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The future is fast approaching, but are we ready? A LongRead on what AI might hold for rural health

The rapidly advancing field of Artificial Intelligence (AI) is set to shake up the health and healthcare of rural communities, the National Rural Health Conference was told last week.

The prediction and its accompanying warning – from a leading rural doctor and medical educator, Dr Jenny May – is underscored by a scan of recent medical publications, reports Melissa Sweet below.

For more of our Croakey Conference News Service reports from the #ruralhealthconf, see here.


Melissa Sweet writes:

Not so long ago, a worrying realisation crept up on Dr Jenny May, Director of the University of Newcastle Department of Rural Health.

Perhaps she was failing in her day job – training the doctors, nurses and allied health professionals of the future.

May began questioning whether she and her colleagues were preparing the next generation of health and medical professionals for models of care and service delivery that might not exist in the future.

She subsequently began a journey investigating the burgeoning field of artificial intelligence (AI) and its implications for the future of healthcare. It was somewhat out of her comfort zone, as May describes herself as anything but “a geek”.

May recently presented her findings to the 14th National Rural Health Conference in Cairns, warning that the rural health sector needs to prepare for seismic changes in how it does business (and her caution no doubt applies more broadly as well).

She painted a picture of a future where intelligent machines have replaced pathologists, oncologists and many other health professionals, and where autonomous vehicles have made large sections of the rural workforce redundant.

It is also quite likely that in this future, she warned, the transformational changes brought by AI and the Fourth Industrial Revolution will exacerbate social, economic and health inequalities.

May’s concerns are underscored by a World Economic Forum assessment of the wide-ranging impacts of the Fourth Industrial Revolution, which is described as “a fusion of technologies that is blurring the lines between the physical, digital, and biological spheres”.

Klaus Schwab, Founder of the World Economic Forum, has foreshadowed an exponential pace of technological change in coming years, writing:

“The possibilities of billions of people connected by mobile devices, with unprecedented processing power, storage capacity, and access to knowledge, are unlimited.

“And these possibilities will be multiplied by emerging technology breakthroughs in fields such as artificial intelligence, robotics, the Internet of Things, autonomous vehicles, 3-D printing, nanotechnology, biotechnology, materials science, energy storage, and quantum computing.”

Schwab says that to date those who have gained the most from such changes have been consumers able to afford and access the digital world, and that there are concerns of the potential for greater inequality to result from disrupted labour markets.

“The largest beneficiaries of innovation tend to be the providers of intellectual and physical capital—the innovators, shareholders, and investors—which explains the rising gap in wealth between those dependent on capital versus labor,” Schwab says.

He adds:

“Technology is therefore one of the main reasons why incomes have stagnated, or even decreased, for a majority of the population in high-income countries: the demand for highly skilled workers has increased while the demand for workers with less education and lower skills has decreased.

“The result is a job market with a strong demand at the high and low ends, but a hollowing out of the middle.”

Advancing AI

“Artificial intelligence” is not a new concept, with a recent review of AI in medicine noting that the term was first coined in 1955 to describe “the science and engineering of making intelligent machines”.

However, the review described an increasing application of AI across healthcare in recent years.

It cited wide-ranging examples, including sophisticated robots providing care to frail elderly in Japan, emotionally sensitive avatars helping people with paranoid hallucinations learn to moderate their behaviour, and the use of algorithms and knowledge management to boost discoveries in genetics and molecular medicine.

StrokeAppImage
Image source: https://aicure.com/

Meanwhile, doctors from New York City reported a small study last month in the journal Stroke, showing that a smartphone app using AI was effective in helping stroke survivors to use anticoagulation medication appropriately.

The randomised controlled trial of 28 patients reported that 100 per cent of the group using the app took their medication as directed, compared with 50 per cent of the control group.

The study was sponsored by a US-based company, AiCure. Its app visually identifies individual patients and confirms their ingestion of medication.

The publication follows a growth in the number of start-ups exploring the use of AI in healthcare, with one industry analyst predicting that by 2025, “AI systems could be involved in everything from population health management, to digital avatars capable of answering specific patient queries.”

Meanwhile, researchers from Imperial College London in England and the Massachusetts Institute of Technology in the US recently cautioned that while AI could identify patterns and trends in routinely captured clinical data that yielded useful clinical insights, it also risked leading to over-diagnosis and unnecessary interventions.

Commenting on a study about AI being used to identify patterns in the clinical data of patients with atrial fibrillation and atrial flutter, the authors said AI brought the risk of generating “a variety of signals with little to no clinical relevance”.

Their article, published this month in the journal, Critical Care Medicine, defined overdiagnosis as the detection of disease that, if it had remained undetected, would not have affected a person’s life.

