Around 1989, Steven Schueler started working on a computer program that could perform symptom triage. The intent was to create something that patients could use to safely decide what to do when they were sick. In 1990, his company DSHI Systems released “Home Medical Advisor” on a floppy disk. Later it was issued on CD-ROM’s, and claims to have sold over 2 million copies over the years. A major win for DSHI since 1999 has been its adoption by the Veterans Health Administration (VHA) as the Veterans Health Gateway (VHG). VHG provides over 300 symptom/condition-based triage algorithms and related patient education information and is used by VHA nurses to provide health advice via the telephone.

FreeMD is the free online version of the same underlying triage application. It  uses video to conduct the interview, ask questions and then generates a custom web page that contains care instructions and suggested next steps. I tested it with a few hypothetical cases (from benign nose bleed to serious UTI) and it seemed to do fine for basic diagnosis. With vague complaints like diffuse abdominal pain and vomiting, it stayed roughly in the right categories at a high-level (appendicitis, pancreatitis, kidney stones, gallbladder disease, intestinal obstruction).

Is the underlying logic based on hierarchical structured programming or a more sophisticated expert system with forward and backward chaining algorithms? I don’t know. My interest in FreeMD spiked when I saw the 100K+ unique visitors/month statistic. They are consistently generating a lot of traffic, so there’s got to be fairly comprehensive content and at least some utility in the service. My personal impression is that as a patient-oriented triage tool, it does well. Of course, provider-oriented decision support is tougher and I don’t expect it to hold up like Mcyin or DXplain.

I’m also intrigued why DSHI systems chose to make their application available for free, when the revenue model seems to be based on licensing/co-branding with partners. I was half-expecting to see a feedback loop on FreeMD (like “Was this the right diagnosis? Let us know”) since one of the major reasons for open-sourcing anything is to leverage wisdom of crowds. But there isn’t anything like that, so maybe its all about gaining awareness and marketing the application.

Update: Connected with Dr. Steven Schueler after writing this post. He correctly identified that FreeMD is a triage system, so its a bit unfair to compare it with diagnostic decision support systems like Mycin/DXplain.

David M. Eddy, MD, PhD is a legend when it comes to Evidence-Based Medicine. He coined the term in 1980s, actually. Being exceptionally skilled in mathematics, it was perhaps natural for him to apply it to medicine. The result is Archimedes Model- a mathematical simulation of the human physiology and how it interacts with healthcare interventions.

A more loaded one-line description of Archimedes (taken from his original paper in 2002): “It’s an object-oriented, continuous-time, full simulation model for addressing a wide range of clinical, procedural, administrative, and financial decisions in health care at a high level of biological, clinical, and administrative detail.” Phew. I’ll confess that I don’t know what exactly is under the hood. But I know enough about the informatics field to believe that this approach is viable and very exciting.

This YouTube video explains how the model can be used to run virtual clinical trials. Kasier has already backed the findings of Archimedes to change their diabetes care delivery.  I think there are fantastic, unlimited opportunities for applying such a fundamental model to medicine- personalized health predictions, public health, health policy, cost-effectiveness and what not.  As a startup, they are doing fine. With an impressive list of partners/clients, and a $15.6M RJWF grant (2007), they have a good runway and momentum. They have all the right ingredients to be a change agent for next-generation Healthcare IT.

PharmaSurveyor is a free service that analyzes your medications to point out potential drug interaction and side-effect risks. It was founded in 2006 by Linda and Erick Von Schweber to commercialize the ‘knowledge surveying’ technology they have developed over the last 25 years or so.

Given the fact that Adverse Drug Effects (ADE) are one of the leading cause of death in the US, there is significant market opportunity in consumer education and support around it. Couple of nifty features that I like:

• Direct meds import from Healthvault
• Community Knowledge Base – an aggregation of information and experiences from people who are on multiple drugs. This feature is currently in private beta, but I think that it can be a great revenue opportunity once it gets some traction in terms of number of users. There are plenty of pharma companies who would pay good money for getting early (even though informal) insight into side-effects, efficacy, interactions, and usage patterns of their drugs.

