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Monday, June 29, 2015

"It's not so elementary, Watson." Developments in Health IT

From The Washington Post:
IBM is now training Watson to be a cancer specialist. The idea is to use Watson’s increasingly sophisticated artificial intelligence to find personalized treatments for every cancer patient by comparing disease and treatment histories, genetic data, scans and symptoms against the vast universe of medical knowledge.

Such precision targeting is possible to a limited extent, but it can take weeks of dedicated sleuthing by a team of researchers. Watson would be able to make this type of treatment recommendation in mere minutes.

The IBM program is one of several new aggressive health-care projects that aim to sift through the huge pools of data created by people’s records and daily routines and then identify patterns and connections to predict needs. It is a revolutionary approach to medicine and health care that is likely to have significant social, economic and political consequences.

Lynda Chin, a physician-scientist and associate vice chancellor for the University of Texas system who is overseeing the Watson project at MD Anderson Cancer Center, said these types of programs are key to “democratizing” medical treatment and eliminating the disparity that exists between those with access to the best doctors and those without.

“I see technology like this as a way to really break free from our current health-care system, which is very much limited by the community providers. If you want expert care you have to go to an expert center,” she said, “but there are never enough of those to go around.”

Instead of having to find specialists in a different city, photocopy and send all the patient’s files to them, and spend countless hours researching the medical literature, a doctor could simply consult Watson, she said...

...[T]he Watson project and similar initiatives also have raised speculation — and alarm — that companies are seeking to replace the nation’s approximately 900,000 physicians with software that will have access to everyone’s sensitive personal health information.

While there’s much debate about the extent to which technology is destroying jobs, recent research has driven concern. A 2013 paper by economists at the University of Oxford calculated the probability of 702 occupations being automated or “roboticized” out of existence and found that a startling 47 percent of American jobs — from paralegals to taxi drivers — could disappear in coming years. Similar research by MIT business professors Erik Brynjolfsson and Andrew McAfee has shown that this trend may be accelerating and that we are at the dawn of a “second machine age.”

Scientists are already testing baker bots that can whip up pastries, machines that can teach math in the classroom and robot anesthesiologists.

Many physicians and academics in medicine have come to view Watson’s work with reservation, despite reassurances from IBM officials that they are trying not to replace humans but to help them do their jobs better.

“I think a lot of folks in medicine, quite frankly, tend to be afraid of technology like this,” said Iltifat Husain, an assistant professor at the Wake Forest School of Medicine.

Husain, who directs the mobile app curriculum at Wake Forest, agrees that computer systems like Watson will probably vastly improve patients’ quality of care. But he is emphatic that computers will never truly replace human doctors for the simple reason that the machines lack instinct and empathy.

“There are a lot of things you can deduce by what a patient is not telling you, how they interact with their families, their mood, their mannerisms. They don’t look at the patient as a whole,” Husain said. “This is where algorithms fail you.”...

One of the top priorities for programmers was to give Watson the power to read and understand natural language. They also gave it the ability to generate hypotheses and locate and parse evidence to support or refute them.

Much like the human brain, Watson has become smarter over time by learning from its successes and failures and from user feedback.

Watson is literally evolving.

In the beginning, Watson’s knowledge base was limited to trivia for “Jeopardy!” But since its debut on national television in February 2011, Watson has devoured many thousands of literary works, newspaper articles and scientific journal reports as well as information input  by hundreds of researchers and doctors nationwide. These experts have helped the machine brain make more reasonable inferences and conclusions by reviewing Watson’s ideas and telling it whether it is right or wrong and by highlighting which sources­ of information are considered more reliable than others.

Unlike a human brain that can be distracted, confused or inspired by huge volumes of information, Watson is not a creative thinker but a rational one. It looks at known associations among various bits of data and calculates the probability that one provides a better answer to a question than another and presents the top ideas to the user.

Rob Merkel, who leads IBM Watson’s health group, said the company estimates that a single person will generate 1 million gigabytes of health-related data across his or her lifetime. That’s as much data as in 300 million books.

