Navigating Healthcare – Patient Safety and Personal Healthcare Management

Healthcare – Its Personal

The Great Healthcare Debate

Healthcare is personal and front and center in our minds not just because we all intersect with it in some way but it employs 1 in 9 people in the United States. With the current state of our media and political system with polarized debates, he said she said talking heads on the media, the echo chamber of social media and the 24/7/365 barrage of news and fake news it can be hard to see a pathway out of the quagmire we find ourselves in. But we all want to see that path. I just don’t believe that people get up in the morning wondering how they can decimate the healthcare services and the lives of their fellow human beings. We don’t get up out of bed every day wondering how best to punish people who may have made bad choices in their lives or who find themselves in unfortunate positions though geography (the zip code effect) or genetics. I know I don’t and I don’t think you do either.

Yet the stream of coverage and what we read, see and hear online and sometimes even in person suggests that this is the case. I can’t answer the reasons why but I’ve read a string of articles and reporting that variably suggests its always been like this to this is the fault – and then insert the name of your favorite whipping horse. Ultimately it does not matter – unless you believe that people wake up with malintent every morning it’s better to start with an understanding of the problem and then thinking about possible solutions and how we can apply them quickly and effectively

So Let’s Start with some of the fundamental problems in our healthcare system – to be clear we are not alone in the world. I have seen and heard from many others in different countries who are all struggling to varying degrees and with different focus and priorities the same issues. If I had to boil it down to one issue I would say

Limited Resources and the Prioritization of the Allocation of those resources

It’s a familiar equation to anyone trying to balance their budget or allocate their time. If you are like me you may find there are just not enough hours in the day for the task list you created in the morning and wishing either to stretch time (time dilation) or perhaps be able to turn time back with the Wizarding world’s  Time Turner. There are two basic options available – reduce the inputs or reduce the outputs. In the vernacular of budgeting – either spend less or make more money. Both may be viable and depend on personal circumstance but undoubtedly there will be easier and harder solutions. Ultimately we all have to make our own personal decisions – so one solution or size does not fit all.

Photo from jenga.com

It would be foolish to suggest that this covers all the complexity of the healthcare system as we all know healthcare is incredibly complex and always reminds me of the game Jenga.

 

This does not cover everything and there are many other elements in play but it is certainly a start and one that individuals and organizations can focus on to start to make incremental improvements.

As one Chinese proverb states:

Every journey starts with a single step

And turning that step into a habit is one of the best ways of setting a path to improvement.

Demand Side of Healthcare

This is the access and use of the system and the burden does not just fall on the individual. But it does start there as it is out personal choices to access and use available services that creates demand. Historically in the United States, the cost and payment of this access have been disassociated from the individual. When you visit the doctor or pharmacy you don’t pay the actual cost of the service – your insurance carrier does. Ultimately we do all pay for this through our insurance premiums and for many the contributions made on our behalf by our employer that is part of the compensation we receive for working for them but at the point of care, we are disconnected from the price and cost of a service.

Patient Accessing Care

To a varying degree individuals have some form of co-pay – a personal cost that is defined by the insurance coverage and is shifting increasingly to the individual under the new insurance plans called High Deductible Health Plans (HDHP). One of the intentions of this policy is to make the individual responsible for this cost in an attempt to influence behavior and decrease unnecessary access. But this comes with the inevitable unintended consequences with cost avoidance strategies by individuals who knowing they will be held responsible for the full cost of a visit, drug or test may elect to decline to have or use the service.

 

I’d count myself in that crowd having been on a HDHP plan for several years. I can point to several decision where I have declined tests, treatment and access to care because of the nature of my personal responsibility – I have an associated health savings account (HSA) which should cover the capped amount of cost for the year. But the crippling nature of potential costs associated with a catastrophic medical problem – a serious accident, cancer, heart attack are all so terrifying that I see the HSA as a buffer against the potential of medical insolvency that might result especially when you consider the impact on a family with one source of income that would be impacted by any medical disability.

 

Insurers Paying for Care

Insurers want to reduce their costs – and even the non-profits have to make money so are focused on the bottom line if they want to continue to serve their customers and population. So they look to find ways to reduce the unnecessary access to care imposing barriers and limits. There was a gate keeper concept that requires a referral letter from a primary care physician before you can access s specialist – that service by the way costing you additional fees to see the primary care provider. There are formulary requirements that exclude certain drugs from coverage and attempts to limit access to specific doctors and networks to strengthen the buying and negotiation power of the payor with the providers in the system.

