***IN PRESS--SPRING98 ISSUE OF 'NEW MEDICINE"***

The Globalization of

Interventional Informatics

Through Internet Mediated

Distributed Medical Intelligence

Introduction

Interventional Informatics, the intentional utilization of information and information technology to alter the outcome of a dynamic process, will play an ever greater part in the future of medical services. Distributed medical intelligence services are emerging as viable entities supporting the practice of medicine. The transition from center based medical services to internet based distributed medical knowledge services is made economically feasible by the increased accessibility to the global communication infrastructure.

The purpose of this paper is to contribute primarily to a conceptual preparation for the transformations which have begun to redefine the practice of medicine in the age of the internet. We are no longer in the information age, we are in the communication age. Given the full scale revolution going on in medicine because of increased access to the global information infrastructure as well as the development of multimedia communication technologies, how are we as researchers, clinicians, patients and administrators going to respond? Are we going to bury our heads in the sand and hope it is all just an illusion sweeping through our professional culture playing on the human fixation with bright shiny objects, which like all trends simply dissipates? Or is it something real, in an historical sense, which will absolutely change the character of how disease is perceived and dealt with medically? The ostriches in the crowd will certainly want to dig in and assert the strength and merit of the tried and true ways and cling to them for dear livelihood; the indifferent will typically be conformed to whatever happens; and the passionately concerned will be very interested in what we are attempting to convey here.

Accepting for a moment that allegation of the human infatuation with novelty. The history of invention certainly demonstrates that however diversionary a new technology is, once it has made itself relevant to a particular need it quickly is incorporated and, for better or worse, makes obsolete whatever either proceeded it, or badly addressed a problem which it may have even made salient in a way never thought of or noticed. Whatever the case, the role of the internet in influencing the thinking about and development of technologies for everything from toy sales to radiology has been and only continues to be profound. We will focus here, then, on an emerging process in the world of ‘internet influenced cultural engineering’ (IICE) as a heads up on how far some groups are going in seizing upon what the internet and all of its attendant options for multimedia communications structures and protocols make possible.

This current possibility is based on an instant accessibility to an ever expanding global fund of medical knowledge and the capacity for low cost, world wide, multimedia communication. The emerging opportunities in this new and exciting era of modern medicine are now more than ever impacted by factors outside the traditional "change agents" of the medical community. To contextualize this discussion we will look at a real world example of how the emergence of global communication systems combined with strong political will have been joined into a system which is transforming an entire nation’s outlook and expectation of the future. The Malaysian Multimedia Super Corridor is by far the most comprehensive effort (so far) to stimulate culture migration form an industrial/agricultural base to a knowledge based culture.

1. Multimedia Super Corridor-MSC

With Vision 2020, Malaysia has set before itself the goal of "becoming a fully-developed, matured and knowledge-rich society by year 2020." As technological progress has always been, at least within Western models, a primary index for a country’s level of development, Malaysia indeed promises to catapult itself far ahead of even today’s most fully technologically developed principalities. While many countries are certainly breaking significant ground in all areas of technological progress, few, if any, have really gotten deeper into fundamental questions about how all of these innovations in products and services relate on the level of social and economic reality. All promises about the value of technological development have their reality check in the social units and processes which will marshal that technology over against contexts of need and care in the everyday. The MSC is indeed developing along axes of cutting edge thinking about systems. What exactly then is this internet multimedia knowledge, product and service access & delivery system which promises so much to the future?

The MSC is first and foremost a physical space in Malaysia. It is an area 15 kilometers wide by 50 kilometers long in Kuala Lumpur. In addition to air, land and sea distribution points for products coming out of emerging Corridor companies, the MSC is embedded within an unprecedented digital communications infrastructure: a 2.5-10 gigabits per second fiber-optic backbone. Among other significant communications advantages, it supports high density links to global centers of information, manufacturing and service provision. In essence, "The MSC will bring together, for the first time ever, an integrated environment with all the unique elements and attributes necessary to create the perfect global multimedia climate" (http://mdc.cinenet.net)

1.2 Our Perception of the MSC

The goal for the MCS is in the creation of an environment which by its nature instigates creative and innovative relationships between all of its residents. These are companies, universities, individuals in programming, biology, art etc. To better convey the dynamic of what the MSC fosters it is helpful to be more organically specific and use the term ecology; the MSC is an ecological system; in fact, it is a cyber-ecological system. And from biological research into ecosystemology it has been learned that an ecology is always a kind of metaorganism. It is a whole system emerging from the interconnectivity and symbiotic relationships among its myriad subsystems. For the whole to even be a viable organism all of these parts must be both working within and simultaneously engendering an overarching order which feeds back on itself so as to ongoingly exert a downward organizational formativeness on its elements while the elements continue to maintain the order of the whole. And so it is very much a reciprocating dynamical system.

