Pl read

1. Why o Why?

If you are visiting these writings for the first time, or have not read the entry "Why o Why",

may I suggest you read that first and then read the rest in numerical order?

Sunday, 28 May 2017

21. Enlightened Energy Management

Enlightened Energy Management is not just about turning off unnecessary lights
-- it is about lightening the load on the electric grid using all your smartness.

We wake up to a tune played by our smart phones, immediately click on various apps just in case there’s an alert or a message that can’t  wait, use the tap (aka faucet) at full flow, drive to work in a car even when public transport is easily available, enter an office pre-cooled to a low temperature that we are forced to wear a jacket, and so continues  our day -- consuming more energy than we need, with consequences that we have little time to ponder.

But, why should an individual care? Consider a typical home electricity bill. For many, it is a small fraction of all the monthly expenses. The usual perception is that even when we diligently turn OFF unnecessary appliances at home, the electricity bill is unlikely to drop by more than the  cost of a meal in a mid-scale restaurant. But, given its multiplicative effect, such diligence can help  power deficient countries like India,  whose citizens are forced to contend with power of poor quality (occurrences of blackouts, brownouts and load shedding).

Avoiding or reducing energy usage, by turning OFF devices when not needed, is obviously a highly desirable goal. The multiplicative effect of simple automated steps  can go a long way in addressing the energy problem. But, rather than depending on humans to intervene, there is need  for automated means to manage the devices to reduce energy consumption and these must be exploited especially for  Heating Ventilation and Air Conditioning (HVAC) systems  since they are responsible for a large proportion (30-50%) of energy consumed by buildings.  They should be designed to use easily available/ sensed information to control HVACs and other devices, like fans and lights, without compromising on the thermal comfort. Automated approaches are especially needed to ensure energy conservation, when it comes to large scale and distributed operations so as to make a difference not only to the purse but also to the environment.

So, what is needed for this automation? A lot of research has been done on how energy consumption of a building is correlated to occupancy, number of appliances, temperature and other environmental factors. For example, various sensors such as motion, door or pressure sensors, cameras, etc. can be used to detect occupancy. Temperature of the building can be observed using temperature sensors and power consumption can be measured using smart meters and clamp-on meters.  These sensors enable automated central administration to reduce and optimize power consumption, while also remotely keeping a check on the health of the energy consuming  appliances, maintaining quality of the atmosphere, and tracking occupants during different times of the day (useful to drive staffing and air conditioning based on footfall), to name a few.

With connectivity, infrastructure, and hardware platforms becoming easier to manage than before, prototypes and proof of  concept deployments exist in research labs around the world, including ours at IIT Bombay, and scores of companies that have begun to empower electricity consumers with automated systems that help them better govern energy consumption and achieve significant reductions in energy bills. These use  Internet of Things  (IoT)  based products to do inexpensive monitoring combined with simple rule-based automated control of electrical devices resulting in reduced energy wastage - sometimes to the tune of 20% on their energy bills. Solutions have been deployed to
  • reduce the dependence on unsustainable energy sources – by reducing unnecessary consumption, improving energy utilization and flattening peaks in consumption.
  • increase our dependence on sustainable energy sources -- by exploiting renewables and finding ways to store excess energy from the sun or wind during periods of low consumption.
With the already large share of buildings’ energy usage rising further, the replicability of these solutions to institutional buildings, such as schools, IT-intensive offices, government establishments, etc., make these solutions attractive.

Basic rule driven control, for example, specifying when some appliance should be turned ON or OFF, can in itself result in quick Return on Investment (RoI). More complex control logic, such as controlling multiple HVAC units serving a common space or varying the AC load based on footfall in one part of a building, is also possible.  

Data collected during the operation of the energy manager can be analyzed and mined to improve upon the rules, to deliver even better performance.