 

Providers Delivering Care

On the provider side the clinal professionals delivering the care all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors, it’s persistence and endurance that win out. The barriers to entry are high and tied to economics. They all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and they have bills to pay both for their education but also the infrastructure they must use to be able to both deliver care but also bill and be paid for delivering. They want to reduce their overhead and spend as much of their time and resources on the delivery of care but to survive in the system must allocate significant amounts of money to non-clinal systems and activities. Estimates of these costs suggest that at least 30% of the healthcare costs we as a society pay in the United States are tied to administrative and billing functions. The data’s still lagging but projections for 2016 put the total healthcare bill at $3.207 Trillion (thats $3,207,000,000,000 or more than $10,000 per person in the USA)

Healthcare Administrative Cost: $962 Billion Dollars

$962,100,000,000

 

Reconciling the Differences

Credit Imgur

The difference of opinion often centers on what is unnecessary – in the eyes of the patient they need and want the care they think is appropriate to them. Some of this is fed by a constant stream of information that even for an well informed clinically experienced specialist can be difficult to comprehend and make informed decision. We want wants best for our personal health and the health of our family and loved ones. But sometimes what the patient may think is best may not be – a great example is the steady stream of requests for antibiotics for treatments of minor infections. Not every sore throat or cough demands the use of antibiotics and in fact, in many cases, their use is damaging as we face a future where this line of defense is increasingly being overrun with smartly adaptive bacteria who develop resistance with terrifying speed.

 

Payors Perspectives

The same is true of payor and insurers – they face a rising tide of costs associated with care that is increasingly complicated and expensive and struggle to balance their budget.Faced with one patient who’s costs for treatment might be hundreds of thousands of dollars or more so they limit or decline this in favor of treating multiple other patients where their cost of treatment is thousands of dollars or less? The utopian answer is treat everyone but we they like each of us do not have unlimited budget or resources and have to make hard decisions. And the problem with healthcare fundedfor the population but access individually.

 

Healthcare is funded for the population but access individually

 

Clinicians Perspectives

Clinicians also have a view on what’s appropriate – and the vast majority act with total integrity (I would like to say all of them but sadly there are occasional stories of clinicians and healthcare professionals who game the system – sometimes with simple prescription based fraud or other times over treatment of stenting in cardiac cases). Sadly for a profession that is so dependent on trust the rare cases of fraud and abuse unfairly tar everyone with the same brush. As I said above – I believe everyone gets up in the morning with the best intentions and this is true of the clinal professionals who each and every day battle a system to deliver the care and compassion they set out to deliver when they took the path into healthcare. They want to say no to unnecessary treatment but the personal pressures applied and the underlying compassion and the innate drive that was the foundation of why they entered the profession can influence them to order and prescribe because they are unable to explain the lack of value and offering this option makes their patient happier and comfortable.

So how do we reconcile these differing opinions

 

Economics and Making Choices

Which path is best

There’s a sad fact in the US healthcare system – we do not talk about cost effectiveness. Its not just a taboo subject but also a forbidden topic, As Aaron Carroll (The Incidental Economist) noted in his piece Forbidden Topic in Health Policy Debate: Cost Effectiveness we avoid talking about cost-effectiveness in the United States.

Some think that discussing cost effectiveness puts us on the slippery slope to rationing, or even “death panels.”

As he points out – if there was a pill available that could extend your life by one day but costs a billion dollars, most would accept this as an unacceptable trade off and decline it. But that’ extreme – as you decrease the cost where does that line become blurred?

what’s to stop us from deciding that spending a couple hundred thousand dollars to extend grandma’s life for a year isn’t worth it either?

More troubling is the shackles that have been placed on the Patient Centered Outcomes Research Institute – who were founded but explicitly prohibited it from funding any cost-effectiveness research at all! How can an outcomes institute assess healthcare if cost effectiveness is not part of the equation?

“We don’t consider cost effectiveness to be an outcome of direct importance to patients.”

In fact, we in the United States are so averse to the idea of cost effectiveness that when the Patient Centered Outcomes Research Institute, the body specifically set up to do comparative effectiveness research, was founded, the law explicitly prohibited it from funding any cost-effectiveness research at all. As it says on its website,

PCORI was established to fund research that can help patients and those who care for them make better-informed decisions about the healthcare choices they face every day, guided by those who will use that information.