Technology supports human care and creativity. Humans relate to each other for many diverse purposes through technological elements. The MSC might even be thought of as a kind of prototyping of the next generation society. That is, as the structure and function of information systems and communication technologies become more perfected in their purposes of creating communication pathways between persons and groups they are actually going to be more and more like in their character to the physiological bases for communication within living systems. Further, as more is learned about the neurological bases of thought, language and communication the more and more neurobiological in character will become the information technologies created to allow communications between human beings. The interface boundary between the human and the technology will become increasingly seamless to the point where it is virtually non-existent in some cases. In short, the MSC represents the first real (i.e., in progress) social and systemic thinking about how to significantly change the face of civilization with multimedia communications technology. The communications infrastructure becomes a kind of nervous system for a newly emerging social body, a Homo Cyberiens.

3. The "Cyberizing" of Civilization

Indeed, integrating cutting edge communications technologies into society cannot but precipitate a very different kind of human civilization. Such a multimedia communications based community in cyberspace is what the MSC promises by the year 2020. Technological infrastructure and social systems consciously integrated into it initiate the coming into being of this wholly new kind of ecological system. The MSC is an example of a new event in the history of human culture and thus by default becomes the world’s test bed for studying Cybercology. Malaysia is literally recreating its society from the ground up as part of its development program.

1.3.1. Institutions Being Overhauled

Beyond the afore mentioned infrastructure (s), Vision 2020 is to be inaugurated by a series of "Flagship Applications" of the MSC. A relevant subset is given below

(source –http://mdc.cinenet.net/flagship/index.html)

The revolution in these particular programs is how internet based multimedia communications technologies are being fully integrated into them with the result of changing their very nature (s), while maintaining their ostensible function at the bleeding edge. Courageously, Malaysia is a society rebuilding some of its primary social structures in cyberspace.

As an example of the aims of these sweeping changes, we quote the general remarks on the value of the digital government:

1.3.2. Explosion of Multimedia Technology in the Corridor

Elemental to this work is the research and development of next generation multimedia technologies. Malaysia aims to spearhead this by fostering collaborative work among leading multimedia R&D companies "ongrowingly" residing in the new ecology of the Corridor. These collaborations will result from the sharing of a common ecology and also further create new possibilities for that sharing. Thus, the relationships are dynamically creative and reciprocally sustaining of the process itself, not to mention the actual products and services being developed and made available to the world by them. Again, entities which will become indigenous to the new ecology are corporations, universities, individuals in diverse fields etc. For more information on the details of this see [http://mdc.cinenet.net/msc/index.html]. Current planning around multimedia R&D aims to have the following as residents of the MSC by the year 2000

• At least 15 corporate R&D centers of leading-edge multimedia companies and universities
• At least 10 R&D collaborative centers between foreign companies and universities and local firms/institutions
• At least 10 local R&D centers
• A Multimedia University operating at Cyberjaya to support the R&D Cluster
• 8-10 large-scale pilot projects for emerging multimedia technologies

Telemedicine engineered in a "metaorganism" like the Corridor completely redefines the parameters for what medicine could look like in cyberspace. Now we turn to a discussion of telemedicine itself having laid the ground work for a "future malleable" conception of how to intelligently integrate internet based multimedia communication technologies with the healing arts.

