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Putting WisDoc Together
With the health information problem laid bare, the WisDoc solution above appears ideal but at first sight it looks dauntingly complex. The WisDoc group has devoted much time and energy to devising a simple, efficient, technical and commercial route through the complexity. Patents are pending on the design principles. Here in broad outline is the plan. Selection of diseases covered Whilst a typical medical text might cover some 500 topics, major health problems have a very skewed distribution. 20 domains - the major cancers, cardiovascular disease, diabetes, HIV and asthma - would cover some 90% of the disease burden in the developed world. There is the additional advantage that this group of disorders covers the bulk of the fast paced research which WisDoc uniquely picks up. Careful selection means that building the core of an information utility is then a quite manageable task. Because it is an 'everything you want to know in one place, up to the minute, matching professional and community system,' it immediately fulfills the requirements of the bulk of net users both doctors and patients. Therefore it would have 'stand alone' commercial value even at this stage. Certainly the selection of diseases to be covered is critical to the practicality of the implementation. Multi-faceted approach to the diseases With the increasing sophistication of medicine, many diseases are now distributed over a clinical spectrum much broader than the traditional specialist categories. In particular medicine and surgery are closely intertwined in the treatment of many disorders. Preventive and screening approaches are now also well-developed areas of clinical practice and primary care has a defining contribution. WisDoc approaches each topic from these multiple perspectives. Technical level of the information As indicated above one of the consequences of the increasing interconnectedness of clinical information is that the required level of understanding of both obviously related and apparently disparate fields of medicine has risen significantly. WisDoc is therefore pitched at the inter-specialty level. This is the level at which a specialist could provide a complete explanation of the essence of a topic area to a specialist in another area, an advanced medical or surgical trainee or to an experienced primary care practitioner. It is the highest common level of communication between doctors and is just one step removed from the detail of the specialty. Take as an example the consideration of coronary artery disease treatment options. The latest research concerning the use and outcomes of drug coated stents in angioplasty (tiny tubes that keep a coronary artery open after a little balloon stretches the artery) would be relevant but the extensive detail of the procedures and complications of stent insertion would be omitted. A cardiothoracic surgeon in considering a patient for a particular coronary surgical procedure could at the same time weigh the relative merits of the latest alternative cardiological procedure. A resource pitched at this level allows it to function as the major specialist explanatory text and as the chief cross-referencing resource. Community health information as background in the 'passive patient' model requires far less technical detail than a medical student text. In marked contrast the level of information needed for active patient involvement corresponds exactly to the high level of medical communication described here - converted into layman's language. The professional and community text levels in WisDoc then are natural concomitants. A high level 'multi function' text with its modular format (see below) lends itself readily to various levels of later 'detuning' to suit corresponding training levels including individually specified medical school versions. Modular topic components The next feature is the standardized modularizing system, which structures all topics on a similar matrix. Each topic is divided into a standardized set of components. These are individually quite standard and recognizable to any clinician. They include Genetics, Epidemiology, Pathology, Diagnostics, etc., a total of about 16 modular components. This enables an extremely efficient continuous update system both for matching and adding new research data to the professional text and for translating the professional text to the community text. The real surprise is the relative simplicity of the construction and the ease of maintenance largely because of the modular componentry and serial editorial distillation. All the steps can be concretely described and no medical or technical reviewer familiar with the design doubts that it can be constructed as specified. The relation between significance of information and quality of scientific support. This is one of the core defining features of WisDoc Information in the various topic components changes at quite different rates. The fastest changing areas are usually diagnostics and treatment and they obviously require the maximum input from solidly established resources - multi center trials, pooled trials, Cochrane reviews, evaluation committees etc. Unfortunately the lead-time for high quality scientific support can be quite long - six months would be extremely fast but it may run to ten years and more. As a consequence a very important role for the specialist reviewer is to make best judgement calls and recommendations based on more limited data in critical fast changing areas. For example a small study showing modest success for a new treatment of an otherwise lethal disease is very important. The reviewer's clinical opinion is cross checked with colleagues and of course coupled with a review of the quality of the scientific support. There is also a continuous feedback loop whereby other specialists in the same field are invited to comment on the reviewer's evaluations. Discussion of the Approach An Information Utility WisDoc is, in effect, a design for a health information utility. The general concept of information utilities was first developed by Dr Joel Birnbaum, Hewlett Packard's chief scientist and IT adviser to the National Academy of Sciences. Joel is and one of the 'godfathers' of the Internet and is on the boards of a number of major net sites. (An information utility as the name implies is likened to say the gas or electric utility. The final product in exactly the form that you need is continuously available on tap. The information system, continuously updated and immediately available to say a 747 pilot in exactly the right language and optimally presented, is a good example of such a utility.) WisDoc was developed without knowledge of Joel's pioneering work, but Walter Spring our technical director heard him speak on the topic at the Royal Academy of Engineering. On discovering his contribution to the field he asked him to review the project. Following are some excerpts from his response. '... I am quite familiar with the problem you have set out to solve, and with the pitfalls of amassing the high quality information and then keeping it current. While I am hardly an expert in things medical, it seemed to me eminently doable, provided you can get the kind of corporate and industrial backing and cooperation that you seek ... I should say that applications such as yours are exactly what I had in mind when I first started talking about information utilities some two decades ago. It is very gratifying to see the infrastructure starting to be used in this way ... It is easy to see how enormously useful a system such as you propose would be; I've often wished one existed.'
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