“You are deep into a realm where no human being could ever make sense of this information,” Merkel said. That's where Watson comes in to create a “collective intelligence model between machine and man.”

“We’re not advocating that Watson replace physicians,” he explained. “We are advocating that Watson does a lot of reading on behalf of physicians and provides them with timely insights.”

Originally made up of a cluster of supercomputers that took up as much space at IBM as a master bedroom, Watson is now trimmer — the size of three stacked pizza boxes — and versions of it live in the server rooms of IBM’s various partners.

IBM has so much faith in Watson’s innovativeness that in January 2014 the company announced that it would invest an additional $1 billion in the technology, and it created a new division to grow the business. Since then, IBM has highlighted health care as Watson’s priority and said it will dedicate at least 2,000 medical practitioners, clinicians, developers and researchers to the effort and will partner with Apple, Johnson & Johnson and Medtronic to collect patient information that consumers had consented to share...

It is Watson’s work in cancer that is the most advanced.

Among the most ambitious projects is a partnership with 14 cancer centers to use Watson to help choose therapies based on a tumor’s genetic fingerprints. Doctors have known for years that some treatments work miraculously on some patients but not at all on others due to genetics. But the expense and complexity in identifying genetic mutations and matching them up with potential therapies has made it difficult for more than a handful of patients to benefit from this new approach...
Given the personal revelations I just posted ten days ago regarding my recent cancer dx, this is of particular interest to me.

apropos of all of this, another interesting current article, courtesy of The Daily Beast:

The Human Machine
Biologists Are From Mars, Engineers Are From Venus
As IT feverishly vies to disrupt healthcare—and to hack the human organism—engineers are running up against a mindset that’s planets apart from their own.
In less than a generation, IT has smashed, recast and obliterated entire industries. Now the wunderkinds who brought us the Internet and apps for buying Jimmy Choos are laying siege to healthcare, eager to shake-up this most bloated of industries just like they did travel, finance and pet food.

Some in IT are hammering away at healthcare’s Byzantine cost and payment systems. Others are inventing apps and gizmos to collect heaps of health data on everything from sleep patterns to a person’s complete sequence of DNA. A few even talk about disrupting the human organism itself—hacking and reengineering people’s DNA, neurons and cells as if they were processors, motherboards and lines of computer code.

Not surprisingly, this assault of the nerds has encountered considerable resistance, even as some progress is being made. Reasons include cost and payment structures that defy logic, the heavy hand of regulation in medicine, and a powerful and conservative establishment that resists change. Yet there seems to be a much more basic issue at the heart of medicine’s rebuff of the changes offered by IT: that engineers fundamentally don’t get biologists, and biologists don’t get engineers.

This starts with an attitude towards the biology of humans. Engineers like to compare people to really complicated computers. Physicians and biologists beg to differ, saying that humans are far more complex in ways that might take decades or centuries to fully untangle...
With respect to where we stand today, the money quotes:
Engineers inhabit a planet where humans create the machines and the code, and where a better, smaller, and more nimble upgrade will be unveiled at next year’s electronics show. Biologists come from a land where three billion years of evolution created the bio-machines they work with; where their software and hardware is frustratingly obtuse, messy, and obscure, despite recent advances, and filled with redundant systems and twists and turns that no human engineer would ever design.

Engineers are also in a rush. They like to start small and to scale quickly, hoping to leverage small investments into billion-dollar hits that will reach billions of people. They needn’t bother with years of training, and some superstars of IT are college dropouts. They love taking risks and failing fast, and have a powerful culture built around the idea that if you build something cool, people will come.

Biomedicine moves slowly and deliberately, and is conservative about taking risks, particularly when lives are at stake. Practitioners spend years and decades in training, learning endless protocols and standards and procedures, and many devote entire careers trying to untangle a minute facet of a single bio-mechanism. And the idea of scaling—of creating protocols, drugs, and health apps that help millions or billions of people—only works up to a certain point, since people’s underlying physiology and their diseases tend to be different. This scientific realization is at the heart of what’s called precision medicine, the tailoring of drugs and therapies to an individual’s DNA and physiology.

