Steven Strogatz (NYTimes) on a future for AI via AlphaZero

AlphaZero is now the undisputed champion of Go and now of chess. It recently battled Stockfish, the former chess computer heavyweight, and in that series of 100 matches, it won 28, drew 72, AND LOST NONE.

Lets hear that again. AlphaZero, the deep learning computer originally designed to play and beat human players at Go, the ancient board game, has recently been redesigned in a couple ways: 1) to take the original game rules AND NO HUMAN EXPERIENCE as its starting point, and 2) now can receive the rules for almost ANY game (in this example, chess) as its starting point. Then the programmers set AlphaZero to play itself AND LEARN THE STRATEGIES of the game by brute force and whether each strategy led to a victory or defeat. 

AlphaZero, having spent time playing itself millions of times and having discerned and taught itself the principles of chess, it only considered 60,000 moves per second instead of 60 million by Stockfish. It played smarter and faster.

“AlphaZero had the finesse of a virtuoso and the power of a machine.”

But, can it teach us its insights? No. Perhaps the most troubling paragraphs in this article is:

“What is frustrating about machine learning, however, is that the algorithms can’t articulate what they’re thinking. We don’t know why they work, so we don’t know if they can be trusted. AlphaZero gives every appearance of having discovered some important principles about chess, but it can’t share that understanding with us. Not yet, at least. As human beings, we want more than answers. We want insight. This is going to be a source of tension in our interactions with computers from now on.”

I am both heartened and disturbed by this. Heartened in that AI is on the launch pad to apply itself to all kinds of human challenges that have been difficult to solve until now. Disturbed also; how long will AlphaZero and its contemporaries need human insight and input before it’s always-accelerating capability outstrips our brains’ hardware and our ability to keep up and be relevant?

CMIO’s take? I have no take. I’m gonna wait for my auto-correct from Siri to get smart enough to finish writing this post.

Video: Dr. Sieja discusses EHR Optimization Sprints

Congratulations to Dr. Sieja and team for publication of UCHealths’ experience regarding EHR Optimization Sprints. You can do it too! Read about our published experience at Mayo Clinic Proceedings.

https://www.mayoclinicproceedings.org/article/S0025-6196(18)30788-2/fulltext#appsec1

There are several online supplements: additional specifics about how we conducted the program (30-60-90 day planning meetings, agendas for the 2 weeks of activity, etc), and the actual pre and post-intervention surveys.

Optimization Sprints: Improving Clinician Satisfaction and Teamwork by Rapidly Reducing Electronic Health Record Burden (published in Mayo Clinic Proceedings Feb 2019)

Sprint team action shot!

Congratulations to Amber Sieja, Katie Markley, Jon Pell, Christine Gonzalez, Brian Redig, Patrick Kneeland, co-authors on our published article in Mayo Clinic Proceedings this week. I’ve spoken of some of the details on this blog, so I’ll let the paper speak for itself. Nice to be recognized! Coming soon: a video by Dr. Sieja explaining some of the highlights of the paper.

https://ac.els-cdn.com/S0025619618307882/1-s2.0-S0025619618307882-main.pdf?_tid=c94d2fe7-8f2b-4e66-9852-277fb952f3eb&acdnat=1551313804_a8d687bb190fdb632cd1ed9f45c8ef41

CMIO’s take? When team members do great work, we all get better.

Willy Wonka and the Epic EHR: behind the scenes at the behemoth of Wisconsin (NYTimes)

This article speaks for itself. Having visited the Verona, Wisconsin campus of Epic’s Intergalactic Headquarters, with its dozens of campus buildings, its massive Voyager Training Hall, and its equally massive 11,000+ seat auditorium (the largest in the state), it is an impressive site. Equally impressive is the young talent that this company recruits out of college, how quickly they learn the necessary lingo and communication skills of health professionals, and dive into the constantly evolving code-base of the Epic EHR. Privately held, this company is NOT at the whim of the shareholder, which I think is a key success factor in its market dominance.

Yes, there are tons of criticisms for this and every EHR. Yes, there is a national outcry of physician burnout, directed at EHR’s in general.

Instead, you’ll read here, that the guiding vision of the reclusive CEO and founder, Judy Faulkner, holds true today; have fun, do good, recruit smart talent, improve patient care.

CMIO’s take? Having been part of the Epic community since 2010, I’ve seen lots of innovations and improvements and look forward to many more.

