Staging Healthcare Automation
A proposed staging system for automated healthcare
When thinking about a nascent technology, its final form may be difficult to imagine. Automated healthcare in particular may seem fanciful or farfetched. Of course, technologies do not spring into a final, mature form overnight. Rather, incremental advances get us ever closer to our goal. In fact, we’re unlikely to ever reach a “final” technology. Instead, we approximate an ideal until our imagination reaches for an even more ambitious future.
As regards automated healthcare, we are not starting from scratch. Today we have many if not most of the necessary ingredients. From our current vantage point we can foresee the milestones we will reach en route to complete automation.
Why Classify
Below I propose a 10-point classification model for medical automation. A similar system exists for autonomous vehicles.
Such classifications help to focus our technical efforts but also provide a framework for policy makers and other stakeholders to think about where the technology is, where its been, and where its going.
It’s important to remember that these models refer to technical developments. They don’t touch on other important factors such as public policy and social acceptance.
The Six Dimensions
The levels differ along six dimensions. To keep things simple, each dimension is binary. With six binary dimensions there are 64 possible combinations. However, some make less sense than others as we will soon see. The six dimensions are:
Generalized vs. Personalized: Does the system give general guidance on a topic or does it give personalized guidance on a particular patient
Ancillary vs. Integrated: Is the system integrated into clinical workflow or does it have to be sought out separately.
Suggestive vs. Decisive: Does the system make suggestions that can be overridden by a human clinician or is it an authoritative decision maker.
Cognitive vs. Procedural: Is the system purely a decision maker or does it perform procedures as well. The final level of automation includes full procedural automation
Domained vs. Undomained: Are the preceding attributes constrained to a particular domain or field or do they span all medical fields?
Mediated vs. Autonomous: Does the system require human mediation for some aspect of care or can it be used directly by the patient/caregiver or otherwise operate autonomously
Let’s flesh these out slightly
Generalized systems are not tailored to the particular patient at hand, and instead provide generic guidance. Personalized systems have access or otherwise leverage specific patient information to make personalized recommendations. Personalization itself is not binary. For instance, a system may incorporate only a single personal data point (e.g. patient age) or it may incorporate thousands.
Ancillary decision systems are invoked by human clinicians at their choosing whereas Integrated systems intervene spontaneously. An online clinical decision support tool, for instance for the Well’s Criteria, is an example of an ancillary system. A clinician must seek it out and make use of it voluntarily. If, on the other hand, the same tool were built into an EMR that would prevent a CT scan from being ordered until it was completed, this would constitute an integrated system.
Suggestive systems merely make proposals that can be overridden by a human clinician. Decisive systems make decisions that are definitive and final. A system whose decisions cannot be overridden by a human clinician represents a significant milestone. It implies sufficient confidence in the machine’s decision making capacity and constitutes a human to machine transfer of agency.
Cognitive systems are principally software solutions to the intangible elements of healthcare. Procedural systems combine an autonomous robotic component for any tangible, procedural elements of care. Medical procedures are not rote and predictable and therefore demand their own cognitive processing. As a result this dimension is viewed as beginning from “Purely Cognitive” systems to “Combined Procedural-Cognitive” systems (not purely procedural systems).
Domained systems are bounded to certain fields or settings along the aforementioned dimensions. Undomained systems serve all medical fields. Technology is almost certainly to be rolled out in a piecemeal manner and certain fields are likely to be affected before others. Undomained systems are therefore likely to represent a more mature version of the technology.
Mediated systems require human intervention for some aspect of care for instance data collection, navigating the decision tree, and so on. Autonomous systems can operate with the same level of autonomy as a human physician for data collection and decision making. Autonomy could be purely cognitive or it can include procedural autonomy.
Classification of Autonomous Clinical Care
Below is a synopsis of the 10 levels of medical automation
Level 0: [Generalized, Ancillary, Suggestive, Cognitive, Domained, Mediated]
“Here if you need me” “Passive” (e.g. textbooks, UptoDate)
Level 1: [Personalized, Ancillary, Suggestive, Cognitive, Domained, Mediated]
“Here if you need me” “Personalized (low resolution personalization)” “Passive” (e.g. MDCalc)
Level 2: [Personalized, Integrated, Suggestive, Cognitive, Domained, Mediated]
“Won’t wait to be summoned” “No decision making” (e.g. EMR suggests sepsis order set based on triage vitals)
Level 3: [Personalized, Integrated, Decisional-Suggestive (decision can be overridden), Cognitive, Domained, Mediated]
“Decision making but not authoritative” (e.g. patient meets sepsis criteria, machine orders sepsis order set, doctor can cancel)
Level 4: [Personalized, Integrated, Decisive, Cognitive, Domained, Mediated]
“Decision that is authoritative” (e.g. patient meets sepsis criteria, machine orders sepsis order set, doctor cannot cancel ; implies confidence in machine over human, transfer of agency)
Level 5: [Personalized, Integrated, Decisive, Procedural, Domained, Mediated]
“Can begin to perform limited, non-invasive procedures” (e.g. automated vital sign acquisition)
Level 6: [Personalized, Integrated, Decisive, Procedural, Domained, Mediated]
“Can begin to perform invasive procedures with mediation” (e.g. robotically inserted IV with nurse supervision)
Level 7: [Personalized, Integrated, Decisive, Procedural, Domained, Autonomous]
“Unsupervised cognitive and procedural automation among limited domains” (e.g. automated hernia reductions but not shoulder reductions)
Level 8: [Personalized, Integrated, Decisive, Procedural, Undomained, Autonomous]
“Cognitive and procedural automation across domains with partial mediation” (e.g. control room supervision of machine operations at a systems level)
Level 9: [Personalized, Integrated, Decisive, Procedural, Undomained, Autonomous]
“Cognitive and procedural automation across all domains without mediation” (Oracle, Robot Doctor)
To my mind, today we are somewhere between Levels 3 and 4 in some domains.
Summary
Classification systems are useful frameworks for thinking about new technology. Here we have a proposed 10 stage classification system that considers automated healthcare along 6 dimensions. It’s almost certainly flawed and all feedback is welcome.