2. Telemedicine and the Internet

NASA has defined telemedicine as "the integration of telecommunications technologies, information technologies, human-machine interface technologies, and medical care technologies for the purpose of enhancing health care delivery" (Federal Telemedicine Gateway Menu: NASA). Telemedicine, as it is practiced now, operates primarily on a point to point basis. One medical expert treats one patient at a time, or provides consult services to one remote physician at a time. Typically, interaction with a patient by more than one [remote] expert is systemically precluded. Moreover, recording and filtering of exchange elements (content) has been largely incidental. Video and/or audio tapes are what is left with which to manually collect, analyze, derive generically (hopefully) useful content and archive the rest. Most current infrastructures of telemedicine do not provide support for self optimizing interconnection of caregivers within the same facility. For example, cardiologist is unable to utilize the informatic infrastructure to interact with a pathologist in the same clinic or hospital. All things considered, telemedicine is not yet in a state which significantly comprehends, in its execution, the full potential of internet-based applications. However, as health care professionals, we are in an opportune position to more fully appreciate and to realize the enhanced capacities for enriched communicative interaction the internet provides.

2.1. MSC Telemedicine

In reference to the possibilities for government in cyberspace, the framers of Malaysian’s Vision 2020 aim to reinvent government through multimedia enhanced internet connectivity.

In exactly the same way, the effect of the internet on telemedicine is not just in making medicine more efficient or geographically independent. The promise is that the power of multimedia communications techniques will more fundamentally change medicine and its socially grounded culture of disease recognition and healing. There was telemedicine and there was the internet; then there was the Web. Consequently, once the idea of medicine was linked to the idea of global connectivity it resulted in mass awareness causing a shift in expectation of the possibilities for delivering medical knowledge and services. Development in the MSC discloses a larger agenda for telemedicine which is much more powerful than simply interfacing patients with doctors at a distance over the wire: That is, a shift towards distributed medical intelligence.

Certainly, this is far more encompassing than simply using the internet to do medical consulting at a distance. Builders of virtual health communities need to be familiar with what is going on in Malaysia. Exploration of the vision of the MSC will help to redefine any present future thinking about the relationship between the internet/multimedia complex and the practice of medicine. The Corridor’s telemedicine flagship blows open the categorical fields with which we can think about all of this in the first place.

2.1.1. MSC Pilot Applications

Here we include full text summaries from the MSC Telemedicine flagship agenda for initiating the project of global telemedicine (see: http://mdc.cinenet.net/flagship/medicine/index.html). The pilot applications that will lead the development of Telemedicine in Malaysia are:

• Teleconsultation to connect healthcare providers in a multipoint manner to share opinions and for mutual support. The connectivity should enhance the work processes. Critical success factors include a large number of users, faster services, lower costs and the extent of accessibility to the homes of individuals.

• Continuing Medical Education which is an infrastructural project to build human resources. It will provide information and enhance the capability of healthcare providers. Healthcare providers have to continuously upgrade their knowledge and skills. The use of multimedia technology and networking will enhance this application. Relevant training programs need to be sourced for the development of a content database. The critical success factors include the number and size of modules and the number of subscribers.

• Mass Customized/Personalized Health Information and Education to provide information and education on healthcare to mass and specific communities. This project involves the sourcing and development of information and educational materials followed by the construction of a generic database. Some innovations are expected within this delivery system, especially in capturing the attention of individuals.

For the individual citizen:

• Lifetime Health Plan which is perhaps the most complex and the most encompassing of the four applications. Ensuring patient-focused and continuous care depends on a lifetime health record. Integrating the information in the lifetime health record to develop personalized lifetime health plans for each individual requires the co-operation and acceptance of many users.

To even begin thinking productively about how to create such an ideal capacity for future medicine we will offer a conceptual and technical model which are both actually in prototyping phases at the moment.

2.2. Distributed Medical Intelligence

The act of providing medical knowledge for healing and wellness is going through a shift because of the internet. As multimedia communication technology incessantly progresses with better video teleconferencing, image and sound re-production, physiological monitoring, diagnostic imaging, and medical record data provision, and so on, our options are staggering. However, Distributed Medical Intelligence (DMI) focuses heavily on the process of communicating medical knowledge and service, not just the technological and administrative aspects of developing a multi-media global medical informatic infrastructure. The process of developing medical communication infrastructures to provide medical knowledge on demand distinguish DMI from classical telemedical processes.

