Will ValoBox (Web-powered Books) be the next iTunes for books and text contents?
Research is the fourth “R”, after reading, ‘riting, and ‘rithmetic and we need to learn well, here’s an argument
How technology hurts us — and how it can make us happier
What is Nodding Syndrome and how do you investigate if you come across a case series?
Why AI will eventually drive healthcare, but not anytime soon, or the clinician as a “Go” player
TechCrunch recently published a guest post from Vinod Khosla with the headline “Do We Need Doctors or Algorithms?“. Khosla is an investor and engineer, but he is a little outside his depth on some of his conclusions about health IT.
Let me concede and endorse his main point that doctors will become bionic clinicians by teaming with smart algorithms. He is also right that eventually the best doctors will be artificial intelligence (AI) systems — software minds rather than human minds.
That said, I disagree with Khosla on almost all of the details. Khosla has accidentally embraced a perspective that too many engineers and software guys bring to health IT.
Bear with me — I am the guy trying to write the “House M.D.” AI algorithms that Khosla wants. It’s harder than he thinks because of two main problems that he’s not considering: The search space problem and the good data problem.
The search space problem
Any person even reasonably informed about AI knows about Go, an ancient game with simple rules. Those simple rules hide the fact that Go is a very complex game indeed. For a computer, it is much harder to play than chess.
Almost since the dawn of computing, chess was regarded as something that required intelligence and was therefore a good test of AI. In 1997, the world chess champion was beaten by a computer. In the year after, a professional Go player beat the best Go software in the world with a 25 stone handicap. Artificial intelligence experts study Go carefully precisely because it is so hard for computers. The approach that computers take toward being smart — thinking of lots of options really fast — stops working when the number of options skyrockets, and the number of potentially right answers also becomes enormous. Most significantly, Go can always be made more computationally difficult by simply expanding the board.
Make no mistake, the diagnosis and treatment of human illness is like Go. It’s not like chess. Khosla is making a classic AI mistake, presuming that because he can discern the rules easily, it means the game is simple. Chess has far more complex rules than Go, but it ends up being a simpler game for computers to play.
To be great at Go, software must learn to ignore possibilities, rather than searching through them. In short, it must develop “Go instincts.” The same is true for any software that could claim to be a diagnostician.
How can you tell when software diagnosticians are having search problems? When they cannot tell the difference between all of the “right” answers to a particular problem. The average doctor does not need to be told “could it be Zebra Fever?” by a computer that cannot tell that it should have ignored any zebra-related possibilities because it is not physically located in Africa. (No zebras were harmed in the writing of this article, and I do not believe there is a real disease called Zebra Fever.)
The good data problem
The second problem is the good data problem, which is what I spend most of my time working on.
Almost every time I get over-excited about the Direct Project or other health data exchange progress, my co-author David Uhlman brings me back to earth:
What good is it to have your lab results transferred from hospital A to hospital B using secure SMTP and XML? They are going to re-do the labs anyway because they don’t trust the other lab.
While I still have hope for health information exchange in the long term, David is right in the short term. Healthcare data is not remotely solid or trustworthy. A good majority of the time, it is total crap. The reason that doctors insist on having labs done locally is not because they don’t trust the competitor’s lab; it’s more of a “devil that you know” effect. They do not trust their own labs either, but they have a better understanding of how and when their own labs screw up. That is not a good environment for medical AI to blossom.
The simple reality is that doctors have good reason to be dubious about the contents of an EHR record. For lots of reasons, not the least of which is that the codes they are potentially entering there are not diagnostically helpful or valid.
Non-healthcare geeks presume that the dictionaries and ontologies used to encode healthcare data are automatically valid. But in fact, the best assumption is that ontologies consistently lead to dangerous diagnostic practices, as they shepherd clinicians into choosing a label for a condition rather than a true diagnosis. Once a patient’s chart has a given label, either for diagnosis or for treatment, it can be very difficult to reassess that patient effectively. There is even a name for this problem: clinical inertia. Clinical inertia is an issue with or without computer software involved, but it is very easy for an ontology of diseases and treatments to make clinical inertia worse. The fact is, medical ontologies must be constantly policed to ensure that they do not make things worse, rather then better.
