JIST

Must-Have, Instant-Classic: The Promises (and Perils) of Medical Information Technology

 

Consider the following passage, describing a new iPhone app, which is now available on Apple’s iTunes

app-store: Put a poison control center in the palm of your hand with this unique clinical toxicology resource. The Tox Toolbox is the premiere app for the emergency management of poisoning, overdoses, and accidental exposures to a broad variety of toxic substances. Featured contents include key techniques for decontamination, essential management information on 25 common overdoses, rapid assessment pearls for toxic syndromes, and direct links to key websites for poison control, pill identification, envenomations, and other important online resources. The Tox Toolbox features a (fixed database of important clinical summaries, formulas, and management guidelines for dozens of common toxic exposures, with links to additional resources available through the web, to allow efficient bedside diagnosis and timely treatment for a diverse range of poisonings. Ideal for health providers in the prehospital, acute care, and inpatient settings, as well as a great board-review resource in toxicology. Bonus features include a calendar featuring famous moments throughout toxicology history, and a management protocol for “what to do in the first 10 minutes” after a suspected overdose.

 

What you have just read is an example of an increasingly popular type of communiqué called an “app ad,” which is short for “application advertisement.” These brief, catchy descriptions of new devices, programs, and clinical tools can be found not only at the online marketplaces such as iTunes and Android appstores, but relayed through hyperspace across various other bulletin board sites, social media pages, and web-logs dedicated to explicating the novelties of digital medical culture.

 

And, if you own a smartphone or have friends who do, I don’t need to tell you how tempting are these wailing, incessant siren songs of intellectual deliverance, via the multitude of “must-have, instant classic” apps now available, unto a promised land of “better living through infotech” in medicine and in everyday life. Medical students and house officers today are already embracing these products with open arms, and the older generations of clinicians all around me are stampeding to keep up. This hurried pace to have the latest and greatest gadgets and programs is reaching epidemic proportions. Through the miracle of the Internet’s 24/7 bazaar, there is a veritable deluge of these delightful electronic novelties now available to clinical medicine in all corners of the globe. But sooner or later the question emerges: what does the dang thing cost?

 

Loosely, the term “app” stands for application software and covers a diverse industry of technical products and electronic solutions (e.g., apps and related items) which are being currently created and increasingly marketed to clinicians worldwide. However, I prefer the word appaceuticals as a more accurate reconstitution, because it echoes another more familiar but equally fraught term: pharmaceuticals.

 

The parallels are worth considering. It seems to me that the“appaceutical industry,” like the pharmaceutical and many other powerful industries, now has a lot of goods to promote, and much to gain, by advertising to clinical providers and changing our patterns of behaviour. We are slowly but surely being nudged to embrace new gadgets and technologies, regardless of the consequences of adoption, or the quality or utility of the apparatus being promoted.

 

I should know: I’m a bit of an industry insider myself. I helped author the clinical contents of the Tox Toolbox app described in the passage above. And in taking this project from a hailstorm of ideas, through multiple iterations and revisions, and finally bringing it to the light of the digital marketplace, I’ve learned a lot about the logistical and technical details of computer programming and app development. And, moreover, I have come to appreciate a larger lesson of technical innovation, whether in pharmacology or in informatics: that there are tradeoffs and subtle costs for every new technology we adopt.

 

The dominant narrative, the story which you have probably read about recently, goes something like this: we can all look forward, in the coming decade, to some amazing inventions and incredible medical advances, all brought about by computation, pharmacology, or genetics, or some combination thereof. In addition, the vast neural network of the Internet and its users promises to construct something entirely new for our world - a globally distributed metamind which will change modern culture in unexpected, unforseeable ways. In one extreme scenario, the “singularity” is nigh: a bright and inevitable technical salvation for all the ills of the human species.

 

Here is the smaller story about our toxicology app. About a year and a half ago, an industrious pair of software programmers took my old notes, and, during their spare time and weekend hours, taught themselves how to program an app on the iPhone in order to create the Tox Toolbox app. In January 2011, the app premiered on the iTunes appstore, and since then we have recruited another programming whiz to help launch a parallel product on the Android platform.

 

Vendor data provided by Apple Inc. indicate that within the initial 3 months after release, we distributed over 250 copies of the iPhone app in over 25 countries. (We like to joke, “We’re huge in Latvia!”). These sales were due to unsolicited, spontaneous purchases, indicating a broad geographic demand for toxicology-related apps and related tools. (And here please allow me to add a word of praise to the amazing team who made this possible, though because they are coders and painters they probably haven’t renewed their subscriptions to this fine journal: Brian, Jordan, Erik, Brian C and Mason - awesome work guys!).

 

I share these reflections as one story among the many narratives being weaved today about the course of medical info-technology. I should also hasten to add that, despite this brief and limited excursion into the world of programming, I am in the end much more a passenger than a captain on this cruise. The truth is, because of the decentralized nature of apps and software development, there won’t be any captains in the traditional sense. In fact, for any given subspecialty there may be dozens of similar apps in the pipeline, with more or less the same structure and contents and little or no oversight about the quality, reliability, or accuracy of their contents.

 

We are all of us setting sail on a vertiginous journey in this new ocean of technologies. It’s part of a larger story of technical advancements in medicine, and there are countless other tales of success, failure, and lateral redirections in the quest to create better and smarter technologies to help clinicians do their work. Our best predictions indicate that the flood is only beginning - a surge of apps, websites, and gadgets will soon wash over and remake the landscape of clinical medicine in virtually every subspecialty.