 

Quality-Adjusted Life Years

As he points out there is actually a fairly robust strategy and measure that can offer insights into the value of measuring health outcomes – QALY’s (Quality-Adjusted Life Years) which the National Health Service has been using fro some time in the National Institute for Health and Care Excellence (NICE) that provides guidance, advice, quality standards and information services for health, public health and social care. Also contains resources to help maximise use of evidence and guidance. There is no doubt they are imperfect but very little in life is perfect and perfection should not be a barrier to progress. The use of this is not a sole determinant – but offers some measure of science and data to making what are incredibly difficult tdecisions

So in the current debate of what health system we need to put in place I would advocate the inclusion of cost effectiveness as one of the factors that must be considered and the QALY and perhaps even the Incremental cost-effectiveness ratio (ICER) as part of this difficult discussion.

I’m all about incremental changes and while including a cost effectiveness as a measure may seem a bigger stretch I feel it is a smaller step in the right direction. Can we achieve this? Is there a better incremental step we can take to resolve the challenges of our healthcare system? Leave your thoughts below.

Healthcare – Its Personal was originally published on Dr Nick – The Incrementalist

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Treatment Creep in Medicine – sucking Decency out of Patients

This recent post on the Atlantic: How CPR Became So Popular reminded me of a piece I wrote some time back – Doctors Die Differently. As I said then:

Its not that doctors don’t want to die, its just that they knwo they know enough about modern medicine to know its limits, importantly they have talked about this with their families as they want to be sure that no heroic measures will be used during their last moments in this reality

And the chart demonstrating the big discrepancy between what doctors want in life saving measures vs the general public pretty much said it all

So this piece in the Atlantic took it a step further – tracing the history of CPR from the 1960 at Johns Hopkins where the surgeons had

…successfully resuscitated every one of the first 20 patients they treated, 14 of whom (70 percent) survived without brain damage or other ill effects

But their source patients were not typical (young and mostly healthy) and when you extrapolate that out to an elderly population survival can fall to as low as 0% a variation in the effectiveness when performed in the real world
But it was Hollywood adn the media that pushed these procedures into the general awareness suggesting

…that two-thirds of all (fictional) cardiac arrests portrayed on ER (and other doctor shows) involved young patients who had suffered rare events like drowning or lightning strikes, rather than old people with heart disease (who account for 90 percent of cardiac arrests in real-life settings…..most of these fictional TV patients did well, unlike the vast majority of CPR recipients in real life

Dr Peter Benton was well known as all in life saving heroics

In fairness Hollywood was dramatizing some real life events – and they applied their pixie dust to this as they have to many other things.

But the problem remains and health care professionals need to help their patients understand their disease and make good choices, bearing in mind that heroics and life saving may well be a significant driver as it was for Stephen Jay Gould who was diagnosed with a rare and deadly cancer with a median survival of eight months…but as he said in his essay “The Median Isn’t the Message“.

this median survival means that one-half of patients die within eight months but the other half live longer. Most important, because the mesothelioma survival curve has a very long “tail,” a few lucky patients will live a lot longer

In his case his experimental treatment may have contributed to his 20 year survival past the original diagnosis…leaving a legacy of hope.

Science, Evidence and Clinical Practice

A recent article on the The Difference between Science and Technology in Birth on the AMA site demonstrates the challenges we still face in getting clicnal practice influenced by science and data. Studies and data may show the path for best clinical practice but as the authors note there are multiple instances of the clinical community – in this case the OBGYN – either knowingly or unknowingly failing to follow the best practices

For deliveries in the US evidence tells us that fetal monitoring in low risk pregnancies has a deleterious effect – yet it remains standard practice in most settings to place external scalp electrodes and intrauterine pressure catheters

Although we still see external continuous fetal monitoring employed in many low-risk pregnancies, “as a routine practice [it] does not decrease neonatal morbidity or mortality compared with intermittent auscultation…. Despite an absence of clinical trial evidence, it is standard practice in most settings to place internal scalp electrodes and intrauterine pressure catheters when there is concern for fetal well-being demonstrated on external monitoring” [3].

 

They list several other standard practices including

  • routing episitomy
  • Use of Doula’s
  • Challenges with Epidurals

Reasons for these behaviors are varied but as the authors state:

Many well-intentioned obstetricians still employ technological interventions that are scientifically unsupported or that run counter to the evidence of what is safest for mother and child. They do so not because a well-informed pregnant woman has indicated that her values contradict what is scientifically supported, a situation that might justify a failure to follow the evidence. They do so out of tradition, fear, and the (false) assumption that doing something is usually better than doing nothing

Until we fix these basic issues there seems limited opportunity to implement intelligent medicine and real evidence or science based practices.