It simply does not matter how good the AI algorithm is if your healthcare data is both incorrect and described with a faulty healthcare ontology. My personal experiences with health data on a wide scale? It’s like having a conversation with a habitual liar who has a speech impediment.
So Khosla is not “wrong” per-se; he’s just focused on solving the wrong parts of the problem. As a result, his estimations of when certain things will happen are pretty far off.
I believe that we will not have really good diagnostic software until after the singularity and until after we can ensure that healthcare data is reliable. I actually spend most of my time on the second problem, which is really a sociological problem rather then a technology problem.
Imagine if we had a “House AI” before we were able to feed it reliable data? Ironically it would be very much like the character on TV: constantly annoyed that everyone around him keeps screwing up and getting in his way.
Anyone who has seen the show knows that the House character is constantly trying to convince the other characters that the patients are lying. The reality is that the best diagnosticians typically assume that the chart is lying before they assume that the patient is lying. With notable exceptions, the typical patient is highly motivated to get a good diagnosis and is, therefore, honest. The chart, on the other hand, be it paper or digital, has no motivation whatsoever, and it will happily mix in false lab reports and record inane diagnoses from previous visits.
The average doctor doubts the patient chart but trusts the patient story. For the foreseeable future, that is going to work much better than an algorithmically focused approach.
Eventually, Khosla’s version of the future (which is typical of forward-thinking geeks in health IT) will certainly happen, but I think it is still 30 years away. The technology will be ready far earlier. Our screwed up incentive systems and backward corporate politics will be holding us back. I hardly have to make this argument, however, since Hugo Campos recently made it so well.
Eventually, people will get better care from AI. For now, we should keep the algorithms focused on the data that we know is good and keep the doctors focused on the patients. We should be worried about making patient data accurate and reliable.
I promise you we will have the AI problem finished long before we have healthcare data that is reliable enough to train it.
Until that happens, imagine how Watson would have performed on “Jeopardy” if it had been trained on “Lord of the Rings” and “The Cat in the Hat” instead of encyclopedias. Until we have healthcare data that is more reliable than “The Cat in the Hat,” I will keep my doctor, and you can keep your algorithms, thank you very much.
Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.Related:
- Software crumple zones
- Why geeks should care about meaningful use and ACOs
- Why developers should enter health IT contests
- Epatients: The hackers of the healthcare world
Obama to Take Live Questions on Google+ Hangout Next Week
U.S. President Barack Obama will participate in an interview with YouTube users on Jan. 30, as he has done before. What’s different is that some of those questions will be asked live, via a Google+ Hangout. Would-be interviewers (who might be live, but will surely be tightly scripted) can submit questions via YouTube.
Rough Type: Nicholas Carr’s Blog: The Summers’ Tale
I think genomics-based EHR is a realistic expectation for future EMR designs but also needs to include enviromics at some point
Although I generally agree with what John Lynn posts on his blog over at EMR and EHR, one of his recent posts caused me to wince a little bit (see: Genomics Based EHR). He raises the issue of the “smart EMR” with genomic data as one its “core elements”. Here’s his note:
Why health care news readers need an “information diet”
As we close out the week and prepare to head to a beach for a desperately-needed mid-winter break, here are some catch-up items we meant to write about earlier.
- NPR interview with author of The Information Diet making the case for “conscious consumption of news and information.” We certainly make that case for health news and information – which often floods a thirsty public with a firehose of information when all they want and need is a sip of balanced, unbiased, complete information. Excerpt:
Top Environmental Stories of 2011, Christchurch is glaringly missing from the list.
By Nils Bruzelius, EWG Executive Editor
People are messy. So is nature. And what people do when nature unleashes its fury often makes things worse.
The staff at Environmental Working Group took a look at the major environmental news stories of the year and came up with two lists: the Top 10 Good News storie and the Top 10 Bad News stories.
Since environmentalism is mostly about limiting or preventing the harms done to people’s and the planet’s health by careless human activity, it’s hardly surprising that all but one of the “good news stories” involved doing something about problems that we humans created. The only exceptions involved contaminants that can come from both natural and man-made sources.
