DrChrono (YC W11) Makes The iPad A Doctor's Best Friend In The Exam Room - <AUTHOR> http://techcrunch.com/2011/02/23/drchrono-makes-the-ipad-a-doctors-best-friend-in-the-exam-room/

<comment><USER2> Good luck with this one. After spending a couple of years working on something like this, I found the following:

      1) A majority of doctors are in small private practices
         that reinvent the wheel of how they run their practice.

      2) All of these doctors are extremely pressed for time
         and are practically _always_ behind schedule.

#1 means you need to build heavily-configurable software, and #2 means the doctors don't have the time or energy to learn and configure your software. At best you can get the practice managers to force it down the doctor's throats, which doesn't exactly help either.

Record keeping is to doctors like text editors is to us hackers. Imagine if a doctor had built your text editor; They're probably very smart and energetic, but they don't _really_ understand your problem and how much you personally need specific things _just so_.

<comment><USER3> My guess is that this is more targeted to the "hip" crowd among MDs who embrace this sort of thing (of which there are quite a few).

<comment><USER4> Over 120,000 doctors in the US own an iPad and doctors (even non-"hip" ones) get immediately that the iPad is the ideal platform to use in the examroom.

<comment><USER5> iPad is not the best. Massive, rapid text entry on an iPad sucks. I took an iPad and a cr48 to the a big orthopaedics conference last week, and the cr48 was the hands down winner, using nothing but qemacs. Fundamentally, on the ipad, character recognition or dictation would be best, but I can barely read my own writing sometimes! The iPad would be a lot better if the input precision was as good as the output resolution. If you've tried any drawing apps on these things, you know what I mean. Wacom tablets have much better input precision, or at least they seem to. I want Pilot G-2 0.5 mm black speed, precision, and reliability. Right now only a keyboard comes close.

<comment><USER4> We are very close to launching an integrated clinical speech to text product in our iPad application that should remove the need for most typing!

<comment><USER5> Dictating the note would be huge.

</comment></comment></comment></comment></comment></comment><comment><USER6> This is probably a solid idea (I have a friend working on a similar app) but I've gotta say, the user interface looks horrendous. Form fields slapped anywhere, nothing is aligned with anything else, the sizes of UI elements are all over the place so there's no visual hierarchy, it looks incredibly amateurish.

I know that for an app like this doctors are probably looking at functionality first, but it'd be nice if one of the first iPad apps in this niche actually looked decent. Right now it looks like Interface Builder exploded.

<comment><USER4> Wait, interface builder isn't supposed to explode when you use it?

We are releasing a new version of our iPad application roughly once a month and we are always working on making it better. I think we have a better UI than any other medical company out there, but that isn't hard! It is like playing basketball against Junior High School kids.

If you know a designer who could help us email me and put me in touch with them as we are rapidly expanding the company!

</comment></comment><comment><USER7> I just finished a large project for a healthcare company in Canada. I wish the drchrono team the best of luck. Here are some pointers to watch out for in the healthcare industry.

1\. Doctors can be extremely cheap. I had to port over a legacy dial up system because the doctors would refuse to upgrade to high-speed.

2\. The entire industry, at least here in Canada is ass backwards. It takes ten people to do a single task. You will run into having painstaking long conference calls

3\. Multiple standards. Every provider has there own standard that sometimes overlap.

4\. Older doctors barely know how to use a cell phone, let alone an iPad. Luckily these doctors are fading out fast.

5\. Market to the secretaries. They will pitch to the doctors anything to make their life easier.

Good luck guys....hit me up if you have anymore questions.

</comment><comment><USER8> I work with electronic medical records on the research side, integrating clinical patient data with medical research and clinical trials. However, I work with a large teaching hospital rather than small practices.

A home run offering for our environment would include a migration path for data from years (and many thousands of patient's data) currently in a patched- together system with 40 years of duct tape holding it all together. Top it off with a massive dose of free text data fields (so no easy field extraction) and you're looking at a huge custom effort to pull it off.

But . . . I think there is room here for something that does something nice with machine learning and NLP. Some folks looking into this have found that even free text in path reports contains a significant amount of exploitable structure from a data mining perspective.

And once you solve the migration, you'll have to go around the heavily entrenched IT groups holding the duct tape. But, it would be a big win for patients and most physicians are looking for a better solution . . .

<comment><USER5> >you'll have to go around the heavily entrenched IT groups

The fattest IT guy I ever saw worked database administration for a university hospital. He had his own elevator to his own floor of the building, and you needed a key to get on the elevator! In 2009 that hospital was still using meditech, and still using it on dedicated terminals with orange monochrome CRTs.

</comment></comment><comment><USER9> I'm a physician. I would love to hear about you implemented HIPAA compliance for both the iOS app and for the web service. I think it is a huge problem for any healthcare startup with potentially serious penalties (even criminal!) for mis-implementation. It is a serious third rail.

<comment><USER5> I'm a physician too. I would definitely be interested in this also. However, having developed a web app in med school, my experience was the HIPAA security rule is pretty weakly specified compared to credit card auditing. PGP is specifically mentioned as a best practice last I read, and plain fax in the same rank of good enough. Seriously, you're relying on an underfunded agency with a distinct lack of crypto expertise for auditing. Compare that to, say, FIPS and other serious requirements that NIST manages.

Meanwhile, I have seen IT departments sell physicians on obviously flawed security products, mainly because few physicians have any idea of what crypto is, let alone could they explain the most basic ideas. And frankly, they are not competent to even hire competent IT people. Whole university systems seem have this problem.

<comment><USER9> I think the requirements are fairly nebulous at best and mostly aimed at documenting your practices for access, and (god-forbid) breach/compromise. I think that you are covered if you cover these things in you operating procedures, but that is just from my own cursory research.

I'm mostly curious about the web stack and technical implementation:

* Encryption in transit (SSL) and at rest (whole-database encryption versus field-specific encryption)

* Select auditing (and performance thereof)

* Open-source stack?

I'm a pathologist so I'm primarily interested in interfacing with existing LIS (lab info systems). I'd like to pursue efficiency solutions for the laboratory (like dashboards, specimen tracking, lab ordering, intra-lab communication).

Of course, it's all moot with respect to my day-job because I work for the military and they mostly piss on open-source (MS all the way!) with no real path for putting applications on NIPRnet (yes even at the hospitals) without enterprise-level support and multi-level security audit/approval. Which explains why in the age of digital pathology, we are stuck entering pathology information over ssh (terminal emulation) into a MUMPS system.

<comment><USER5> Here's the combined rules. The security rule starts on page 38.

[http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyr...](http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf)

>they mostly piss on open source

At the top, they guys with stars who sign off the contracts, yes. On the other hand, I was just on the phone yesterday with a Navy cryptographer who is working with Google on NIST certification of Mozilla's Network Security System (NSS) for FIPS 140-2 compliance. I think getting the network changed will ultimately come down to smart people like yourself continuing to beat the drum.

BTW, I'm military too! I know CHCS and AHLTA all too well. email me: niels.olson at gmail

</comment></comment></comment></comment><comment><USER10> Speaking as a _patient_ , I've vastly preferred my visits to doctors who had a laptop with an inverted touch screen. Fewer questions about what was already in my (occasionally quite large) medical history - they could find it. Access to the relevant info like X-rays or blood tests, with more information than printouts carry, and adjustable contrast on digital X-rays. And the full history of _every_ similar test I've ever had. My visits have been faster and far more useful _every single time_.

Bring on the tech! I'm tired of having doctor visits where I have to re-state my history when they can read it in a second, and they're tired of lengthy reviewing of my data before the visit (if they do so at all). The only complaint I've heard from the doctors / nurses (and I've asked every single one I've encountered with them) is that they hate using a pen and hate the interface (missing the maximize button and closing the application, for instance).

The nurses in particular loved that the doctors _typed_. Universally, they've said they had fewer medication errors, fewer "what is that?" questions for the doctors, and they get a bit of history and can see abnormal changes and question them in case of a mis-type. Which happens, but usually goes unnoticed if it's not on a computer.

YMMV, of course. And theirs.

Billing and medical: why do they belong together? I doubt the doctor is also the accountant in even the smallest clinic, and they have no need to see the information. It's more noise, doesn't help them, and can influence their perception of the patient in front of them.

<comment><USER11> The tech has been around for years, the hard problem is getting the doctors to actually use the tech. The doctor I used to go to seemed to have no idea who I was I why I was there every time I showed up for an appointment, despite the fact that there was a perfectly good computer standing on his desk where he could quickly have looked up everything he needed to know.

</comment></comment><comment><USER12> Personally I am pleased to see more of an effort being made of late with advancing health care technology. It's a fact - doctors are using the iPad. I see more and more of them in the hospital. I'm not certain whether this will lead to widespread adoption or is just a novelty. In our hospital you can use the iPad to first log into the hospitals Windows based network, then log into HMS, which only works with Internet Explorer. Given how tedious a process this is, and to perform order entry using this technique, to me doesn't seem like its going to last long. I'm thinking a 11" MBA would come in more handy.

In the office, tablets should be used to review patient data, but the physician should probably not be entering any data - such as writing up the progress note or billing - while in the exam room. This takes away from the physician patient relationship. So to review data, tablets can be helpful, but are not exactly revolutionary. Real changes in how healthcare is delivered will be determined by how data is collected and how it is interpreted (like the Crimson Initiative).

