Monthly Archives: December 2010

How to Stay Awake in Meetings, Episode #7

Sometimes I get bored in meetings. Here are some scribblings from one of my 2009 notebooks:

Ενα “whiskey” σε παρακηλω!

Le soleil sûr ma tête, ce me fait comme un bête.

ΑΡΧΕ ΚΟΡΙΝΘΩΣ

La pluie de l’Espagne reste pour le plus part dans les pas.

शान्ति ॐ शान्ति

οίμοι κακαδαιμων εγένετω τυφλός

Je veux crasser arracher mes yeux.

Compiled apps don’t run
In R2009b.
Missing DLLs.
— A haiku

Mon petit chat a des cheveux blancs et noirs.

ή γύνη σπεύδει προς των αγρών

Posted in From the Yellow Notepad, General, Hoarding | Leave a comment

Early Ideas about Using Checklists in Software Engineering

Some months ago, I wrote a review of Atul Gawande’s Checklist Manifesto and about using checklists in software development.

I’m pleased to say that it looks like I might get a chance to follow-up on that idea more in the coming year. I’ll keep you updated. In the meantime, here are few ideas on the subject from one of my notebooks. (I appear to be going through these “historical documents” in a rather random chronological order.)

When are the pause points where we might use checklists?

  • Before starting to design
  • Before starting to code
  • Before code review
  • Before submitting changed files
  • Before QE-led testing

Who might be included in the check-off activities? The goal is to catch problems and communicate what’s happening.

  • Coder/Developer
  • Quality Engineer/Tester
  • Buildmasters
  • Doc Writer
  • Project Leader (?)

What’s so mindless that it’s taken for granted? (e.g., “build and run tests on every platform.”) Are these second nature? Or are they sometimes forgotten/overlooked/not done?

What goes onto a “pre-flight” checklist? What goes onto special circumstance (“OMG the plane is crashing!”) checklists? The idea is to have lots of small checklists.

What level of specificity is required for a checklist?

Posted in From the Yellow Notepad, Hoarding, Life Lessons, Software Engineering | Leave a comment

Requirements . . . again

It’s the week between Christmas and New Year’s Day . . . time to clean out the files at work. Actually, this year at the office I’m going through all of my yellow notepads — about 17 of them. As I find something interesting, I’ll post them here.

Today, requirements. I honestly can’t remember if I’ve written here about defining requirements in software projects. Getting them defined right is so important, I would be surprised if I hadn’t. Here are just a few more notes.

Questions to ask about your requirments:

  • Are they adequately motivated?
  • Are any missing?
  • Are there any included that aren’t really needed?
  • Are any solutions masquerading as requirements?
  • Are they testable?

These requirements are often overlooked:

  • Localization (L10N)
  • Robustness
  • Performance (speed, memory)
  • Backward compatibility

And remember, not all requirements have the same priority. Try to stage solutions to address different priority levels.

Update: It’s hilarious how many times I’ve already found names and telephone numbers for people who work at Medtronic Minimed.

Posted in From the Yellow Notepad, Hoarding, Software Engineering | Leave a comment

Picking Winners and Losers in the Prescription Drug Wars

This article will soon be is cross-posted on the DSMA weblog. Many thanks for the opportunity!

Note: I know this post is long. Here’s the takeaway in a nutshell: In the American system, we can have lower prices or more choices but probably not both at the same time. If you don’t like that, we have to change the system to work for us. If you read the whole article, I’ll tell you why . . . and how.

During last week’s Diabetes Social Media Advocacy tweet chat one of the topics touched on something that’s been on my mind a lot since about this time last year when the healthcare reform debate started raging in the US: how to balance medication choices, treatment costs, and insurance companies. Here was the question:

Do you think insurance companies are overstepping their boundaries by dictating the cost of drugs versus the best treatment for the patient?

I ended up on the opposite side of the issue from most of my fellow patients, saying that in general I don’t have a problem with insurance companies choosing to favor some medications and therapies over others. I know it’s probably an uphill battle, but let me try to convince you why. If I can’t do that, let me at least try to convince you that the only alternative is something even more radical. (If you’re impatient, you can skip to that part.)

The UHC Decision on Novolog
First, a little backstory. The event that spawned the conversation was a recent decision by United Healthcare (UHC) — a private company that provides health insurance to American patients — to move Humalog insulin into a lower copay price tier at the same time that it moved Novolog into a more expensive tier. The claim made in the chat is that Novolog is now 250% more expensive.

I’ve always been on Humalog ever since I went on the pump, and I’ve never used Novolog. I know there are people with diabetes who swear by it, saying they’ve had better success managing their blood glucose using it. From what I’ve seen, though, their action profiles are very, very similar. The same is not identical, of course; and I have no doubt that some people really do have better outcomes using Novolog than using Humalog. But it’s important to remember that it’s a difference in degree between very similar drugs. It’s not like UHC is trying to switch patients between Novolog and regular insulin or NPH.

