Wednesday, May 10, 2023

Machine Learning: Answers to Aged-old Problems or New-Aged bust?

Machine learning (ML) is a technique garnering increasing popularity given its base within technology and promise of addressing complex issues. This popularity is apparent when reviewing publications over the previous 30 years. For example, in 1985, one can find four publications in PubMed. Over the last two years, the number of publications addressing ML has increased to over eighteen thousand (see Figure 1).


Figure 1


Introduction to AI and Machine Learning

Choi and colleagues (2020) describe one of the earliest propositions of machine learning in 1956. At that time, computer scientists thought that humans would have, at some point, the ability to mimic the intellectual tasks only previously described in humans. Artificial intelligence (AI) is a term commonly used when describing machine learning but is limited to simple issues with pre- defined factors (Choi et al., 2020). Machine learning falls within a deeper level of AI, using

high-level pattern recognition for prediction and identification. The focus of ML is the development and utilization of algorithms from a data set and can fall within four methods. These ML methods include unsupervised, supervised, semi-supervised, and reinforcement learning.


Supervised learning takes pre-identified factors to identify patterns within a training data set. Like when you ask a child the color of various objects, supervised learning algorithms take in large amounts of data to predict an outcome (Choi et al., 2020). As the number of input increases, the algorithm hopefully becomes more precise. This developed algorithm continues to learn with a validation data set, identifying the relationship between a feature (e.g., red) and target (e.g., apple). After the model has learned the association, evaluation occurs with a test data set to determine how well it can predict the feature and outcome.


Unsupervised learning identifies patterns within a dataset without any assistance from humans. An example of this is clustering which categorizes instances into groups based on features (Choi et al., 2020). Semi-supervised learning is a combination of supervised and unsupervised; most helpful in

circumstances where imaging is involved (Choi et al., 2020)


The final category of machine learning is reinforcement learning, in which the model is allowed to learn and "play" to reach an outcome. Its application in healthcare and research is limited but appears the closest to the human mind and has the potential greatly influence the future (Choi et al., 2020).


Machine learning is tackling large problems…


One of the advantages of machine learning is the sheer number of data points that computer scientists and bioinformaticists can evaluate quickly. However, the human mind is not only limited by a storage capacity but can be influenced by bias as well. For example, there can remember an argument between two brothers during childhood very differently years later. As humans, we are constantly evaluating data coming in and influencing it with values.


Many issues the human society face is due to a large number of factors at play and the limitation of the human mind. As we (humans) have made more discoveries, more questions arise. We discovered DNA and mapped the human genome, but that is only the start. As the problems become more complicated, the limitations of the human mind become more apparent. This does not mean that the human mind is obsolete and that AI is the answer; it just means we need to supplement our knowledge with this new tool.


For example, since scientists first mapped the human genome, laboratories worldwide have painstakingly worked to identify the proteins coded by the genome and their structure.

Determining how a protein is structured (or folded) can assist in identifying new diseases, treating rare conditions, creating enzymes to break down plastics, and generating new hypotheses. Many methods and hours of work from many people have yielded more than 100,000 human protein structures (Jumper et al., 2021). However, there are still billions of known protein sequences without known structures despite these efforts. AlphaFold is an AI system created by Deepmind that reviewed the structure and sequence of over 100,000 proteins. AlphaFold (embedded link: https://www.deepmind.com/research/highlighted-research/alphafold) uses an approach called a neural network-based model (similar to that of the human brain) to

predict with atomic accuracy the structure of proteins (extensively outperforming many of the commonly used methods) (Jumper et al., 2021). The potential of this one AI system far outstretches what we can even begin to conceive.


Limitations

The basis of ML and AI is the utilization of large datasets. However, this basis is limited in instances of rare diseases as it will take some time to generate a large enough data set for ML application (Choi et al., 2020). Additionally, DL is not immune to bias. As humans input the pre- defined factors (in supervised learning) and evaluate the output, bias is possible. The data itself is also subject to poor quality or error.


Overall, the use of ML and AI within research and medicine will continue to grow. Machine learning has the potential to change how we approach research, hypothesize questions, and even interact with patients. This offers much promise and excitement but caution as well.



