AI and the Canadian doctor


In the deluge of recent presentations on artificial intelligence (AI) and medicine,  one of the more relevant for Canadian doctors came at last month’s annual meeting of the Canadian Medical Protective Association (@CMPAMembers).

The video of that presentation has just become available and gives people an opportunity to hear from CMPA Executive Director and CEO Dr. Hartley Stern and Dr. David Naylor (@CDavidNaylor), professor of medicine and president emeritus of the University of Toronto and one of the most respected voices in Canadian health care.

Given that the CMPA provides legal advice to physicians, Dr. Stern’s comments were particularly relevant, and Dr. Naylor had the opportunity to expand on remarks he published last year in the Journal of the American Medical Association on the topic.

“Every area with images at its core for practice will become a realm where AI will have transformative effects ,” Dr. Nayor said, because of ability of a computer algorithm to quickly analyze individual pixels rather than just patterns and to characterize in much greater detail.

“Used intelligently (and) used to augment human intelligence, AI can streamline workflow and relieve us of drudgery and give us time to better physicians caring for people.” In addition, he said, AI can help solve complex analytic problems and capitalize of the widening availability and richness of data.

“Many of these algorithms will be at their best supporting us and not making decisions on their own,” he said.

On the negative side, Dr. Naylor said, AI has the potential to devalue judgement and dehumanize care, is dependent on the quality of information on which algorithms are based and makes decisions where causal pathways are hard to determine.

When it comes to the potential uses for AI in medicine, Dr. Naylor said, “these are early days,” noting Dr. Eric Topol’s assessment that few of the algorithms currently in use have been rigorously tested and evaluated. And, he said, nobody has yet established how to critically evaluate publications dealing with AI because they vary so much.

Dr. Naylor said physicians should take the middle ground and not be stampeded into either unquestionably rejecting or accepting the value of AI in medicine. The integration of AI into medicine will either be smooth or disruptive, Dr. Naylor concluded, and which way it goes will depend to a large degree on physicians.

Speaking after Dr. Naylor, Dr. Stern reiterated the potential benefits and challenges for using AI and deep learning in medicine. “There is great promise that we can improve diagnostic accuracy,” he said, and  the ability of physicians to improve treatment plans can be improved, while reducing costs and the overuse of medical tests.

The promise, if properly implemented, is that AI will be able to transform the healthcare system and in so doing improve well-being and quality of life for physicians, Dr. Stern said.

However, he added, the regulatory framework and legal environment for using AI lags significantly behind the development of the technology.

For AI to be properly integrated into health care, Dr. Stern, said individual physicians need to be able to trust that the technology will do what it says it is going to do. One of the roles of CMPA, he said, will be to provide a bridge between the interest in these technologies from physicians and patients and their trust in them.

With poor communication being a main reason for complaints about physicians to regulatory authorities and the CMPA, the ability of physicians to properly explain the algorithms used by AI to their patients will be of critical importance. “You are going to have to learn how to tell that patient what this AI is going to do for you.”

Dr. Stern went on to then elaborate a number of key challenges to integrating AI including considerations of patient privacy while gathering the immense amounts of data required to develop reliable algorithms.

“In our environment, health care professionals are accountable clinical diagnosis and treatment plans. It’s you, not the machine.” He noted the Canadian regulatory and legal framework is not yet established for determining accountability when a wrong diagnosis is made based on an incorrect algorithm.

Dr. Stern urged the audience to get involved with medical associations and regulatory authorities in developing frameworks to provide adequate protections for physicians. “Without a clear policy, you are at risk.”

The session was accompanied by the release of a CMPA background document: “Can I get an (artificial) second opinion?” That document notes: “While AI can provide information for you to consider, it is important to ensure that actual medical care provided to the patient reflects your own recommendations based on objective evidence and sound medical judgment.”