Still, considering that EMR systems like AllScripts are charging over $600 a month PER physician (and that's at a "special" discounted rate for a few years), it's nice to see companies like DrChrono taking a stab at it, to see if they can offer something better, or equally compelling, for a cheaper price. A lot of existing EMR systems are bloated with features that most physicians will never use, and don't even really fully understand.

</comment><comment><USER13> I'm interested in learning how DrChrono is planning to market to physicians.

I personally think DrChrono is going for a diminishing slice of the healthcare pie. The current trend in healthcare is that a decreasing proportion of physicians are working in small private practices - the cost of healthcare infrastructure, logistics, and billings means large practices and hospital based have significant savings on scale and tremendous bargaining power with insurance and etc. This kind of app, with the appointment scheduler and prescription system, seems very much geared to small private practices.

I imagine this kind of system will make limited leeway in large healthcare practices and large academic institutions - this is the difference between enterprise software and web applications. Epic and the like, despite being aesthetically unpleasing and rather cumbersome, is dominating this segment of the market. It's not even a question of cost - these solutions cost much more than competitors, but there is a perceived level of stability and a proven track-record. In both culture and priorities, I think YC companies are not as well prepared to offer enterprise solutions. Large institutions are fickle, full of politics, and without a dedicated sales team, difficult to sell to.

They are definitely going for the "meaningful use" incentives as part of healthcare reform - the healthcare reform gives physicians incentives to adopt an EHR (electronic health record) system and going for the sex appeal of using ipads - but I am wondering if that is enough incentive to adopt an electronic health system. Personally, I type 1000x faster on a keyboard than with an iPad, and speed would be an consideration - ie. even as a physician-in- training (hypothetically with comfort in technology), I would have to look hard to decide whether to use such a system.

As a medical student, don't think there is enough of an market for general primary care physicians and not enough specificity (currently) to most subspecialities. There are a lot of older physicians that have limited comfort in medicine. I would imagine there is a good market for concierge medicine practices - the kind of places that already have iPads and are interested in distinguishing themselves from the market.

<comment><USER4> Most US private practice healthcare providers (roughly 80%) practice in small groups of 1-5 physicians. That is our target market and still the way that the majority of personal healthcare is delivered in the US!

There is a multi-billion dollar per year market in selling EHR services to the private practice doctors we all see everyday.

Large hospital level systems are designed for hospital admins 1st, doctors 2nd; they are widely hated even in hospitals and unusable in a small practice.

We are launching a speech to text integrated product in the coming few weeks that will remove the need for most typing on the iPad.

<comment><USER13> "The percentage of U.S. physicians who own their own practice has been declining at an annual rate of approximately 2% for at least the past 25 years."

<http://www.nejm.org/doi/full/10.1056/NEJMp0808076>

Most numbers I have see range from 50-60% in small to solo practice, while I would argue that this is a lagging indicator - a lot of older physicians are in solo practice and seeking to pass on their patient panel. It might be more interesting to see where current residents are going after graduation. That said, there is still a large market and I think it's definitely something that should be pursued. Good luck!

</comment></comment></comment><comment><USER14> So what happens when Apple pulls this app for $arbitrary_reason? Are your medical records gone?

<comment><USER4> The iPad is a front end for <https://drchrono.com> which is a full SaaS product in its own right to manage all of the backend of the doctor's office.

We have a really good relationship with Apple, and we are one of the killer apps that make doctors go out and buy iPads. We launched on the iPad initially within a month of its release and work closely with Apple to make sure we comply with security and Apple standards.

So it is unlikely Apple will yank our app. We do have an Android phone application frontend and we can invest more in Android tablets as they evolve in the future.

<comment><USER15> What about their recent changes to billing models? Do the doctors pay your $99 fee through the iPad's in app purchasing?

</comment></comment></comment><comment><USER16> It seems as though people may not know what exactly goes on in an exam room, and how exactly is the one taking notes. Often, especially with specialists, there's an MA or RN taking notes. Note only that, but this seems vastly superior to digging through a pile of charts or working with an ungainly EMR system.

The market has been BEGGING for this, and this looks like it might be the right answer. Good luck!

</comment><comment><USER17> The idea of doctors using iPads scares me; I know plenty of people who make casual typos with numbers on the iPhone or iPad as it is -- the last place I want someone doing that is in a hospital or doctor's office.

<comment><USER4> You bring up a really good point. Moving to electronic systems has both huge benefits and some risks that have to be mitigated.

An example of a huge electronic benefit you can't get on paper charts is drug interactions. drchrono can automatically check drug interactions and warn the Doctor in realtime based on latest available clinical information and drug warnings. My parents take 20+ prescription and non-prescription drugs each, there is no way even a genius Physician would be able to process that number of associations at first glance of a paper chart.

The risk of misentered information being accepted as factual because the computer presents all information in the same way is a very real risk that has to be addressed and have safety nets put in place to scrub and check for these errors. One cool way we are tackling this problem is launching an industry leading speech to text processing system in the coming weeks. Letting Doctors record their notes and have an automated transcription can give a safety net for errors.

<comment><USER17> What about a number interface -- hit a button to bring up an oversized numeric pad?

</comment></comment></comment><comment><USER18> Three years ago when we took my daughter to her first pediatrician appointment, the doctor brought a laptop into the examining room with her. The doctor barely looked at my kid. She just sat there typing away looking at her machine. In my mind technology had become a barrier to the doctor/patient (parent) relationship. It was very frustrating. But, there were many things frustrating about that Dr. so it could have just been her. We quickly found a much better one.

So, maybe you should design the interface good enough that docs want to use it but not too good that they use it all the time. Or you can put some alerts in there so that when the doc has been watching too many videos, it reminds them to look at the patient..... just kidding....

</comment><comment><USER19> I wonder if having an Ipad-enabled EHR system will be a compelling enough proposition to migrate practitioners from existing experienced vendors with a track record. I would imagine if you already have a system, even if it is an old expensive legacy system, you would not switch simply because of an IPad enabled device.

Even if there are other benefits associated with it such as being SaaS-based and cheaper/more secure, the conversion rates I would think would be low when there already exists free cloud based solutions and open-source solutions which they haven't already converted to already.

Thus, this makes me think the target market would be the pen & paper crowd. I'm curious to see what the conversion rate is for this crowd since this seems like a tough crowd to convince.

Even in scenarios where the EMR/EHR system is completely free (either through pricing plans or government grants) you don't see many of them moving away from the pen & paper which signals price might not be the most important factor here either.

To me this leaves overall usability and learning curve which I'm not sure if DrChrono necessarily promotes as their pitch seems to be portability.

I'd like to see how their product matures to tackle that issue since in my opinion their competitors really aren't other EHR vendors as much as the huge pen & paper market that's a much larger share of the pie.

</comment><comment><USER20> My girlfriend does some admin work at a hospital that uses meditech software, seems like the kind of old bulky enterprise software startups are trying to replace. It covers a lot of areas in hospital admin as far as I know, more than just the doctors interactions with patients. I have mnetioned it would be great for doctors to take out the middle man and use things like ipads so this seems great for that.

Just wondering if you have thought about integrating into the big bulky industry standard type software? (of course I could be off on what most hospitals use, sample size of 1)

</comment><comment><USER21> That's another "burning platform" in a week from YC (the other one was that fax-in-a-browser thing). The correct solution to this kind of problem is government backed centralized system. Like in Estonia: <http://eng.e-tervis.ee/overview.html> . Sooner or later all countries will have this kind of solutions in place and sadly, DrChrono will die..

<comment><USER22> The growth of the internet was impeded by a government backed centralized service in France, it was called Minitel.

Centralized planning never has and never will work as well as a decentralized market driven system where the best ideas can rise to the top.

Dr Chrono may have its drawbacks, but I'd rather see my physician make that call instead of some over-age government bureaucrat.

<comment><USER21> It works that way in Estonia, that all the doctors are _forced_ to use that system, which results to a wonderful thing where _every_ doctor has access to _all_ data there is about you - so when you lie unconcius on the street, 911 knows all your allergies, illnesses and treatments etc in that second.

</comment></comment></comment><comment><USER23> I worked on an EMR app for a while and DrChrono feels very childish. HIPAA compliance seems like a back seat at this point instead of first priority.

Maybe a dr would pay $99, but the first HIPAA lawsuit they are going to spend $99,000+ defending all due to software.

I also have to admit that DrChrono reminds me of Dr Mario Nintendo game..

</comment><comment><USER24> I really don't like your UI, but on another note, Jay Parkinson is the guy you should seek out and ask for advice. He's probably _the_ go-to guy in innovating health sector tech.

<http://jayparkinsonmd.com/>

<comment><USER4> We actually have a quote from Jay Parkinson about us on our homepage! Constantly improving the application (including the UI) is our company's mantra.

<comment><USER25> i think your ipad emr is a great start to the mobile emr space. and jay is the man! looking fwd to seeing drchrono grow.

</comment></comment></comment><comment><USER26> I don't know anything about this industry, but the UI looks stunning.

<comment><USER27> The UI looks like a HIPAA violation as soon as the Katelyn can see that Boris is in Exam Room 3.