The message, once again, is that we are our own worst enemy. Good news comes when we do something to clean up our messes. Bad news comes when we create brand new environmental harms or risks, or just plain fail to address the ones already out there – even when we recognize the threat.
By a wide margin, EWG staffers said that the two top bad news stories of the year were President Obama’s decision to kill the Environmental Protection Agency’s latest effort to reduce the health threat from smog and the nuclear disaster that erupted in Japan when an unprecedented tsunami overwhelmed the defenses that were supposed to protect a complex of five reactors built at the very edge of the sea.
Trying not to get too depressed in the middle of holiday season, we’ll go to the good news first.
Again by a wide margin, EWG staffers said the two top good news stories were the growing momentum to limit or ban BPA and (in the messy category), the emergence of evidence that the drilling technique known as hydraulic fracturing really can be a threat to drinking water supplies. Drilling companies have insisted for years that fracking poses no threat to water supplies, but we’ve been skeptical, and so have many property owners in the states where drilling is intensifying. We’re glad to see some hard facts on the table.
First, the Good
Here’s the full rundown of the top good news stories as chosen by EWG’s researchers and other staff:
1. BPA Feels the Heat
Two months after trend-setting California banned the endocrine-disrupting chemical BPA in baby bottles and sippy cups (as of 2013), the federal Food and Drug Administration agreed under the pressure of a law suit to decide whether to eliminate BPA in all food packaging. Meanwhile, the American Chemistry Council, a trade group that has fought fiercely against the California bill and other legislative curbs on BPA, appeared to throw in the towel, at least part way, as it petitioned the U.S. Food and Drug Administration to “clarify for consumers” that it no longer uses the chemical in children’s food containers.
2. Truth Will Out: Fracking Has Tainted Ground Water
Giving the lie to gas drillers’ long-standing insistence that hydraulic fracturing to release shale oil and gas has never contaminated drinking water supplies, the Environmental Protection Agency announced that it had detected chemicals associated with fracking in groundwater in Wyoming. Earlier, EWG’s own investigation uncovered a long-forgotten 1987 EPA report that found fracking-related contamination in water wells used by West Virginia residents. In the face of mounting public pressure, meanwhile, regulators decided to postpone action on rules that could open the door to widespread drilling and fracking in the vast Delaware River watershed.
3. New Reason for Caution on Cell Phone Radiation
In another case where bad news is seen as good news – because it indicates that important new information is coming to light – the International Agency for Research on Cancer, a branch of the World Health Organization, for the first time listed radiation from cell phones as “possibly carcinogenic” to humans. The jury is still out on the possible health risks from these ubiquitous devices, but the decision was significant for those who live by the precautionary principle.
4. The Grand Canyon Gets Protection
Interior Secretary Ken Salazar took an important step toward protecting the chief water source for California and the Southwest when he extended for 20 years a ban on new uranium mining on 1 million acres around the Grand Canyon. EWG called attention to this looming danger in its report, Conflict at the Canyon.
5. Getting Rocket Fuel out of Water
Reversing a decision made during the administration of former President George W. Bush, the EPA said it will begin the process of setting legal limits on perchlorate, an ingredient in rocket fuel, and 16 other chemicals known as volatile organics that have contaminated water sources used by millions of Americans.
6. Blowing the Whistle on Sugar in Kids’ Cereals
Bringing renewed attention to a problem that food makers have persistently refused to correct, a widely publicized EWG report pointed out that a number of heavily-marketed children’s cereals contain unhealthy amounts of sugar, some of them more than popular desert items.
7. California Moves to Curb Chromium-6
California’s state Environmental Protection Agency adopted a first-in-nation health-based standard (public health goal) for hexavalent chromium in drinking water, the initial step in establishing a legal limit in drinking water for this widely found carcinogen that gained public notoriety in the movie Erin Brockovich.
8. HHS Calls for Less Fluoride in Drinking Water
Citing potential health risks to children, the U.S. Department of Health and Human Services proposed in January that utilities a, which EWG and other public health advocates had long recommended. Three days later, the EPA granted a petition by EWG and two other environmental groups to end the use of sulfuryl fluoride, an insecticide and food fumigant that is also a source of fluoride exposure.
After deliberating for 33 years, the FDA finally got around to proposing rules governing the content and labeling of sunscreen products, but in EWG’s view, they fall far short of the mark.