(Image: Dr. David Naylor from CMPA video)

#HIMSSEurope19: The B side


 “These are the days of miracles and wonders

Don’t cry baby, don’t cry”

The Boy in the Bubble: Paul Simon

After every major digital health conference I seem to come away with the sound of Paul Simon’s Boy in the Bubble from his 1986 Graceland album ringing in my ears.

The recent #HIMSSEurope19 conference in Helsinki, Finland was no exception.

As always – and seemingly with increasing rapidity and volume at these conferences  – there were demonstrations of new innovations, start ups and other impressive tools facilitating how care can be delivered more effectively and efficiently. Miracles and wonders.

But to the credit of the HIMSS organizers they also had sessions focusing on the dystopian elements of health technology – the B side of the digital revolution if you will. In fact, there was a whole stream of sessions called radical health dealing with issues such as climate change and migrant health. To quote the program: “The world is currently witnessing an unprecedented global migrant and refugee crisis that will fundamentally affect and challenge European health systems in the future. And these migration waves will only accelerate with climate change refugees. Are European health systems ready for a tsunami of migration waves? What can we do in order to prepare? Can technology help the integration of migrants and refugees?”

However, a more fundamentally troubling session was the one that featured a number of futurists and researchers discussing the potential downsides of technologies which are fueling our advances in digital health

To quote @Artu Olesch, a freelance journalist who attended the session: “As human species, we develop slower than the technology. On the other hand, we have to keep experimenting in search of innovations that can potentially improve our world. Unfortunately, there is always the danger that radical technologies created for a good purpose will influence our lives negatively.”

This negative side was expounded with great eloquence by the speakers who referenced the social-control aspects of technology as being seen in China now, the impossibility of maintaining anonymity of health data (“two data points and we have you”), the potential consequences of Big Data and the use of AI in health care (especially if the algorithms used fail to reflect women and those who are not white) and gene editing (which, to quote one speaker, “is liking having nuclear weapons in the hands of apes”).

When you hear speakers such as biohacker Teemu Arina (@tar1na) talking about the need to modify our genetic code to adapt to today’s fast-changing society you realize the magnitude of the changes we are currently facing and how unprepared we are for them.

The session made it clear that a future in which people will trade their personal health information and approve real-life constant monitoring of their health in exchange for lower health insurance rates is very, very close indeed.

(Image courtesy of Go Clipless)


Morphing with Moomins: #HIMSSEurope19


To be honest, one of the main reasons to write this blog was the chance to use the headline – which probably needs some explanation. And if the explanation doesn’t make too much sense then I can only blame jet-lag and a degree of digital health overload from attending the first day of the HIMSS Europe 2019 digital health conference in Helsinki, Finland.

And just to be even more inexplicable, the main theme of this blog is – as it has been a few times this year – AI and its applications in health care.

It is currently impossible to avoid AI as a conference theme/main topic of conversation at health technology or digital health conferences. In fact, as this conference goes on in Helsinki another conference in Boston dedicated specifically to AI and machine learning is just about to begin. To quote from an AI session description here at HIMSS: “Personalized medicine, predictive analytics, augmented diagnostics, real-time processing of wearable data… AI is buzzing and feeding our imaginations with hopes and dreams of a truly data-driven healthcare with optimal clinical and financial outcomes.”

But what struck me while listening to that well-attended sessions is that AI has morphed from Big Data as a major theme in digital health care.

Remember how just a few years ago everybody was talking about Big Data (with the capitals) and the potential benefits for care delivery from the incredible amount of data being accumulated on all aspects of people’s health? Well, it is clear that this theme has been coupled with machine learning and artificial intelligence to take the potentiality to another level. Now when speakers – such as those from the Helsinki University Hospital (HUS) talk about the “data lake” they are filling with a wide range of genetic, demographic and health data from their patients, they are doing it in the context of taking all of this information to create algorithms to enable AI use.

In fact, according to session moderator Dr. Mikka Korja, a neurosurgeon at HUS, Helsinki is one of the world leaders in exploring the use of AI in health care with 100 projects underway here.

