A patient-centric health record

29 Dec

It´s not too late, even if Google has discontinued its offering and the status of MS Healthvault is a bit hazy, especially in Norway.

It´s not too early, either. Patience is running out.

The health record (pasientjournal) is a document which serves the needs of the health care professional (HCP). That´s how it came to be, and that´s how it is described in law. When you provide health care, you have to keep a record. It serves both to document your actions and deliberations, and to communicate with the next HCP. It is to a far lesser degree intended for the eyes of the patient. Let´s fast forward to today. While you´re sitting in the waiting room you´re googling the latest info, and most of the time, you are up to speed on the disease and your outlook. The world has changed.

But the health record (including lab results, images etc) are still kept and controlled by the health service. In Norway, where the public purse pays for most, but not all health care, the public sector creates solutions that serve to move records between HCPs, without involving the patient. The newish “kjernejournal” does little to change this. If a major piece of information is missing, you cannot add it without involving your GP.

What´s more, or worse, if you get treated by a private HCP, or abroad, you cannot add information. If you then observe, as most will, that the right hand (AHUS) has no idea what the left hand (OUS) is doing, you have to bridge the gap yourself by acting as a kind of paper-based records service: you carry with you a bunch of print-outs to make sure the different actors are coordinated. You are your own best doctor, patient-coordinator, etc etc. If you have kids: repeat.

The solution is to create a personal health record which is controlled by the patient. Sounds like MS Healthvault, really, and I must find out what the snag is with that.

More likely than not, the rub lies with the law:  you cannot collect information about a person´s health just like that. You need a legal grounding; for instance that you are offering health services as an authorised HCP; in short, you´re a doctor.

So how can someone who´s not offering health services (not-a-doctor) collect health information legally? I do not know yet, but I suspect the key lies with encrypting the data at rest. I will argue that a collection of random 1s and 0s are not health information.
Let´s put the burden of proof on our opponents: give them a few megabytes of encrypted data and make them prove that it is health data. If they can´t, how can they argue that is IS health data?

So here´s the proposal. The architecture comprises three parts:

  • Client
  • Security Provider
  • Health Record Provider

The Client is any application, web or “app” or otherwise. The Security Provider controls who and what gets access to information; this in turn is determined by the user, who may delegate access to others. Further, the Security Provider manages encryption keys. These are used to unlock the information stored by the Health Record Provider. The latter entity is legally separate from the Security Provider, and stores encrypted data that happen to be about a person´s health. The Health Record Provider does not have access to the encryption keys until these are provided by the Security Provider. The Health Record Provider has logic to store incoming information and to transform information for display and export. This means that any information being treated must be decrypted on-the-fly, and exist in-memory in clear-text. As soon as the session ends, the memory is purged and no personal information is available to the Health Record Provider or any of its staff. A sine-qua-non requirement in this context is the requirement that the Health Record Provider never persists the keys it receives from the Security Provider. The key will most likely be symmetric. We could envisage using a number of keys, of course.

Another sticky detail is the fine-grained authorisation of access. This function entails storing information about information, which is in itself information. In order to solve this, the metadata about a given role´s access must in itself be encrypted. One way to solve this would be to associate a given role with a specific key. The couple (role, key)  must be managed by the security provider and stored by it. When a given role is authenticated and routed to the Health Record Provider, the key will unlock metadata such as “Physio record”, and this will in turn be used to filter the information that is stored. In order to avoid having to decrypt the entire record, an index will be stored as part of the metadata, pointing to the relevant parts of the record. An important detail to solve is how to update the index when new information is added to the record, since this might require access to the “Physio”-key and all other keys.

In order to avoid “tapping” of data from the Health Record Provider, the code that this entity runs must be audited and signed, and only the signed code must be possible to run. The auditing must be carried out by a trusted third party, like DNV-GL or similar.

On might argue that this introduces a fourth element in the architecture, namely the software provider. The role of this entity is to provide software that is guaranteed to be “leak-proof”. Beyond this, it must be possible to guard against scanning of the memory of the application.

