better questions. This art of questioning get honed in the context of classroom discussion. It requires close listening and then patience. Sometimes the sequencing of questions can be the key: asking “What?” before “Why?” Get facts and symptoms out on the table, before entertaining diagnoses or remedies. Good probes are also helpful. “How do you know that?” “Do you agree?” and then “Why?” The patience part requires a tolerance for silence. Quick answers are not always good ones. Questions must work their way into minds and hearts; reflection takes times. I’ve had to work getting comfortable with what feel like extended silences in the classroom, but at the same time I’ve found, as have others, that if you extend so-called wait time, then you’ll get better, deeper discussions.

We hold tightly to our opinions and beliefs, so it takes a powerful question to pry us apart from our cherished biases. A good question can reveal the fallacies of our logic or test its limits and perhaps provide a startling and revealing change of perspective.

Answers are easy. Questions–good questions–are hard.

Getting under way

I am a professor at Saint Louis University–have been for over 25 years. One of the things I like about my position is the variety it affords. So considering the length of my tenure at SLU and the variety of my work, I ought to have sufficient material to at least undertake this blog.

I teach a range of students: undergraduate, graduate, also executive students and a handful of Ph.D. students. I also have the opportunity to teach an interesting variety of courses: marketing, ethics, decision-making and, just this past semester, a course on digital marketing and social media–for which I needed more than a little help from my friends. As a professor in a b-school (mine is the John Cook School of Business), I also get out into the community do some consulting work, some speaking and other work.

I hope to use this blog to keep in touch with students, colleagues and friends both at the school and beyond. At the same time I’ll be working through the daily challenges of teaching and research. I hope to engage a few others in these efforts, sharing resources and thinking–and, who knows, maybe have a little fun in the process.

I’m slowly developing this aptitude for blogging having done micro-blogging on Twitter (@Prof_Fisher) and also having done some longer form material on Quora where you can follow me as James Fisher. I find myself writing quite a bit on Quora and so thought maybe I could benefit from taking a more active role in the management of my own writing and thinking. We’ll see…

I should also thank Sam Coren who edits the Student Advisor. She invited be to write a piece for her blog. You can read my inaugural effort: Picking a Major: Is Majoring in Business Bad for You? Let’s see if a can develop a little momentum.


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