 

Five Technologies that will Change the Practice of Medicine

Speech Technology

Speech recognition offers efficiencies today but recent innovations and new technologies will expand the horizon of opportunity with speech technologies that will change the human computer interface, simplifying the interaction and offering new and innovative tools that increase efficiency and safety of healthcare delivery and reduce the administrative burden and decrease costs.

Medical Intelligence in the Cloud

We’re facing a tsunami of patient data. The ability to process and leverage this data at the point of care is gone. Cloud based intelligence, analyzing data content and delivering contextually relevant information in real-time will become essential.

Continuous Mobile Monitoring

Our current perspective of a patient’s healthcare record is comprised of snippets of our total healthcare record (imagine a piece of string as the record – all we get is a very short piece when we visit a doctor/facility). Continuous monitoring (wireless, cloud based and automatically monitored and tracked) changes this and offers more complete view of our health record and more important data that is not just single data points but trends and changes.

Personal Health Management

This is becoming essential as we move from a system that disconnects the purchaser from the payer. It’s as if we were buying a car but someone else was paying with no personal financial consequence – we would all buy Ferrari’s, Porsche etc. As we move away from this model, personal responsibility, personal health management tools and PHR’s will become essential, not just for capturing and holding the data, but for helping people interpret and manage their own care. We will all become our own care coordinators for ourselves and our extended family, but will need the tools and solutions to help – these will come in form of PHP and health management tools.

Social Media in Healthcare

If World of Warcraft can engage a generation of young adults and teens to stay online, engaged and spending enormous sums of money, the gaming industry is doing something “right”. Applying this to health and getting folks engaged is the next frontier. We have already seen that just giving a patient access to their medical record and putting a definitive Diagnosis of obesity has a positive impact on their behavior and general health. Imagine what else you could do with social media and gaming engagement.

But as always – don’t forget the patient. As I have noted before Doctor Please Look at Me not Your EMR

This was amplified in a recent article in JAMA: A Piece Of My Mind (JAMA. 2012;307(23):2497-2498. doi:10.1001/jama.2012.4946) that included this drawing from a 7year old girl:

Evidence Based Medicine, Medical Malpractice and Incentives

Posted in Evidence Based Medicine, Health Reform, Malpractice, Safety by drnic on December 8, 2010

A recent Dustin Comic like all good comics hit the proverbial nail on the head

Unfortunately the healthcare reform fails to address key aspects to the incentive problem in healthcare. The system remains centered on measuring what we do for patients rather than the end result.

There are moves by employers and the insurance industry to incentives patients towards healthier behavior. This approach is not without problems as highlighted in this piece in the New England Journal of Medicine “Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives” where the authors highlight the challenges for employers, employees and insurance in creating incentive and how this can introduce inequities that do more harm than good. As they point out

If people could lose weight, stop smoking, or reduce cholesterol simply by deciding to do so, the analogy might be appropriate. But in that case, few would have had weight, smoking, or cholesterol problems in the first place

There is no doubt that patient incentives must be part of the solution but require thoughtful design and implementation to avoid the pitfalls

Incentives for healthy behavior may be part of an effective national response to risk factors for chronic disease. Wrongly implemented, however, they can introduce substantial inequity into the health insurance system. It is a problem if the people who are less likely to benefit from the programs are those who may need them more.

But incentives aligned to the practice of evidence based medicine and in particular the financial challenges facing the ever increasing ordering of tests is where there seems to be significant progress. The announcement of a statewide adoption of Radport by the Institute of Clinical Systems Improvement (ICSI), a nonprofit comprising 60 medical groups, 9,000 physicians, and six payers and health plans was covered extensively at RSNA 2010 in Chicago this year and featured in this piece in Information Week “System Helps Doctors Pick The Right Tests” demonstrating a saving of $27 Million over the preceding year

During the yearlong pilot involving more than 2,300 ICSI-member physicians, ICSI saw no growth in the number of high-tech diagnostic imaging tests ordered. In previous years, the number of tests ordered grew about 8% annually…The lack of growth translates to a savings about $28 million for the year

But any discussion on incentives needs to include the issue of malpractice – liability drives behavior in the same way as incentives do (in some respects its incentive in another from). Peter Orszag opinion in the NY Times Malpractice Methodology makes the point that

The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.