<comment><USER14> I'm also a little uncomfortable with having my balance due more visible to my doctor than what my medical problems are. Doctors should deal with medicine, office clerks should deal with the balance due. Having emotional information like money on the info screen can adversely affect the emotional doctor/patient relationship in a way that's completely unnecessary.

Fucking programmers.

<comment><USER4> There is a clear divide between the clinical tools on the iPad and practice management (medical billing and invoicing) tools for Doctors.

<comment><USER28> Not in the screenshot TechCrunch is using to illustrate their article there's not.

<comment><USER27> It appears that it may be two screen shots in landscape mode.

</comment></comment></comment></comment></comment></comment><comment><USER29> how is this better than the existing computer systems doctors use? (It's on a iPad doesn't cut it IMHO)

<comment><USER4> Being on the iPad is a huge win since the Doctor won't have their back turned to the patient while using the system. The base EHR (Electronic Health Record) system is also FREE and a doctor can start using it right after downloading the free App from iTunes.

Our price point for advanced features and integrated billing is also better than any competitor, $199/month to do all of a Doctors medical billing will save a Doctor thousands of dollars a year (in addition to EMR incentives!)

<comment><USER29> Back turned? :/ Over here (UK) there's a desk, in a corner, with a chair next to it. The doc sits at the desk, using the computer, facing you sitting on the chair to the side.

Works pretty well for doctors surgeries anyway.

But I have no idea how things work in the US so maybe it's completely different.

<comment><USER4> Several clinical studies have shown that patients will have better healthcare outcomes if their doctors make eye contact with them. One of the reasons I co- founded drchrono was because I went to a lot of doctor visits with my Father when he was ill and sat through countless appointments where the doctor spent 10 minutes talking to us over their shoulder.

Computers are always an afterthought in most Doctor office setups, that is why they seem to be universally built into walls or tucked away into corners.

<comment><USER5> I applaud your effort. I think dictation is going to be crucial. Keep pushing!

</comment></comment></comment></comment></comment><comment><USER30> I understand the motivation for these applications, but anything that, in a room with a patient, takes one away from interacting with the patient has drawbacks. A lot of docs are taught NOT to use this kind of device in the room. Even burying your nose in the patient's chart, of course, is problematic. Using it outside may have its advantages, but in the room it's ideally two humans and not much between them.

And if you'll forgive me, I have a hard time believing an app like this will drive pad adoption by physicians. Most docs have pads because, well, they just like toys.

Some docs have used laptops, which are a lot easier for data entry than these pads, and these don't require turning away from the patient either. In my experience, it's not common for physicians to write their progress notes in the room with the patient. Certainly writing a prescription and sending that to a pharmacy directly makes sense in the room, but there are classes of prescriptions where that cannot be done. Looking up drug interactions may be useful, but dedicated applications like eProcrates and other dedicated apps probably have become standard for that and I'm not sure I'd trust an "everything and the kitchen sink" app like this more than dedicated solutions (eg, these drug interaction databases require constant updating and care).

Billing info and medical data combined on a view is a no-go, if that's there. They don't belong together. Period.

Probably most importantly, most of us would need details about security of the transmission and storage of medical records before considering this at all. Someone said below this app is "HIPAA compliant", but I'm leery of that overused phrase because the HIPAA requirements are quite vague, and as far as I know there is no actual certification for something like HIPAA compliance. Vague claims of "HIPAA compliance" are likely NOT going to impress or satisfy juries and medical licensing boards. In addition, some information (depending on the state) requires more stringent care; for example, mental health records, record of drug abuse/dependence, etc. Hospitals and clinics typically have dedicated IT departments who put into place much more security than HIPAA requires. If someone hacks a system like this, the fact that you require passwords and do some encryption is not going to cut it if you can't demonstrate you are using standard of practice medical record security measures.

Specifically, many physicians would want to know, at a minimum, complete details for:

\- backup, recovery, and retention policies for all data.

\- logging mechanisms in place to track access and change of data. By "access" tracking, I mean a record of every last living creature who _views_ the data, at any time, for any reason, and that includes everyone at "DrChrono", the employees of any firms that manage their servers, etc.

\- audit mechanisms and schedules.

\- policies Yet Another Third Party ("DrChrono") would have in response to subpoenas, direct request from patients for their medical records, requests from insurance companies, etc.

<comment><USER5> This comment deserves a lot of up votes.

<comment><USER10> I think this is the most ironic thing I've seen in the past year.

</comment></comment></comment><comment><USER31> this is revolutionary...wow.

</comment><comment><USER32> Company launches practice management software. Film at 11.

<comment><USER33> Wow, it's almost as if we weren't on a social news site catered toward companies and their launching products.

<comment><USER32> Living in Nashville, a healthcare center, and having personally seen >100 million dollars blown by healthcare startups, have made me very cynical. HCA is about to "go public" again making the Frist family another 15 million dollars while healthcare informatics continually gets underinvestment and underdevelopment. An iPad app isn't what healthcare IT needs. A drastic smashing of the legacy of MUMPS and overgrown piss poor legacy solutions will require a large health crisis, with opportunities blown due to bad processes and bad systems.</comment></comment></comment>


Drug giants Novartis and Bayer fail to stop NHS offering cheaper eye treatment - cirrus-clouds https://www.bbc.co.uk/news/health-45588983 <comment><AUTHOR> Where I live doctors are only allowed to give prescriptions for the generic chemical compound and are forbidden to give prescriptions for specific brands. They may suggest the use of a particular brand if they know of a benefit over others but the one who decides is the patient. Of course this is not very useful when the drug is patented or if there is only one laboratory producing it, but none the less it seems like a sane default. And this is in a private healthcare system, it is surprising that the NHS doesn't have a rule like this when is their taxpayer's money being used.

<comment><USER2> The cheaper alternative that the NHS wants to offer is not actually the same as the more expensive drug that's licensed to treat wet age-related macular degeneration. It's related and there's every reason to believe it's as safe and effective as the licensed drug, but it's still not the same stuff.

<comment><USER3> The cheaper one is 3.5% and 5% the price of the other two and is recommended by WHO and used widely around the world, including the US. As always the decision as to what will be appropriate will lie with the doctor but at least they have the option now.

I expect that the price of the other two will mysteriously drop quite dramatically now ...

<comment><USER4> Yes but there's 2 issues:

1) not in the same concentration/dose (patient will need to change the dose by breaking pills)

2) not according to the UK government (which has never approved the cheaper drug)

So now the big question is, suppose this goes very wrong for a patient, who is responsible ? The doctor ? The patient ? The government ?

<comment><USER5> >1) not in the same concentration/dose (patient will need to change the dose by breaking pills)

Specifically I don't think they are using pills (untouched or broken) to make intraocular injections.

</comment></comment></comment></comment></comment><comment><USER6> I don't understand their arguments. Do they have proof that their licensed drugs are safer and/or more effective than the replacement?

The article says "In January, the National Institute for Health and Care Excellence (NICE) concluded that Avastin was as safe and effective as the two licensed drugs, Lucentis and Eylea."

If they have no proof, they should stfu.

<comment><USER4> No. The issue is different. You see, the government demands drugs are proven to be safe before use, and safe for specific purposes, specific treatments.

Now I say "demands" because the government does zero research on the subject, zero testing. Rather, the government demands that the pharmaceutical companies do this, at great expense, by third parties, extensively regulated, involving at least hundreds of UK patients, ... a total maze (that somehow seems to provide excellent, HIGHLY paid jobs for ex-government regulatory doctors in these pharmaceutical companies). Also, this has to be done on a per-country basis.

Now there was an issue. These companies had done that for one drug for this specific treatment, this was the more expensive drug. They hadn't done it for the "cheaper" alternative they used elsewhere in the world for that treatment, but that drug was being used for another treatment. Note: this makes it highly illegal for these companies to suggest using that drug.

(so the accusation made that these companies were preventing the use of the cheaper drug is ... evil. I don't know another word for it. They refused to allow prescription of that drug for the eye problem _because the government forces them to refuse that_. And now the government also decided it's illegal as well. Great. If we're unlucky they'll just withdraw the drug altogether. Then eye and cancer patients are fucked, but hey, the government won't have to pay. Hurray !)

Also cheaper is between quotes because it's only cheaper because they never went through the governments' expensive approval process, which would have added to the cost and therefore changed the picture. Furthermore it would have factored in the pricing decisions made by the companies.

So now we have established that the government gets to completely disregard it's own safety rules to save a buck (no worries "it's safe" because it's proven to be safe elsewhere with a differently manufactured pill with the same active substance ... except ... no it isn't, or at least, you can't be sure). And if, for some reason, there is a difference between the drug when using it for cancer and using it for eye treatment ... who will pay for the damage caused to patients ? Because does this now also mean the government assumes responsibility for this drug (which they did in the past (not for this drug), then when it cost them money ...).

The issue with drugs "having issues" is that generally patients die or develop a very serious health issue when drugs have unanticipated side effects. This whole safety regulation is setup to avoid that and to make sure pharmaceutical companies never take too much risk, and can be forced to carry the cost of fucking up.

