Informational Asymmetry

Accurate, timely, relevant information is a prerequisite for effective delivery of healthcare services at the individual and population level. A healthcare provider uses information, consumed in a myriad of forms, and filters the filters the new information through a framework of experience, to arrive at a conclusion and a plan of action. Jerome Groopman has detailed many of these thought patterns of doctors in How Doctors Think. The book describes numerous limitations to informational processing at the individual level.

An example clinical encounter is described:

A 28 year old female develops a painful rash on her left forearm. It starts without any apparent cause to the patient. The young lady has no other chronic medical issues and takes no regular medications. There has been no travel, no recent contact with any sick persons, and no change in her regular routine as a consultant. For several days the rash progressively worsens, and pain increases.  She schedules a visit with a dermatologist. In the medical encounter with the health professional a broad list of possibilities is considered. It could be one of several types of infections, it could be an allergic reaction, it could be underlying chronic skin condition that is just manifesting at this time. Tests of the skin are obtained, and treatment was prescribed.

Informational input needs to be accurate. The best thing in medicine is the people, the patients. Patients know the most about themselves and how they are feeling at any particular time. The challenge is in the details. For those not familiar with medical language it is not easy to remember the specific terminology, or names of medications. Was it ciprofloxacin or levofloxacin? What was the result of the heart test? Was there any particular exposure to the skin, or any new detergent, or perfume? Many times details of exposure and chronology stand out in peoples’ minds, often times they do not.

At the level of the professional, clinical information is filtered through an information mesh-work to pull out the important pieces of data in order to arrive at the conclusion/diagnosis. The process of training physicians in the U.S. system involves a high volume of exposure to individual patient care in an appropriately graduated structure. The broad experience base generates a mental framework that subsequent information is processed through. This is what Groopman discusses as heuristics; the experience-based technique for problem solving. The challenge in medical training is that is often hard to infuse more wisdom than their experience allows. Certainly, information acquired through reading builds and expounds the mental framework. That is how a medical student can know someone has appendicitis before they have ever seen or diagnosed their first case. The modern challenge is that there are now (as of 2010) 75 medical trials, and 11 systematic reviews of trials, per day.(Ref) All of that newly created information adds layers of nuance to the diagnostic and treatment processes. The human body and its ailments have not suddenly altered, but the highest value testing and treatment practices do change over time. This is the modern challenge, the smartest individual in the world does not have the capacity to consume and retain all of that information. An internet connected provider, speaks to a potential of leveling the playing field, by having access to up to date information. This ultimately will be a good thing. 

Asymmetry is the disunion that happens when the processing framework fails to properly connect and add value during the throughput of individual data. Miss-connections include:  the drug was X, not Y as the patient had originally remembered it. The previous electrocardiogram (EKG) was not available to compare for any change. From the provider perspective: that type of case, with similar type symptoms, lab results, and outcome has not been encountered before. Is this a new presentation of a new disease, or an unusual combination of symptoms for a common disease. Or from a dermatology perspective - a specific type of skin rash has not been seen before.

Facilitating a more open posture for informational flow, such as producing open source medical databases, offers a potential to augment the processing framework. At the individual level an open-source dermatology database (adequately marketed) could be searched, just like I have observed Attending physicians search Google Images for skin diagnosis. The open data could be accessed to augment the providers information mesh-work in order to decrease the probability of asymmetry. The leverage of computers/screens/phones is informational connection. This rationale assumes that the answer is out there somewhere. Finding the answer is a matter of reducing the asymmetry. When we open informational networks it is not immediately clear how commercial value will be derived. However, connecting people to the right information at the right time is one of the challenges we have taken on as we try and keep ourselves and our society healthy

The young lady described above is my wife. After time, testing, and contact with multiple medical professionals, she was ultimately diagnosed with phyto-photo dermatitis. That term was coined by Klaber in 1942.(Ref) It is a skin eruption caused by exposure to certain plants and their extracts and then being exposed to sunlight. Kelly reviewed the literature and reported that various authors make mention of the fact that the condition was probably known of in countries such as India, Arabia and Egypt many centuries before Christ.(Ref) The rash resolves over time, and with some steroid cream. She is doing well. Reducing the asymmetry in our own lives would have helped us avoid such an arduous process for a rash that has been around and known for such a long time. 

Forward Movement

I recently received an email, the contents of which are shared below:

CONGRATULATIONS!