Letting patients file their Advance Care Planning (Advance Directives) online via Patient Portal (Hillary Lum et al)

Dr. Hillary Lum

https://www.sciencedirect.com/science/article/pii/S0885392418310479

Thanks to Dr. Lum for her persistence and clarity of purpose. She led a team of physician leaders and IT staffers through a complex process, resulting in a first-of-its-kind online tool:

The ability for patients to complete their Advance Care Planning and upload the results using an EHR (electronic health record) patient portal. 

Why is this so important 

  • Very few patients, much less US adults, have an Advance Care Planning document (including Advance Directive, Living Will, 5 Wishes, No CPR, or any other document that records the wishes of the patient in regards end-of-life care)
  • It is difficult for patients to find the form, to understand the form, complete the form, return the form, AND THEN to have clinical staff file or record the form and its wishes in a way that is easily accessible by both healthcare providers as well as patients themselves.
  • Patients without any advance care planning documents risk the possibility of receiving unwanted care at the end of their lives; since patients are so often non-communicative as their health deteriorates, unless the doctors and nurses have a clear statement from the patient, we must assume that the patient wants CPR and other aggressive measures, even if it borders on inappropriate. This tragedy can easily be avoided with easily available documents expressing the patient’s wishes.

And now, at UCHealth, patients can avoid this risk! From the privacy of home, patients can now log in, launch the Advance Care Planning module, complete the questions, and even upload any signed documents in regards to their wishes, into their online Patient Portal, in a permanent storage location easily accessible by the patient (or their permitted proxy) or any of their healthcare providers at UCHealth.

This is pretty cool, and a big leap forward. In fact, even without any publicity to patients (the module just appeared in the portal), over 1000 patients recorded a NEW advance care plan in the first month after this module went live. And, patients continue to sign up at a constant rate.

We hope this continues at UCHealth, and more importantly, that other organizations start doing this as well. Only 36% of US adults (studied in 2017) have an advance directive; meaning that about 2/3 do NOT!

CMIO’s take? We have a lot of work to do, people. Let’s get the rate of advance care planning much closer to 100% of US adults; we never know when we’re going to need one, and by then it is often too late.

Arborealization and the Ping Pong Robot (from Omron)!

OMRON’s ping pong robot is a demonstration

Interesting. OMRON, maker of the blood pressure measuring device that I recommend to patients, is moving into human-augmenting AI. Purely as a demonstration project to showcase technologies, they built a Ping Pong robot that will play with you to:

  1. Rally with you
  2. Assess your ping pong skill
  3. Assess your emotion from facial recognition
  4. Use the “net” as a screen to tell you what it is thinking and doing
  5. Coach you to be a better player, using what it knows about you

From the video, it is not infallible, but it will rally with you, it will serve the ball, it will give you a ranking, it will speed up or slow down based on how you are doing and feeling, it will note that ‘we are having fun!”

Part of the idea of “arborealization” of technology (a made-up word), this is a term I heard about a decade ago. In short, with technology acceleration powered by Moore’s law and the constant doubling of computing power, tech acceleration is NOT in just a single direction (eg: self-driving cars, faster personal computers), but in ALL directions (eg: ping pong robots, poetry-composing AI, symphony-composing AI, deep-sea diving AI, Google Duplex being able to book an appointment by telephone for you, etc).

Still, weak AI and strong AI are different things. Pointing software at a difficult single problem (Weak AI solution) is very different from building an AI that can tackle ALL problems (Strong AI). I’m reading Life 3.0, a easy-to-read NYT bestseller that is the latest foray into describing the exploding fields of AI and general intelligence.

CMIO’s take? I need one of these robots in my basement ping-pong room. Humans are so disappointing; no one will take me up on my nightly ping-pong challenge.

Holy Geez! Storm surge animation takes imaging to the next level

storm-surge_crop

https://www.wired.com/story/weather-channel-hurricane-florence-storm-surge-graphic/

We are living in a wondrous time. Read this WIRED article about how the Weather channel very quietly deployed a brand new imaging technology to very viscerally depict Storm Surge data in a way that WILL GET FOLKS OUT OF THE FLOOD ZONE. Some do not leave because there is a lack of understanding of “how bad will it be, really?” After watching the video above, I don’t think there will be ANY question.

It is a fascinating illustration of how far we are coming with virtual reality, and combining this with real images to create augmented reality.

CMIO’s take: We need this in EHRs and healthcare IT to bring home the visceral impact of our care and our decisionmaking. Who’s in?

