Introduction To Biomedical Informatics!

Michael P. D'Alessandro, M.D.!University of Iowa College of Medicine / University of Iowa Children's Hospital!

michael-dalessandro@uiowa.edu!

www.educationalinformatics.org!www.slideshare.net/michaeldalessandro!

Welcome to the Medical Profession The Greatest Adventure in the World!

Stay connected to world ~ Stay connected to family ~ Golden Rule ~ Read about your patients!

About Me!•  Started programming in 1977!•  B.S. in Computer Science in 1985!•  Educational Informatics Lab's vision since 1989!

•  To improve patients' care, outcomes and lives;!•  By changing physician's knowledge, attitudes, and behaviors;!•  Through the creation and evaluation of tools, techniques, and procedures that shift learning

from the classroom and lecture hall to the point-of-care and document + preserve this learning to create a personalized learning environment / knowledge management / e-memory system for every physician!

•  Strong record of innovation in medical education!•  Resulting in grants, peer-reviewed publications, awards!•  Currently serve 2 million learners / year ~ highest impact factors on Internet!

What is Biomedical Informatics?!

•  The application of computers in medicine, specifically in !• Patient care (clinical informatics) !• Education (educational informatics) !• Research (bioinformatics)!

Why is Biomedical Informatics Important?!

• As medicine becomes digital in the 21st century, a working knowledge of informatics is a medical core competency, with its own place in physicianʼs toolkits alongside anatomy + physiology, pathology, the physical exam and diagnostic reasoning !

Overview!•  Biomedical Informatics!

•  Past - Clinical Informatics!•  Electronic medical record!

•  Present - Educational Informatics!•  Providers!•  Patients!

•  Future - Bioinformatics!•  Data mining!•  Personalized Medicine!•  Tricorders!•  Artificial intelligence!•  Singularity!

•  Assignment - Hands on Biomedical Informatics!•  To Learn More!

What is Powering Informatics?Moore's Law!

• Gordon Moore - 1965!• Number of components that can be put on a

computer chip doubles every 18 months while price remains same!

• Means computer power doubles every 18 months!

What is Powering Informatics?Moore's Law!

•  Technology in !•  1963 - Born!

•  Mainframe computers!•  1985 - Start medical school!

•  Personal computers + Internet + social networking!

•  2013 - Today!•  Ubiquitous computing!

•  This is what happened computationally in my half century!

•  What will happen in your half century?!

The Past!

• Clinical Informatics!

Electronic Medical Record!•  History!

•  1960's-1990's - Rare, institution-specific, handmade (HELP)!•  Medicine been the last industry to go digital - Why?!•  2000's-today - Universal, institution-independent, commercial!

•  Components / Plumbing!•  Laboratory system!•  Documentation system!•  Communications system!•  User interface (requires training)!•  Patient portal!

•  Moving towards standards compliance + interoperability!•  @UIHealthCare!

•  Good news - you have the best – EPIC!•  Bad news - it is universally disliked!

Electronic Medical RecordEnables!

• Billing!• Disease correction - Consistency of care /

improved patient outcomes !• Disease prevention - health promotion!

• Answer to the question - what do you gain from going paperless?!

Electronic Medical RecordSupports!

•  Provider-centric model of health care!• Current paradigm of medical practice for

providers and patients - disease correction!

The Present!

•  Educational Informatics for Providers!

The Learning Continuum!

Data -> Information -> Knowledge - > Wisdom / Mastery! [acquired + organized] [reflected] [shared] !

Personal learning environment -> Social learning network![focus on individual] [focus on group]!

Learning is an Apprenticeship!

"In what my be called the natural method of teaching, the student begins with the patient, continues with the patient, and ends his studies with the patient using books and lectures as tools, as means to an end." !

! ! ! ! !- Sir William Osler!

How the Medical Apprentice Learns!•  Diagnosis!

•  Clinical skills related to experience!•  When seeing a new case you encapsulate it

in an "illness script" which you pattern match to previous cases "illness scripts" in order to diagnose!•  Case-based reasoning / Storytelling!

•  Expert is the person who can best capture, organize, and retrieve their experience (cases)!

