Future of Health IT: Trends and Scenarios

Red herrings swimming around Google and Microsoft PHRs

I spent three days last week at the American Medical Informatics Association (AMIA) Spring Congress. I was there to present lessons learned from Michigan's $3.2M NIH Roadmap contract funded under the 2003 "Re-Engineering the Clinical Research Enterprise" Broad Agency Announcement (BAA) in the Clinical Research Informatics track, but I spent a few of the sessions in the Personal Health Records (PHR) track.

Unsurprisingly, there was a lot of buzz in the PHR track about Google Health, and to a lesser degree, Microsoft HealthVault. Google Health was more prominent for several reasons, not all of which are enduringly pertinent: its public debut happened more recently; Google does not suffer from the Borg-like "Evil Empire" image from which Microsoft suffers; and Dr. Roni Zeiger, MD, Google Health Product Manager, was an eloquent and well-received speaker at one of the sessions.

That was Thursday. My presentations were on Friday right after lunch, so I was a bit distracted that morning and missed a couple of breakout sessions. After my time in the limelight, I spent a very inspiring hour talking with Bob DiLaura of Cleveland Clinic, during which we speculated about the future of PHRs. One assertion with which I believe we both agree is that the entry of these two major players is going to revolutionize the healthcare records "marketplace".

I put "marketplace" in quotes because in the USA a market implies exchange of value that can be represented in monetary terms. HealthVault and Google Health are free, and as FasterCures CEO Greg Simon said in one of the keynotes, "Free is the new money". Google and Microsoft will aim for volume, and monetization will come later. It's not terribly difficult to imagine a variety of ways huge volumes of consumer health records could be monetized without violating patient privacy. But there are a lot of red herrings in these waters. Let's look through the glass window in the bottom of the boat here and see what these red herrings look like.

The IT community's greatest challenge

This is another one of those posts that has taken me a while to write - a little over a month, in fact. Today I added a few final sentences and feel it is finally good to go. Whew! I feel the subject was important enough to be worth the effort. I hope you feel that way too.

Back at the end of March, I read an online article by Bill Snyder at the Infoworld site called Multi-core to leave developers in dust?. It concerned the looming challenge of leveraging the parallel processing resources being made possible by the emergence of inexpensive, soon-to-be-utterly-ubiquitous multiple-core CPUs.  Snyder feels the IT industry is not ready for the challenge. I agree. I first wrote about the problem last December in a post entitled The Landscape of Parallel Computing Research: the NY Times and Berkeley EECS. In many ways this post is a continuation of that thread.

Here's a bit of what Snyder has to say:

That's not to say that the IT industry is scoffing at the potential benefits of multi-core processing. But the mountain between IT and some future multi-core promise land -- namely, the task of developing parallelized apps that keep pace with continual core advances -- is huge, says David Patterson, the Pardee Professor of Computing Science at UC Berkeley and director of the parallel computing lab. "It's the biggest challenge in 50 years of computing. If we do this, it's a chance to reset the foundation of computing."

In the short run, Patterson says, we can parallelize legacy software and gamble on getting value out of eight cores. But that would be only an interim solution, as such apps would not scale to 32 or 64 cores, he adds.

What is frustrating is that this problem didn't exactly sneak up on the industry. Chip development cycles are very long, and key software developers are well aware of what's moving through the pipeline. Sure, software always lags hardware. Many of us complained that we didn't have software that would take advantage of 500MHz back in the '90s. But what Patterson and others call the multi-core revolution poses problems for developers that are qualitatively different than the problems of the past. Why wait so long to get serious about solving them?

The answer to the last question is, in my opinion, a personality characteristic common among IT personnel, which is the always-incorrect belief that my current technology - architectural model, operating system, hardware platform, programming language, integrated development environment, application framework, or what-have-you - is the be-all and end-all of IT evolution.

Case in point: Not long ago I was indirectly involved in the port of an application from Ingres on a Vax to a Java/J2EE platform on Windows 2003 Server (web container) and JBoss/Oracle on Linux (EJB container and DBMS).  A single programmer had worked on the system for almost 20 years, was not far from retirement, and had much fear of and no interest in learning the new technologies. What was sad about the situation is not the programmer's mindset, but the fact that her managers had allowed the situation to devolve into the state it was in at the time of the need for conversion. If the leaders don't lead, the followers oftentimes don't follow.  This was by no means the only time I have encountered this mindset malaise.

