Healthimer

If you decide to build a new Electronic Medical Record (EMR) System or some other smart tool to make a difference for the clinicians, would you build it up from scratch or would you look around for a ready-made platform to build upon. What if I told you told you there exists just the technology for building that next generation tool of yours? What more, it is free. Don’t believe me? Just read on.

• The said technology has at its heart a well-thought out and clearly documented protocol
• It allows plug and play applications that can be built with relative ease, because of exposed APIs that are easy to understand. Some of these might be automation tools, like agents or even user-assistance tools. So you can build a feature-rich system just by assembling third party gadgets. Suppose you want your coding done at the run time as you type or dictate your clinical notes, you might be able to just “add” such a tool to your application.
• It allows collaboration. This is not your mom’s collaboration (recipes over email), but real time collaboration, not just of text but of other database operations and actions that every other participant can see and modify. One could even think of hundreds of participants working over a common artifact. I daresay, the healthcare reform bill could have been written in 2 weeks if they had used Google Wave. (Not really. Technology can only help this much. Agreeing to agree, agreeing to disagree, disagreeing to agree, waffling, and grand standing would still take as long). The collaboration would not just extend to entry of clinical data (which itself could have multiple authors and sources, the clinicians, paramedical personnel, patient and families, medical devices, etc.) but also metadata and the knowledge artifacts that make such applications truly clinical by changing their behavior based upon current medical knowledge. Imagine, a group of cancer specialists and radiologists collaborating to create new rules for screening for breast-cancer – rules that are executable, not text admonitions. Rules that can be directly executed by the rules-engine of your clinical application to allow advising your next patient, whether she needs mammography or not based upon current research. The collaborations can be changed easily, with participants being included and dropped as easily, as needed, across boundaries of organizations.
• It automatically maintains a record of actions of all participants, so one can tell what data was changed by whom, where and when. This means you can roll-back any actions if you want, you can even rewind and play forward. This also allows keeping an audit trail of clinical activity and makes provenance possible for the knowledge and metadata that is authored by experts to provide the clinical intelligence for the applications.
• It has in-built capabilities for user authentication and data privacy.
• It has federated service architecture, which allows for flexibly linking up networks and for safety of data by redundancy. You may keep your network all to yourself of course, if that is how you like it.
• The specification for the technology is open and free and so is a much of the code for the service and the tools. Anyone can contribute towards improving the protocol and the API specification.

In short, it has much of the infrastructure taken care of so that you need to develop only the interesting stuff. Just a little bit of baking and some icing and you could have killer cakes going around.

I doubt if it is the first thing that comes to your mind, but I am talking of Google Wave of course. (https://wave.google.com/).

I became aware of Google Wave when it was rumored as Google’s next big project, to be released at Google IO 2009.  And released it was, with some fanfare. It was received with matching enthusiasm by developers. In the world of technology, new tools are announced every day. Most these days seem to be designed to facilitate teenage banter. Google Wave seemed like one more fun channel to help you make doodles while you chat.  I kept checking it on and off and saw it progressively improve. However, I never quite saw its value beyond chatting and working on documents with someone else at the same time.  Sure, some of the gadgets and robots that other developers created seemed clever but nothing that would make me log in everyday. Clearly, it was no alternative to email as it was made out to be by Google.

I was prodded into taking another look at Google Wave only recently when the paper by two Googlers, Gaw and Shankar was released. They propose use of Google Wave to create Personal Health Records (PHRs). They emphasize the collaboration capabilities of the Wave technology and how it would allow aggregation of clinical records for a patient from different resources. Spurred by it we had started researching if Google Wave is where we should be building authoring tools for Proteus and GreEd. We were really excited about its potential to provide a platform for collaborative development of executable clinical knowledge.

But soon we got the bad news that Google is pulling the plug on the product and any further development of the technology.

I am not the one to rush in to take up causes. But because you belong in a certain field some causes are given to you and you can’t just turn a blind eye to them. Google Wave is certainly one cause that seems worth fighting for. If enough number of thought leaders and developers make an appeal to Google, they may reverse their decision to kill Google Wave. Thus the campaign “Save the Wave”.

Please click on the following image and express your support.