You have been nominated by Andrew Rens to receive a Shuttleworth Foundation Flash Grant to work on your CrowdSourced Dermatologic Picture Database. We have a funding model that rewards brilliance and new ideas by awarding full-time Fellowships. However, bubbling around
the periphery of our model it has become clear that there are voices that are not heard, ideas not seen and Fellows that are not ready to be Fellows - just yet... This is where you and the new Shuttleworth Flash Grant come in.

We tasked our Fellows to seek out and nominate an impressive change agent, who may not be able to concentrate on their brilliant idea yet. This grant is for the sum of $5,000 and will be awarded to you personally to bring that idea forward. The only string attached is that we ask you to live openly, tell us and the world what you have done with the money.

_______________________________________________________________________

I am very thankful for the opportunity. This pilot financing will be used for website development and beta-launch. The bottleneck up to this point has been mobile and web development. The goal is to use as many open-source platforms as possible in order to limit cost and because the project speaks to open-source values.

Concept for Open Source Dermatology Database

The pilot grant will be used for the development of a platform (website-mobile if finances allow). The platform will be used to facilitate the proof of the following idea: An global online community of non-professionals can effectively create a database of dermatology skin pictures of sufficient accuracy and volume such that it will produce a database that is more valuable compared to current proprietary databases. One unique value of this project is that the product – the database with tagged skin images will be made available under a creative commons data license to all. The data represents a collection of global biological information. The project is trying to use the website as a platform for sharing this knowledge in the form of skin pictures.

This has never been tried before, in quite this way. Patientslikeme.com enables the sharing of patient contributed information, the angle is more from a patient support group perspective. Another uniqueness for this project is the idea of the medical community inviting wisdom and participation from patients. The openness and invitation to contribute is a different posture compared to the current status of medical knowledge creation. Medical research is currently conducted in such a way that information about how you reacted to a medication is recorded from you as a one in a large study. The information is stored in a data-set and is the property of the university medical center or pharmaceutical company conducting the research. The research subjects rarely have complete/open/free access that they were a part of creating. The current posture infuses the culture surrounding personal medical records in the United States. In many instances, there is formality and red tape to cut through in order to obtain your personal health information - in an age where access to information is becoming more ubiquitous. 

This concept brings up large questions. At this point, these are open questions for the which the implementation of the project will seek to address. That is a part of the joy of the project for me. From the viewpoint of the physician, one question is how accurate do you need the diagnosis on the submitted picture. We know that not every visit with a doctor generates the correct answer with regards to a skin rash. There are not the resources to follow up and send  a dermatologist and examine and biopsy every piece of skin from a submitted image. The first layer is to ask the user to submit an image of a skin lesion or rash only after it has been evaluated by a medical professional.

Several other open questions:

How do you ensure unhelpful image submissions are limited (ie. non skin)?

What is the photographic/pixel quality needed in order for the image to be seen clearly/re-usable and ultimately useful?

What data needs to be submitted along with the image? To much information and you lose participants, too few pieces of info (age, diagnosis) and you limit the power of the database.

How do you guard against fraud such as fake/false submissions?

Should you be required to submit an image in order to use the database?

At this point I am seeking to engage with web developers and move the idea forward.

Data Exhaust

In 2010 more than a billion visits were made to clinicians in the United States by patients in the ambulatory setting. Ambulatory means an office based, outpatient clinic. This is compared to, and specifically not an emergency room, or surgery, or a clinic inside of a hospital, but a free standing building. Most of those patients were seen by general practitioners.

Of those 1 billion encounters approx. 50 million left their visit having been diagnosed with a disease of the skin or subcutaneous tissue (a word meaning just underneath the skin). These numbers of skin disease diagnosis come from visits to pediatricians, family medicine physicians, as well as dermatology specialists.This data is from the publicly available National Ambulatory Medical Care Survey, conducted yearly by the United States Centers for Disease control.

The table below displays results for skin diagnosis for the years 2008, 2009, and 2010.

Primary diagnosis at office visits, classified by major disease category. United states. 2008-2010
Diagnosed as: Diseases of the skin and subcutaneous tissue
Year	Number
2010	50,224,000
2009	43,109,000
2008	46,097,000
	139,430,000

Considering the previous post indicating the size of currently active skin image databases, these numbers suggest they are performing at a margin below their capacity. The implicit suggestion here is that at every office visit that a healthcare provider diagnosed a skin disease, if a  picture image was also captured (by doctor or patient) and contributed to a common database, the volume of images would far outpace the current offerings  This gap represents the data exhaust of the clinical encounter. There is valuable information captured in the eye of the professional, used to make decisions and move forward with treatment. The utility of the information carries forward in the mind’s eye of the individual doctor which made the decision about the diagnosis. However, when it is not shared, the utility of that encounter has diminishing returns, as the doctor retires from practice for example.