Note: this is an example of the UK government "taking responsibility" for it's own medical fuckups: [https://www.bbc.com/news/uk-england- birmingham-45101091](https://www.bbc.com/news/uk-england-birmingham-45101091)

I would argue that even if this turns out to be safe, sooner or later letting the government just bypass drug safety rules will cause very severe issues (or should I say, will cause very severe issues _again_ ), and then these people are going to find out that not only does the government not take care of them ... well ... read the above link and then read the next paragraph:

> In October 1979, three judges at Birmingham Magistrates' Court dismissed the > prosecution's evidence that the University of Birmingham had contravened the > Health and Safety at Work Act.

(Just so we're clear, at this point it was clear that the government had not only failed to provide adequate isolation to a lethal disease, but gotten a report that it had failed to do so BEFORE any actual harm, THEN the government lab accidentally infected someone working above the laboratory, imprisoned her and most of her family and colleagues immediately (with zero compensation), ... and then decided the government had zero culpability in all this. Why ? Because it was impossible that this woman was infected with a lethal disease that didn't exist anywhere in the country except in that lab, but she had not gotten it from that lab, so ... no compensation ... yes, really. To add extreme insult to very severe injury and death, the queen granted honors to the witness that exonerated the government later that year ...

So to say that I don't think the UK government should be trusted to make medical decisions like this is a vast understatement. We are all going to die)

</comment></comment><comment><USER7> Suddenly drug companies don't want off-label use when it doesn't suit them...

</comment><comment><USER8> This debate has happened in the US for many years. Here is a wsj article from 2011 [https://www.wsj.com/articles/SB10001424052748704463804576291...](https://www.wsj.com/articles/SB10001424052748704463804576291572903925578)</comment>


Details on EVE Online's server infrastructure - <AUTHOR> http://www.eveonline.com/devblog.asp?a=blog&bid=769

<comment><USER2> EVE has a single instance world which is a much more difficult problem than what WOW has to deal with. WOW basically caps the total amount of people that can be in one instance (or at least they used to, haven't played in a few years).

It kinda boils down to a massive supercomputer simulation where your limiting factor is the speed, but more specifically latency of communication between servers. Notice how this upgrade brings them far greater internal networking capabilities which should mitigate performance pressure from growth for the time being.

If you look at their hardware you can kinda glimpse how their software stack might function:

TQ Tech Details: (Not the whole system, just what runs TQ)

Servers 64 x IBM HS21 2x Dual Core 3.33GHz CPU's 32GB of RAM Each 1x72GB HDD Each

                    2 x IBM X3850 M2's
                    2x Six Core 2.66GHz
                    128GB of RAM
                    4 x 146GB HDD

Cores \- 280 total Cores \- ~1 THz

RAM \- 2.3TB of Total RAM

Storage \- 4.8TB of Local Storage \- 2TB of SSD SAN \- 256GB of RAM SAN

Network \- Gigabit Ethernet \- 4Gb/s Fiber Channel

<comment><USER3> The WOW dungeons are instanced but the worlds aren't - in WOTLK there used to be a major problem with the new World Battleground (Wintergrasp) where hundreds of players would be playing in it at once and the entire zone would become unusable. Eventually they fixed that by instancing it.

<comment><USER4> WoW uses Shards to split the game world into several servers and then Instances to split off players from each Shard. Eve does the same thing with missions but only has one Shard.

The difference is if you meet a Eve player in real life your characters can meet in game, but in WoW it's unlikely for two random people to play on the same shard/server.

<comment><USER5> The game design makes that much easier to do. WoW has 4 continents with no loading screen (except for moving into instanced dungeons or battlegrounds) on each continent. By contrast, EVE is split into several thousand star systems. So while WoW has to put each continent on its own server, EVE can be as granular as to put each star system on its own server (though they usually use virtualization to run dozens of systems on one machine).

That's why WoW has to be sharded - each shard can only be split into 4 servers, whereas EVE naturally splits up by solar system.

<comment><USER4> It might look that way to a player, but if everyone on a continent moved to the same zone the game does crash. Also, you can't drag a mob vary far from its home area.

On the client side loading screens had more to do with loading textures for each zone to your graphics card than they did with handing off your character from one server to the next. You might not see a loading screen but if you gate home they still show you as the textures are loaded.

</comment></comment></comment></comment></comment><comment><USER3> Gotta hand it to MMOs when it comes to architecture - they have some very unique problems to deal with. Sending media-heavy data back to a number of widely dispersed clients in real time has to take the cake in my book, not to mention continuously writing that same data back onto a database (you log in the same place as you logged out, don't you?)

I'd imagine the media messages they send to clients are a continuous broadcast of 3D coordinates and audio processing signals for player characters but I honestly have no idea. I'd love to learn more about it.

<comment><USER6> They don't send "media-heavy data" back to clients, actually. All the media comes with your installation DVD. Used to play Eve over dial-up.

<comment><USER3> /facepalm

The network has to send you coordinates about where you and every other player are in relation to each other so your view of the gameworld is synchronized. Had you actually read what I wrote you would have understood my meaning.

</comment></comment></comment><comment><USER7> Before I had my daughter I played this game all the time. The politics, drama, and complexity of the game are very compelling. Their infrastructure and design always impressed me. Keeping the whole world in one instance makes for a lot more fun when playing with people you know.

<comment><USER8> Also a former player. They do have instances, but they are based on locations, like star systems. I think someone should rewrite the drive mechanics so that instances are attached to reference frames. (Which have a fictional physics upper limit on the number of ships that can join to prevent lag.) This way, a battle could rage in a particular system, but it would consist of many encounters. Such a system would load-balance itself!

<comment><USER9> Hehe, one of the most compelling features of Eve Online is inventing ways to make the game better. I'm sure I've spent more time discussing that on forums and with friends than I ever did playing it.

Then again, though the battles are extremely short it's the most exhilarating battle I've ever had in an online game, the death penalty is pretty harsh so you do get real adrenaline rushes. Pity they're always so hard to find. I can still remember most of my non-trivial ship losses.

<comment><USER8> _Then again, though the battles are extremely short it's the most exhilarating battle I've ever had in an online game_

Carriers/Dreadnoughts vs. a fleet of non-capital ships. This can go on for a very long time. If you're on the non-capital side, you can die quickly, but you'll still be listening in to an exciting event.

</comment></comment></comment></comment><comment><USER10> I get so used to my tens of thousands of cores that I forget the amazing things that can be done with far less . . . only two hundred cores! Only two terabytes of RAM! Astounding.</comment>


Entrepreneur's Paralysis - <AUTHOR> https://medium.com/@Jon_NP/entrepreneurs-paralysis-924a1af8d856#.2yrlpt912 <comment><USER2> This sounds very much like occupational burnout.

[https://en.wikipedia.org/wiki/Occupational_burnout](https://en.wikipedia.org/wiki/Occupational_burnout)

The eroding self confidence and inability to perform mundane tasks. If not addressed, which can take years, you risk more than the business, you risk your life.

</comment><comment><USER3> What an interesting discussion of the mental illness that you suffered while running your own company. Thanks for sharing.

M

</comment><comment><AUTHOR> tl;dr It's an honest, transparent, humble, story of the trauma of a startup founder. It focuses especially on ugly details that most wouldn't admit.</comment>


What Should I Say? - <AUTHOR> http://whatshouldisay.com/ <comment><USER2> Love the diverse nature of questions:)</comment>


Delays in Emergency Care and Mortality During Major U.S. Marathons - <AUTHOR> https://www.nejm.org/doi/full/10.1056/NEJMsa1614073 <comment><USER3> If delays of 4.4 minutes drive this effect, shouldn't there also be massive swings in mortality every day (rush hour), and at the end of the weeks?

<comment><USER4> Yes, but I'm not sure what that would matter. I suppose they needed to control for time of day among marathons, but often they are all early on weekend days.

The point is to study the causal impact of having marathons vs not. Comparing that effect to other times of week which does not contain a marathon is not useful for much.

It could tell you if hosting a marathon is about as costly as having X more rush hours' worth of mortality or something, but does not relate to the causal effect of the marathon.

For an example to compare, think about studying the impact on crime of heatwaves in a winter month. Someone could say, but won't there be spikes of crime from heat in summer months? Yes, but why is it relevant — the point is to know the effect of the heatwave.

<comment><USER5> Effect size and comparison to other causes matters, because every study will be used as evidence for some political argument.

This study ("Marathons kill people!") will be used to argue for banning marathons in cities by people why are inconvenienced by the road closures.

A comparison to other common and accepted causes of traffic delays - <USER2> positive health impact of marathons - will prevent this misuse.

A similar thing happens with wind turbines killing birds. Yes they do. But radio towers, power pylons, agriculture, pesticide use, cars _each_ kill 100x more, building windows 1000x more, and cats 10000x more. Yet it is still a popular argument used by people who are against renewable energy for other reasons, while nobody argues for banning skyscrapers.

<comment><USER4> I agree in general and even said exactly this in my comment (comparing effect size in terms of X rush hours' worth of mortality).

But in the specific case of policy adoption towards marathons, I don't agree that comparison matters much for interpretation.

Banning marathons is totally different than taking action to reduce generic or rush hour traffic. Marathons are a purely recreational thing for society, nobody has any sincere need for them, certainly no needs to be colocated with dense urban areas.

Rush hour traffic is an emergent effect of necessary daily commuters and operations of a city.