Open notes in a Resident clinic: research study results

19498357-10-4-cover

Research study paper is here:    http://ow.ly/6eY530jYZJy

We’re published! Thanks to co-authors Bradley Crotty MD, Corey Lyons MD, and Matthew Moles MD, we helped a multi-health system collaborative to study the idea of Open Notes in primary care residencies (family medicine and internal medicine at University of Colorado Health system), with research findings above.

Ultimately there is some anxiety from both faculty and residents about patients reading their written progress notes online, after the physicians have signed off on those visit notes. We are happy to claim that our program, of all the training programs was least optimistic that this would turn out well for our physicians and patients.

Overall, though, since we gathered this survey data, we have gone on to turn on Open Notes throughout our health system (UCHealth) and now uniformly offer Open Notes to all patients in our 700 clinics, 11 hospitals, and 21 emergency departments. The fear that the “world would come to an end” has not yet come to pass, and we are hearing positive things from our patients about their ability to read notes and benefit from them, including:

  • I often forget much of what we discussed in the visit, now I can go back and refresh my memory
  • Sometimes my wife asks me “what did the doctor say?” and now we can go review it together
  • Sometimes my other doctors don’t receive the consultation letter from my specialist, and now I can show him/her that letter/note from my patient portal. I can be in charge of my own information
  • I can use my doctors note to look up words I don’t understand and get more background information so that I can ask more intelligent questions at my next visit; I feel like a part of my own healthcare team

CMIO’s take: it is good to study what we do. As Robert Anderson MD, one of my mentors told me: “We should use the laboratory of our direct patient care to study and learn. Everything we do with patients should be evaluated and can be improved.” Thanks, Bob!

I wanted Vicodin, not Herbal Tea (nytimes)

We are in the midst of a national opioid crisis. It is a crisis, partially, of our own making. In the past decade we physicians were criticized for not adequately addressing the pain of our patients, to the point of creating another vital sign: “pain score.” And then dutifully tracking this score and catering to it, and addressing pain, often with rehab therapy, with more aggressive interventions, injections, surgeries, and, yes, sometimes with pain meds, including narcotics and anxiolytics.

And on top of this, we layered “patient satisfaction” as a rubric, and now a method of affecting physician reimbursement. What could go wrong? Isn’t satisfying our patients a core precept of our identity as physicians?

Actually, come to think of it… no.

We are here to help our patients get better.

To cure sometimes, to relieve often, and to comfort always.
–15th century folk saying

But there’s nothing in that saying that says “and always write for a narcotic script if you’re in danger of getting a low satisfaction score.

So, here we are, with an opiate crisis, and faced with the very difficult task of reducing or eliminating opiate use in patients whom we have PUT on chronic opiates. So, this NYtimes article is timely and fascinating.

In fact, we are in the midst of designing and implementing an ERAS program (Enhanced Recovery After Surgery) in our health system, to entirely eliminate the use of opiates before, during and after surgery. Apparently pioneered by surgeons at Duke University, we are well on the way to experiencing similar benefits for our patients, faster recovery, reduce hospital stays, higher patient satisfaction.

This is reminiscent of Atul Gawande’s book “Better” where he describes the idea that “If even elite athletes have coaches to improve their game, maybe surgeons should have coaches.” And then finding that having a former mentor observe him during surgery, he received pages of notes on how to improve his operating technique and outcomes. Hmm. We should do more of this, inspecting our usual practices, and working out how to continuously improve.

CMIO’s take? There is always something new to learn.

Augmented Reality: the Homecourt app on iPhone XS: wow!

nash01

https://www.si.com/tech-media/2018/09/12/steve-nash-homecourt-app-apple-event-iphone-xs-camera-watch-shot-tracker

More whiz-bang tech. The latest iPhone now supports more augmented reality, by allowing the app access to a video stream of someone practicing shooting hoops and giving feedback in REAL TIME as to the spots from which shots are attempted and made. In other words, AI now auto-processes video that used to take hours of video TAPE pored over by coaches and players, and simplifies this into a device we already carry. (OK, those of us with >$1000 disposable income and a desire for the latest and greatest geek toy).

But, think, if we applied this to healthcare, would we use this to:

  • Monitor patient meals by automatically calculating what is being consumed?
  • Watch how patients are flowing through clinic to learn how to optimize efficiency?
  • See how ER patients are doing in the waiting area and triage and in the treatment areas?
  • Watch for improved efficiency in procedural areas like endoscopies, bronchoscopies, cath labs?
  • Watch how minor procedures are performed and suggest tweaks to clinician performance without the shame of having a human supervisor around?

CMIO’s take? Interesting to see how and where Augmented Reality might show up in healthcare, based on bleeding edge ideas in other fields like sports.