Thursday, February 2, 2012

Power of Acronyms and Algorithms at the Point of Care:A Personal Story

For of all sad words of tongue or pen, the saddest are these: it might have been.

John Greenleaf Whittier (1807-1891), American Poet and Abolitionist, Maud Muller (1856)

Woe is me!

Isaiah, 6:5

February 2, 2012 – Let me begin at the end of my story. I conclude it is now possible to have patients enter their personal data, complaints, symptoms, and history into a computer, add laboratory data and other clinical information, crunch the information and data, and the computer will spell out in plain narrative English the differential diagnosis, treatment options, and prognosis.

Whether this process is desirable or will pass privacy, security, and legal muster is another matter altogether.

Basis for Conclusion

I base this conclusion on my personal story on a series of laboratory letters I wrote starting in 1968 and ending in 1985, which contained a series of computer-related acronyms; on a book I wrote in 2007, Innovation-Driven Health Care (Jones and Bartlett) with a chapter, “An Innovator’s Personal Experience and Vision”; and on an outpouring of 2132 (this is #2133) Medinnovation blogs I have composed from November 2007 to the present.

Or perhaps as Winston Churchill so famously said, “This is not the end. It is not even the beginning of the end. But it is the end of the beginning.”

Before I delve into my personal story, let me make this observation: the power of the computer and information technology resides at the intersection of government, entrepreneurship, and venture capitalism, and, in turn, on the integration of humanism and computer algorithms – a combination Steve Jobs, founder of Apple so brilliantly exploited and articulated.

The WOE Index

If you give the matter any thought at all, you will soon realize cumulative and weighted evidence, which I dub the WOE (Weight of Evidence) Index, is the basis for most of the chatter about evidence-based medicine, and, indeed, for the existence of the government’s Affordable Care Act agency, which goes by the non-felicitous bureaucratic acronymn of PCORI (Patient Centered Outcome Review Institute).


My story begins with the Internet. Here is how Wikipedia explains the history of the Internet

“The history of the Internet began with the development of computers in the 1950s. This began with point-to-point communication between mainframe computers and terminals, expanded to point-to-point connections between computers and then early research into packet switching. Packet switched networks such as ARPANET, Mark I at NPL in the UK, CYCLADES, Merit Network, Tymnet, and Telenet, were developed in the late 1960s and early 1970s using a variety of protocols.”

In the late 1960s, as co-owner of a Minneapolis-based clinical laboratory, Lufkin Medical Laboratories, with the aid of a University of Minnesota physics professor, Russell Hobbie, using an early version of the Internet, I helped write a software differential diagnosis program based on disease patterns of 700 abnormal tests performed at our clinical laboratory. The University of Minnesota computer center was one of a dozen or so University-based Internet centers founded by the U.S. goverment as communication centers in case of a Soviet nuclear attack.

Using the Univesity of Minnesota Internet center, we constructed and attached a report, Unified Presentation of Relevant Tests (UNIPORT), with every set of abnormal laboratory results. Six million of these reports, which include the top ten diagnostic possibilities, were sent out over a 5 year span and were well received by thousands of clinicians.

UNIPORT was just one of a series of acronyms I coined and described in the Lufkin Medical Laboratories Letter.

Other acronyms included.

Diagnotes – diagnostic possibilities attached to each abnormal result, March 1970.

SORT, which I explained, stood for the simple verb “sort and not an acronym for System of Revolutionary Technology, nor for “sortilege) A divine forecast, January 1971.

WOE (Weight of Evidence) Index, February 1973.

UNIPORT (Unified Presentation of Relevant Tests, March 1977.

HQ (Health Quotient), in 1985, an algorithm calculating health status based on body measurements and vital signs, cardiovascular history, and certain laboratory data (glucose, blood lipids) with a normal range of HQ of 75 to 125, the health analogue of the IQ.

Effective for Laboratory Marketing but Not for National Business

These acronymn-named reports were effective for local laboratory marketing and were acompnied by playful commentary in my laboratory letters. But like a lot of physician entrepreneurs, I did not have the business sense or knowledge to capitalize on them for a national business enterprise. I was not alone among physicians in lacking the sense of how to organize ideas, in backing them with venture capital, and taking them to the next level of a national market. Note: Lufkin Laboratories was acquired by a national laboratory in 1985, and they discontinued our the computer programs.

Ed Roberts, MD (1942-2010), a Cochrane, Georgia family practitioner, in a former career as a biomedical engineer, came up with the idea of the personal computer. In 1974, Roberts, an employee of an Albuquerque engineering company, developed the Altair 8800, a breadbox-sized contraption that sold as a computer kit for personal use. An article appeared in January 1975 in Popular Electronic Magazine “Project Breakthrough: world’s First Microcomputer Kit to Rival Commercial Models ...Altair 8800”.

Paul Allen, Bill Gate’s sidekick, and then a Harvard undergraduate, flew to Albuquerque to see it. He told Gates what he saw, the two developed software for it, Microsoft was founded, Allen and Gates quit Harvard, and the rest is history.

Of Gates, Roberts said,”Bill is an extremely bright guy, but as far as his technical ability, he isn’t unique. He has enormous business kills. He has a genius for business.” Similarly, Steven Jobs had a business sense for integrating computer model design, with software design, with anticipation of what the public wanted but did not know what they wanted until they saw it.

My Point

My point is this. To bring an idea to market and to back it with sufficient capital, one needs to have business sense and the entrepreneurial skills to get venture capital. Capital is the oxygen of big ideas and billion dollar companies.

As Brad Feld and Jason Mendelsohn, explain in their 2011 book Venture Deals: Be Smarter than Your Lawyer and Venture Capitalist (John Wiley & Sons), the venture capital industry is of relatively recent vintage. Venture capital created many of the great technology companies starting in the 1980s - Apple, Google, Microsoft, Cisco Systems, Yahoo!, Digital Equipment Corporation, AOL, and more recently Facebook, Twitter, Linking, Zynga, and Groupon. Venture deals require multiple players - entrepreneurs, venture capitalists, angel investors, syndicate, lawyers, and mentors - and tangled layers of back-and-forth deals and control issues, starting with term sheets. Most physicians, including myself, have neither the time nor the skills nor the patience to master the art and woes of the venture deal.

Tweet: Power of humanist-IT integration resides in attention-getting acronyms and detail-rendering algorithms backed by venture capital.

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