 

I am excited, and at the same time a bit apprehensive (or should I say, APP–rehensive!) about these predictions. While these new technologies hold tremendous promises, and will no doubt fulfill much of their potential to help humankind (as many pharmaceutical drugs have), they should nonetheless prompt a critical attitude from us as a community about their references, their limitations, their untested claims, and their clinical utility. Just like new drugs, new research, and new journal articles, these legions of new gadgets we introduce into our work should be rigorously analyzed within a rational, evidence-based framework.

 

There is also a philosophical dilemma at the heart of technical innovation, and, paradoxically, the quandary grows more acute with the growing success of each innovation. The miraculous outreach of Apple and iTunes has, almost automatically it seems, distributed hundreds of copies of the Tox Toolbox into smart-phones all over the world. Which is just plain wonderful for my programmer friends, but in the back of my mind I wonder whether the bells and whistles included in our app - the handy and amazing toxidrome guide, the user-friendly anion gap and osmolar gap calculators, and the convenient and weight-based N-acetylcysteine dosing tool - whether these features will somehow make all those Latvian doctors and Brazilian internists and even my own house officers lose some special, intimate connection with the unique skills and precious craft which constitute the daily practice of clinical toxicology. Will making a cheaper, more portable, phone-based toxicology resource end up cheapening the wonderfully nuanced detective work and careful considerations required for the management of poisoned patients?

Will reducing what we do to a computer program ultimately reduce our capacity to learn, to teach, and to inspire future generations of dedicated and deep thinkers? Will having so much information at the behest of a touch screen collapse the utility and surveillance functions of poison call centers? Will anyone want to memorize the features of the anticholinergic toxidrome, by writing them over and over on flashcards like we used to, when the answers are only a thumbprint away?

 

It can be hard to fathom these consequences because most apps, like the Tox Toolbox, are still in their infancy. The gadgets are far, far away from replacing a real human being doing a bedside tox consultation. But I do wonder what will happen as these creations evolve: eventually, with each improved version of the app, by incorporating advances made in the halls and laboratories of artificial intelligence research, by patching in a vast array of new tools and techniques borrowed from the frontiers of clinical research, by reducing all that I do clinically to a complex algorithm inside a microchip, am I helping to source-code my own obsolescence as a clinician and specialist? Am I outsourcing my skills and training to a collection of sleeker and faster gadgets?

 

I don’t know the answers to these issues; there are too many uncertainties and the future is far from predictable. (And anyway, since we haven’t made enough money from sales to be yet profitable, I am in no hurry to quit my day job!). But any technology always reflects the values of its creators and adopters (at least initially), and clinical innovations in infotech today are no exception. The designs and consequences of today’s gadgets and tomorrow’s tools are not locked in; the development and evolution of our electronic creations is something that the medical community has the power (and responsibility) to influence, just as we (ideally, anyway) prioritize and influence the development of pharmaceutical drugs which we feel are the most suitable and safest for our patients. This is why the “why” conversation about information technology is one which medical professionals in general (and toxicologists in particular) need to begin in earnest.

 

Medicine will continue to change and benefit as information technologies mature. As apps like Tox Toolbox find their way into daily clinical practice, clinical toxicology and generalists alike stand to benefit from the fruits of these advances. I believe that while the latest infotech developments are essentially good ones, they nonetheless will require a constant and renewable supply of vigilance, creativity, and flexibility in order to fulfill the gifts which they promise without endangering our values and our patient’s well-beings. India and South Asia will witness a surge in new technologies and gadgets in the years ahead.

 

My brief experience with creating toxicology apps has taught me that clinicians in training today need to be equipped with the skills and technical literacy to use these tools wisely. Information is not the same thing as insight. I warn my house officers not to confuse “information technology” with “insight technology.” Because even though many legions of programmers from Silicon Valley’s start-ups to Bangalore’s laboratories are diligently working on it, the latter hasn’t been invented yet.

 

My suspicion is that real insight, real clinical acumen, is something that no gadget will likely provide even half as well as a human mind can. Because even though our minds are increasingly fragmented by data storms and distracted by status updates from around the world, we are still much more original than the computer-as-brain metaphors give us credit for. Every original thought, every new diagnostic or therapeutic consideration, is after all highly unpredictable in everyday experience. It emerges only after much practice and patience and disciplined focusing on a problem done by a real, living mind. An insight is yet another pattern of clouds coming together as a cyclone, and one which we understand only incompletely at best.

 

In closing, the times they are e-changing. There are palpable cultural shifts in medical informatics which toxicologists need to appreciate: the Internet, social media, app technologies and a brave new world of diagnostic tools are changing the landscape in terms of the potential for education, research, surveillance and outreach. There is ample reason to believe that clinical toxicology can pioneer the fulfillment of these potentials; after all, in forming the first modern poison centers sixty years ago, toxicologists brought into clinical medicine the proof of concepts that would later become commonplace: telemedicine, sophisticated informatics, biosurveillance, inter-agency cooperation, and critical checklists for the rational use of antidotes - all of these and more “givens” of today’s medical culture were first trialled, and later refined and improved, through the dedication of the poison centers and clinical toxicologists of decades past. It is my hope that medical journals like this one take on the challenge of educating readers about digital literacy, reliability, and accuracy in an era where the digital instruments of smartphones and handheld devices come to take a place alongside pocket references, penlights, and stethoscopes in the daily practice of clinical medicine. We pay a price for access to more information, which seems so free and effortlessly automated, with the capacity to have meaningful insights. It’s a trade-off which requires more open discussion, and a price worth pondering twice.

 

 

But in the meantime, do check out the Tox Toolbox - it’s a must-have and an instant-classic!