Jace Johnny Ph.D. Student

University of Utah College of Nursing

References

Choi, R. Y., Coyner, A. S., Kalpathy-Cramer, J., Chiang, M. F., & Campbell, J. P. (2020). Introduction to Machine Learning, Neural Networks, and Deep Learning. Translational vision science & technology, 9(2), 14. https://doi.org/10.1167/tvst.9.2.14

Jumper, J., Evans, R., Pritzel, A., Green, T., Figurnov, M., Ronneberger, O., Tunyasuvunakool, K., Bates, R., Žídek, A., Potapenko, A., Bridgland, A., Meyer, C., Kohl, S. A. A., Ballard, A. J., Cowie, A., Romera-Paredes, B., Nikolov, S., Jain, R., Adler, J., … Hassabis, D.. (2021). Highly accurate protein structure prediction with AlphaFold. Nature, 596(7873), 583–589. https://doi.org/10.1038/s41586-021-03819-2

Tunyasuvunakool, K., Adler, J., Wu, Z., Green, T., Zielinski, M., Žídek, A., Bridgland, A., Cowie, A., Meyer, C., Laydon, A., Velankar, S., Kleywegt, G. J., Bateman, A., Evans, R., Pritzel, A., Figurnov, M., Ronneberger, O., Bates, R., Kohl, S. A. A., … Hassabis, D.. (2021). Highly accurate protein structure prediction for the human proteome. Nature, 596(7873), 590–

596. https://doi.org/10.1038/s41586-021-03828-1

Your Home Your Health

What is telehealth and why should we continue to expand its use and accessibility




Paradigm Shift

A large portion of health care, particularly specialized care is centered around urban areas. Most patients live in on the edge of urban areas and have difficulty travelling to medical appointments. Proposed over 40 years ago in order to reach patients for follow up, telemedicine Telehealth means being able to access healthcare remotely, through a variety of telecommunications ie a phone call, a video conference, interface of self-monitoring devices

The COVID pandemic and associated emergency authorizations put in place brought telemedicine to the forefront. Emergency waivers allowed CMS payment for telehealth across state lines. This is very important for many underserved areas in our country. As an example, Salt Lake City, Utah has a plethora of specialized medical care for catchment area which includes four other states. Prior to emergency waiver, patients who live out of Utah would have to travel to see a specialized practitioner who is licensed in Utah. As you can imagine there is great cost and productivity loss for patients and their care givers.



Technological Revolution

The COVID pandemic not only forced the hand of payors but also accelerated access and utilization of telehealth by all large health care institutions. What was otherwise being slowly adapted became immediately adapted as organizations recognized the shift needed to take care of patients at home.


Who is innovating

One such example is from Geisinger Health Care in Pennsylvania. The Chief Innovation Officer, Karen Murphy, PhD, RN, spoke to Becker’s Health Care News about a new program, ConnectedCare365 (Adams, 2021). ConnectedCare365 revolutionized the traditional chronic disease model, which included case managers following up over the phone or in person. The new system includes consistent monitoring and contact through a communication platform. With this platform, patients can report their systems; parts of vital signs are automatically input with specific devices. The system allows providers to triage patients based on generated data.

There are many potential advantages to an application such as ConnectedCare365. It improves access and data collection. Since it includes patient-reported outcomes, there can be symptom management. Taking care of chronic disease patients from home decreases local health systems, likely leading to less emergency department utilization and led hospitalization. All of these components improve financial toxicities associated with chronic illness.


Policy Plays

Many of the emergency waivers for re-imbursement have ended, which is a good sign because it means COVID is now viewed as endemic instead of pandemic. This may not affect patients and health providers within the same state as much as those who live in different states but the loss of reimbursement structure rolls downhill and has already changed the way most telehealth is done- in that it is not as frequent. In order to better understand the implications please visit:

https://telehealth.org/


This acceleration of policy that allows telehealth is critical to how health care teams follow chronic disease patients. It behooves health care organizations and the federal government to continue telehealth services and access for patients.