Like IT, biotechnology has created dazzling wonders of high technology, everything from lightning-quick gene sequencers to surgical robots and drugs that target specific gene mutations to treat cancer. Most med tech, however, requires colossal investments and most fail, just like in IT, though they seldom fail fast. This is one reason that new technologies in medicine tend to elevate costs rather then decrease them, and why IT’s efforts to do to healthcare what Priceline did to booking hotels has proven so annoyingly difficult.

Enlightened leaders on both sides are working to breach the gulf between the two worlds. Smart engineers are realizing that they need to listen to and work closely with physicians and hospitals. (Just building a cool app isn’t enough). Doctors are also becoming more entrepreneurial as they work from the inside to build systems that save money and better serve patients—though they face a long slog to make this work...
"Most med tech, however, requires colossal investments and most fail, just like in IT, though they seldom fail fast. This is one reason that new technologies in medicine tend to elevate costs rather then decrease them, and why IT’s efforts to do to healthcare what Priceline did to booking hotels has proven so annoyingly difficult."
Which, among other things, begets repeated congressional hearings full of "Use Case Factories,™" "interoperababble," and general Policy ADHD whining about ONC "failures."

The foregoing articles take me back "Down in the Weeds'."
A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2 1⁄2 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about...
Physicians are right to condemn forms of control that involve exclusion of information and power over decision making. But physicians are in denial about the extent to which they themselves impose these forms of control on patients. Physicians are right to reject impoverished, cookbook medicine, but they are in denial of how impoverished is their own know-how. So too are they in denial when they view themselves as “highly skillful,” because their levels of skill would be far greater within a disciplined system of care. Physicians are right that “one cannot separate the decision from its context,” and they are right to reject uninformed controls by ‘outsiders.’“ But they are in denial of how much they themselves are uninformed outsiders to patients’ lives, outsiders whose exercise of control inevitably separates medical decision making from its context. And they are in denial of the need to submit to different forms of control over their own inputs to care—both decision making inputs and execution inputs.

Available on Amazon. My most recent excerpting citation of the Weeds' seminal book comes in my April 2015 post "Nurses and doctors in the trenches."

The Incidental Economist has also cited the WaPo article: "The algorithm will see you now, ctd"

Interesting links therein:
Here’s a University of Oxford paper on how susceptible jobs are to replacement by computers. Here’s Steven Pearlstein on a book from MIT scholars on the same theme. Here’s an article on algorithms replacing anesthesiologists.
Yeah. See my May 22 post "The Robot will see you now -- assuming you can pay."

More broadly, on this topic of "the end of work," a new book is coming out.

Preview of the riff here at Jacobin.
Much of the literature on post-capitalist economies is preoccupied with the problem of managing labor in the absence of capitalist bosses. However, I will begin by assuming that problem away, in order to better illuminate other aspects of the issue. This can be done simply by extrapolating capitalism’s tendency toward ever-increasing automation, which makes production ever-more efficient while simultaneously challenging the system’s ability to create jobs, and therefore to sustain demand for what is produced. This theme has been resurgent of late in bourgeois thought: in September 2011, Slate’s Farhad Manjoo wrote a long series on “The Robot Invasion,” and shortly thereafter two MIT economists published Race Against the Machine, an e-book in which they argued that automation was rapidly overtaking many of the areas that until recently served as the capitalist economy’s biggest motors of job creation. From fully automatic car factories to computers that can diagnose medical conditions, robotization is overtaking not only manufacturing, but much of the service sector as well.
Taken to its logical extreme, this dynamic brings us to the point where the economy does not require human labor at all. This does not automatically bring about the end of work or of wage labor, as has been falsely predicted over and over in response to new technological developments. But it does mean that human societies will increasingly face the possibility of freeing people from involuntary labor. Whether we take that opportunity, and how we do so, will depend on two major factors, one material and one social. The first question is resource scarcity: the ability to find cheap sources of energy, to extract or recycle raw materials, and generally to depend on the Earth’s capacity to provide a high material standard of living to all. A society that has both labor-replacing technology and abundant resources can overcome scarcity in a thoroughgoing way that a society with only the first element cannot. The second question is political: what kind of society will we be? One in which all people are treated as free and equal beings, with an equal right to share in society’s wealth? Or a hierarchical order in which an elite dominates and controls the masses and their access to social resources?