•  Treatment!•  Work up driven by medical knowledge!

- Schmidt HG, Norman GR, Boshuizen HPA. A Cognitive Perspective on Medical Expertise: Theory and Implications. Acad Med 1990 Oct;65(10):611-21.!

E-Memory System - Digitization Of Your Life!•  A digital archive of

your life!•  "Lifelogging"!

•  Made possible / inevitable by!•  Most memories are

digital!•  Near-infinite space

to store them!•  Every improving

technology to recall them!

•  Captures, stores, organizes and makes retrievable your experience + reflected wisdom!

•  You become the librarian, archivist, cartographer and curator of your life!

•  Early example: www.evernote.com!

Learning Portfolio!

•  A digital archive of your medical educational life = learning diary!•  Document + store clinical questions + answers !

•  For each case!•  Question ~ Story ~ Answer ~ Impact on

Practice ~ Resources Used!•  Educational construct!

•  Case-Based Learning!•  Constructionism ~ Learning by doing / Creating

learning artifacts!

Personal Learning Environment!

•  Composed of mobile devices, apps, and Web sites that will allow medical apprentice learners to capture, store, organize and make retrievable their medical experience!

•  Help support medical education's increasing emphasis on problem-based and case-based learning in undergraduate, graduate, and continuing medical education!

•  Help to focus medical learning and allow individuals to better enjoy their voyage towards medical mastery!

•  Can be used at all levels of medical education by all learners and should facilitate communication amongst and between learners at all levels!•  This usage can begin the first day of medical school and continue

throughout their career!

Personal Learning Environment!

•  System that help learners take control of and manage their own learning including providing support for learners to!•  Set their own learning goals!•  Manage their own learning - both content and process !•  Communicate with others in the process of learning!•  = summation of software programs / apps / Web sites you use !

•  Learner-centric ~ "This is what I will learn today"!•  Decentralized ~ Standards are the glue that hold it together!

Medical Student Personal Learning Environment!

Custom search engine Apps / Web sites Learning Portfolio! Librarians indirectly play a key role in this!

The Present!

•  Educational Informatics for Patients!

Health is Not Dependent on Physicians!

•  90% of variance in illness and premature death is related to factors other than access to medical treatment!• 50% = Behavioral - Diet / Nutrition / Exercise!• 25% = Environmental - Presence or absence of

war, sanitation, toxins!• 15% = Genetic!• 10% = Access to medical treatment!

•  Immunization mainly!•  Your physician is almost inconsequential !

•  Unless you live in the western world and are susceptible to ills of affluence / lifestyle!

- MHS 2025 - Toward a New Enterprise, Section 4 page 2!

Dose of Reality Regarding Compliance!

• Four good health rules!• Don't smoke, maintain normal weight, eat

fruit + vegetables, exercise!•  Only 3% of Americans follow all 4 rules!- Archives of Internal Medicine 2005;165:854-7!

[Two more rules - Don't drink to excess + Practice safe sex]!

• 40% of seniors don't take all the meds their physicians prescribe for them!

- Health Affairs 2005 April 19!

Patient's Information Seeking Behaviors!

•  There can be no more motivated learner than the patient!•  81% of U.S. adults use the Internet!•  59% of U.S. adults say they have looked

online for health information in the past year!•  35% of U.S. adults say they have gone online

specifically to try to figure out what medical condition they or someone else might have!

- Pew Internet & American Life Project, Health Online 2013!

•  You should use Information Prescriptions to partner with them!•  Doctor means teacher - you must teach your

patients!•  www.medlineplus.gov!

Quantified Self!•  Goal - to Stay Healthy!•  Step 1 - Sequence your genome!

•  "23andMe can help you manage risk and make informed decisions" - (for $99)!•  23andMe is creating vast database of genetic

information of its customers + cross referencing it against the health history they provide!

•  Is Big Data, CEO is spouse of Larry Brin of Google!•  www.23andme.com!

•  Step 2 - Engineering approach to life !•  Quantify it with biosensors, analyze it, act on it!

•  www.quantifiedself.com!

