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. The challenges she faces are no less daunting. The potential unknowns are many, and the knowns to be dealt with are numerous. A slip-up could easily cause injury or death (to the patient, not the clinician of course! Come on now, space travel was only a metaphor). Yet our brave clinician leaps into this void several times every day. I believe she deserves a “Houston” too. Indeed, it is almost certain that she will get her Houston.
What would a clinician’s Houston look like? As with NASA’s Houston, this too will have three components: the hardware, the software and the humanware. To the clinician, however, these would seem like a seamless support system working unobtrusively in the background and popping up only now and then to make the clinician aware of things that it cannot address on its own. The hardware would contain a rich net of sensors, reading the patient’s parameters and constantly feeding the data into the software, the electronic record for the patient. The EMR system itself would have clinical intelligence interwoven with it. No more would there be the divide between the EMR system and the clinical decision support system. Each datum would be wrapped with intelligence of its own and in turn would be a part of the schema which is subjected to ongoing intelligent interpretation. Alluring as all this is, for a long time, the humanware will remain the mainstay of our Houston. While the scenario where the patient is swathed in a fabric of sensors is in its nascent stage, a change is already underway. The nature of the clinical humanware as we know it, is about to undergo a sea change.
The Remote Physician
A new kind of physician is in evolution – the remote physician. As distinct from the point-of-care physician, the remote physician does not interact directly with the patient. She is more of a cerebral, left-brained individual, a bit of a nerd, has specialized in a micro-niche area of clinical medicine, and is quite adept at drawing sound conclusions from only data. She doesn’t collect the data but is plied with it by the point-of-care team and equipment. She also has a panoply of software, electronic libraries and other resources at her disposal. Throw a problem at her and she will give the most rational answer mixing sound clinical common sense with the best available evidence, if the problem is from her area of expertise. Indeed, she revels in tackling the knotty ones quicker than other mortals.
In course of time, physicians of her tribe will come to play an important role in healthcare. Each member of this tribe will dwell in his own micro-niche, but together they will cover much of the gamut.
Why Not Today?
The interesting thing is that such clinicians exist even today, the ones who much rather deal with the intellectual components of patient care than submit themselves to the hurly burly of the clinical world. We have all seen them – amidst our colleagues or perhaps in the mirror. Although the hardware part is gradually evolving to play its role in this scenario, the software technology, like the humanware component is already mature enough to deliver on this promise.
If the software technology is mature and the humanware is capable, why hasn’t at least this part of the ‘Houston’ supported care come to a pass already?
The main reason is the lack of software systems that can integrate the remote expertise with the local care. The clinical decision support has for long been viewed as a software-only problem. It is as if if we could only develop a great clinical rules system (or neural network system, or other pattern matching systems) the healthcare could be taken the next level in quality. The architecture has to allow not just the AI based clinical decision support but also the more powerful NI-based one (NI = Natural Intelligence, just in case you didn’t figure that out). The point of care clinician should get the best possible knowledge and decision support; it doesn’t matter whether at the back end the the required processing is done using expertise of humans or the smarts of automatons.
The other reason has lot to do with politics and sensitive issues surround healthcare and outsourcing. That might well be the topic of a future Healthimer post. For now suffice it to say that this is one area where much more outsourcing will be the other way round – the world would be seeking expertise of researchers and clinicians in countries like USA.
Read the article “Prescription for Change”, in WSJ by Amar Gupta which has similar ideas.