Lifelong Learning: Problems of Corporate Software Development Today

I found a breath of fresh air this AM in a blog that is still under construction, and saw immediate connections with the work of Irving Wladawski-Berger,  one of my favorite bloggers over the two and a half years I've been involved in the Blogosphere myself. The fresh-air post is about the malaise we face in the computing facet of modern large organizations. Nabil Hijazi is from the corporate world, but everything he says applies "spot on" to academic health centers. The post is called Lifelong Learning: Problems of Corporate Software Development Today. Among Nabil's bullet list of ailments, this was my favorite:

Innovation - or lack of.  IT professionals that are uncreative implementation drones. Professionals that master implementation arts and techniques that are popular and fadish at the time - mostly by copying and imitating without much alteration. They excel at the mechanics of coding and testing, but have no imagination to create new things.

Not that we don't need excellence in the mechanics of coding and testing, of course, but the absence of that creative spark in someone working in an inherently creative discipline is saddening at best, and maddening if the organization's success depends on innovative thought and action. Irving Wladawsky-Berger is a past master at fostering creativity and innovation in engineering organizations, which is why I read his blog regularly. His recent thoughts on innovation and globalization are pradigmatic of his eloquence in this arena.

I look forward to more from Nabil Hijazi and welcome his voice in the technology-and-innovation corner of the Blogosphere.

"Better Than Free": Lessons for Open Source healthcare software systems

In The Technium, Kevin Kelly's "Better Than Free" post should be a wake-up call for Open Source project leaders, in particular those in the healthcare arena. I first got wind of his post via The Edge, and when it popped up again in Seth Godin's blog, I had to stop and take a look.

This super-distribution system [the Internet] has become the foundation of our economy and wealth. The instant reduplication of data, ideas, and media underpins all the major economic sectors in our economy, particularly those involved with exports -- that is, those industries where the US has a competitive advantage. Our wealth sits upon a very large device that copies promiscuously and constantly.

Yet the previous round of wealth in this economy was built on selling precious copies, so the free flow of free copies tends to undermine the established order. If reproductions of our best efforts are free, how can we keep going? To put it simply, how does one make money selling free copies?

I have an answer. The simplest way I can put it is thus:

When copies are super abundant, they become worthless.
When copies are super abundant, stuff which can't be copied becomes scarce and valuable.

When copies are free, you need to sell things which can not be copied.

Well, what can't be copied?

A great question. Fortunately, Kelly has an answer ready, though I think he left out one important point.

Broken Is Fixed: Health informatics standards in light of Clay Shirky's "In Praise of Evolvable Systems"

I recently re-read an old essay by Clay Shirky (shirky.com) called In Praise of Evolvable Systems. It opens with a laughable description of designing a novelty protocol to slip past the IETF as a joke - however, the feature set described is an accurate description of the World Wide Web, as it existed when Shirky wrote the essay in the late 1990's. That lead-in ends with this:

HTTP and HTML are the Whoopee Cushion and Joy Buzzer of Internet protocols, only comprehensible as elaborate practical jokes. For anyone who has tried to accomplish anything serious on the Web, it's pretty obvious that of the various implementations of a worldwide hypertext protocol, we have the worst one possible.

Except, of course, for all the others...

It seems the WWW protocol family has turned out to be another example of "less is more", or more accurately, "broken is fixed".

Nanotechnology: A novel technique borrows from screen printing to provide a way to build tiny devices using miniature stencils

A brief tidbit from this month's Technology Quarterly at Economist.com: A novel technique borrows from screen printing to provide a way to build tiny devices using miniature stencils. The article may be subscribers-only, in which case I apologize, but I can point you instead to the original news story from IBM's research lab in Zurich back in September, a story called  IBM researchers bring printing to the nanoscale. Here's the teaser text from the Economist article:
 

THE field of nanotechnology—making widgets just a few billionths of a metre across—has been slow to take off. One reason for the delay is the difficulty of assembling useful devices from such tiny building blocks. Tobias Kraus, of IBM's Research Laboratories in Zurich, Switzerland, and his colleagues have come up with a new way to print such structures which could help. It is based on screen printing, which uses a stencil and paint to create an image. Existing ways of printing devices at the nanoscale tend to be complex and expensive, and more appropriate for making silicon chips. By contrast, the new technique is easy and cheap.

The IBM news article described some of the possibilities:

"This method opens up new ways to precisely and efficiently               position various kinds of nanoparticles on different surfaces, a               prerequisite for exploiting the unique properties of such nanoparticles               and for making their use economically feasible," explains Heiko               Wolf, researcher in nanopatterning at IBM’s Zurich Research               Lab.