That data are critical to effectively utilizing AI in health care is without question. But, as speakers repeatedly noted, it is not just the quantity of data points needed to create effective algorithms but also the quality of data required. It is clear that effective use of AI is impossible without standardized digitized data collected in an electronic format. The point was also made that most health care organizations are currently not configured to continually gather data and feed it back into the system in a manner that is required to develop AI functionality.

Most of the speakers at the HIMSS session discussed the potential applications for AI to improve clinical diagnosis and this remains the most sexy aspect of AI. Yet, I thought it was actually Dr. Kaveh Safavi, senior managing director at Accenture Health, who gave the most compelling presentation when he noted that enhanced diagnosis is actually one of the more challenging roles for AI to play in health care. During question period he noted that that for AI to augment diagnosis requires a high level of machine learning with masses of data which might require years of work and with all of this compounded by dealing with privacy and security concerns.

Where AI can and will have a huge impact, Dr. Safavi said, is in cost reduction and improving the consumer experience, in addition to outcome improvement. He argued that effective use of AI will help reduce staffing requirements and increase capacity at a time when “we’re running out of people to provide health care.”

Dr. Safavi also quoted an Accenture study showing the main benefits from AI in health care will come in areas unrelated to diagnosis with the biggest estimated potential benefits being in the areas of; robot-assisted surgery, virtual nursing assistants, administrative workflow assistance, and fraud detection.

For all the hype you hear about using AI to better detect melanoma or leprosy, Dr. Safavi’s comments are worth serious consideration.

Oh and about that headline. For those unfamiliar with Finnish culture, Moomins are an incredibly popular family of fictional creatures created by Tove Jansson in the 1940s and featured in books, comic books, TV, plush toys etc. And at a conference in Finland who could resist working them into a headline.



Two-tiered texting: Do virtual visits spell an end to medicare


Arguably the most significant plenary session at this year’s recently concluded #ehealth2019 conference in Toronto was a panel discussion on the impact of virtual primary care visits on continuity of care.

The panel featured Dr. Ed Brown (@DrEdMBrown), the CEO of the Ontario Telemedicine Network (OTN), Dr. Brett Belchetz (@Brettbel), founder and CEO of Maple, the country’s largest private provider of virtual care, and Dr. Monika Dutt (@Monika_Dutt), a family and public health physician and an outspoken advocate for social justice.

Among the dozens of presentations at the conference co-sponsored by Digital Health Canada, Canada Health Infoway and the Canadian Institute for Health Information this presentation shone the brightest  light on the core issue facing the growth of digital care in Canada – how can the demand and interest in such an approach be accommodated within a publicly funded health care system already overwhelmed by financial demands?

One answer that seems clear is that the demand to be able to text a family physician at any time and receive an answer within minutes is so attractive that those with money or 3rd party insurance can and will pay to do so – thereby creating the two-tiered system, based on ability to pay, which has always been so adamantly avoided by the Canadian psyche.

The growth of Maple shows just how this demand is big and is growing. Dr. Belchetz noted that when Maple started in 2014 only one quarter of one percent of physician visits in Canada were done virtually. Now, he says, Maple has a network of 400 family physicians across the country with 350,000 patients paying for “almost instantaneous” access to care.

Dr. Brown noted the interest in this approach was confirmed by both patients and providers in a pilot conducted by OTN in five regions of Ontario  involving 277 providers and 33,000 patients. That pilot showed overwhelming support for the approach and he noted 90% of the interactions were resolved through secure messaging and did not require in-person follow-up.

“Basically, people just want to be able to text their doctor,” Dr. Brown said adding that the pilot documented very little overuse or abuse of the approach by patients.

While acknowledging the benefits of virtual care especially in rural and remote areas, Dr. Dutt noted virtual primary care must be integrated into the comprehensive, integrated and publicly funded primary care system or else it risks creating inequities between those who can and cannot pay privately for the service.

British Columbia is currently the only jurisdiction in Canada that provides funding for family physicians to interact virtually with patients. And, as Dr. Belchetz noted, this is confined to video visits while he said what patients really want is the ability to text with their physician.