The downsides of overdiagnosis included patient anxiety, harm from further testing and unnecessary treatment, and the opportunity cost of wasted time on the part of both patient and provider, and healthcare resources that could be better used to treat or prevent genuine illness. The researchers said:

“The use of AI may well contribute to this problem by discovering patterns undetected by the human mind that are not actually causing problems and never will.”

“Clinically meaningful advances in this field will be an iterative process, where new algorithms are developed and systematically tested in real clinical settings for relevance against hard clinical endpoints. Only those that demonstrate value should be refined and improved before consideration for systematic bedside implementation.”

These authors also noted that despite several decades of research and hype, the AI field had failed to deliver on its promises of automated and improved disease detection, more effective monitoring and efficiency boosts in workflow – a caution also echoed by a CSIRO scientist in this article in The Conversation late last year.

However, algorithmic advances have started to trickle into areas such as radiology and pathology, the researchers said.

Future fast approaching

May predicts that the use of AI in healthcare is set to advance rapidly in coming years, with smart phones being used for X-rays, pathology tests and genomic profiling.

“If you are a pathologist, I think you need to be having some career counselling about now, because many of the things that you would have considered bread and butter are probably yesterday,” she told Croakey.

“I think there will be very few things that in the future that computers with the use of AI can’t do.

“I was very surprised to find just how much technology using AI is already out there, and is already part of many other peoples’ daily clinical work flow.”

Examples cited by May included the use of sensors in the homes of elderly people to assess gait length and alert health professionals when this was noted to shorten, which is predictive of the likelihood of falls.

IBMWatsonImage
Image sourced at: https://www.ibm.com/watson/health/oncology-and-genomics/oncology/

She also said that IBM’s Watson for Oncology (and read more here), which can crunch lab tests, read doctors’ notes and provide highly validated treatment recommendations, raises questions about the future of oncologists, as well as other health professionals.

May also described another IBM algorithm called Medical Sieve, which aims to build a next generation “cognitive assistant” with analytical, reasoning capabilities and a wide range of clinical knowledge, to help clinical decision making in radiology and cardiology.

Last year, Atomwise, which uses supercomputers that root out therapies from a database of molecular structures, launched a virtual search for safe, existing medicines that could be redesigned to treat the Ebola virus, May said.

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Image sourced at: http://www.atomwise.com/

They found two drugs predicted by the company’s AI technology that may significantly reduce Ebola infectivity. This analysis, which typically would have taken months or years, was completed in less than one day, according to May.

Developments in AI outside of healthcare also will have significant implications for health.

The advent of autonomous vehicles – which the recent World Congress of Public Health in Melbourne was told had the potential to bring public health gains by reducing traffic accidents – could add to rural unemployment, May said.

Self-DrivingTruckinNevadaShe noted that a significant proportion of rural workers are employed driving cars, buses, trucks and harvesters, for example.

“We are going to lose a swathe of these jobs,” she said. “That’s of great concern; we need to be preparing for this sort of structural reform. This is a whole-of-community revolution.”

May said the potential for AI to reduce the number of health professionals needed in rural communities also could contribute to wider job and population losses.

“In some of our smaller communities, the health service is the major employer,” she said.

She also warned that the AI revolution had the potential to exacerbate health inequalities because it was likely to be unevenly available in an environment where developers were likely to focus on profits rather than providing equitable service to communities.

“Similar to the institution of other market-based approaches, it may be of benefit to individuals but not to communities as a whole,” she said.

May is also concerned about inability of current structures to adequately regulate AI developments, especially as it is likely that vast amounts of personal health data will be held offshore.

NBN failings

But one of the major barriers to equitable access was the uneven access to high quality NBN, she said.

May has recently returned from a year working in rural British Columbia in Canada where a town of 6,000 people had unlimited high speed broadband.

“The Canadian Government had invested significant amounts in high speed broadband, which made all these technologies possible,” she said.

“Ubiquitous high speed broadband is a necessity. I’m not interested in an answer that it’s too expensive or we can’t do it.”

As just one example of how uneven NBN access is already affecting healthcare, May said she finds it almost impossible to place students on even short-term clinical placement in rural areas without good broadband access. They just won’t go there.

At the moment, she says broadband is patchy in northwest NSW and through to the coast, although some towns have excellent access via the NBN.

“For anybody who would like to see regional rural and remote communities go ahead with the potential that they have, I believe that we need the highest possible speed broad band,” she said.

Contrary to some suggestions that rural people do not need quite the same bandwidth or speed as city people, the reverse was true, May said.

“If we look at agriculture or health or education, I would have thought the need was on steroids.”

By the time the next national rural health conference is held, in Hobart in 2019, May hopes that rural communities and the health sector have progressed much further in their understanding of the likely impacts of AI and the