President Obama weighed in on this issue in June 2009 when he spoke to the American Medical Association when he highlighted the “unnecessary tests and treatments (ordered by doctors) only because they believe it will protect them from a lawsuit” and as he put it

We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines

Medicine remains “more evidence-free” than should be the case:

One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice

Addressing the issue of liability can take the traditional approach of limiting punitive damages but as Peter Orszag said “provide safe harbor for doctors who follow evidence-based guidelines” is a much better idea and one that would sit well with patients and doctors alike (I’d be interested to hear from lawyers who agree or disagree on the merits of such an approach).

There are some initial moves in this direction and a need to implement technology to help guide the treatment (as we see with ICSI) and all this would also lead to higher quality of care for everyone and possibly a new system that reimbursed based on the quality of care delivered versus the quantity of care.

Radiology Examinations – How Much is Too Much

Posted in CPOE, DrVoice, Evidence Based Medicine, Radiation Exposure, Safety by drnic on November 11, 2010

As is often the cases conflicting information in the media on the benefits of screen, x-rays and healthcare.
This piece in the NY Times: CT Scans Cut Lung Cancer Deaths, Study Finds suggests that annual CT Scans of current and former smokers reduces the risk of death form lung cancer:

Annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent, a huge government-financed study has found. Even more surprising, the scans seem to reduce the risks of death from other causes as well, suggesting that the scans could be catching other illnesses.

And while there does seem to be some benefit as Dr Patz (professor of radiology at Duke who helped devise the study) put it:

he was far from convinced that a thorough analysis would show that widespread CT screening would prove beneficial in preventing most lung cancer deaths. Dr. Patz said that the biology of lung cancer has long suggested that the size of cancerous lung tumors tells little about the stage of the disease. “If we look at this study carefully, we may suggest that there is some benefit in high-risk individuals, but I’m not there yet,” Dr. Patz said.

And before you run out the door to get your CT scan its worth taking note of Dr Ben Goldacre’s insightful blog Bad Science that takes a hard look at the science behind claims and does a great job debunking the myths and taking a hard look at statistics. But as we have seen over the last few months there is an increasing focus on excessive use of imaging technologies. Earlier this year the Imaging e-Ordering Coalition (Co Chaired by our very own Scott Cowsill) Successfully made a case to congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation:

the Coalition is making several recommendations to policy makers in Congress and CMS…One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR’s appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.

In recent news the Healthcare alliance aims to improve the imaging process, Changing the Game the coalition continues to push for

E-Ordering, also referred to as clinical decision support (CDS) (to) provide(s) physicians with real-time, electronic access to pre-exam, case-by-case decisions linked to evidence-based clinical guidelines and tailored to a patient’s specific circumstances

and cites a 7-year study at MGH (pub 2009) that showed a dramatic decrease in the growth rates of several imaging exams

  • CT exams down from 12% growth to 1%
  • MR exams down from 12% dropped to 7%
  • Ultrasound down from 9% to 4%

So with that in mind the concurrent news that Minnesota’s Institute for Clinical Systems Improvement (ICSI) is spearheading the First Statewide Effort to Help Ensure Patients Receive Appropriate High-Tech Diagnostic Imaging Tests that is targeted to save Minnesota healthcare community more than $28 million annually (this was the savings estimated from the year long pilot with 2,300 physicians from five Minnesota medical groups, five health plans taking part. You can read more about it here, and here in the Star Tribune in Minneapolis St Paul and here on ZDNet

The process and challenges are outlined in this video:

Showing how you can help the busy clinician by providing them with a simple, intelligent and above all standardized appropriateness criteria to guide the clinician in ordering the most appropriate study for the patient at the time of consultation. This improved patient satisfaction, clinic efficiencies and reduced administrative costs. While there will be those who distrust technology over seeing clinical decision making the solution does not force or prevent clinicians from ordering the test they deem the most appropriate. What it does do is provide evidence based guidance on the suitability or clinical appropriateness of the test.

How do you feel as a patient or as a clinician on technology guiding care choices? Like it or not expect to see more as we continue to cope with a veritable Tsunami of clinical data, studies and discoveries that by some estimates require a doctor to read for 70 hours per week just to keep up in their one speciality.