Disentangling what part of it is needed, what can be reduced, and how to politically coordinate it is an entirely different situation.

In this sense, if banning marathons prevents even a tiny effect size on mortality, it's obviously worth it, no matter if it is only saving 0.1 rush hours' worth of mortality, or 0.01, or 0.001. Comparing with rush hour effect size adds virtually nothing to the process.

<comment><USER3> > If banning [something] prevents even a tiny effect size on [bad outcome] > it's obviously worth it

The same logic is why we now shuffle around in our socks at the airport. It is a _terrible_ recipe for making policy.

<comment><USER4> Of course if you take it out of context it fails to generalize. Why would you think it should generalize?

Nobody is saying this about [something] or [bad outcome], only about marathons that demonstrate causal impact of higher mortality rate due to traffic impact on emergency services.

It's not a recipe. It's weird to me that you'd even suggest such a non sequitur concept.

</comment></comment></comment></comment></comment></comment><comment><USER6> To me, the central question is whether marathon running is more popular amongst parts of a community with more political clout, and whether this explains the how participants manage to impose inconveniences (and potentially more serious harms, as suggested in this paper) on the rest of the community by staging a marathon.

<comment><USER7> This is maybe a tangent but if everything collapses when one road is closed that suggests a system lacking resiliency.

<comment><USER8> True, but you don't need a marathon to tell you that. Just go anywhere downtown at rush hour on a weekday. Every 5 minutes, some driver will enter the box before it's clear, and block the intersection both ways for everybody.

A couple months ago, a package truck crashed on the freeway a mile ahead of me, and traffic didn't move for over 3 hours. Our roads are not designed with redundancy as a primary concern.

<comment><USER9> Not exactly what you meant, but I believe the interstate highway system was designed for redundancy for military mobility as a primary concern after WWII because of how easily rail could be taken out.

</comment></comment></comment></comment><comment><USER10> Looking forward to all the contortions people will suggest so that we can do literally anything except not ban cars on crowded marathon days, which is the obvious and easiest solution.

<comment><USER11> 26.2 miles can be laid out anywhere in a rural or suburban area. Those of us that run on country roads know that space is never a problem. There is no need for it to be run in the heart of a city other than vanity and trying to leech money from the attendees.

<comment><USER12> Not everything is about need. I don't see too many residents of NY or Boston clamoring to get rid of their respective marathons because they're inconvenient. You could say the same thing of other notable sports and other events.

It's true they bring in money and it's also true that most residents are sort of proud of them even if they don't participate. But I'm not sure how any of those things are so horrible.

<comment><USER3> Heck, it's possible that urban marathons, by promoting fitness (etc), have a net positive effect on health despite this.

</comment></comment></comment></comment><comment><USER13> I wonder if they properly controlled for the Boston Marathon bombing. Although there were amazingly few direct casualties given the circumstances, the extra strain on the hospital system may have had substantial second order effects.

<comment><USER14> They did not include 2013 in their analysis.

They also typically found ~11 hospitalizations of Medicare recipients for heart attacks on a study day and included ~12,000 hospitalizations, so 1 day wouldn't impact the data that much anyway.

</comment></comment><comment><USER15> How's this compare to weekday rush hour, though?

<comment><USER16> It looks like the study doesn't have data that would enable them to determine that. The marathon event presents a known day where there is disruption, which they can see in ambulance transport times. They then can see in Medicare data patient outcomes based on days. Looks like they'd need much more granular data on admission times, etc from the Medicare data set which probably is not possible.

That said you can probably infer from everything we know that if ambulance transport times are longer during rush hour then patient outcomes are also worse.

<comment><USER17> In theory that data exists. The NEMSIS data set includes transport timestamps and locations (allowing you to determine some sort of "rush hour impact score"), and enough identifying information follow up with the pt's outcome.

There's no unified dataset linking the two though, so it would be a fair bit of work.

[https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDiction...](https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDictionary/PDFHTML/EMSDEMSTATE/NEMSISDataDictionary.pdf)

</comment></comment></comment><comment><USER18> They article says on marathon days it took 4.4 minutes to get to the hospital, with similar number of incidents as on regular days. That's believable. That would also be true if there was a parade or a big football game.

<comment><USER19> No, it doesn't. It says it took 4.4 minutes _longer_.

<comment><USER18> right, sorry, that was a typo, you are of course correct it was 4.4 minutes longer. doesn't change my thought, does it?

</comment></comment></comment><comment><USER20> > 2757 deaths in 11,074 hospitalizations

That seems like a high death rate for hospitalizations, does it not? Would be interesting to see the breakdown of admissions and cause of death.

<comment><USER21> It's probably for emergency only admits, and probably also includes DOAs. Which would make it more understandable.

</comment></comment><comment><USER22> This is amazing research.

</comment><comment><USER23> Why can't these people run far away from cities and suburbs ? There are plenty of remote roads. Sort of like Dakar.

<comment><USER24> They could possibly do this but the logistics would be messy. For large marathons, people travel to the destination from all over the world and book hotels in the city where they can easily get to the start location. Also, seeing the city while running the marathon, however inconvenient to others, is part of the attraction of the location.

If the actual marathon course is somewhere remote from the city, it's unlikely such a place would have the hotel space for all the runners, and transporting them to/from the site would be a massive undertaking in itself. Chicago has about 45,000 runners every year. Then there are all the volunteers who need to get to and from stations around the course.

I'm not saying any of this to discount the argument that marathons impose a huge inconvenience, only that moving them elsewhere isn't so cut and dried a solution.

<comment><USER12> >people travel to the destination from all over the world and book hotels in the city where they can easily get to the start location.

Or at the end. The Boston Marathon actually starts pretty much 26 miles to the west of downtown in a suburb/exurb. So runners do need transportation to get to the start. It's not really accessible by public transit but I imagine there are buses in addition to people just getting rides from friends/family.

It _is_ held on a (state) holiday and a lot of Boston companies give the day off. (And companies out by the start like EMC do as well because their parking lots are used.)

</comment></comment></comment><comment><USER25> Seconds count. We already know that speed bumps kill 9 for every 1 life they save, due to ambulance delays. Ambulances are heavy and can't go over speed bumps very quickly. The 1 life they save is from someone not going so fast.

<comment><USER17> I'm not so sure that's a thing we "known". I didn't have any luck tracking down the origin of that stat (it looks like it may be from a study in Boulder CO, but other than the same sentence referencing it that seems to show up in a bunch of articles, I can't find actual study).

I'd be very surprised if that was actually a rigorously proven stat.

<comment><USER25> You may be right. It's been a while. I remember reading a news article some place where they had the stats before they put them in, and found out after that ambulance times were delayed and the death rate went up, and then they tore them all out at great expense. The other ones I remember seeing are more like the one linked below. I think they proved the speed bumps result in ambulance delays, and assume deaths based on a rate. I also recall not being able to find any solid data that the speed bumps save lives.

<comment><USER17> Absent some solid evidence, I just don't buy it (based on a fair bit of experience as a paramedic). Speed bumps don't slow you down that much, and "seconds" really aren't that important.

<comment><USER25> Interesting, I have a few friends who were formerly EMTs and when I spoke to some former paramedic acquaintances, they seemed to believe the speed bumps were detrimental in certain specific medical cases, things like cardiac arrest and aortic aneurysms.

I'm in SoCal and some of these neighborhoods are just full of speed bumps, so maybe it's all of those seconds adding to minutes? Also there are different types of speed bumps, some don't slow you down at all and others you go 5mph and feel like you're ruining your suspension. Or maybe there's some other confounding factor? Do you only have a few where you live?</comment></comment></comment></comment></comment>


F.T.C. Online Privacy Plan Seeks 'Do Not Track' Option - <AUTHOR> http://www.nytimes.com/2010/12/02/business/media/02privacy.html?hp <comment><USER2> User tracking is so essential to business optimization and ad targeting that the FTC's initiatives can only backfire.

Today, the analytics and advertising industries increasingly self-regulate, cookie-based opt-outs are usually available, and concerned users can quite effectively opt-out through technical means. Should the FTC or Congress mandate opt-in or even a broadly promoted 'do not track' list, companies will quickly protect their revenues by making opt-in mandatory for content access - and the opt-in that's required will likely be a whole lot more intrusive than the relatively benign tracking that takes place today.

</comment><comment><USER3> Beef Taco is a Firefox extension designed to opt out of tracking cookies.

<https://addons.mozilla.org/en-US/firefox/addon/180650/>

I think it's an acceptable compromise to use such an extension.

</comment><comment><USER4> How would they track which people chose not to be tracked?

<comment><USER5> I briefly scanned the pdf report linked by the new york times, and it seems that one of the ftc's ideas is to basically make the private browsing option available in more browsers, a bigger, bolder and more obvious button, and also probably the default option.

So, I think if they were to follow through with this plan, they probably wouldn't deal with lists or anything, but would have each browser send a blip to the website saying the user is opted in.

</comment></comment><comment><USER6> Is the only way the FTC could possibly enforce this to grab more power? to check up on website administrators?