Figure below shows six different patterns of consumption in one apartment complex,  with 60 households. A peak in the consumption of an apartment  might occur when many energy-consuming appliances are ON at the same time in that apartment. For example, in the 5th graph we notice two distinct peaks,  one around 9 am -- perhaps because people are taking hot water showers before leaving for work, and another around 9 pm -- perhaps because food is being prepared while the TV is ON.)

In addition to the increasing gross demand, peak demand has also been rising, causing concerns over increasing costs, poor quality of power and the depletion of resources; the continued dependency on fossil sources will have a detrimental impact on the environment. Furthermore, peak demands are handled by turning ON stand-by power generators that add to the capital costs,  increasing per-unit generation cost. About 20% of the generating capacity exists in a power grid to meet the peak demand, which occurs less than 5% of the time. The quick-responding oil/gas fired (highly polluting) generating sources exacerbate damage to the environment. The latter can be seen in the form of dramatic climate change and the alarming increase in the number of health problems due to the ever increasing environmental impact of the huge demands for more energy.    Since a smoother load profile improves grid stability and quality of service, flattening of peak demand is an important energy-challenge, requiring  suitable demand-response (D-R) techniques. In general, Demand-Response techniques are designed to:

  • Avoid / reduce consumption (e.g., turning off devices when not needed). Simple motion sensors are often deployed in places like restrooms to turn off lights when they are unoccupied.
  • Optimize/ balance demand and supply (e.g., by setting optimal comfort levels and scheduling appliances).  For example, most offices see increased energy usage between 2pm and 4pm, which can be mitigated by pre-cooling; energy needs of homes can be managed by better scheduling of appliances such as washing machines and dishwashers.   
  • Flatten  peaks in consumption profile (e.g., by shifting time of operation). Research on flattening or reduction in peak demand spans over the gamut of work from minimizing peak demand through buffering of energy from renewable resources to the use of predictive control  in building HVAC systems.
  • Store excess energy (e.g., in batteries, which can also help handle blackouts). Energy Storage Systems (ESS) aid in smoothing out this cyclical and stochastic power flow thus complementing distributed generation systems. Under time-varying pricing schemes, ESSs also reliably allow shifting power consumption to low price periods thus cutting down the electricity bill. The maximization of this economic benefit is achieved by smart scheduling of the ESS under uncertainty.
  • Exploit renewable sources (e.g., rooftop PV, wind)   Rooftop photovoltaic systems allows buildings to reduce grid power dependence by harvesting solar energy. For example, a recent study in Mumbai  concluded that the total rooftop PV installation potential for Greater Mumbai is around 1.72 GWp which if fully harnessed can reduce the dependence on the grid almost by half.
These considerations have led to the proliferation of Building energy Management Systems (BMSs). A smart BMS should also be able to perform tasks like reducing and optimizing power consumption, monitoring the status and health of the `appliances in the building, maintaining expected energy consumption in different parts of the building, profile energy consumption of different areas, identifying zones with anomalous power consumption, to name a few.   A BMS delivers these services by tracking, using sensors, various pieces of information like environmental parameters (temperature, humidity, etc.), occupancy status and count, energy available and cost of control. A  BMS  can also flatten the power consumption peaks seen in buildings. It can employ other techniques, such as use of renewables, use of storage devices for storing excess energy during times of low consumption, etc., which can be brought to bear on the energy problem

With many start-ups in this space, making immediate use of the low-hanging solutions, there is a real excitement in the air. Business models including SaaS (Software as a Service), whereby the hardware cost is borne by the solution provider and monthly fee is charged, benefit users from day one. Other innovative models can also serve as attractive ways to spur wide scale adoption of the many solutions.  