The DMI model enables us with greater accessibility to a wider range of knowledge tools and communication resources. This, in turn, extends our telemedical capacity to deliver quality, care improving services to a wider range of persons in need. Conceptual, pragmatic and techno-procedural foundations of medicine itself will undergo great changes if pollinated by the principles of ubiquitous extensibility, and time-sensitive need specific inter-connectivity. Below we give the basic structural features of an intelligent multi-point distributed medical communications infrastructure with multiple points of participation. We believe this concept begins to move in the direction of MSC caliber medical communications into the 21^st century. The DMI network is precisely the kind of system sought after by Malaysia.

2.2.1. DMI Elements

1. Point of Need: Care Portal: Any site which seeks/requires an informatic intervention. Optimally, a remote and medically specific environment instrumented with an operational tool kit of diagnostic and evaluative technologies for diverse and quantitative

assessments of patient biological states. These devices connect the care portal to the DMI network via a central intelligent communication hub known as the Bridge (see below). The care portal is also designed to provide educational content to patient and medical personnel for both immediate and more long term purposes.

2. Point of Expertise: Docking Station: a 'lookout' of sorts from which a medical expert gives consultation, collaborative input and education. Highly specialized interfaces designed to optimize an expert's ability to provide the highest quality of service

characterize the docking station's environment. Docking stations also connect the DMI network via bridge mediated access. Docking station personnel (specific medical experts) will perceive and interact with a great diversity of medically relevant information coming in firstly from the care portals and secondly from multiple [other] experts participating in the same exchange. This exemplifies the value and power of the distributed collaborative medical matrix vs. the traditional telemedical point to point connections! Processual and technological aims are to empower an expert so as to optimize their capacity for intelligently, competently and effectively responding to the point of need. This is an example of interventional informatics in action.

3. Optimizing interconnector: Bridge: an intelligent medical communications hub which orchestrates and optimizes the flow of information between the care portals and the docking stations. The bridge is the first point of contact for the care portal. It serves as a request refinery directing the care portal to the most relevant resources to service their needs, whether a knowledge base or a live expert. The bridge is the central nervous system of the DMI organism. Bridge function maintains dynamic connectivity,

data tracking, and data base access. It proactively draws, supplements and anticipates patient and expert inputs/outputs, provides the ancillary information of patient and expert education, and filters, refines and directs knowledge. The bridge optimizes inner connectivity between any point of need and point (s) of expertise. Using (human derived) synthetic intelligence, the system will capture information already filtered, refined, and interacted with. The bridge is designed so that it 'learns' over time: repeated uses within similar categories will induce the system to begin anticipating (with user approval) requirements of tried and true interaction protocols around specific medical events, etc. The bridge insures operationally appropriate connectivity between expert and need (e.g., making sure EMG output is being rendered via proper EMG rendering systems as opposed to video). Point of need has a characteristic of request (e.g., cardio vs. neuro) which incurs an appropriate response from an expert system. Furthermore, the bridge acts as both a knowledge broker and an educational service. This is where the idea of knowledge vending comes into play in its non expert knowledge system use (i.e., a physician imparting expert direction, etc.).

Given the bridge’s intelligent refining and databasing of session elements, it can begin to create packages of highly refined information to be sold on demand over the net. Finally, in time the bridge may be capable of reaching out and creating new [kinds of] articulation between relational components (i.e., researchers, clinicians, etc.) both in real time usage and in data base maintenance. Eventually, it may even be possible and desirable for the bridge to automatically generate a kind of journal of its monthly work outlining new uses and what it learned etc. Its intelligent cummulation of knowledge could result in its becoming something of a meta expert system in its own right ( an intelligence synthesis engine); for it will have assimilated the knowledge and behavior of myriad experts and watched the action from all vantage points during a session.

2.2.1.1. Dynamic Collaborative Structures

A very important part in the development of a functional DMI network is the implementation of internet-based collaborative techniques. Collaboratory systems provide necessary structure to the communications DMI network. Web-based collaboratories are recently emergent functionality to be added to the list of "Web technologies." Below we outline the basic structure and function of a collaboratory model and demonstrate its utility with a simple real world example of medical care at a distance with multiple participants as well many other functional innovations to the old model of telemedicine.

2.2.1.2. The basis of a medical collective

A Web-based medical collaboratory is one wherein a specific group of expert medical personnel, their support staffs, clinical/hospital resources and all related on-line databases comprise the collaborative linkages. The collaborative, then, is a spontaneously networked aggregate of expert knowledge and skill resources deployable as an entity, as needed: " an integration platform which enables building useful and deployable Web-based collaborative environments. The system provides the means of fast integration of Web and non Web applications into one multi-user collaborative environment" (Walczak et al., 1996).