NLP in Healthcare

Posted in Evidence Based Medicine, NLP, Speech Recognition by drnic on June 21, 2010
Along the lines of Deep Blue IBM is breaking new ground with its latest research innovation “Watson” focused no Natural Language Processing applied in this instance to the well known television game of Jeopardy. Take a look at the video that features the Super Computer Watson pitted against contestants in a real game of Jeopardy. The only accommodation for the “silicon based” life form was providing the questions as text rather than requiring the additional step of speech recognition

Certainly impressive and looking like a real leap forward even with errors occurring. This is of course a enormous task for any computer but even to achieve success in certain instances is extremely impressive and very exciting. Here we are 13 years on from Deep Blue’s famous feat of beating Gary Kasparov at chess. The New York Times featured this in the magazine over the weekend: Insert Title. As they point out this is approaching the innovation we have seen on Star Trek

The computer on Star Trek is a question-answering machine, it understands what you’re asking and provides just the right chunk of response that you needed. When is the computer going to get to a point where the computer knows how to talk to you?

Well it seems we stepped a lot closer to the Hollywood vision that’s been in place since 1963. In fact I have been making this point for a number of years. We have been fooled into believing Speech Recognition achieved much more than recognizing words. In fact Spock’s original interaction with the computer in 1963

Computer, compute to the last digit the value of pi” — Spock (Wolf in the Fold)

Was asking for much more than just speech recognition but included comprehension and then actions based on that comprehension
Over time we have seen many instances but the challenge of comprehension is brought home in Star Trek IV – The Voyage Home when Scotty discovers that speaking to a computer and expecting it to understand was beyond the capabilities:
As we see (even in Hollywood) computers continue to struggle with complexity in language (Direction Unclear):
But with Watson’s success in what is a good analogy of the complexity of human language we are approaching the point of genuine interaction with technology and as some of the contestants intimated:

Several made references to Skynet, the computer system in the “Terminator” movies that achieves consciousness and decides humanity should be destroyed. “My husband and I talked about what my role in this was,” Samantha Boardman, a graduate student, told me jokingly. “Was I the thing that was going to help the A.I. become aware of itself?”

I think we are still a ways away from this but with the change in approach as opposed to trying to teach computers all the variations of data and linkage allowing the system to “learn” by feeding in data and creating algorithms that link data statistically for future inference.

Much like the challenge in medicine Watson applies extensive knowledge that has been previously analyzed and stored and importantly applies multiple algorithms to come up with a stack rank of answers. In fact in the of all the predictive systems available ones that take multiple predictions form different sources and then takes the most frequent tend to be the most accurate

Watson’s speed allows it to try thousands of ways of simultaneously tackling a “Jeopardy!” clue. Most question-answering systems rely on a handful of algorithms, but Ferrucci decided this was why those systems do not work very well: no single algorithm can simulate the human ability to parse language and facts. Instead, Watson uses more than a hundred algorithms at the same time to analyze a question in different ways, generating hundreds of possible solutions. Another set of algorithms ranks these answers according to plausibility; for example, if dozens of algorithms working in different directions all arrive at the same answer, it’s more likely to be the right one. In essence, Watson thinks in probabilities. It produces not one single “right” answer, but an enormous number of possibilities, then ranks them by assessing how likely each one is to answer the question.

Thinking about this system and its application to medicine we are stepping increasingly closer to analysis of multiple inputs of signs, symptoms and subsequently examination and laboratory testing and imaging. A number of years ago I saw a similar solution in very basic form that analyzed inputs as they arrived and started to produce a short list for differential diagnosis. The limitations at the time related to computing power and inputs but and to some degree the capture of knowledge in a form that could then be used. Watson turns this process on its head providing a means to input knowledge in large quantities that can then be analyzed, cataloged and then applied. There remains the question of what is valid information that can and should be accepted but even with this problem processing the rapidly expanding knowledge base automatically provides a means to help clinicians who today do not have the time to process all the moves/adds/changes to the clinical corpus of knowledge:

The problem right now is the procedures, the new procedures, the new medicines, the new capability is being generated faster than physicians can absorb on the front lines and it can be deployed

I don’t see call centers being the route of interaction but much more likely as an adjunct tool providing guidance and short lists to the clinicians at the point of care of differential diagnosis and what steps (what additional history, examination or investigation) can help rule out or confirm the various choices. This may not be a patient level tool but as an adjunct to clinical knowledge is likely to offer significant support to clinical care and help improve the diagnosis and treatment of patients.

Combine this with a speech recognition tool that accurately renders the clinical data and you have some level of real time evidence based medicine that will revolutionize healthcare. DoctorNet will become self aware….very soon.