10. Brazilian Blowout Declared Unsafe
The FDA warned the makers of “Brazilian Blowout” in September that the company’s hair straightening product, which contains carcinogenic formaldehyde, is “adulterated” and “misbranded.” Earlier in the year, EWG’s investigation found that a total of 16 companies used high levels of the chemical as an ingredient in similar products.
Now for the top Bad News. Take a deep breath.
1. President Obama Kills Tighter Smog Limits
As summer was winding down, Obama shocked EPA Administrator Lisa Jackson and the environmental community by blocking plans to impose stricter national standards on ozone-containing smog. It was the strongest indication yet that the administration was approaching major environmental decisions with a cold eye on the 2012 election.
2. Fukushima Melts Down
By itself, the Japanese tsunami was a horrendous, almost unimaginable event, one that reminds us that even the most highly developed nations can be left all but helpless when the full forces of nature get unleashed. But what happened at Fukushima had a more profound lesson: that technological hubris, self-serving bureaucracy, lack of transparency and a host of other human failings always have the capacity to take a bad situation – and make it worse. Unfortunately, Japan will be reminded of this lesson every day for decades to come.
3. A Deadly Year for Foodborne Illness
Cantaloupes and sprouts. Record-setting outbreaks of foodborne disease in the United States and Europe underscored once again that assuring food safety is a critical priority. The U.S. listeriosis outbreak, which came just months after Congress passed major new food safety legislation, was linked to cantaloupes grown in Colorado. It killed 29 land sickened at least 139. In Europe, an outbreak ultimately linked to sprouts unleashed an unusually deadly strain of E. coli, killing at least 18 and sickening about 2,000.
4. House Republicans Target EPA and Environmental Regulation
Propelled by the anti-regulatory fervor of the Tea Party and Republicans’ desire to blame unemployment on Obama and “job killing” regulation, GOP members of Congress took aim at the EPA and environmental regulations of all types, even voting to block a non-existent rule on rural dust. The cost in lives, illness and economic loss from environmental degradation didn’t enter into the discussion.
5. Still No Reform for Outdated Toxics Law
Thirty-five years and counting. That’s how long it’s been since Congress passed the Toxic Substances Control Act, the only one of the 70s era environmental reforms that has never been updated. In public, there seems to be consensus that it’s high time to update a law that allows new chemicals on the market with no meaningful safety testing. But when it comes to actually working out a reform bill in the halls of Congress, that consensus evaporates.
6. Emissions Up, Action Down on Climate Change
Recently released data shows that in 2010, carbon dioxide emissions from fossil fuels jumped by the largest amount of any year since the industrial revolution. But in the United States, parts of Europe and much of the rest of the world, the prospects for concerted international action to curb climate change seemed to be fading away. Que sera, sera?
7. Fracking Wastewater Reaches Rivers, Water Treatment Plans
Wastewater from the natural gas drilling boom, laden with chemical contaminants and sometimes radioactivity, passed through sewage treatment plants that weren’t designed for it and ended up in rivers that supply drinking water to cities in Pennsylvania and elsewhere. Meanwhile, the battle over whether and how to allow fracking in New York State neared a climax.
8. Federal Judge Blocks S.F. Cell Phone Right-to-Know Ordinance
The EWG-led campaign to require cell phone retailers to post information about cell radiation emissions suffered a setback when a federal judge struck down most of an ordinance passed by the San Francisco City Council, but the battle isn’t over. A revised ordinance passed in 2011, but it, too, is being challenged.
9. Ballyhooed Solar Panel Company Goes Belly Up
President Obama’s effort to promote a “green economy” alternative to fossil fuels and to help revive the economy took a hit when Solyndra, a California manufacturer of solar panels, declared bankruptcy. Critics used the scandal to attack subsidies for alternative energy programs, but the fact is, petroleum and other fossil fuels have fattened up on federal subsidies for decades.
10. Contaminated Chinese Dry Wall
The online news organization Pro Publica brought national attention to the growing scandal over contaminated Chinese dry wall that emits foul odors, causes appliances to fail and mades people sick. Thousands of homeowners and renters were affected, and the scandal is still unfolding.