</comment><comment><USER7> People can start by disabling 3rd party cookies in their browsers.</comment>


Ask HN: Is 5G Safe? - <AUTHOR> After reading handfuls of articles and watching some videos on 5G, it's still very difficult to discern fact from speculation. Mainstream media is no longer a reliable source for truthful coverage due to many of them being sponsored by the purveyors of this technology (Verizon/Sprint/etc). Can anyone here shed accurate light on any real health concerns associated with 5G proliferation? <comment><USER2> At Astroscreen[0] we're working on analyzing the activity around #Stop5G and related Twitter discussions. We haven't published a full report yet, but I can reveal preliminarily that we found manipulation by a network of bad actors (one random member is [1]) who tried to artificially spread disinformation about the risks of 5G technology.

[0]: [https://www.astroscreen.com](https://www.astroscreen.com)

[1]: [https://twitter.com/WarriorWifeMom](https://twitter.com/WarriorWifeMom)

</comment><comment><USER3> It's not safe, as the tinfoil theories sprung up about 5G technology can make you die from laughter.

It's fricking non-ionising RF. TV stations were sending with much more power than the 5g base stations replacing them.

It's not new (em-)radiation, or more of it, it's only a new use, with actually lower sending power than before.

Better turn your WiFi off, if you fear the water heating 2.1GHz radiation.

<comment><USER4> You are actually right.....but the issue is that 5g doesnt travel distance well and particularly not thru walls very well. So, those safe frequencies that you mention needs to be amplified and you need a LOT more towers and repeaters to extract the real value of 5g.

<comment><USER3> That's why TV frequencies got freed up (600MHz), and are also used in 5G: they travel great though walls. And one or two stations serviced a city.

The FR1 range is nothing new.

Yes, FR2 ranges (aka mmwave) has more potential for higher speeds partly _because_ it doesn't travel through walls, you need practically line of sight. (Spatial multiplexing).

And you cannot simply amp up the power, to get through it as reflections will drown you.

Different use-cases, different frequencies.

And those frequencies are still non-ionising, and at most heat your skin.

So why the qualifier of "safe" for frequencies? We are talking radio here, not UV, x-ray or gamma.

</comment></comment></comment><comment><USER5> A lot of the anti-5G material comes from a series of reports on RT, which many blogs have repeated without attribution. Details in this comment [1].

[1] [https://news.ycombinator.com/item?id=20788559](https://news.ycombinator.com/item?id=20788559)

</comment><comment><USER6> Dr. Martin Pall's work on the effects of EMF on Voltage-Gated Calcium Channels (VGCC's) is the most compelling critique of non-ionizing EMF I've seen.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780531/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780531/)

</comment><comment><USER7> Non ionizing radiation is safe. Ionizing radiation (gamma rays, x-rays, some uv rays) are dangerous when the dose is high.

The main problem with multimedia is that they don't have some specialist to cover the news and they just copy&paste the press release of any study floating around. So they make a big scandal about in a study that report like 20 subexperiments and only one of them is statistically significant with p < 0.05.

<comment><USER5> > Non ionizing radiation is safe.

The assorted things that have burned or exploded when I left them in my microwave oven too long suggest that this is not entirely correct.

Ionizing things is not the only mechanism by which radiation can cause harm. It's the only one known to be able to cause cancer, which seems to be the main thing people worry about, so it would be accurate to say non-ionizing radiation cannot cause cancer.

The non-ionizing ways radiation causes harm also tend to require high intensity and prolonged exposure, so it is probably accurate to say you don't have to worry about them unless you make a habit of, say, hanging out directly in front of high power microwave antennas.

<comment><USER8> You realize your microwave operates at over 1100 watts in a small enclosure designed to reflect RF, while 5G currently maxes out at 1100 watts in an open space that dissipates the energy in all directions, right?

You also realize that a microwave is designed to use a frequency band that sympathetically excites hydrogen atoms, while 5G is a collection of technologies that use UHF, high microwave, and submillimeter bands that _do not_ sympathetically excite hydrogen, right?

</comment></comment></comment><comment><USER9> My biggest concern with 5G is whether the standards and implementation are being done by [1] companies based in democratic countries, or [2] companies based in non-free (dictatorship-run) countries where the companies have close ties with the regime that runs the country.

Products from companies in the latter bracket seem to have a history of suspiciously simple backdoors and a record of sending data "back home".

<comment><USER10> Based on what CIA, NSA and FBI is known for, is USA [1] or [2]?

</comment></comment><comment><USER11> I've watched see video on this very interesting subject a while ago. Take a look at it:

[https://www.youtube.com/watch?v=KbNh7x3lVWc](https://www.youtube.com/watch?v=KbNh7x3lVWc)

My opinion is that we still don't know for sure, and anybody who pretends to be sure about a certain position doesn't have a clue in reality.

<comment> exo-pla-net Fearmongering. Our current understanding of physics precludes 5G from having any effect on the human body. 5G is not ionizing: this is a matter of physical reality. And non-ionizing electromagnetic waves lacks the energy to do anything interesting to matter.

The fear is induced by calling electromagnetic waves "radiation," a scary word. If you accurately called these waves "high spectrum light", the fear would evaporate.

The pedantic scientific caution is that our model of electromagnetism may be wrong. Indeed, light may be small demons seeking to enslave us, and only coincidentally behaving in accordance with the Schrödinger equation, but this is unlikely.

And so it is just as reasonable to outlaw rain dances from subsistence farmers in Africa (Our model of cloud formation could be wrong! Who knows what effect these dances could have?), as it is to be worried about 5G.

Myself, I'm looking forward to high resolution, negligible latency VR, as well as no longer having to buy computer hardware: VM's will perform just as well as your tricked out local computer, so it won't make sense to buy computer (or even a smartphone) anymore. The smarts will live in the cloud, and you'll just need a screen, an input device, and a connection to work or game. 5G is coming, so you might as well be excited about it!

<comment><USER11> What?! Light is not small evil demons coming from the sun directly into our eyes?! Anyway amazing, I've never thought about the non-hardware perspectives. You got me excited!

</comment></comment></comment><comment><USER4> I think the key point is that the media outlets are not a reliable source of information. I can tell you that the big wireless providers are working hard to influence local governments to push their agendas. For example, one local non-profit that I know (that advocates for startups and tech in the city) received a sponsorship out of the blue from one of the big wireless companies. They gladly accepted the $7500. A few weeks after, the company was asking the non-profit to give them access to the City, Managers, advocate for 5g, etc. Essentially, they were acting as a lobby and tried to leverage the non-profit for this. Yeah, I know.....its how the system works. But just imagine that this wireless company is doling out $7500 to multiple organizations in every mid-sized city in America (this city is 200k population). It just tells you how important this initiative is to the wireless telcos.

</comment><comment><USER12> Any research biologist I know would balk at the idea that anyone outside of people that have had access to 5g in a bio lab for 10 years could even have a credible starting point from which to answer this question.</comment>


NEON is the new black: fast JPEG optimization on ARM servers - <AUTHOR> https://blog.cloudflare.com/neon-is-the-new-black/ <comment><USER2> This made me think of the story about SnappyCam, whose author handcrafted a JPEG encoder in Arm NEON assembly to enable iPhones to capture still images at 20fps on the iPhone5 (before burst mode was a thing in iOS), and was subsequently acqui-hired by Apple:

[https://www.theguardian.com/technology/2014/jan/06/apple- buy...](https://www.theguardian.com/technology/2014/jan/06/apple-buys-iphone- camera-app-snappycam-and-gets-australian-algorithms-whiz)

[https://newatlas.com/snappycam-iphone- app/28558/](https://newatlas.com/snappycam-iphone-app/28558/)

</comment><comment><USER3> This is a really good article. Couple of comments:

* Intel is dead man walking. They've been coasting on superior process technology for years, and now they're being attacked on two sides in the datacenter: From ARM many-core chips like this, that have 50% of the performance per core, but 4x as many cores for about the same price and TDP. On the other side, you've got NVIDIA. The Volta has something like 9X the memory bandwidth of typical Intel server CPUs. This is starting to get used in databases, and of course they already own deep learning.

* libjpegturbo is a great choice if you need fast CPU JPEG encoding/decoding. It's a very near drop-in replacement for libjpeg, and it runs about 2x faster, mostly due to AVX/NEON optimizations.

<comment><USER4> Disagree that Intel is a dead man walking. If they see a serious threat in the number of 1U size ARM servers actually going into production at scale, which is not happening yet, they have the ability to make 50% price cuts on 16/24/32-core xeons to make them competitive again. With no new r&d money.

You cannot yet buy small to medium sized quantities of ARM motherboard from any of the top ten taiwanese motherboard manufacturers. Intel and AMD have advantages of massive economy of scale.

If you look at the global server market for individual bare metal hypervisor platforms priced from $900 to $11000 each, x86-64 is literally like 99% of motherboards shipped. The other 1% is probably spread between arm, power and other even more esoteric platforms.

I would dearly like to be proven wrong. If anyone is aware of a $400 arm board I can buy right now from MSI, asus, gigabyte, supermicro, tyan, quanta, or others please post a link here.

<comment><USER5> _> I would dearly like to be proven wrong. If anyone is aware of a $400 arm board I can buy right now_

Not from the manufacturers you mentioned, but it is possible to buy an ARM board in a standard form factor that can be used in high performance applications. [1]

[1] [http://macchiatobin.net/](http://macchiatobin.net/)

<comment><USER6> Good luck getting a standard Linux kernel to run on those Armadas though.