References:


Adams, K. (2021). 10 Execs share their systems’ best innovation projects. Beckers Hospital Review. https://www.beckershospitalreview.com/digital-transformation/10-execs-share-their-systems-best-innovation-projects-in-2021.html

Paradigm Shift: Symptom Management vs Preventative Care in Diabetes Mellites

Symptom Management Perspective

Preventative Care Perspective

Pathogenic View-Disease Oriented

19th Century-Clinic and Hospital Surveillance

  • Prognostic sign-what will happen
  • Anamnestic sign-what has happened
  • Diagnostic sign-what is taking place now 

Patients views and opinions set aside. Responsibility was on MD exclusively. Body and Mind Separate

Salutogenic View-Health Oriented

Focus-producing theories of health based on more holistic approaches and methods. Well-being rather than disease pathogenesis.

  • Positive Health-predictability, sense of having control over one’s own affairs and value or importance attached to things or other people. – active or rich life experiences by oneself.
  • Life-Course Perspective-focus on different stages of life. Different life conditions (housing, nutrition, access to education or healthcare) impact health later in life. Includes Social Capital developed over the life span.
  • Health as Adaptedness-As people age, they compensate for problems


Common Complications in Diabetes Patients




Shifting to Prevention

Building a Diabetes Self-Management Education and Support Program Center for Disease Control and Prevention (CDC)

DSMES Toolkit


Preventative Care in Diabetes Mellites in both Type 1 & Type 2 is essential in supporting the long-term health of individuals living with diabetes.


The CDC has an excellent toolkit to help providers and diabetes educators to create an evidenced based patient and care partner self-management and support program to improve individuals’ ability to work on individual prevention of complications related to diabetes.


From the CDC DSMES Toolkit Website: DSMES has been shown to improve health outcomes.

In the United States, less than 5% of Medicare beneficiaries with diabetes and 6.8% of privately insured people with diagnosed diabetes have used DSMES services. (Strawbridge LM, et al. 2015)

The purpose of this toolkit is to increase use of DSMES services among people with diabetes and promote healthcare provider referrals. Expanded use of DSMES can help ensure that all people with diabetes receive the support they need. The toolkit provides resources and tools in one place to assist with the development, promotion, implementation, and sustainability of DSMES services (Strawbridge LM, et al. 2015)



What to Include in a Diabetes Self-Management Education and Support Program

  1. General information about diabetes
  2. Pathophysiology
  3. Medications
  4. Use of devices
    1. Insulin Pump
    2. Blood Glucose Monitoring Tools- Continuous Glucose Monitor
    3. Insulin Pens
    4. Diabetes Management Apps
  5. Lifestyle
    1. Nutrition
    2. Exercise/Movement
    3. Mindfulness
    4. Meal Preparations
  6. Support
    1. Medical
    2. Family/Care partners
  7. Prevention of Complications





Diabetes Education Program at the University of Utah

Inclusion of Family and Care partner support in Diabetes Self-Management Education and Support Programs


Intensive Diabetes Education and Support (IDEAS)


Diabetes Self-Management Education and Support Programs (DSMES) are designed for both patients and their care partners. Demographics of those who attended two different DSMES programs in 2019-2021 was examined. Surprisingly, attendance of a care partner was higher in the eight-hour program than in the 4-hour program. Understanding the reasons for the difference in care partner attendance is important to review in the future.




Family and Care partner Support




References


Centers for Disease Control and Prevention. (2021, August 10). Diabetes self-management education and support (DSMES) toolkit . Centers for Disease Control and Prevention. Retrieved April 26, 2022, from https://www.cdc.gov/diabetes/dsmes-toolkit/index.html


Strawbridge LM, Lloyd JT, Meadow A, Riley GF, Howell BL. Use of Medicare’s Diabetes Self- Management Training Benefit. Health Educ Behav. 2015;42(4):530-538.


Strawbridge LM, Lloyd JT, Meadow A, Riley GF, Howell BL. One-Year Outcomes of Diabetes Self- Management Training Among Medicare Beneficiaries Newly Diagnosed With

Diabetes. Med Care. 2017;55(4):391-397..