Vote for Saving Google Wave

Some Clarifications:

• The protocol and the APIs are still undergoing development but have already demonstrated their potential by numerous applications that third party developers (individuals and corporations, both large and small) have created
• As far as I know, no auto-coding tool currently exists, but it will not be too difficult to build one on top of Spelly, the semantic spell-check robot that Google’s NLP group has developed.

One perk of managing your own blog is that every once in a while you can let your inner anarchy take over. You can violate its editorial policy or wander outside the confines of its designated subject area when the impulse gets the better of you.

Hearing about a new book, Long For This World, on NPR was the impulse for this post. The book, a fictionalized exploration of biology of aging and death, raises the possibility that living up to 1000 years or more may not be such a far-fetched thing.

So at last we will be immortal!

Or are you saying that our bodies will be? But to what avail?

Do we really want our physical forms to be around forever? Who would want a frail body to look after once we can have a fulfilling and perpetual existence in ‘cloud’, in a universe shaped exactly as we like?

I am convinced that as a species we have run the gamut and are nearing the end of our biological existence. We better get ready for an in silico existence, if not an extra terrestrial one.  No one knows when we will acquire capability to inhabit other planets but when it comes to a non-organic existence, we have already started creeping in that direction. Just chart the increase in time, over the last few years, which you spend in virtual domains including Facebook and Twitter each day. The culmination of this transition will of course be the complete relinquishment of our dependence on our bodies.

Paradoxically biological immortality might prove to be the death knell for our civilization if not our species. One good thing about a clock ticking away is that we all work (or at least some of us do) frenetically to get something worthwhile done between the two bookends. This has sustained our growth for thousands of years. With that pressure removed, won’t we become slackers?

One theory advanced for aliens not visiting us is that once an intelligent being is able to create perfectly satisfying virtual environs, real world exploration is not so thrilling anymore. You could create, or ask the computer to create, a perfect new adventure for you, one every nanosecond or one every millennium. Why explore boring planets.

Wishfully, we might imagine that we would want to keep on working on this progress thing and keep developing ‘cerebrally’, given that we would continue to be challenged and stimulated by our friends and peers who would also dwell in the same ethereal world. However, I am not too sure if we would remain tolerant of anyone challenging our line of thinking, if in our virtual existence, we could simply wish them away, replacing them with more pliant ones. In the final count, it might be just each one of us, alone. Alone, yes but lonely, never. Because we will always have the constructs and automatons, most beautiful ones, with just the right level of intellect accompanying us. After all we will be the ones imagining them into existence.

Once the transition is complete, it would not be as if a new species would be created (Homo siliconensis? Homo eletcronensis?), evolution itself would have evolved. And evolved in the most dramatic way. No more constrained by the physicality of molecules it will leap forward in ways unimaginable, at a speed quantum states can flip flop.

Will it be the Nirvana that Hindus and Buddhists so crave? Or the comfort that Shakespeare offers his soul?

So shalt thou feed on Death, that feeds on men,
And Death once dead, there’s no more dying then.

IEEE’s annual International Conference on Web Services and Cloud this year is featuring a special health informatics workshop.

Find more about the workshop and its call for papers here.

If you are interested in use of Web Services or Cloud Computing to make a difference in healthcare this will be an event to keep an eye on.

This is a great opportunity to present your ideas and experiences or demo some of the work you have already done.

Colonel Jack O’Neill, the intrepid leader of the Stargate SG-1 taskforce of the eponymous popular Sci-Fi TV show, in his time took some remarkably astute decisions, oftentimes in situations of great stress, saving our galaxy from being overrun by nasty alien races more than a few times. Now, O’Neill is a great generalist and thinks fast on his feet but he never was a paragon of erudition nor does he have any such pretensions. Indeed, he harbors a robust disdain for anything resembling scholarly pursuit. However we all know, in intergalactic matters our gut-level decisions are not always enough. From time to time we have to invoke a higher body of knowledge. When the Replicators were on the verge of exterminating humans and no weapon in possession of humans and their alien allies seemed to be having any lasting impact on the ferocious onslaught, it was clear a new kind of weapon was desperately needed if the Replicators were to be thwarted. Fortunately for the earthlings, Colonel O’Neill very recently, had downloaded into his brain the entire knowledge repository of an incredibly advanced race, the Ancients. Armed with this knowledge he could quickly devise a weapon capable of annihilating the Replicators. Needless to say, once again the Milky Way Galaxy was saved.