In a public document UHC states their reasons for making the changes to the costs of Novolog and Humalog:

Impending higher costs for the FreeStyle and Precision Test Strips as well as the Novolin and NovoLog Insulin products prompted a class review.

None of these medications are in the top 100 based on utilization. When medications are clinically similar to one another, their value is measured in terms of cost.

We were able to negotiate lower net costs for Accu-Chek products as well as the Humalog and Humulin insulin products, making them a better health care value.

Medications in the Select Designated Pharmacy Program will be up-tiered to Tier 3 to encourage Tier 1 use and increase member savings. For more details, see the section below.

And later referring to Eli Lilly’s Humalog products . . .

These medications offer sufficient health care value to be down-tiered. Some have been down-tiered since our last pharmacy benefit communications. The majority of down-tier decisions will be implemented prior to Jan. 1, 2011 so
members can take advantage of the cost savings.

While it says this about Novo Nordisk’s products. . . .

Novolin and NovoLog product rebates were reduced, lowering their overall health care value.

To be sure, these insurance decisions impact UHC’s bottom-line. They appear to have had more success negotiating lower prices with Lilly than with Novo, making Humalog less expensive for them when they pay pharmacies for it after UHC’s patients fill their prescriptions. The more of their customers/patients they can move from Novolog to Humalog the more money they will save. And they plan on doing it through both positive and negative incentives (lower costs for Humalog and higher costs for Novolog).

Who Decides?
Still with me after the backstory? Good. And to the people reading this who don’t live in the United States: Yes, it’s really this complicated and seemingly capricious.

Who makes these decisions about which tier a drug belongs in? It’s certainly not patients deciding. And since we can’t really choose between different insurance providers, we’re stuck paying what they demand. Do doctors decide? Well, yes and no. Doctors create many of the studies and reports that say how well different drugs can be used to treat the same condition. Insurance companies have staff doctors who help them make claims like two drugs being “clinically similar to one another.”

But really it’s the insurers making the decision. They see the price of Novolog going up (for them) and they need to pass that cost along to the consumer pool either by higher premiums or bigger copays. Or both. But certainly not by reducing their profit margins.

While I’m sympathetic to people with diabetes who use Novolog and are insured by UCH, I think we’re in a world of tough choices.

The Tough Choices
I suspect we’d all say that it’s foolish for an insurance company to let a patient stay on a high-priced drug when a much cheaper generic of the same drug is available, without passing on some or all of the price difference to the patient. And I think we’d also say that, when given a choice between two drugs that do the same thing, it’s wasteful of healthcare dollars to pay for the more expensive option.

It gets tricky when there’s a tiny difference between two drugs and a not-so-tiny difference in the price between them. That’s the situation UHC and Novolog users were looking at.

If you had a say in making the decisions, what would you do? Would you pass on the cost of providing the more expensive one at the same copay cost by raising everybody’s premiums? Would you raise the rates of the people who use the most healthcare dollars? Would you stop covering Novo products altogether, since you couldn’t agree on an acceptable price? Would you keep paying for the more expensive drugs and tell your shareholders to expect lower returns, knowing you’d likely lose your job?

The decision that UHC made to move people toward a lower cost drug while passing on the cost to the people who stayed starts to looks less perfidious, money-grubbing or ill-reasoned.

By the way, I was in this situation myself when Blue Cross Blue Shield of Massachusetts decided to raise the cost of Freestyle test strips — again — last year. The lingering objections I had to changing blood glucose meters kinda melted away when I realized that OneTouch meter supplies would cost me half as much out-of-pocket. Those products are almost indistinguishable in terms of quality — unlike some other options. No brainer, right? (I do hope that BCBS doesn’t give me too much run-around now, as I try to get them to reimburse me for continuous glucose monitoring supplies. Their cost is high, but the long-term cost saving should be greater.)

In my opinion, UHC made the right decision, and the only wrong decision would be to let the pharmaceutical companies set the price of therapies without getting any resistance from insurers. For better or worse, insurance companies are the intermediaries between us and the healthcare system. It’s true that this means we often don’t know the real cost of therapies; but I would much rather see someone negotiating a drug price on my behalf and the have the power to pool my interests with hundreds of other people instead of seeing all of the price and having to pay it all.

Alternatives
Suppose I haven’t been able to convince you yet. What are the alternatives?

If you object to letting health insurance companies pick the price tier structure for particular drugs, who would you have do it? The only realistic alternative is to have a panel of doctors pick winners and losers between similar drugs, steering people to particular therapies that work and aways from others that don’t work as well. (Or recognize that there’s no real difference between them. Or that some therapies shouldn’t be covered at all.) If cost comes into it in this situation, it might only be to say, “Between two therapies with the same outcome, always pick the less expensive one.” That might actually help drive drug prices down.