But, conservation of traditional energy sources while diversifying into modern renewable energy sources and integrating them into the grid  offers many challenges including:

  • Stochasticity of renewable sources introduces significant technical problems for their integration into the existing power grid. Vagaries introduced by changes in cloud cover and wind speed imply increased unpredictability in the load imposed on the electric grid, complicating the task of scheduling power generation.
  • Energy has become a commodity, with wholesale markets seeing dynamic real-time prices. Retail markets  typically provide flat rate contracts to end-consumers but even there time-of-use pricing is not far off. So it makes sense to provide incentives to users to shift loads from high-price hours to low-price hours of the wholesale market. The decisions also depend on the availability of different sources of energy.
  • In the presence of a large number of sensors, enormous amount of data is generated. The data may have issues like missing values, corrupted values, and inconsistencies. These can further complicate the process of energy management and also introduce other problems, e.g. privacy.
  • Localized heating and cooling systems (that often use community waste as heat sources), commonly found in EU countries, may be applicable elsewhere as well. But capital costs may deter their adoption.

Fortunately, as evidenced by the recently concluded ACM eEnergy Conference in Hong Kong, researchers from around the world are busy addressing these and other problems, so one can expect an even better set of  energy management tools and techniques to be available in the coming years.

When people become more aware of the energy problem, we can expect them to take the necessary steps to manage energy more effectively in their offices and in their own homes. But, experience suggests that there is a  need for smart energy management systems which can enable people to tackle their energy needs without manual intervention or without changing their behavioural pattern -- with  users’ support needed just to install the automated solutions. That will lead to a millions-fold multiplicative reduction in energy consumption, helping realize energy savings that  will cross the tipping point.

This indeed is the holy grail!

Monday, 15 May 2017

20. Call your mother, even if it is not Mother's Day

One more Mother's Day is history.

The number of messages  sent  (to  mothers) would have been record-setting.

With whatsapp ruling the day, most messages would have been text messages with lots of esoteric attachments proclaiming a son or daughter's love for their mother. However attractive your message to your mother was, it may not have had same impact on your mother as hearing your voice and responding to your greetings with her loving verbal hugs.

Fortunately, you don't have to wait for the next Mother's Day to make amends. Mother's Day or not, mothers love the voice of their children.

So, even if you sent a text message to your mother,  call her. Like any mother, yours would love to hear your voice. I am sure your mother will not complain that  you had already written to her. And, you have many reasons to call her...

  • because she is always wondering how you have been -- during your last  call to her, weeks ago, you sounded as though you had a cold. She is worried whether  you are ok now. 
  • because you had to interrupt your last call to her -- your boss called to firm up the date for an important meeting. You had promised to call her soon after, but that is yet to happen.
  • because even though she has live-in help since she lives alone,  a call from you will perk her up like nothing else. At her age, hearing the voice of her children and grandchildren  can do wonders to her demeanor. 
  • because your mother's experience in managing a family can benefit you;  so far, even though you need her advice badly, you have been reluctant to ask.
  • because your mother  has done for you things like nobody else can or will. For all the hours she has  put in to nurture you, you can not compensate  her, but calling her  is the least you can do.
Whether or not you called or wrote to your mother on Mother's Day, call her today.

She deserves to hear from you everyday!

Wednesday, 10 May 2017

19. Self-financed medical care -- A case study

This posting is in the context of the ongoing furore about the overhaul of medical care in the US.  Much of what we have been hearing about have no faces attached to them, and so in some sense remain abstract. This blog entry -- which is an actual letter written to hospital authorities -- presents a real-life case study, elaborating on  the kinds of charges patients are highly likely to see in their hospital bills -- charges that they usually do not care about or take the time to decipher since they don't directly pay the bills. But, with more people expected to become uninsured, it is imperative that we get familiar with them.

The purpose behind the sharing of our case is to educate and inform.  The actual players in this case are not important, but the scenarios and their implications are. I hope others  will come forward and share their experiences, nay, nightmares.

Comments, as always, are welcome.


Dear Doctors:

Greetings !

At the outset allow me to introduce myself. I am Prof. Krithi Ramamritham, Former Dean of Research and Development, Indian Institute of Technology, Mumbai, India. I have lived in the US for over 20 years (during which time I was a tenured professor at UMASS). I am a US citizen and both my children are studying in the US. I am considered to be an accomplished computer scientist and returned to India to enhance its research potential in information technology and computer science, but I continue to travel back and forth.