According to the Advanced Telemedicine Technology Roadmap, the first objective is to "Develop a telecommunications infrastructure that is comprehensive, reliable, ubiquitous, and compatible across applications" (Sanders et al., 1996). Once in place, a networked collaboratory of geographically remote participants may look like the following example.

2.2.2. Hypothetical Scenario for DMI Network

As an example of the MWW collaboratory in action we offer the following scenario:

1. A remote site encounters a person at risk.

2. Care portal application is set up around the patient (e.g., monitoring devices, diagnostic equipment, etc.) by remote personnel. Via phone dial up, they launch a collaboratory session.

3. The bridge provides remote access to case-compliant forms in which all relevant patient information is entered.

4. Upon completion of forms the remote site submits data and so re-engages the bridge.

5. The bridge then initiates optimal responses:

• provides open access to patient education content for remote site
• simultaneously contacts suitable and available participating physician (s)
• opens linkages to all expectedly necessary databases and waits for additional connections requested by expert (s).
• opens access to all necessary immediate and archived patient record information for physician (s).

6. Inside a docking station, the physician accepts connection with remote The physician then becomes the knowledge source providing guidance and directives.

2.2.2.1. Considerations

As a user of a DMI network, the information you have access to see is a function of the kind of user you are (i.e., what kind of expert you are), what you are doing, where you

are and your need to know. This simple example hopefully demonstrates the DMI network collaboratory's capacity for spontaneous response, emergent functionality,

ubiquitous access to relevant resources, and communicative nature supported by a future malleable internet-based multimedia communications infrastructure for use in medical services. In crisis, maintenance or other episodes of medical need this globally accessible cyber-spatial infrastructure is in place and facilitates necessary expert functioning. By integrating internet-based telemedicine technologies with the computational and system application requirements of collaboratory systems, a powerful and realistic system of Distributed Medical Intelligence emerges: "Distributed Medical Intelligence promotes the development of an integrative medical communication system which addresses the process of providing expert medical knowledge to the point of need" (Warner et al., 1995). As a spontaneous and emergent system it is a network gestalt dynamically changing its shapes with the changing needs of deployment.

3. Cyberspace and Medicine as a Social-Cultural Process

Availability of technological options ongoingly changes the expectations of those who stand to benefit from those options. Medicine is obviously tied to our primary concerns as humans: quality of life when confronting trauma and degenerative disease. As an information bank, the internet has massively fostered an awareness of human health and the possibilities for its improvement. Particularly in Western cultures, the past 10 to 15 years have seen an explosion of interest in non-allopathic approaches to disease and healing. Everything from basic vitamin approaches to acupuncture, homeopathy, psychic healing, past life regression and psychedelic shamanism are flourishing to one degree or another. That all of this material has made its way onto the internet creates all manner of issues for the science, practice, and certainly the economics of medicine.

No longer can a doctor, for example, dismiss a question about different perspectives on a particular disease out of hand; getting a second opinion means a great deal more than paying more money for another allopathically trained doctor to give you a different take from within the same medical framework as the first. No doubt in many cases these are sufficient alternatives. However, now people’s knowledge is moving so far out of the box of conventional medicine that the medical community cannot avoid having to come to terms with a transcultural multiplicity of viewpoints on what constitutes health in the first place, let alone the methods for dealing with its aberrations. These many views are now cyberspatially adjacent and are protected from the kind of censorship that traditionally comes with ideologically supported knowledges outside cyberspace. Medicine becomes social as soon as natural phenomena associated with human bodies are languaged by a healing system working with those phenomena. Society is thoroughly woven into the scientistic, practical and political economy of any medical tradition. Thus medicine on the global information highway is not just going to be reserved for the type of practitioner which comes from an western medical school and was trained in a hospital. While the technology comes largely from such a culture, the content will be profoundly diverse. There is, then, no precedent for medicine in cyberspace. It is something we will make up as we venture out into this yet to be created reality where in some contexts not even the laws of nature are what they are in the "real" world.