•  Result - Empowered patients who will present with data driven chief complaint!•  Gordon Bell - www.totalrecallbook.com!•  Larry Smarr - hacking his own body!

Personal Health Record!

www.healthvault.com!

Patients Taking Control of Their Care!

•  Internet was designed to route around obstructions!

• Now patients are using the Internet to route around obstructions like you!

•  They are running their own clinical trials!• www.patientslikeme.com - "Share

your experiences with treatments. Find patients just like you. Learn from others who know."!•  Social network for sick people!

The Future!

• Research Informatics!• Paradigm of medical practice will change from

disease correction to disease prevention!•  Informatics tools will allow super empowered

patients to live healthy lives!• When patients become ill, informatics tools will

help them take control of and guide their treatment and the role physicians will play!

The Next Step:Big Data + Data Mining!

•  Definition!•  Big Data - Huge data sets (exabytes = 1 billion gigabytes)!•  Data Mining - Algorithms extract and synthesize knowledge from analyzing

large numbers of individual cases!•  Applications!

•  Disease surveillance!•  Speed learning about benefits + harms of current treatments!•  Speed development of new treatments!•  Support efforts to improve quality of care !

•  Advantages!•  Non-medical companies (Google) may bypass HIPAA!

•  Disadvantages!•  How do you protect patient privacy!

•  Barriers!•  Interconnecting disparate databases!•  Overcoming HIPAA!

Examples of Big Data!

Personalized Genomics + Personalized Medicine - The Coming Revolution in Health Care!

•  How health care will be reformed!•  Your genome sequenced to tell you what diseases

you are at risk!•  Your health will be continuously monitored by

wearable computing devices + sensors!•  Your information will be stored in a personal health

record !•  Decision support tools will help you live a healthier

life and decrease your risk of disease!•  The refrigerator will be your health hub!•  The physician will interface with you, rather than you

with them!•  When the patient is ill they will run their own clinical

trials!•  Bottom line - Taking responsibility for your own

health ~ influencing your destiny!

Future - For Patients Tricorder X Prize!

•  Goal - create a mobile platform that will enable people to diagnose a set of 15 conditions (pneumonia to diabetes to sleep apnea) without having to rely on doctor or nurse!

Future - For Providers Artificial Intelligence / Machine Learning / Watson!

•  Will Watson serve as an assistant to, or replacement for physicians?!

From Search Engine to Question Answering System Through Artificial Intelligence!

• Artificial Intelligence!• Arises not through rules but through statistics!

•  Example question answering systems!• Watson - IBM!

•  Inspiration - computer on Star Trek!•  Interface - natural language processing!•  Approach - statistical computation - using hundreds

of statistical algorithms simultaneously, then chooses best answer from amongst them!

•  Hardware - very fast, lots of memory!- Clive Thompson, What is IBM's Watson? New York Times Magazine, June 20, 2010!- James Bamford, The New Thought Police, for PBS Nova Feb 3, 2009!- Steven Levy, The AI Revolution is On, Wired, Jan 2011!

How Watson Works!•  Expert systems definition - computer systems that can reason over knowledge!•  Expert systems failed in 1980's because it was difficult to capture and maintain

a mathematization of a domain!•  The promise of Watson is that it can reason over unstructured information, in

the form that humans are creating it in textbooks and articles in natural language!

•  If we have a computer that can reason over natural language it can scale and do useful things without a lot of work on our part!

•  Watson will never be as precise as an expert system - it won't have a chain of reasoning - it will deliver explanations in your words!

•  Why medical expert systems have not been widely adopted so far - primary reason is that they are very narrow and hard to keep up to date and don't show you the context for the rules - they don't let you judge the evidence, which is changing all the time!

•  We don't want to take judgment away from humans, we want to enable better judgment and provide the content that persuades them!

•  Prior expert systems are brittle and narrow and don't give you the kind of information you are comfortable with!

•  Watson is not rules based!- A Computer Called Watson - Presentation at the Computer History Museum on Nov 11, 2011 by David

Ferrucci - starting at 42:30 minutes!