In December 2009, I was diagnosed with Leukaemia in India. We had several options, but ... undoubtedly your hospital  was our first choice and we are glad to have made that choice. My medical record number is ... . At that time however, I had no medical insurance in the US but had to leave for medical care immediately, as the window of opportunity for treatment was small.

We were asked to pay a deposit of $40,250 which we did before we arrived here. Subsequent to seeing me in person and based on results of diagnostic tests, decision was made by Dr. ...  to proceed with a Bone Marrow transplant, at which point we were asked to pay another deposit based on a detailed estimate. So we paid up a total of $276,950 upfront. However, to our dismay my family discovered that even before the transplant, the balance in my account was just $12,000! And, this is on the 7th day after admission and without any complications. Of course this imposed a great amount of stress and anxiety for my family, as we had borrowed heavily to comply with the prepayment requirements of your hospital.  My family, out of concern for my health, shielded me from this news. If I had known then I would most certainly have reconsidered our previous decisions.

I have now seen all the letters and the discussions my family members had with you. I was very happy to know from my wife and brother in law, the consideration you have given to our case. I was also briefed by my brother in law that Dr ...  specially met him and assured him that he and Dr ... would do the needful and find a fair solution and help the family. He also reassured that the family should not worry about the financial aspects and should look after me very well and Dr ... and Dr .. will try and do their best on the financial aspects. Thereafter, I understand that my family members met Ms. .... While she conveyed that Mr ... has approved a special discount of 15% on the gross billings from the first dollar, we explained to her as to why we deserve a much higher discount than the 15 % specially approved by Mr ... We also followed up with a mail giving all the justification. I would like to present the justification once again here:

o       I am a US Citizen but unfortunately uninsured when I was admitted.

o       I file my tax returns in the US and has been paying taxes. My adjusted total income was about $xyz for the year 2008 and about $xyz for the year 2009.

o       Since the doctors that we consulted suggested that it is best for me to go ahead with the bone marrow transplant immediately without losing time we decided to go ahead with this decision even though the insurance through my visiting position at UMASS commenced from 1st July, 2010 and only the expenditure incurred after this date would get covered under such insurance.

o       We were asked to pay a deposit of $ 276,950 which we paid promptly in a matter of few days time. In order to meet this, we had to borrow and fund the treatment. You have to appreciate that it is extremely difficult for an ordinary person to promptly respond to a huge payment obligation of $ 276,950.

o       The deposit of $ 276,950 included about $ 150,000 for transplant which would cover hospitalisation for about 40 days (10 days prior to transplant and 30 days post transplant), all the labs, diagnostic investigations, doctors' visits, medicines and IV infusions, etc. It also included about $ 63,000 for 90 days visit to the hospital post discharge. My performance so far has been above average (as confirmed by the doctors) and I stayed in the hospital only for 23 days (instead of 40 days as estimated) and luckily I have had no complications and since I was self paid, most of the medicines by way of tablets were purchased by us outside of hospital pharmacy. Thus I would not have used at least $ 50,000 of the deposit for the transplant due to early recovery and purchase of medicines outside of the hospital. To summarize, based on the estimate which was given for an average case (whereas my recovery has been above average), our bill should not have been more than $ 225,000 until end of August 2010. Considering the insurance coverage from 1st July, 2010, the bill should not be more than $ 200,000 whereas the bills total $ 434,000 as of date.