Note that O’Neill did not learn from the Ancients. Instead his mind just imbibed the knowledge. He ‘acquired’ countless skills, including those needed to deal with the Replicator emergency, without having to go through the arduous process of learning. I shudder to think what would have happened if O’Neill had had to read countless PDFs and WebPages before he was suitably equipped.

In short, the Ancients had developed the perfect technology to bridge the last mile knowledge gap, the gap between existing knowledge and its translation into practice, the gap that every human institution that works with knowledge has struggled with. No matter the amount of conclusive findings clinical research throws up, if the clinicians do not integrate them into their care-delivery is it worth anything?

Since beginning there has been the gap, the gap between research findings and how it is applied in practice.

The good intentioned knowledge producing people and institutions reduced it by making it easier for people to access the results of the research. This was done by using journals, monographs, textbooks and such, and later on making much of it available for little or no cost by the medium of internet.

But soon the realization dawned upon the knowledge producers and providers that just providing easier access to the research results is never going to be enough. The outputs of research efforts need to be sifted through to allow only the reliable information to impact practice. What came to be known as Evidence Based Medicine was driven by such meta-analysis. Besides vetting research for quality, the research results have to be articulated in actionable terms, which, in the field of medicine, came be known as clinical guidelines. The users of the knowledge, such as the clinicians, do not usually have time and inclination to undertake such analyses and translations. So it seemed to make sense that pre-processing the research results into meta-research and guidelines before it is made available will lead to improved application of the research into practice.

These efforts did result in narrowing the gap but not remarkably. The original enthusiasm for guidelines and meta-research seems to have lost steam.

What if a clinician’s mind had access to a knowledge repository just like the Ancients’, and had the ability to simply suck in on demand, the most appropriate pieces of knowledge? That would surely eliminate the gap.

A clinician with access to such a knowledge repository would be able to manage almost any condition using the best evidence and recommended practices. For such a scenario to unfold will take a very long time because we do not yet possess that level of ability to tinker with minds. However, we do possess reasonable knowledge of computers. After all we created them. Can we then think of a way in which all human wisdom, expressed into actions, be made available in a shared knowledge repository. The computer of the clinician can then access this knowledge on demand to get precise advice about what next needs to be done about the patient on hand. The wisdom in such a repository could be deposited, over course of time, by clinicians themselves to be shared with other clinicians. The clinicians would enhance the knowledge to work for themselves but will also be able to share it to be able to make significant difference to others.

What will be the form of knowledge contained in such a knowledge repository? Remember, the knowledge should be able to modify behavior of a computer system to be able to advise the clinicians about individual patients. Software has been used for a long time as the standard way of altering the behavior of computers. However, software is created by programmers with special skills using sophisticated development tools. If the knowledge repository has to acquire the necessary knowledge that evolves with the understanding of the experts and clinicians, it will need to be modifiable by people with clinical expertise who normally do not possess software development skills.

This is where knowledge form like Proteus comes in. The Proteus knowledge is executable and yet modifiable by clinicians. We are in the process of building early mechanisms to allow clinicians to deposit such knowledge in a publicly available repository, which will allow clinicians to integrate, on demand, any part of knowledge they need to modify behavior of the Proteus Engine, a software module which interprets the knowledge and provides advice to the clinicians about individual patients based on the data from those patients.

An annual fixture for Henry Ford Health System is its Quality Expo. This is an opportunity for the hospitals, clinics and many other departments of Henry Ford to present any efforts aimed at improving quality of our services. This year our Semantic Data Capture Initiative project was also on display. Team members, Teresa Hantz and Patti Williams of the CSRI Department created the flash video that was displayed next to the poster. We all were impressed by how quickly Teresa mastered the applications, Protean and the video capturing tool. It is also noteworthy that she managed to highlight the essence of the tools in less than three minutes of video.

This introductory video provides you with a quick overview of knowledge editing in Proteus environment as well as how easy it is to edit a rule in GreEd.

You can check out the video here: quality_expo2009.swf.  We suggest running the video in full-screen mode of your browser (press F11).

This is to announce the availability of source code for tools related to clinical decision support guidelines model, Proteus under an open source license (EPL). The open source development will proceed under the new Proteus Intelligent Processes (PIP) project.