If you object to having tiers altogether, the only realistic alternative is to have higher prices overall for everybody. Maybe you’re okay with that. After all, that’s how systems like Medicare in the US work. Everybody pays taxes so that everyone gets what they need covered. But remember, to keep prices affordable, it’s often necessary to not cover some things at all.

If you object to insurance companies looking at the bottom line when making decisions, then the solution is obvious. Take the profit motivation out entirely. Make all insurance companies be not-for-profits. Convert health insurance companies that make money by denying people what they need into ones that reduce costs by trying to keep people well and looking at the long run.

If you object to the high price of prescription drugs, empower someone with real regulatory power to set the price of drugs. Allow importation of drugs from other developed countries. Demand to know why pharmaceutical companies get away with charging so much more in the United States than elsewhere.

If the status quo doesn’t work for you — and there’s a lot of evidence that it’s not working for most people or for the long-term stability of the country — then change the status quo. The insurance companies are working in the system as it is. We need to change the system so that it works for us and so that it benefits us more than it does them.

Posted in Diabetes, General, Health Care | Leave a comment

Smaller works by Arvo Pärt

I’ve been a big fan of Estonian minimalist composer Arvo Pärt since I heard a recording of “Te Deum” in 1993 or ’94. Since then I’ve listened to a lot of his recorded compositions, and I made myself a goal for my “101 in 1001” project to listen to all of the different Pärt works that have been recorded.

As with many things in this project, I had already started it before the beginning of the 1001 days. While I had bought some recordings over the years, starting with “Te Deum” and mostly sticking with ECM New Line recordings of the Estonia Philharmonic Chamber Orchestra and or Paul Hillier, for this project I wanted to use the public library as much as possible.

But after tapping out that resource, I realized there were still a lot of smaller pieces that I had never heard. So I bought the very affordable Arvo Pärt: 75 Year Celebration on iTunes. There was some overlap with my collection, but lots of new (to me) works, many of which were small, early compositions.

I’m still not done listening to all of the Pärt works at least once, but I thought I’d share some of my favorite smaller works (thus far) with you:

  • Fratres for Strings and Percussion (1977/1991)
  • Für Alina (1976)
  • Spiegel im Spiegel for Violin and Piano (1978)
  • Tabula rasa for Two Violins, Strings and Prepared Piano (1977)
  • The Beatitudes for Choir and Organ (1991)
  • Festina Lente for Strings and Harp (1990)
  • Fratres for Violin and Piano (1977/1980)
  • Summa for Choir (1990)
  • Symphony No. 3 (1971) — Yes, it’s a short symphony.
  • “Nun eile ich zu euch” for Choir (1989)
  • Variationen zur Gesundung von Arinuschka (1977)
  • Annum per annum for Organ (1980)
  • Cantus in Memoriam Benjamin Britten for Strings and Bell (1977)

All of these works are available on the “75 Year Celebration” download, along with some other recordings that were either a little too dissonant for my taste or that I need to give another listen.

How about you? Do you know about Pärt? Do you have a favorite piece or recording?

Posted in 101 in 1001, General, Hoarding | Leave a comment

The Reluctant Triathlete

People go for a run all the time without racing.

In fact people do a lot of potentially competitive activities just for the pure enjoyment of the thing.

People go for bike rides, have a swim, play “horse” or pick-up basketball, toss around a baseball, lob the football, go ice skating, etc. And these things happen all the time. In fact, you might say that most sports activity is the noncompetitive kind.

So why is triathlon so weird?

No one goes out to “have a little triathlon” or “do a quick swim/bike/run.” No. You only ever hear of people “competing” in triathlons (even if it’s only against themselves).

And yet. And yet.

I kinda want to know what I can do. What is it like to do three crazy things back-to-back-to-back? Could I be anywhere near “okay” at it?

That’s the damnable thing about triathlon: You can’t just go and find out without going “all in.”

sigh

Posted in Cycling, Reluctant Triathlete, Running, This is who we are | 1 Comment

Blunt Lancet Interview

Unless you’ve been living under a rock, you no doubt have heard about Blunt Lancet’s new album that’s set to drop soon. Thanks to some connections, I got an advance copy of the CD, which I’ve had on heavy rotation. The band’s A&R team is really pushing the group, even helping make a VH1 “Behind the Music” episode.

But I don’t think they’re too happy about a leaked Rolling Stone interview with “Lancer,” the band’s faithful roadie. Here’s the full, previously unpublished article with details of an (as yet) unknown tell-all book about the band.