The interest and demand for virtual primary care is so great, Dr. Belchetz said that other provinces are “terrified” to fund it because of the financial demands it will place on already overburdened systems.

Drs. Belchetz and Brown said it will be important to be able to demonstrate that virtual primary care provides value for money and can be delivered in a cost-effective manner in order for provincial governments to agree to put it into the fee schedule for physicians.

Dr. Belchetz also made the point that instantaneous virtual access to a family physician means a person with a non-urgent or self-limiting condition – he used the example of an itchy toe – might be inclined to contact a physician about it whereas if an in-person visit was required then they probably wouldn’t bother. He said there needs to be a way of triaging or gating access, so such frivolous demands do not overwhelm the system.

Today that is done in Canada by requiring payment to access systems such as Maple – a two-tier system based on ability to pay if you will.

Should virtual access to a family physician become an essential requirement for health care in the 21st century – as many think it is fast becoming  – absent any effective method of making this affordable it arguably spells the end to equitable access to care as we know it.

One EMR to rule them all: The @HQOntario #HQOchat


Recently, Health Quality Ontario hosted a lively and informative tweet chat (#HQOchat) on integrated care – and again and again the need for a shareable electronic source of patient information was mentioned as key enabler.

The chat featured a distinguished panel of moderators: Health Quality Ontario VP of Quality Improvement Lee Fairclough (@lfairclo), patient advocate Annette McKinnon (@anetto), University Health Network President and CEO Dr. Kevin Smith (@KevinSmithUHN) and Marathon, ON family physician Dr. Sarah Newbery (@snewbery1). With more than 100 participants, the discussion was wide-ranging and focused on what is already being done and what could be done better to integrate the care patients receive in Ontario.

The importance of a unifying electronic medical record (EMR) or source of patient information to allow patients and providers to better manage care and help ensure the seamless transition in care across different environments was raised repeatedly.

Those who have been following discussions about EMR and health technology over the last couple of decades will recognize this as a riff on the old theme of interoperability and the need for EMRs and other systems housing patient data to be able to communicate better with each other.

“Today it seems so possible, and (it’s) time to put focus on digital solutions to support integration,” was how one participant put it. Asked what integrated care meant to them, another responded “from a patient’s perspective, the whole team knows what it’s going on – there’s no need to repeat that story / circumstance over and over again,” to which a physician responded: “(we) need a way to have easy digital transitions of this info.”

In response to a question about what was needed to build a fully integrated health care system, Health Quality Ontario Interim President and CEO @annagreenbergON answered in part “patient and caregiver access to their own records. EHR. Virtual care.” Another participant answered: “A fully integrated system is 1 inspired by patients & caregiver needs, as articulated by them. Patients & caregivers are fully involved co-designers of that system. There is single portal where all medical data are held, synchronously accessible by patient & doctor.”

On the flipside, the lack of accessible electronic patient information was identified as a barrier to integrated care.

“ …. who can take lead in shepherding all providers into using common EHR (electronic health record) framework? It’s tragic that even hospitals across from each other can’t share easily. We also block innovative private partners who are lost/blocked from plugging into a standardized network,” one physician wrote in a post.

“…we don’t have access to our primary care records and even access to hospital records and lab results is uncommon. So, we need access to more info,” @anetto posted.

Another doctor tweeted: “I think the genie has already left the bottle to consider a single EMR – need instead to focus on joining up the info out there – Connecting Ontario is probably the best option to build on!”

“We need multiple options to access and share information,” stated one post.

And this post put some context to the discussion: “A province wide record would definitely be helpful, but I think it’s more than that. The technical solutions are important, but we also need to be mindful of things like relationships, good communication, & having time/skills to collaborate.”



How do you license a black box?



Amidst all the recent hype and hope surrounding the use of machine learning and AI in medicine it is good to know someone is also asking how the heck we going to figure out whether the proposed algorithm or application is doing what it is supposed to be doing.