The MSC provides the most powerful, future malleable and superior conceptual, social and technological model for the crafting and implementation of a truly intelligent practice of distributive, collaborative medicine (see Warner & Rusovick 1997). Technology like the Corridor will help us benefit and be responsible for the information that is being made available. By intelligently and non ideologically evaluating the diversity and challenges the internet is bringing to medicine we can separate the real from the fantastic and save many the trouble of being sold an illusion (which is already occurring in fact) while at the same time making healing options available which could probably never have shown up without the synergistic and serendipitous dynamics of the information ecology of cyberspace.

3.l. Benefits

From our own work towards a Distributed Medical Intelligence Network nested inside an infrastructure like the MSC we can give some possibilities for change stemming from the cyberizing of medicine: The act of making resources, knowledge and services available refines and changes the act/processes of making resources, knowledge and services available

• Real time processing and archiving of on-line medical practice content: the computational centers (i.e., bridges) of any distributed knowledge and service vending process will be filtering, refining and "judging" interaction through the use of artificial intelligence and neural networking technologies. For the first time in medical history, the patient record and the physician’s log will be talking to each other and then to the respective parties involved over time. This "conversation" will be simultaneously checked and augmented through the system’s access to the most up to the minute on line medical breakthroughs in the forms of clinical and experimental practice. Never before has such connectivity between knowledge and service vendors occurred with systems to process, refine and intelligently provide syntheses of that information. This all gives to practitioners options they may have never gotten around to having the cognitive resources to produce or the serendipitous circumstances to exploit. These are just a few of the basic advantages of having intelligent systems connecting, processing and facilitating medicine. There are certainly more that we can’t even think of because our thinking often only sees virtually into the future; for it is not until the new roads have been constructed that we actually get to travel out into the wild blue yonder to see what is really over that next hill. That is, the power of this system: it really is about volitionally and reciprocally operant panconnectivity. A knowledge and archive bank absolutely secure when needed and absolutely accessible otherwise.

Important Memes

• Rapid diffusion of knowledge
• Auto-emergent knowledge
• Socially processed knowledge
• Community anticipates future need
• Collective of "linked intelligence’s"
• Collective medicine
• Training data bases
• Education
• Content development
• Multiple channels to access any information
• Knowledge Vending
• Service delivery systems and knowledge workers
• Physician on demand services
• Web-based knowledge delivery systems

Out of these ideas and with this technology, there will emerge a culture of medical cybernauts committed to creating a world of healthy individuals, families, and communities enhancing the quality of life for all.

4. Adjacent Realms and Spill Over

The Multimedia Super Corridor is essentially a model for a highly effective and future malleable system to pursue global expert knowledge work in cyberspace. As the system evolves there will no doubt be major shifts going on in those institutions and industries associated to the primary flagship entities. Government, education, medicine, finance/banking, manufacturing, media science, and so many more cannot but undergo the kind of cyberizing being instigated by the Corridor. As we mentioned early in this article, if a new technology is working all will follow suit and take up the opportunity. Just in the context of medicine, the MSC will have significant effects on adjacent realms:

• It will support the development of a global hub for Telemedicine services,

• Linkages with other applications and agencies will support the delivery of health services and lead to more effective use of resources throughout the world

• Participation of myriad technology companies: the MSC will be the most comprehensive test bed yet devised for learning and experimenting with high technology.

• Healthcare Providers will be able to develop links with the centers of

• The Healthcare Industry can provide information and expand their business scope utilizing their current resources.

• Drug and pharmaceutical companies together with manufacturers and suppliers can market their products globally.

• Universities and teaching institutes will be able to collaborate and set

• Content Providers will have opportunities to develop on-line health

• Multimedia Companies will have the opportunity to develop leading-edge

• They will be able to collaborate with international providers and develop solutions that can be marketed globally.

5. Conclusion

MSC and DMI initiate global accessibility and compatibility of intelligent medical communication matrices. Success with our goals is measured directly in terms of the number of patients healed and given information about their health and medicine in general. The latter is to prevent problems and dispose a patient to being participatory in care given by their physicians.

We close with a sense of the relative urgency to act now in ways which will ensure the development of intelligent medical communication systems designed for long term, open-ended and modularizable integration in internet-based health care provision. Doing medicine over the net means getting our bearings and really seeing all of what is possible, desirable and downright intelligent .

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