Kenny Powers from 'Eastbound and Down'

Rolling Stone: Lancer, you’ve written a book called Logbook: My Life on the Road with Blunt Lancet

Lancer: You know, it was originally supposed to be called F**k the D-Police: It Takes a Nation of Millions to Hold our Blood Sugars Back.

RS: Really?! So how did it end up as —

L: Logbook? Yeah, I wasn’t too happy about that. I mean the band hates logbooks. But the lawyers made us do it, you know? Both Chuck D and Ice Cube threatened to sue. And if there’s one thing I wanna steer clear of, it’s that whole East Coast / West Coast bullsh*t.

RS: In your book, you reveal that the band had different names in the past, too. I think most die-hard fans know about the performances (and bootlegs) by “Dull Poker,” but what were some of the other names?

L: Yeah, there were about a dozen names the band used or considered. Most of them never came to anything, but we did produce a couple 45s under a couple of the names. [Conspiratorially] That’s something for you vinyl junkies out there to be on the lookout for.

RS: And what were some of those names?

L: Oh, right. Well, they tried “The Fab-104s” and “The BGs.”

That last one actually was the thing that got the band together, you know. We were all sitting around in Raw Sugar‘s basement when the BeeGees came on the “Hi Fi,” and we’re all thinking “We gotta check our blood sugar.” So Testkit, who was feeling a little hypo at the time pulls out a guitar and just starts riffin’ on “Stayin’ Alive.” And I’m thinking, “Hey, I think we really might have something here.”

RS: You tell in the book about the band’s troubled relationship with British heavy metal band Motörhead.

L: Tossers!

RS: Care to explain?

L: See, we were initially named “Blünt Lancet,” ’cause, ya know, it sounded really f**cking cool when Syringe would try to say it with his Aussie’s faux German accent. Anyway, we scrapped the umlaut because when we put the “U” with the dots on the drum kit — well, it just looked a bit too happy for the hardcore mood we were trying to set. That didn’t stop motherfü**ing Motörhead from using it. And “Ace of Spades?” PLEASE! We played those losers “A1Cs of Spades” one day, and they just totally ran with it. . . . “And don’t forget the poker. . . . Ace of Spades!”

RS: “Ace?”

L: Yeah, the “1″ is silent. What else do you wanna know, man?

RS: They’re not the only musicians you’ve feuded with in the past, though. Brian Eno, for example.

L: If you want to call that atmospheric stuff “music.” [pause] I see that you do.

It’s like this. The group is always up for switching it up. I mean we started punk/disco. Went country for a bit. Threw some R&B into a few albums. But all that “made for soundtrack music” that he wanted us to do was just dull as sh*t. I mean he’s a great producer, but I think he took the band’s name a little too seriously.

RS: Not to keep going on a sour note, but Motörhead wasn’t the only group that you “inspired.”

L: That’s right. Def Leppard pretty much stole “Pour Some Sugar on Me” from our B-side “I’m Low And I Need Some Juice.” That was something our (two-armed) drummer, Pancreas, said when we were on tour with them, and she wrote down the melody in the 15 minutes it took to rebound. That’s partly why it’s so ridiculous. People are always stealing our stuff.

RS: From time to time the results of working with other artists must be a little more positive. Any you want to share?

L: Well there was this one time we were all hanging out in the back of the bus with Carly Simon, and we were checking our BGs again, and Pumps was like “You’re all veins.” Carly was beside herself with joy. I don’t want to be too egotistical, but really that song is all about us. I got a writing credit on it, you know.

RS: Pumps?

L: F*******k! Backup singer — Sh*t! I swore I wasn’t going to say anything about that Fleetwood Mac-like period of the band. They were great times, but the drama. Both Pumps and Bumps were fighting over supplies and got busted by the D Police all the f**king time, man.

RS: Bumps?

L: Next question!

[We suspect that either "Pumps" or "Bumps" might be K2, the former lead singer of the on-again-off-again Insulin Whores Riot Grrrrl punk trio. — RS]

RS: When —

L: I don’t think I mentioned in the book that we got kicked out of East Germany. . . . We were playing some underground venues, but we overstayed our “diplomat” visas by a few hours. So they showed us to the border. We had to watch the wall come down from a bar in Frankfurt. It’s a shame. 24 hours later, and we might have been playing “Rage Bolus” from atop the wall.

We got kicked out of Tuscaloosa, too.

RS: So what’s next for the band?

L: Well, I’m just the roadie.

RS: Now you’re being modest.

L: Or maybe a bit coy. I don’t want to jinx anything. [Pause] We’re trying to get a bunch of bands together for SugaPalooza. The Insulin Whores, SugaSheen, George Simmons, . . . maybe even the alt/contemporary-classical group Langerhans Quartet. They’re hard to get. And weird, man.

RS: Motörhead?

L: Funny. Are we done here?

Posted in Diabetes, Historical Record, Life Lessons, Worthy Feeds | 7 Comments