There are therefore four logical combinations of the two oppositions, resource abundance vs. scarcity and egalitarianism vs. hierarchy. To put things in somewhat vulgar-Marxist terms, the first axis dictates the economic base of the post-capitalist future, while the second pertains to the socio-political superstructure. Two possible futures are socialisms (only one of which I will actually call by that name) while the other two are contrasting flavors of barbarism...
Interesting stuff, all of it. Including this, below (My hardcopy Atlantic):

A World Without Work
For centuries, experts have predicted that machines would make workers obsolete. That moment may finally be arriving. Could that be a good thing?


Register today. Hope to see you there. Joe Flower will be on hand to meet & greet and sign his newest book, scheduled for release on July 30th.

I was honored to be among the pre-publication manuscript reviewers.


The day would be incomplete were I to fail to pimp my drought page.


I'm a regular at Science Based Medicine. I recently ran across this Atlantic article (I'm also an Atlantic subscriber)

I emailed SBM's Dr. Gorski to alert him. He replied:

LOL. Man! He did not disappoint.
NCCIH and the true evolution of integrative medicine

There can be no doubt that, when it comes to medicine, The Atlantic has an enormous blind spot. Under the guise of being seemingly “skeptical,” the magazine has, over the last few years, published some truly atrocious articles about medicine. I first noticed this during the H1N1 pandemic, when The Atlantic published an article lionizing flu vaccine “skeptic” Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration, entitled “Does the Vaccine Matter?” It was so bad that Mark Crislip did a paragraph-by-paragraph fisking of the article, while Revere also explained just where the article went so very, very wrong. Over at a blog known to many here, the question was asked whether The Atlantic (among other things) matters. It didn’t take The Atlantic long to cement its lack of judgment over medical stories by publishing, for example, a misguided defense of chelation therapy, a rather poor article by Megan McArdle on the relationship between health insurance status and mortality, and an article in which John Ioannidis’ work was represented as meaning we can’t believe anything in science-based medicine. Topping it all off was the most notorious article of all, the most blatant apologetics for alternative medicine in general and quackademic medicine in particular that Steve Novella or I have seen in a long time. The article was even entitled “The Triumph of New Age Medicine.”

Now The Atlantic has published an article that is, in essence, The Triumph of New Age Medicine, Part Deux. In this case, the article is by Jennie Rothenberg Gritz, a senior editor at The Atlantic, and entitled “The Evolution of Alternative Medicine.” It is, in essence, pure propaganda for the paired phenomena of “integrative” medicine and quackademic medicine, without which integrative medicine would likely not exist. The central message? It’s the same central (and false) message that advocates of quackademic medicine have been promoting for at least 25 years: “Hey, this stuff isn’t quackery any more! We’re scientific, ma-an!”...
And I get accused of writing long blog posts. Wow. Read this puppy. Where do you people find the time?

See also 'Drinking the “Integrative” Kool-Aid at the Atlantic' at The Neurologica Blog.

EHR Science update:

The latest at Dr. Jerome Carter's excellent site.
A Care Coordination Resources Page! 
by Jerome Carter on June 29, 2015 

Most EHR systems do not excel at coordinating care across multiple sites and clinicians. At a minimum, care coordination requires support for data sharing, synchronous/asynchronous communications, role-based information access and workflow support. Creating an ideal system for managing care across people and sites presents interesting architectural and workflow challenges, and as we move closer to the next generation of clinical care systems, more research and discussion into what makes for a good care coordination system is required.

With the above in mind, a resource page dedicated to care coordination has been added to EHR Science. In the first pass at gathering resources, I have added materials that go beyond those focused on technical aspects of software design or system requirements. Because care coordination requires significant organizational changes and workflow adjustments, resources that describe and analyze impacts on patients, clinicians, and organizations have been added as well...


More to come...

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