"People ask me if this is HAL. HAL's not the focus; the focus is on the computer on 'Star Trek,' where you have this intelligent information seeking dialogue, where you can ask follow-up questions and the computer can look at all the evidence and tries to ask follow-up questions. Thatʼs very cool."!

"The computer on ʻStar Trekʼ is a question-answering machine. It understands what youʼre 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? Thatʼs my question."!

"Wouldn't it be great to be able to communicate with the computer like Captain Picard or Captain Kirk does on "Star Trek," where you can fluently dialogue with an information-seeking computer that can understand what you're asking, ask follow up questions, and get exactly at the information that you need? That would be incredible. That's kind of this motivating vision, and whether Watson loses or not in this big game is really not the point. The point is we were able to take a step forward in that direction, and I think that's what we're most excited about."!

!- David Ferrucci, PhD, IBM, principal investigator DeepQA / Watson!

The Coming Singularity?!"Kurzweil believes that we're approaching a moment when

computers will become intelligent, and not just intelligent but more intelligent than humans. When that happens, humanity - our bodies, our minds, our civilization - will be completely and irreversibly transformed. He believes that this moment is not only inevitable but imminent. According to his calculations, the end of human civilization as we know it is about 35 years away."!

"Here's what the exponential curves told him. We will successfully reverse-engineer the human brain by the mid-2020s. By the end of that decade, computers will be capable of human-level intelligence. Kurzweil puts the date of the Singularity - never say he's not conservative - at 2045. In that year, he estimates, given the vast increases in computing power and the vast reductions in the cost of same, the quantity of artificial intelligence created will be about a billion times the sum of all the human intelligence that exists today."!

"One of the goals of the Singularity Institute is to make sure not just that artificial intelligence develops but also that the AI is friendly. You don't have to be a super-intelligent cyborg to understand that introducing a superior life-form into your own biosphere is a basic Darwinian error."!!- Lev Grossman, 2045: The Year Man Becomes Immortal, Time, Feb 10, 2011!

Thematic Quote!

"You have zero privacy anyway. Get over it." !! ! !- Scott McNealy, Sun Microsystems!

Hands On!

• Clinical Informatics!• Open a Microsoft HealthVault

account for your own electronic medical record!•  Help you understand the benefits

and challenges facing patients who do this !

•  www.healthvault.com!

Hands On!

•  Educational Informatics / For Patients!• Use Information Prescriptions to

partner with them!•  www.medlineplus.gov!

Hands On!•  Educational Informatics / For

Providers!•  Use medicine-specific search engine

for point-of-care learning during case-based learning and in clinical rotations!•  www.searchingmed.com!

•  Maintain a learning portfolio !•  www.evernote.com!•  For each case!

•  Question ~ Story ~ Answer ~ Impact on Practice ~ Resources Used!

•  Be HIPAA compliant!•  No protected health information!

Hands On!• Bioinformatics!

• Let's make *you* a patient!!• Consider undergoing genetic

testing to learn what diseases you are at risk of developing and then develop strategies to manage your disease risk over your life time as a super-empowered patient would do!•  www.23andme.com!

• Be aware of your online persona + keep it professional + restricted!

To Learn More!•  Life as a Healthcare CIO – John Halamka M.D.!

•  geekdoctor.blogspot.com!•  American Medical Informatics Association!

•  www.amia.org!•  TED Talks!

•  www.ted.com/topics!•  health, health+care, medicine, medical+research!

•  How to live your life from Steve Jobs!•  news.stanford.edu/news/2005/june15/jobs-061505.html!

•  Ask me anything!•  michael-dalessandro@uiowa.edu!

•  These slides!•  www.slideshare.net/michaeldalessandro!

Conclusion!•  Medicine – It's not just a job, it's a profession!

•  They can stop you from coming to work but they can't stop you from learning at home - so read about your patients!!

•  Spend less time looking down and more time looking up!

•  Let's model good informatics behavior for our patients!

•  Join me in being an advocate for excellent informatics for our patients + ourselves!•  28 years ago it was just me, now we have a critical mass!•  Let's change the world!!

One More Thing…!

"Hereʼs to the crazy ones. The rebels. The troublemakers. The ones who see things differently. While some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do."!