A lot of tech is required. At the end of the day, the importance of this system lies in its ability to treat information of many kinds, index it (one patient at a time; index must be encrypted also) and make it available in a very granular form to clients. As an example I may want to share my data about my foot with my physio, but not the rest of my record, and to allow the physio to upload relevant information about the treatment. I may also decide that I want to store some biological parameters in the solution and make these, but only these, available to researchers or to a commercial party.

Why go to all this trouble? Chiefly because today´s health service can only scale if we make the patient autonomous, and replace service by self-service, like the banks have done.

Gjer ein annan mann ei beine

23 Aug

Han kom or fjellet, skulde heim,
fekk føring ifrå Osa
ut til Øydvinstó.
Og han var raust og baud betal.

Men Osamannen
var ikkje fal:

Eg vil betala;
eg kan ikkje nå deg
med ei beine att.

So gjer ein annan mann
ei beine då,
sa Osamannen,
og skauv ifrå.

Olav H Hauge

Beine: tjeneste. Øydvinstó er en plass i Hardangerfjorden.

Sirolo Numana Loreto Recanati 2017

27 Jul

This summer we went to Sirolo and stayed in www.lanticomulino.it .

Sirolo is a small town or village about 20kms south of Ancona. What makes Sirolo and Numana interesting, is nature itself. South of Ancona a mountain rises to about 570m along the coast, known as the natural reserve of “Conero” . At the southern end of this natural reserve are the villages of Sirolo and Numana – and then the coast is flat again. What this means is that for a short while you get a very different, and much more interesting, coastline, with white cliffs falling straight to the sea, and a very narrow beach strip below, sometimes only reachable via the sea itself. Essentially, the scope for tourism is limited by the the narrow beaches and the lack of big hotels, so the area is never crowded, and the tourists are mainly Italians. Numana has a breakwater, so you can swim also on windy days.

The picture below is taken from a boat, and shows a beach which can only be reached by sea.


Whenever you want to get to the beach, you have to descend a steep road or track; but there are also public buses and in some places a “navetta” or shuttle-service, often in the shape of a white-painted Land Rover. Once you get there, you will find the usual Italian set-up: part of the beach is public, part of it private, and there you pay 15-20 Euros/day for a couple of sunbeds and a parasole. The sea is blue and transparent and warm.

In both Sirolo and Numana there are excellent restaurants specialising in fish. Our marks go to “La Taverna”, for its menu and friendly staff.

Then maybe you get into your hire car and drive to some of the medieval towns sitting on hill-tops in the immediate vicinity.

Recanati is famous for being the birthplace of Giacomo Leopardi, and also the place where he lived many years and wrote many of his poems – or at least, whence he drew inspiration for his poems. To get maximum benefit from Recanati, it helps to be familiar with Italian and with Leopardi….  the local Leopardi museum is a bit on the quaint side, but does contain his death-mask and the only portrait said to bear his likeness. You can visit the garden which is the key place in his (lovely) “L´Infinito”, the famous isolated hill (quest´ermo colle), but frankly, it´s a bit of a mess, a dilapidated garden. The view of the surrounding landscape is great, though, and that´s what inspired Giacomo. You can also visit his house, and the 20.000 volume library his father created.

Loreto is a place of pilgrimage. You will be absolutely astonished to find a huge monastery and a big basilica there, as a well as a busy trade in Catholic paraphernalia.

It´s an awe-inspiring place. It makes you feel small, and it makes you think, or even feel, all the suffering and longing that people have placed at the feet of the Madonna over the centuries.

The photo below shows the entrance to the basilica´s raison d´être, the sacred house. Well worth a visit in the afternoon, when you´re tired of the beach.


Here´s what I believe to be the German chapel in the same basilica:


Summing up: a very good place for an adult get-away. Ancona is reachable by train from Venice in 3 hours or so.


11 Jul

Her er liste over noe musikk jeg har et forhold til og anbefaler. Det handler kun om meg. Spotify-lenker der det trengs.

Titler med “fnutter” er enkeltsanger, ellers er det hele albumet.