o       There was no communication from anyone in the hospital until the last week of May 2010 post the transplant that I can apply directly to companies manufacturing drugs and seek assistance. Though late, we approached the companies through Mr ..., Patient Reimbursement Specialist and convinced some of the companies to provide assistance to us. Some companies agreed but some did not, saying that they don't cover treatment for past dates and would cover only for future consumption. One such replacement we could succeed was for Clofarabine for which we were debited $ 119,250; we have talked to the company directly several times and convinced them to support us before they agreed to the same. Ms. ... also confirmed that   the replacement medicines have arrived and she would reverse the amount by end of this month and that would reflect in the bill by the first week of July, 2010. To conclude, we have put in efforts to secure 100 % replacement for many of the costly medicines; the pharmacy has charged at least 5 times the prevailing market price in US, but has agreed to just 15% discount.

o       The estimate given by the hospital for entire transplant and post discharge of 90 days was exhausted even before the transplant had taken place giving my family unbearable shock and distress. No one has explained to us about the cost of the medicines or treatment for the plan chosen. We were repeatedly told that the estimate is based on the average and if there are no complications or above average, our spending will be much lower than the deposit paid.

o       The price charged by the hospital for us after the discount is much higher than price charged to insurance companies who were able to negotiate. Considering the fact that I started my employment on 1st May, 2010 we have requested a higher discount as you would have given to any large insurance company. This would help us financially to cope with the present situation.

o       We have also explained to Ms. ... that from all the information we have been able to gather, the prices we have been charged by the pharmacy for medicines and the prices charged by the hospital for room rent, doctors' visit, labs and diagnostic investigations are much higher than the price paid by insurance companies.  We were advised by one of the large insurance companies that a similar transplant from investigations, harvest, hospitalisation and transplant to post discharge activities would cost about $ 145 k as compared to $ 434 k which is billed as of date. Hence our request for a higher discount rate, trusting the words of Dr ... and Dr ... who agreed to find a fair solution. We are sure that you can verify these numbers as you have all the information with you. We are sure that our request for a higher discount is reasonable and would qualify very well in the definition of "fair solution" as committed by Dr ... and Dr .... When we are charged over 60% higher rates than that of market rates or insurance company rates, we deserve much higher discount than the 15% offered now.

I would have expected a bit more sensitivity and consideration towards a patient's situation, that too to a patient who is doing everything to follow the rules and who paid upfront the entire amount after having borrowed the funds. First of all, communication and information appears to be rather disjointed giving rise to unnecessary confusion and misinterpretation. Secondly, since we were forced to borrow funds at high interest rates, I have repeatedly requested for consideration for a slightly higher discount with your business service and the finance offices.

While I fully appreciate your kindness in agreeing to a discount of 15% on gross billings, I have given all the justification as to why it has to be more than what you have given. Also, we completely trusted the words of Dr ... and Dr ... that they would find a fair solution and we feel that what has been offered does not appear to be fair and hence our appeal. I sincerely request you to allow me the privilege of meeting with you in the hope that at least I can come across and convince you for a higher discount. Your kind consideration in this regard will be highly appreciated.


Krithi Ramamritham

Sunday, 7 May 2017

18. What does the future hold?

Today is the First birthday of our grandson. What an exciting year it has been!

With Facetime, Skype and other communication tools helping us to keep in constant touch , one would not expect any surprises when you see someone after a long gap. Does the lack of physical proximity and the missing sense of touch make a difference? Indeed, it appears that it does and it seems that the difference is more for the child than us, but it does exist for both. Be that as it may, even if you “see” the child almost everyday, nothing prepares you for the thrill of  tactile  as well as face-to-face experience.

One expects that since the child had been seeing you everyday, he would jump from his parent’s arms on to you without hesitation, and when that happens only after some delay, you ask, why? But, the exhilaration is to be felt to be believed. Neither is one prepared for the almost daily changes in the child’s cognitive and physical skills. Sometimes one wonders, how does a child learn? How is it that suddenly it seems he starts crawling or standing up and one fine day starts walking without support. What makes some toddlers do some of these things sooner than others? Do one year olds have worries like their parents? Do they think to themselves: OMG, that kid who was born 10 days after me has already started walking, whereas I  am barely able to crawl.

