I have read two stories this week.
The first was written in an interesting, contemporary literary style – you know the sort – short sparse sentences almost factual, leaving lots of ‘space’ for your own imaginative inference, not making explicit links between facts and events but leaving you to do that for yourself. It was a love story, rather charming and quite short, describing a familiar narrative of boy meets girl, invites her to the cinema and they fall in love (probably). It could be described as Chandleresque in style – though it isn’t that good – in fact it could have been written by an 11+ student. It wasn’t though – it was in fact written by a computer using a form of artificial intelligence called natural language generation with genuinely no human input. You can read how it was done here.
The second story I read is a description of a falling out of love – of the medical profession with the IT industry and the electronic patient record. This one is very well written by Robert Wachter and is a warts and all recounting of the story of the somewhat faltering start of the digital revolution in healthcare. It is called ‘The Digital Doctor’ and I would highly reccomend you read it if you have any interest in the future of medicine. It is not the manifesto of a starry eyed digital optimist, nor is it the rantings of a frustrated digital skeptic – he manages to artfully balance both world views with a studied and comprehensive analysis of the state of modern health IT systems. His realism though extends to understanding and articulating the trajectory of the health IT narrative and where it is taking us – which is a radically different way of delivering medical care. I won’t use this blog to precis his book – its probably better if you go and read it yourself.
From Data to Information to Understanding
The falling out that Dr Wachter describes really is quite dramatic – this is the United States the most advanced healthcare system in the world – yet there are hospitals in the US that advertise their lack of an EPR as a selling point to attract high quality doctors to work for them. Where has it gone wrong? Why is the instant availabilty not only of comprehensive and detailed information about our patients but also a myriad of decision support systems designed to make our jobs easier and safer to carry out – not setting us alight with enthusiasm? In fact it is overwhelming us and oppressing us – turning history taking into a data collection chore and treatment decisions into a series of nag screens.
The problem is there is just too much information. The healthcare industry is a prolific producer of information – an average patient over the age of 65 with one or more long term conditions will see their GP (or one of her partners) 3 – 4 times a year, have a similar number of outpatient visits with at least 2 different specialists and attend A&E at least once. That doesn’t include the lab tests, x-rays, visits to the pharmacy, nursing and therapy episodes. Each contact with the system will generate notes, letters, results, reports, images, charts and forms – it all goes in to the record – which, if it is a well organised integrated electronic record, will be available in its entirety at the point of care.
Point of care being the point – most health care episodes are conducted over a very short time span. A patient visiting his GP will, if he’s lucky, get 10 minutes with her – it doesn’t make for a very satisfactory consultation if 4 or 5 of those minutes are spent with the doctor staring at a screen – navigating through pages of data attempting to stich together a meaningful interpretation of the myriad past and recent events in the patient’s medical history.
How it used to be (in the good old days)
So what is it that the above mentioned hospitals in the US are harking back to in order to attract their doctors? What is the appeal of how it used to be done when a consultation consisted of a doctor, a patient and a few scrappy bits of paper in a cardboard folder? Well for a start at least the patient got the full 10 minutes of the doctors attention. The doctor however was relying on what information though? What the patient tells them, what the last doctor to see them chose to write in the notes, and the other events that might have made it into their particular version of this patient’s health record. This gives rise to what I call a ‘goldfish’ consultation (limited view of the whole picture, very short memory, starting from scratch each time). We get away with it most of the time – mainly because most consultations concern realtively short term issues – but too often we don’t get away with it and patients experience a merry go round of disconnected episodes of reactive care.
When I used to still practice intensive care medicine one of the things that occupied quite a lot of my time as ‘consultant on duty for ICU’ was the ward referral. As gatekeeper of the precious resource that is an intensive care bed my role would be to go and assess a patient for their suitability for ICU care as well as advise on appropriate measures that could be used to avert the need for ICU. My first port of call would be the patients notes – where I would go through the entire patients hospital stay – for some, particularly medical patients, this might be many days or even weeks of inpatient care. What I would invariably find is that the patient had been under the care of several different teams, the notes would consist of a series of ‘contacts’ (ward rounds, referrals, escalations) few of which realted to each other (lots of goldfish medicine even over the course of a single admission). I soon ceased to be surprised by the fact that I, at the point of escalation to critical care, was the first person to actually review the entire narrative of the patient’s stay in hospital. Once that narrative was put together very often the trajectory of a patient’s illness became self evident – and the question of whether they would benefit from a period of brutal, invasive, intensive medicine usually answered itself.
The defence against goldfish medicine in the ‘old days’ was physician continuity – back then you could expect to be treated most of your life by the same GP, or when you came into hospital by one consultant and his ‘firm’ (the small team of doctors that worked just for him – for in the good old days it was almost invariably a him) for the whole admission. They would carry your story – every now and then summarising it in a clerking or a well crafted letter. But physician continuity has gone – and it isn’t likely ever to come back.
The EPR promised to solve the continuity problem by ensuring that even if you had never met the patient in front of you before (nor were likely ever to meet them again) you at least had instant access to everything that had ever happend to them – including the results of every test they had ever had. But it doesn’t work – data has no meaning until it is turned into a story – and the more data you have the harder it is and longer it takes to turn it into a story.
And stories matter in medicine – they matter to patients and their relatives who use them to understand the random injustice of disease, it tells them where they have come from and where they are going to. They matter to doctors as well – medical narratives are complex things, they are played out in individual patients over different timescales – from a life span to just a few minutes, each narrative having implications for the other. Whilst we don’t neccessarily think of it as such – it is precisly the complex interplay between chronic and acute disease, social and psychological context, genetics and pathology that we narrate when summarising a case history. When it is done well it can be a joy to read – and of course it creates the opportunity for sudden moment when you get the diagnostic insight that changes the course of a paient’s treatment.
Natural Language Generation
Turning the undifferentiated information that is a patients medical record – whether paper or digital – into a meaningful story has always been a doctor’s task. What has changed is the amount of information available for the source material, and the way it is presented. A good story always benefits from good editing – leaving out the superfluous, the immaterial or irrelevant detail is an expert task and one that requires experience and intelligence. You see it when comparing the admission record taken by a foundation year doctor compared to an experienced registrar or consultant – the former will be a verbatim record of an exchange between doctor and patient, the latter a concise inquisition that hones in on the diagnosis through a series of precise, intelligent questions.
So is the AI technology that is able to spontaneously generate a love story sufficiently mature to be turned to the task of intelligently summarising the electronic patient record into a meaningful narrative? Its certainly been used to that effect in a number of other information tasks – weather forecasts and financial reports are now routinely published that were drafted using NLG technology. The answer of course is maybe – there have been some brave attempts – but I don’t think we are there yet. What I do know is that the progress of AI technology is moving apace and it won’t be very long before the NLG applied to a comprehensive EPR will be doing a better job than your average foundation year doctor at telling the patient’s story – maybe then we will fall back in love with EPR? Maybe…