Seems like they are planning to integrate with DestinationRx and Polka, which is a good idea since the traffic from those sites will already be primed for the services that PharmaSurveyor provides. The advisory board has some significant names, including Barney Pell, Matthew Holt and Mark Musen.

They do have some interesting marketing techniques like analyzing celebrity cocktails, not requiring registrations, etc. Business model seems to be only google ads for now, which is no surprise given their research-oriented background. The site is more a proof-of-concept for the underlying technology (although I’m not sure what it is exactly). It’ll make a lot of sense to integrate this service with commercial CIS offerings, and take it one step beyond just using RxNorm.

Google.org’s flutrend is an attempt to model flu activity across US based on the search terms that Google.com users enter around flu symptoms, treatment etc. The underlying premise is that there is a relationship between how many people search for flu-related topics and how many people have flu symptoms. Think of it as a virtual public health surveillance proxy. If you are not convinced that this is a brilliant idea, take a look at how their analysis relates to CDC reporting.

In case you didn’t know, Google.org is the philanthropic arm of Google, and it was formed with the commitment of 1% of Google.com’s profits to address some of world’s most urgent problems (read the famous 2004 IPO letter by Larry and Sergey where they mention it). The site humbly admits that the Flutrends system is experimental. Nevertheless, it’s impressive that in some instances Flutrends was actually predicting flu before CDC.

Of course, not all people who search for flu have flu necessarily, but the power of this analysis comes from the coverage and promptness, not the granular accuracy. The basic idea of harnessing the collective thought (a.k.a. search needs) of the population to predict/monitor health events is fantastic. And this is just the beginning, IMHO. When a population is connected real-time and discussing what they think/want/need, abstracting that information can yield powerful insights- not just for prediction and monitoring, but for most aspects of healthcare (diagnosis, prognosis, news, followup etc).

The concept is applicable to domains outside of healthcare too. Take twitter for example. Twitter is another platform with mass adoption where people are having real-time conversations about what they are thinking/doing. Just look at what intelligent twitter mashups did for getting real-time snow report of the Feb’09 storm in UK or the Dec’08 Ice Storm in New Hampshire. There are health related examples too- the feb’09 salmonella-in-peanut-butter recall could be tracked promptly on a Twitter feed (btw, this slideshare presentation by PF Anderson at the University of Michigan explains ‘Twitter for Health’ in detail. Thanks to Christine Gorman for the link).

Healthmap is a perfect example of what technology can do to adavnce healthcare information. It aggregates online media reports to enable infectious disease intelligence on a global level. Its a near real-time internet-based infectious disease surveillance that is free from political and geographical restraints.

Healthmap extracts real-time information from more than 10,000 sites every hour and text mines them for disease and location patterns using bayesian filtering. The interface is clean and intuitive mashup with google maps. Links to the source of alert and a ‘heat index’ (composite score for each incidence based on things like recency of alerts, number of sources etc) are provided.

There are limitations too-  dependance on other sources, unstructured text, lack of integration between sources, not comprehensive, etc. But if you think of it as a free resource that supplements existing public health systems, its a great asset for general public and clinical professionals.

SimulConsult is a diagnostic decision support system started by Dr.Michael Segal. It covers 1,800 diseases that have at least one neurological finding in them.

SimulConsult has an interesting logic behind it. Roughly speaking, its knowledge is derived from a ‘computational wiki’ that is restricted to physician users only. So its database is not only open for viewing, but users can submit modifications to the database. The system performs bayesian pattern matching and also considers temporal information like the age of onset and disappearance of each finding for each disease under consideration.

According to Dr.Segal, there are about 33,000 data points (disease findings) in the system and the future expansion plans are to include more of metabolism and genetic diseases. Interestingly, the wiki approach for knowledge gathering in healthcare is becoming more common (AskDrWiki, WikiDoc, wikiMD to note a few- more on them later).

Feb 20, 2009 Update: Got an email today announcing that those who contribute information to SimulConsult database will now get paid for their contributions. As they are adding sponsored links in the software, I guess it makes sense to share the wealth. More info here.