<comment><USER4> I looked briefly and found no mention of being able to run a Debian or centos derived distribution on them. Chicken or egg problem.

</comment></comment></comment></comment></comment><comment><USER7> There's a huge problem with these improvements. They rarely make it to the original project.

Luckily, the SIMD acceleration for progressive Huffman encoding was a rare exception [1]. So, alone with other improvements, it made this fork [2] rather pointless. Adding the NEON optimizations would have been easier with a proper rebase, and that would require less work for both to keep things up to date.

[1] [https://github.com/libjpeg-turbo/libjpeg- turbo/pull/46](https://github.com/libjpeg-turbo/libjpeg-turbo/pull/46)

[2] [https://github.com/cloudflare/jpegtran](https://github.com/cloudflare/jpegtran)

<comment><AUTHOR> We push everything we can upstream. Sometimes maintainers don't want our changes. We expect to push a _lot_ of ARM changes to a lot of different software in the coming months.

<comment><USER8> Any chance the other optimizations will have a blog post similar to this?

<comment><AUTHOR> Very likely.

<comment><USER8> Thank you!

</comment></comment></comment></comment></comment><comment><USER9> I'm really impressed with the Cloudflare Engineering team, their collective knowledge, and their ability to roll up their sleeves and optimize the hell out of the products and services they run. From looking in, it seems almost everything they run has been source code customized to their requirements, from OpenSSL, to JPEG compression, to their HTTP/2 implementation.

<comment><AUTHOR> We switched away from OpenSSL to BoringSSL (in part to get rid of our own modifications): [https://blog.cloudflare.com/make-ssl-boring- again/](https://blog.cloudflare.com/make-ssl-boring-again/)

</comment></comment><comment><USER10> This is the kind of in-depth stuff that I love to read; the CloudFlare blog has been a source of good articles for a few years now, might be time to just add that to the list of things to check on a regular basis instead of waiting for some of them to pop up on HN :)

</comment><comment><USER11> It's always kinda humbling to see how much performance is still left on the table in some base/core libraries everyone uses. It'd be nice to have seen what the compiler output is in comparison - and explore if there is a way to reorganize the code to "coerce" the compiler to output something similar.

The few times I've had to do similar things - I usually work by tweaking the code to give me the desired compiler output and I really try to avoid inline assembly. This usually helps me learn some limitations of C/C++ and what the compiler can deduce

<comment><USER12> godbolt?

edit: curious as to how you perform this optimisation.

<comment><USER11> It's been a few years since I've had to do it - but back then I just used the Visual Studio disassembly. You can get something similar (but more messy) with objdump.

Godbolt seems like a good solution now-a-days, but you still need to run benchmarks

</comment></comment></comment><comment><USER13> I wonder what types of controls they have over the data they cache. While caches are by nature "public", given suitable naming, unless you have a link, they are effectively private.

> To understand the impact on overall performance I ran jpegtran over a set of > 34,159 actual images from one of our caches.

<comment><AUTHOR> That's a great question. Answer: a lot of control.

In order to run the cache experiment Vlad had to file an access control ticket which I had to approve. He was given access to cached images from two dogfooding/guinea pig machines and was able to run his experiment on those machines. They are not machines through which we run 'normal' production traffic.

</comment></comment><comment><USER14> Can we get asm/bytecode instead of C intrinsic? It's easier to reason about, without spawning actual compiler.

<comment><USER15> I ended up writing asm for the important part:

[https://github.com/cloudflare/jpegtran/blob/vlad/arm/jchuff_...](https://github.com/cloudflare/jpegtran/blob/vlad/arm/jchuff_util_armv8.S)

</comment></comment><comment><USER16> > NEON is the ARMv8 version of SIMD

NEON was actually introduced in ARMv7.

<comment><USER17> How does that make the statement incorrect?

<comment><USER18> Technically, ARMv8 has no such thing as "NEON"; it was renamed Advanced SIMD. Only in ARMv7 is it officially called NEON.

But everyone sensible ignores a lot of the stupid names ARM uses in ARMv8 (AArch64/AArch32, A64/A32/T32, etc.)

<comment><USER15> Yes and no. [http://infocenter.arm.com/help/index.jsp?topic=/com.arm.doc....](http://infocenter.arm.com/help/index.jsp?topic=/com.arm.doc.den0024a/CJHECGIH.html)

> The ARM Advanced SIMD architecture, its associated implementations, and > supporting software, are commonly referred to as NEON technology. There are > NEON instruction sets for both AArch32 (equivalent to the ARMv7 NEON > instructions) and for AArch64. Both can be used to significantly accelerate > repetitive operations on large data sets. This can be useful in applications > such as media codecs.

The NEON architecture for AArch64 uses 32 × 128-bit register, twice as many as for ARMv7. These are the same registers used by the floating-point instructions. All compiled code and subroutines conforms to the EABI, which specifies which registers can be corrupted and which registers must be preserved within a particular subroutine. The compiler is free to use any NEON/VFP registers for floating-point values or NEON data at any point in the code.

</comment></comment></comment></comment><comment><USER19> In case anyone else was confused by a 200KB file taking so long, the original file is 9933x7016 (7.1MB) and actually _does_ take that long.

I'm not going to link it here because the site already seems slow, but it is easy to find if you want to do your own benchmark.

<comment><USER20> Found the file. 230 ms decode and 96 ms encode on i9 7900x. :)

</comment></comment><comment><USER20> Timings with the original test image ( [https://www.eso.org/public/archives/print_posters/large/prin...](https://www.eso.org/public/archives/print_posters/large/print_poster_0025.jpg) )

9933 x 7016 (7.4 MB)

        load turbojpeg: 309 ms
        load mango:     225 ms
        save turbojpeg: 388 ms
        save mango:     96 ms

Started with 800 ms save time earlier today but got motivated to finally optimize the encoder; thanks! :)

</comment><comment><USER21> Cloudflare, Uber, Netflix engineering teams are all amazing.

</comment><comment><USER22> Very interested in seeing this for libPNG for platforms other than Linux. The ARM intrinsics are always the sticking point when doing cross-platform stuff. Very good write-up I'll be following the project now.

</comment><comment><USER23> How transcoding on this centriq compares to FPGA transcoders cost-wise?

Can you put your testset images on github?

<comment><USER24> There are commercially available FPGA JPEG transcoders?

High end FPGAs cost an arm and a leg, so I find it hard to believe they would be cost effective, though Intel seems to claim otherwise.

<comment><USER23> Cyclone V board with onboard network, some ram, and flash costs $7k a piece. 2 years ago, we benchmarked an off-the-shelf jpeg transcoder IP to be ~30-40 times faster than libjpeg on top of the line 8 core xeon.

<comment><USER24> Oooh, that's pretty awesome then. I was pretty sceptical after reading about somewhat "meh" results for deep learning applications a few weeks ago.

<comment><USER23> > I was pretty sceptical after reading about somewhat "meh" results for deep > learning applications a few weeks ago.

To begin with, nobody even bothered yet to make an optimised HDL design for this purposes.

This is unlike for all kinds of media transcoders which are the bread and butter of the SoC industry. An image transcoding asic you find in cellphone SoC these days can easily max the I/O ceiling, which means they can transcode faster than the SoC's memory interface can work.

</comment></comment></comment></comment></comment><comment><USER25> Using `-copy none` with jpegtran can be a bad idea in some cases, because it wipes out the color profile data. Be absolutely sure you don't need it, before you go blowing that data away everywhere.</comment>


Pixar rendering from 1989 - <AUTHOR> https://twitter.com/gifs_bot/status/1096957413943595008 <comment><USER2> Love seeing day ones. If you're reading this and you're not saving your day ones but do believe in yourself — might as well start today

<comment><USER3> Pixar was almost 10 years old by this point, and 5 years after their first short.

[https://www.youtube.com/watch?v=a_9Tsbduk9E](https://www.youtube.com/watch?v=a_9Tsbduk9E)</comment></comment>


Review on the concept social travelling - <AUTHOR> http://www.youtube.com/watch?v=hoaqJml_Afc

<comment><AUTHOR> any comments?</comment>


At Scale, Rare Events Aren't Rare - <AUTHOR> http://perspectives.mvdirona.com/2017/04/at-scale-rare-events-arent-rare/ <comment><USER3> One quote I've heard, that i find helps non-experts:

You don't have to personally prepare for winning the lottery, but the lottery has to prepare for somebody winning.

</comment><comment><USER4> As a pretty good rule of thumb, a system that fails 1/nth of the time and has n opportunities to fail has ~.63 probability of failure, where n is more than ~10.

Graph: [http://www.meta- calculator.com/online/?panel-102-graph&data-...](http://www.meta- calculator.com/online/?panel-102-graph&data-bounds-xMin=-10&data-bounds- xMax=10&data-bounds-yMin=-7.28&data-bounds-yMax=7.28&data- equations-0=%22y%3D1-\(1-\(1%2Fx\)\)%5Ex%22&data-rand=undefined&data- hideGrid=false)

<comment><USER5> Very nice rule of thumb, honestly I did not expect it to (sort of) converge to ~63%. Does anyone have some intuition for this?