I am sure pediatrics science has answers such questions but won’t be surprised if each study designed to find answers to such questions raises more questions than it answers. For example, how does a baby learn to recognize its parents at an early age? But, that raises the question: How do we know that  the baby has indeed recognized its mom or dad?

Now, why do we ask such questions? Even more puzzling is: why do humans spend  the time and resources to answer such questions, which do not seem to have any material consequences?  (See) Why do we do what we do?From time immemorial, humans have been curious, sometimes just because of the joy and satisfaction one gets in solving a problem, sometimes because the answers lead to a better world. Once we have the  answers and they can be targeted at benefiting humanity, obviously it is important to capitalize on our new-found knowledge, for example, by converting the answers into the development of  useful interventions for combatting medical problems.

That brings us back to our ongoing struggle to make the benefits of developments in medical science reach those who are desperately in need of it, but just cannot afford it? Is it ethical to allow such a phenomenon to prevail? Consider the turmoil that is about to be unleashed by the end of  Obamacare. Most people seem to have reconciled themselves to the inevitability of its demise.  

How can we combat this palpable apathy and indifference?    

How can we make the world a better place for my grandson?

Friday, 5 May 2017

17. Overhaul of the US healthcare system -- speak up America

The  US Congress has taken the first step to  repeal of The Patient Protection and Affordable Care Act, often shortened as the Affordable Care Act (ACA) and nicknamed Obamacare. 

The nightmarish experiences of seven years ago appear in front of my eyes. Even deep inside me, I can feel the jitters. 

So can 10's of millions of Americans who have what is  referred to as a "preexisting condition". And, I have two!  So many "what if"s. Patients without insurance have more than their medical condition to worry about. "Control the spiralling nervousness", I tell myself. But, given what happened seven years ago, it seems like a hard ask. 

Subsequent to seeing me in person and based on the results of diagnostic tests, decision was made by my doctors  to proceed with a Bone Marrow transplant, at which point we were asked to pay a deposit (since we had no medical insurance in the US) based on a detailed cost estimate. So we paid up a total of $276,950 upfront. This included about $150,000 for transplant which would cover hospitalisation for about 40 days (10 days prior to transplant and 30 days post transplant), all the labs, diagnostic investigations, doctors' visits, medicines and IV infusions, etc. It also included about $ 63,000 for 90 days visit to the hospital post discharge. 

However, to our dismay my family discovered that even before the transplant, the balance in my account was just $12,000! So, the estimate given by the hospital for the entire transplant and post discharge of 90 days was exhausted even before the transplant had taken place giving my family unbearable shock and distress. And, this is on the 7th day after admission and without any complications.  We were repeatedly told that the estimate is based on averages and if there are no complications, our spending will be much lower than the deposit paid, and that is how it should have been. 

Since the doctors that we consulted suggested that i must go ahead with the bone marrow transplant immediately without losing time we decided to go ahead with this decision even though there were questions about the finances needed for further treatment. Fortunately my colleagues at UMass came to my rescue  and worked out an arrangement whereby I was able to carry out a collaborative project long distance, and benefit from the accompanying medical insurance.

After the transplant,  from all the information we were able to gather, we inferred that the prices we had been charged by the hospital's pharmacy for medicines and the prices charged by the hospital for room rent, doctors' visit, labs and diagnostic investigations were much higher than the price paid by insurance companies. This was truly unconscionable.  I was reminded of these and other aspects of the treatment  that happened  6 years ago. 

Clearly, many sleepless nights are in store. 

A patient undergoing treatment for deadly diseases such as LA is clearly worried about whether he or she will be lucky enough to see the next day.  For an uninsured patient, the worries are compounded by the question of where the next Dollar required to continue the treatment will come from; this worry will only help hasten the end of the patient's life!

Clearly, such an outcome will reduce the overall costs of medical care in the US. After all, there is no need for any further spending on a person who is no more. 

A very clever idea indeed!