Opera: (her ble det mye Puccini…)
Tosca: “Va Tosca” og “Lucevan le stelle”
Gianni Schicchi: “O mio babbino caro”
Turandot: “Nessun dorma” og “Non piangere Liú”

: Ein Deutsches Requiem, Otto Klemperer, Elisabeth Schwarzkopf, Fischer-Dieskau:

Bach: “Ehre sei dir, Gott, gesungen” fra Juleoratoriet: Peter Schreier og Rundfunkchor Leipzig.
(https://open.spotify.com/track/5tHU8QNYy0epHrH27VuFlz) (denne lenken funker ikke 100%, bla ned til del 5, No. 43 Ehre sei dir, Gott, gesungen)

Mozart: “Die königin der nacht”, f.eks. med Elisabeth Norberg-Schulz
(https://open.spotify.com/track/38gwrE0xxk2M9fx0mF6nu0) (spor 13)

Frank Martin: “Messe pour double choeur”. Dette er genial musikk.
https://open.spotify.com/track/6y3FlEUVwicL5DRI4YN0nL , f.eks. later til å være en OK innspilling! (Peter Dijkstra)

Grieg: Peer Gynt-suiten og “Fire salmer”

Pop og jazz og sånn
Miles Davis: Kind of blue og “Time after Time”, Sketches of Spain
Dire Straits: “Down to the waterline”,”Telegraph Road” og “Making Movies”
Pink Floyd: The Dark side of the moon, “Another Brick in the Wall ptII”, The Final Cut
Steely Dan: Aja og Gaucho (begge album)
Joni Mitchell: Hele hennes produksjon. Kun ett album?: Hejira. Eller Blue. Én låt? “A case of you” eller “Both sides now”
Bob Dylan: Infidels, og “Blind Willie McTell”, Live at Budokan
Neil Young: Harvest, Weld (live)
Bruce Springsteen: “The River”, “Factory”, “The promised land”, “Youngstown”, “Thunder Road”, “The Promised Land”, “Candy´s room”, “Independence day”, osv
Lillebjørn Nilsen: “Gategutt”, “God natt kjære Oslo”
Francesco de Gregori: “Rimmel”, “La leva calcistica del 68”, “Viaggi e miraggi”
U2: Under a blood red sky
Joy Division “Love will tear us apart”
Amy Winehouse “Back to black”
Elton John “Your song”, “Goodbye yellow brick road”
Michael Jackson “Beat it”
Whitney Houston “I will always love you”
Johnny Cash “Folsom prison blues” og “Sunday morning coming down”
Joan Baez “Prison trilogy”
Rickie Lee Jones “Chuck E´s in love”
The Beatles
David Bowie “Ashes to ashes” og “Space Oddity” og “Let´s dance”
Abba “The winner takes it all” og “Slipping through my fingers” og “Dancing Queen”
Queen “Bohemian Rhapsody”
“Alfonsin y el mar”, eks. https://open.spotify.com/track/2ed6hjsLkwjvXqe73olQCN
A-ha “Hunting high and low”
Nirvana “Smells like teen spirit”
Cock Robin “Just around the corner” – en av de beste popsangene, ever!
Maggie Reilly “Every time we touch”
Randy Crawford “You might need somebody”
Grover Washington Jr “Winelight”
George Duke “Prelude” fra Guardian of the Light (https://open.spotify.com/track/2Km6Z0cMr55jxVPcvOEm9m) samt “Reach out” fra samme album
Quincy JonesThe Dude (hele albumet)
Manu Dibango “Emma” med Salif Keita (hurra for Spotify!!) (https://open.spotify.com/track/1ltlkrZ2qV3JlCbdXNUa3N)
Marillion: “Kayleigh” ( og albumet den kommer fra )


Asics Super-Gel J33 / DS Trainer 23

27 Jun

*update June 2018: I find the DS Trainer 23 is a good replacement*

So Asics, you´ve discontinued this great shoe. Not good. I had to spend a lot of time in different shops. Loplabbet, where I got them, were no help at all. My request was simple: get me a replacement for these shoes. I switched to forefoot about 7 years ago and I have completed two half-marathons since then.

In the end, I was recommended Nike Lunartempo 2 at Oslo Sportslager. They share some characteristics, like a flat broad front, low drop, and moderate cushioning, key features I was looking for. I don´t like the squishy feel of the Nike foam in general, but here the sole is so thin it´s not an issue. In general I prefer the feel of ASICS, and will never forget my first pair, the Gel Lyte III, the one they made 25 years ago…

In June 2018 it was back to ASICS: DS Trainer 23.