Enter Health Canada’s Digital Health Division (you will be pleased to know we have one), created a year ago to do just that (among other things).

At the recent CADTH symposium in Edmonton, Dr. Tyler Dumouchel (PhD), a senior scientific evaluator in that division gave a fascinating overview of regulatory challenges currently facing Health Canada as applications utilizing machine learning and AI are already being submitted (and receiving approval).

While noting that AI has the potential to revolutionize health care, Dumouchel said there is currently no established regulatory framework for assessing AI in medical devices. Hence the challenges, he enumerated which include:

  • How to balance encouraging innovation and facilitating market access with safety and effectiveness.
  • What pre-market authorization should be required from the manufacturer and should we be regulating manufacturing processes rather than the finished product?
  • How reliable and representative are the training data used to develop the particular application (a biggie)? Dumouchel noted such data need to reflect the Canadian patient population, be accurate, done on multi-centre basis, and include accurate disease prevalence data.
  • How do we know the algorithm used is generalizable and transferable and what is the best approach to use to ensure the algorithms used generate correct and predictable results?
  • What are the best metrics to use to assess the performance of an AI algorithm?
  • How can we ensure that AI is integrated appropriately into its intended environment without unintended consequences?
  • When and how do you assess to continuous learning algorithms where results can vary in time?
  • What sort of post-market regulation framework is appropriate for AI applications?
  • Who is accountable if the application makes a mistake?

These are all obviously important issues and it is gratifying that the federal government has acknowledged them and is taking them into consideration.

But there is some sense of urgency here. As Dumouchel points out, Health Canada doesn’t want to be left behind internationally when setting standards for medical devices that use AI algorithms.

Disrupting a futuristic health care system near you – patients #CADTHsymp


Artificial intelligence, genetic engineering, targeted wonder drugs? The opening plenary on the topic of disruptive technologies in healthcare transformation at arguably Canada’s top health technology policy conference held the promise of all of these.

But patient partnering and involving patients?


Perhaps it should be no surprise that discussion at one of the first Canadian healthcare organizations to wholeheartedly embrace patient involvement, the Canadian Agency for Drugs and Technologies in Health (CADTH), should settle on patient participation as the biggest potential disrupters in health care in the years to come.

Opening presenter at the CADTH symposium in Edmonton, Dr. Irfan Dhalla, VP of Evidence Development and Standards at Health Quality Ontario, set the stage by stating that biggest change to health care in next few decades may be partnering with patients for not just their own care but in how we organize health care and run health care organizations.

Dr. Dhalla said he came to this conclusion after crowdsourcing input through Twitter on the most disruptive technology to come and found that patient input was by far the most popular response. During the session when he delved into more technical issues of how reassessment of health technology assessments should be done, he stated it must be done “with patients at the table.”

Other speakers on the plenary panel also touched on this theme. Carole McMahon a patient, caregiver and patient advocate stated that in future patients should have new roles such as in helping design clinical trials or in designing patient surveys.

At the end of the session when asked what changes the panelists would make to improve health care, involving patients was among their answers.

Despite being a strong leader in patient partnering, CADTH was not spared criticisms from the patient community at this year’s conference.

A conference session on patient engagement that was listed with four speakers and no obvious patient presence was the subject of a critical tweet prior to the main conference that generated widespread concern from the patient community. “I find this unrelentingly frustrating,” was one response. “These kinds of presentations have the potential to actually ‘model’ what they’re allegedly talking about.”

Fear not though, the patient presence remains strong on the second day of the conference tomorrow beginning at a breakfast session at which Zal Press (@PatientCommando) will be hosting a session on the “thorny issue” of patient compensation in research and health care.

And lest people fear, the debate between patients might become too intense as it did at times at least year’s Halifax meeting, CADTH now has a meeting code of conduct that notes “harassment or disrespectful conduct do not belong at any CADTH event” including “sustained disruption of a speaker” and “grouping or isolating.”