<comment><USER6> I'd say, hey, how do you calculate (1-h)^k? First take the natural log: ln((1-h)^k) = k ln(1-h) = -kh. And then exponentiate back up: e^(-kh). (For small values of h, ln(1-h) = -h by linear approximation.) (Edit: Wiped out looong comment.)

<comment><USER7> I think by "intuition" the GP meant "for the non-mathematicians" :P

<comment><USER8> It's always amusing when someone asks for a layman/non-math/intuitive reason why something works out and HN responds with a 3-paragraph long proof that seems to always require university-level math. And it seems those comments almost invariably start with "Oh, you just..."

<comment><USER9> 'pedrosorio gave a nice one upthread[0].

Ultimately, it's hard to give a math-free explanation for something that comes out straight from math. If you break down an explanation into small enough steps, they should be comprehensible for anyone even if they have to take some steps on faith.

\--

[0] - [https://news.ycombinator.com/item?id=14040434](https://news.ycombinator.com/item?id=14040434)

<comment><USER7> He did, yes, I was just amused by the GP's answer!

</comment></comment></comment></comment></comment></comment></comment><comment><USER10> Coincidentally, a couple months ago one of my professors told me about James Hamilton, apparently, they met when he was studying at Waterloo. I started reading his blog.

This guy is brilliant. And his comments are often gems. The articles are good too but think of them as conversation openers. The real deal is in the comments imho. I recommend it. A somewhat funny article is about Zynga, the "prodigal kid" who left AWS for on-premises, only to come back later: [http://perspectives.mvdirona.com/2015/05/the-return-to- the-c...](http://perspectives.mvdirona.com/2015/05/the-return-to-the-cloud/)

In the comments, he debunks (or take a shot at it) the idea that cloud providers like AWS aren't a good fit for organizations which have massive, but stable workloads.

This guy is so cool. I only wish he had more time to write.

</comment><comment><USER11> It reminds me of an old story about Microsoft Windows. Back in the early 2000's, compiling and building Windows from source code took many hours on very specialized build hardware. Meanwhile there were thousands of developers who contributed to the full Windows stack. If any developer checked in a build failure, it would cause the build to be delayed. Well, at that scale (of thousands of developers), you can't compile Windows even if devs only commit 1 build break per year. Bad times...

<comment><USER12> There was essentially instability and chaos in the big dev heavy divisions at MS when they all worked in one branch, but that led very rapidly to more sophisticated models with more points of validation between the average dev and the common code/builds that qa and everyone else shared and used.

<comment><USER13> The common pattern nowadays is to code review each commit, build each commit on Jenkins & pass tests, git bisect, etc... What was the procedure back then ?

<comment><USER14> "don't break the build" was the procedure.

<comment><USER13> amen!

</comment></comment></comment></comment></comment><comment><USER15> "One in a million is next Tuesday" from Larry Osterman is another great reflection on this from the software perspective. [1]

[1] [https://blogs.msdn.microsoft.com/larryosterman/2004/03/30/on...](https://blogs.msdn.microsoft.com/larryosterman/2004/03/30/one- in-a-million-is-next-tuesday/)

</comment><comment><USER16> Love this article but think the headline actually makes the wrong point - <USER2> is a product management issue, not a "it may never happen" issue. That it takes someone like James to know two wildly different domains - both the business-level details at risk (a $1M generator is worth potentially damaging if the alternative is a guaranteed $100M revenue loss) and the details of power engineering (overriding the switch only risks the generator, not a datacenter fire or loss of life) - is a shame.

Could the power engineering team have made this tradeoff more clear to the project managers doing the initial install? And yet, exposing a million little configuration options to the end-user isn't the right approach either.

</comment><comment><USER17> It may be silly but if something is unlikely I stop and remind myself: if something is a 'one in a million' chance, then it happened to 7000 people today.

<comment><USER18> "one in a million" happens several times per second, in todays CPUs :)

Fun small experiment. Pick a random number between 1 and 15000000 (odds for winning the lottery in my country). Loop until you pick it again (i know it's pseudorandom and cylic; but the period seems big enough for the experiment).

Watch how freaking fast it happens (sub-second), and how many iterations it took (dozens of millions).

<comment><USER19> Also why ECC memory is used... and chances to corrupt a bit of memory are much lower than that.

</comment></comment></comment><comment><USER20> Storage devices regularly go berserk in really novel and interesting ways when you have a large enough pool. Most projects I've worked on, I've known enough to fix the bugs, had a working theory of what the issues were and could fix if I really needed to after higher priorities, or could somehow work around. With storage devices, I'm frequently bewildered and stuck maybe to the last category at best. There are times when I sit back and just think, wow, how amazing is it that computers work at all knowing the things that do go wrong.

<comment><USER21> > There are times when I sit back and just think, wow, how amazing is it that > computers work at all knowing the things that do go wrong.

There is a special category of bugs named for that kind of feeling, they're called schrödinbug. The idea is that once you've noticed that something couldn't work it promptly stops working.

</comment></comment><comment><USER22> The part about the switchgear vendor deciding to do something a certain way that the customer didn't want because it can cause a rare failure reminded me of something that happened to me. Way back I bought a 1500VA UPS that was not an APC but still a known brand to protect my home server. The decision was based on cost as it was significantly less money.

One night I was near the server when the power went out. So I sat there waiting to see the auto shutdown. Soon enough the UPS told the server to shutdown and it was well on it's way to power off. Just before it shut off the power came back. And the UPS stopped beeping and went back to normal operation... while the server completed shutdown.

And know I have a server that's off and if I wasn't around I would have not known what happened. When I got the UPS I just did one test to make sure the server shut off and the UPS shut itself off without draining its batteries. This meant that I plugged it back in AFTER the UPS powered off. I never considered that the manufacturer of the UPS would botch the power restored after telling the server to shut down sequence.

I contacted the manufacturer about this. I told them that after telling the server to shut down there was only a brief window where a power restored signal would maybe abort shutdown. Once the UPS monitoring program is terminated during shutdown there's no turning back. Nothing came of that.

So now I buy only APC gear. They do the proper thing that if the AC power comes back after a shutdown command is issued the UPS will continue the shutdown sequence. And when the UPS shuts off it sees the power back on and restarts itself and the server comes back online.

Other manufacturers may do it correctly and the one I dealt with might have clued in and fixed it but I'm not willing to gamble anymore.

</comment><comment><USER23> Though it's not all that rare, there's the question of dealing with death in large online social or identity networks.

With Google having some 3 billion Android / Chrome / Gmail profiles, and Facebook roughly as many users, standard actuarial statistics suggest that, even if allowing for multiple profiles per human, the number of newly dead accounts per day probably runs to the tens of thousands.

(Globally, deaths run about 120,000/day, so the figure's within reason.)

Which means you probably want to consider your processes for such matters, as well as various related issues, such as mistakenly presuming a user has died, or being falsely informed, how to handle data assets after death, etc., etc.

Scale matters.

</comment><comment><USER24> Related: Wired profile of the author

[https://www.wired.com/2013/02/james-hamilton- amazon/](https://www.wired.com/2013/02/james-hamilton-amazon/)

</comment><comment><USER25> Unfortunately most people don't realize this until they are at scale.

<comment><USER26> It's ok, since most people never get "at scale". When you start getting these problems, it means you reached the stars you were shooting for. Having those issues are a good thing.

<comment><USER27> Assuming you have the resources to cover these events, sometimes you hit scale, but not profitability..

<comment><USER26> Yes but in that case the scaling technical issues are not your main problem. Your main problem is your business model. Priorities, priorities...

</comment></comment></comment></comment><comment><USER28> Reminds me of this: [http://spectrum.ieee.org/tech-talk/computing/it/nsa-data- cen...](http://spectrum.ieee.org/tech-talk/computing/it/nsa-data-center- electrical-problems-arent-that-shocking)

</comment><comment><USER29> There was an article a while back that used the term "Walmart scale". If some weird customer interaction happens one time in a million transactions, it happens ten times a day at Walmart.

</comment><comment><USER30> "You know, the most amazing thing happened to me tonight. I saw a car with the license plate ARW 357. Can you imagine? Of all the millions of license plates in the state, what was the chance that I would see that particular one tonight? Amazing!" \-- Richard Feynman

</comment><comment><USER31> Well, Murphy's law. Any non-zero probability event will occur at least once given infinite time.

<comment><USER32> More like infinity times

x __* ∞ = ∞ where X > 0

</comment></comment><comment><USER33> In an infinite universe, nothing is rare, by that logic?

Rare is relative, so just because something happens an trillion times it can still be nearly nonexistently rare, given the data sample is trillions of trillions?

Seems like a silly thought..

</comment><comment><USER34> i would have chosen a slightly different title, perhaps "at scale, improbable events are frequent" or something like that

"at scale" of course just means more much frequent sampling; it's not some sort of alternate reality where good become evil, rare becomes not rare, etc

</comment><comment><USER35> Rare events are self-similar.

</comment><comment><USER36> And yet we still haven't observed proton decay.

<comment><USER19> Partly because observing it requires very specific conditions. That makes the scale really tiny actually.

</comment></comment><comment><USER37> It's a one in a million shot. But it might just work.

</comment><comment><USER38> There is a market opportunity here for serving customers who would rather risk broken generators but ensure constant power.</comment>