14 Jun

Her kommer bilder av båten min, krumstevninga “Luna”. Den er bygget senvinter/vår 2017 av Kai Linde i Rognan, bygg nr. 98 fra hans båtbyggeri.
Les mer på kailinde.no og https://kailinde.no/2017/02/05/krumstevning-som-robat/

Luna er satt inn med Owatrol D1 og D2. Dette er ikke i henhold til tradisjonen, som tilsier linolje og så en dash med furutjære. Men jeg ville ha Owatrol. Sammen med furu gir dette en flott effekt. Pyntestripene er malt med Jotuns Shipolin. Fargene grønn og rød har disse fargekodene: ( … )
Luna er bygget med galvanisert stålsøm, og altså ikke med kobberklink

Under vannlinjen er båten primet med en vannbasert primer fra Jotun, og dernest har den fått hvitt nonstop bunnstoff fra Jotun.

Her er Luna før lakk og maling:


Sjøsetting på Sørlandet, 16. juni 2017.



Akershus slottskirke mai 2017

31 May

Så ble det konsert igjen med Asker kammerkor, dirigent Birger Egge-Hoveid.

Siste uken var preget av at musikken kvernet i hodet – neppe konstant – men som en stadig tilstedeværelse. Det var noen fraser som gikk igjen. Hvad est du dog skjøn.

Følelsen minner om den jeg har før en halvmaraton. Energien retter seg inn mot det som skal skje. Helsen overvåkes – hvordan er halsen? Fikk jeg for mye vind på meg i dag? Marerittet er å bli forkjølet. Som den gangen stemmen nesten forsvant dagen før H-moll messa. Spis et eple, sa Birger. Kanskje det var placebo, men det hjalp på sitt vis.


Ønsket om å prestere er sterkt, ikke misse, falle ut.

Koroppstillingen er så krevende som den kan få blitt. Vi står spredt, mine nærmeste er en alt (kjempegod) og en sopran (kjempegod). Men akkurat nå hører jeg ingen tenorer, og da er det som å synge i en kvartett. Alt jeg gjør avhenger kun av meg. Ingen å støtte meg på, må kunne alt. I gruppevis oppstilling kan den halte hjelpe den blinde. Og feilene kan fordeles, så vi henter oss inn sammen. Og det er nesten alltid én på stemmegruppen som er stø som et fjell.

I tillegg skulle slottskirken varte opp med en besynderlig akustikk der det var umulig å høre annet enn egen stemme, samt naboens. Det var litt som å synge inn i vatt, og det gjør det også vanskelig å vurdere volumet, pådraget. Man skal jo helst ikke stå der og skrike.

Så kom kvelden, en fuktig junikveld, junivått og junigrønt og junilyst. Man sover for lite og går rundt i en døs, en drøm.

Kirken er mer som et kapell, 170 plasser, sies det. Nedtonet interiør, langvegger av murstein. Kanskje bygget til annet bruk? Prekestolen er bygget inn i en nisje oppe på veggen. Stoler med fire kroner på, dog ikke med trekk av gyldenlær. Det skulle tatt seg ut.

Generalprøven var forferdelig. Toner og rytme satt ikke, lokalet var merkelig. Dirigenten holdt humøret oppe og viste til den gamle devisen om at dersom generalprøven går dårlig, går konserten bra, og omvendt.

Ola Gjeilo ”Northern Lights” var åpningsnummeret: Tota pulchra es. Bjørk, Distler, Brahms, Gjeilo igjen, med Griegs fire salmer som høydepunktet. Stjernebaryton Halvor Melien Fostervoll  behersket folketone-tonaliteten; takk for at du kom!

Synge konsert er noe eget. På sitt beste er det en transelignende tilstand. Vi var innom det beste under Grieg-salmene. Det å synge uten noter flytter det over i en annen dimensjon. Minner litt om å bade naken – frihetsfølelsen, intimiteten. Det ble noen feilslag. Men totaliteten gavnet på det. Det var ganske elektrisk til tider.

Publikum var fornøyd, dirigenten var fornøyd, koret var fornøyd.

Så var det over, og ute lå junifuktigheten over byen, øredøvende grønn.