With this announcement, we are also opening up the project for general participation. The code and related information can be found at http://kenai.com/projects/pip/.  The home for Proteus will remain at http://proteme.org. Introductory information about the rule authoring system GreEd is available at http://proteme.org/blog/greed/.

This also coincides with the release of the version 2.7 (beta), which has several new features to make knowledge authoring more exciting and easy.  Take the new application for a spin by downloading it from http://www.proteme.org/download3.html.

What’s New

I list some of the new features in Version 2.7 below:

Protean (Clinical Workflow Authoring Tool)

• Sharing executable knowledge
• Unlimited undo and redo
• Promotion and demotion
• Move an item from one location to another
• Search your library of components

GreEd (Rule Authoring Tool)

• Undo and Redo
• Default Inference
• Semantic Guidance and constraints
• New operators for your expressions, like [N of M] and [Between]
• Date Fields and Operations

Read more about the new features here: http://kenai.com/projects/pip/pages/WhatIsNew.

This is a major milestone for Proteus which was made possible by contributions from many wonderful people. Much of the development for this version was done in the Semantic Data Capture Initiative project of Henry Ford Health System, my employer. Besides Henry Ford, Lister Hill Center of National Library of Medicine played a critical role at the nascent stage of Proteus. Several ideas related to metadata usage and rule authoring were developed at City of Hope National Medical Center.

We will be scheduling a web seminar to provide a quick introduction to Proteus, GreEd and the PIP project and demonstrate the tools. Please let me know if you are interested in participating.

I will be at the upcoming AMIA annual symposium, in San Francisco and will be happy to meet you if you are planning to attend.

We welcome your participation and feedback.

Feel free to contact me.

In one of my previous posts, I had promised that I will be share with you more information about GreEd.  I did one better; I posted several pages about GreEd. You can find these here: http://proteme.org/blog/greed/

The same pages can also be accessed from the top menu of this blog.

Stay tuned, we will be adding some flash demos and tutorials for GreEd in near future. I will also keep you informed about development of GreEd.

P.S. Do not worry about mispronouncing GreEd, it is pronounced same as the good old human foible – greed. Either way, we wouldn’t be too offended.

The Henry Ford Health System is one of the largest health care providers of USA. It has also been at the forefront of many cutting edge innovations in healthcare. One such Henry Ford effort has been in progress, silently and away from the limelight, for the the last two years.  However, soon it will lead to deployment of Proteus – the unique clinical decision support technology and GreEd – the clinical/business rules management system to implement clinical guidelines to allow physicians to save time and yet make better decisions about their patients.

This effort is called Semantic Data Capture Initiative project. I have just added a new page on this blog to give you some idea of what this project is about.

The Semantic Data Capture Initiative page provides you with an overview of the project. I will keep posting updates from this project here. Stay tuned.

An interesting article in Washington Monthly highlights how VistA achieved its popularity was referred to on the AMIA Clinical Information System LISTSERV by Scot Silverstein.

To my mind, the key elements of VistA’s success are:

• Participation of clinicians at every stage of its development including their writing of pieces of code and modules
• Continuous, ongoing evolution and innovation
• High degree of adaptability to different needs, not in small measure due to its being open source
• Starting small and growing outwards, organically, rather than with a grand plan in a top-down approach

The bottom line is, Clinical Information Systems belong to clinicians. The sooner the Information Technology finds a way to hand it over to them the better it will be for the clinicians and for healthcare.

Imagine an astronaut hurtling through the immense void on his journey towards Mars in a space probe. It is a lonely journey and scary adventure. There are untold unknowns and even the known variables are so many that to keep a constant eye on each one of them is not possible for a single human. The only chance he has of making the adventure a success is by getting constant support from the proverbial ‘Houston’. ‘Houston’ translates into a large of team of scientists and engineers manning an array of sophisticated equipment in constant radio contact with the Mars probe. So not only can our astronaut flip a switch and say, “Houston, we have a problem”, when he senses something out of the ordinary, ‘Houston’ can also proactively inform the space traveler of any important issues that he needs to be aware of. ‘Houston’ might even address some of the issues remotely without distracting the astronaut from whatever else he might be doing.

Turn your gaze earthward now and look at a clinician entering into an exam room to see her patient. Read the rest of this entry »