            

In biomedicine this printing process could, for example, be applied               to the printing of large arrays of biofunctional beads that can               detect and identify certain cells or markers in the body. One example               could be rapid screening for cancer cells or heart attack markers.               As part of new point-of-care diagnostic devices, regular arrays               of functional beads could enable a fast and automated read-out that               only needs the tiniest amounts of samples.

            

Nanoparticles can also interact with light. With the new method,               optical materials with new properties could be printed, for example,               for use in optoelectronic devices. So-called "metamaterials"               could be created in which the printed structures are as small as               the wavelength of the light and therefore act as if they were a               single lens with unusual properties.

            

Moreover, the method holds promise for semiconductors. In one experiment,               IBM researchers achieved the controlled placement of catalytic seed               particles for growing semiconducting nanowires. Such nanowires are               promising candidates for future transistors in microchips.

Cool!

More on the $1000 genome: Gary Wolf on The Quantified Self

I found a more skeptical take on the 23andme story I reported on in my last post.  It's in the Kevin Kelly blog, and the post (not by Kevin himself, but that's OK, Gary's cool) is called The Quantified Self.

Still, within all of these stories I caught the first hint of a backlash. This backlash has little to do with the main objection all of these writers presented, which was: do I really want to have this important knowledge about my genes? I don't think this objection is serious. I don't even get a sense the writers seriously entertain it. I suspect it is a rhetorical effect, an exaggerated worry that lends interest to the promise at hand. (Gray goo serves this function for nanotech.) Perhaps it is the nerd in me, but I have difficulty imagining that accurate medical self-knowledge would be rejected by consumers because they are afraid to know.

Anyway, there's a bigger problem. The companies offering these tests carefully insist that they are not be taken diagnostically, and acknowledge that that are not currently accurate indicators of clinical risks. They give these caveats, while of course also trying to satisfy our desire to get accurate clues to our genetic predispositions to scary diseases.

There's more detail and references than I can describe in this necessarily brief post, but here's a taste:

THIS JUST IN: Announcing the arrival of the $1,000 Genome

OK  I admit it's not quite what the NIH is referring to in their $1,000 genome RFAs (RFA-HG-06-020 (R01), RFA-HG-06-021 (R21) and RFA-HG-06-022 (R21/33)), but it's a nice start, and it's available now.

I just got hold of a press release from a startup called 23andMe. The title is  23andMe Launches Web-Based Service Empowering Individuals to Access and Understand Their Own Genetic Information.

MOUNTAIN VIEW, Calif. -- November 19, 2007 -- 23andMe, Inc., a privately-held personal genetics company, announced today that it has officially launched and has begun offering its services directly to consumers in the United States. 23andMe is helping individuals understand their own genetic information through the latest advances in DNA analysis and web-based interactive tools. The Company's service will enable customers to gain deeper insights into their ancestry and other inherited traits which are marked in an individual's genetic code.

The 23andMe service allows individuals to:

* Search and explore their genomes;

* Learn how the latest research studies relate directly to traits identified in their genome;

* Compare their genomes to family and friends who are also 23andMe participants;

* Discover their genetic roots and find where they sit on the tree of human genetic history; and

* Give individuals the option to actively participate in a new research approach.

Linda Avey, co-founder of 23andMe, said, "Over the past several years, significant advances have been made in the field of genetics. The mission of 23andMe is to take the genetic revolution to a new level by offering a secure, web-based service where individuals can explore, share and better understand their own genetic information."

Anne Wojcicki, co-founder of 23andMe, said, "23andMe is designed to provide our customers with scientifically accurate, high-quality information about their own genetic code in a format that is easy to understand and use. We believe this information provides intriguing insights into an individual's genetics, with the goal of expanding the collective knowledge base by enabling active participation in research."

But wait. It gets better.

Healthcare Scenario Planning: Irving Wladawsky-Berger on Multidisciplinary Innovation

Catching up on reading my favorite blogs, I came across a couple of posts by retired IBM R&D honcho Irving Wladawsky-Berger (hereinafter W-B). The first entry I'll write about is called Some Thoughts on Multidisciplinary Innovation.  This is of interest because multidisciplinary innovation is the keystone factor in the translation of recent discoveries in genomics, proteomics, and metabolomics into public health benefits.

W-B says:

Coping with Asperger's in Second Life: More about Brigadoon

Here's a little more about the Asperger's Syndrome support site in Second Life called Brigadoon, named after the mythical Scots village where life is perfect, but only accessible every 100 years or so. The post is called More about Brigadoon.