This is occuring in the context of 50% of the U.S. cellular phone market with smartphones as of early 2012. That means a portion of each of these doctor’s visits (i the United States) happens with a either a patient or physician, or both, with an internet connected camera sitting in their pocket throughout the entire experience. My personal experience with patients and my own family suggests we are utilizing this technology to take pictures of things that happen to our skin. Unfortunately, there is not yet a platform for citizens to participate in the science. 

Thinking forward, this idea is inherently a global project. As robust mobile telephony spreads there is global potential. A chart aggregated on Wikipedia suggests 5 billion people live in countries with >70% mobile phone penetrance.

Allowing the non-professional individual to contribute to the commons is the conceptual next step. The crowd-sourced dermatology database is one platform for one disease category that will attempt to capture that potential.


Much in the same spirit that built open source soft-ware, this data is inherently part of the global commons. Human biology is unique to the individual, but also shared and common to us all. The data from personal pictures of a patient's skin is inherently private-in the sense that it is connected to one individual and part of their personal health record, protected and disclosed at their discretion. However, in another very real sense the image skin forms part of a common knowledge. The coders who produced much of the Linux operating system, which forms infrastructure that supports much of the internet, contributed their knowledge to a common project. It allowed those that came after them to use prior leaps in knowledge to step even further. This pursuit of open knowledge, rich in other fields, has found limited voice in the house of medicine up to this point. This project represents a new kind of trial, a proof of concept. 

Email with questions.

Strengths, Weaknesses, Opportunities, Threats

Concept of Crowd-Sourced Dermatologic Picture Database

Project: An online and mobile platform through which participants voluntarily submit user-obtained images of a skin rash or lesion that has been evaluated and diagnosed by a health professional. 

The purpose is to create the largest database database of dermatologic images

The unique value added will be that the raw data will be curated as an open source project. 

The intention is not to make medical diagnosis. Nor is the goal to have individuals contribute without professional interaction. There is a level of accuracy that is needed between image and diagnosis. That exact level remains point is an open question. Non-professionals up to this point are typically not involved in this way with the collection of biologic data. This project is unique because opens up the potential volume of contributors to the civic space, while actively engaging in answering the question on accuracy. 

The hypothesis behind the project is that a larger volume of images even at a lower accuracy rate is of equal or greater value compared to the proprietary curated databases.

Participation will open to contribution to by all; and the resultant community product (the database) will be made openly accessible to all, layman and professional alike.

Strengths	Weaknesses
Monetary cost of starting (website) is relatively cheap in early stages. Small team in initial phase. Low manpower costs up-front. Participation with website/database  could enable users immediate gratification. Access to image database is free/open to world for research etc. i.e. - other skin conditions with similar “tags” could show up on screen after submission. The concept readily taps into the ethos for a more genuine/communal approach to solving the worlds problems	Limited accountability over submitted images. As a truly open site limited ways to prevent upfront the inappropriate image submissions (ie genitals or cartoon images) Similar to prior: at beta stage (unless there is some type of research funding) has limited ability to “double check” validity of user-submitted diagnosis. Relying on trust-worthiness of the crowd of participants (this could also be a strength). Cost of double checking images via phone, or person-person review would be large. Limited initial monetary and human capital (person-hours) to devote to early development of project. Initial small team has limited execution experience in the entrepreneurial space. Not-for-profit driven at conception; not extensive thought has been given to potential for monetization which may limit broader interest/investment. Has never been truly tested in this specific way, first-mover advantage, which brings with it all of the potential pitfalls such as potential for legal disadvantages.
Opportunities	Threats
Potential for database of vast size, larger than current private databases (see previous post) Medicine is specialized, and the culture is often slow to adapt and adopt change. This intransigence allows space for innovation with a relatively  lower risk of early competition compared to other industries. Ability to tap into the power of the crowd - similar to paradigm shifts already further along in  encyclopedias (think Wikipedia) and news (think Twitter). Enabling the community to more fully participate in the health conversation has potential for better outcomes/lower costs. Riding with the wave of the “crowd sourcing” concept, not in a hollow way that  some companies are trying to do for marketing purposes. This project would solve 1 problem-crowd source 1 specific health niche. If  there is proof of concept --> idea becomes  a building block of a larger project to crowd-source health data then → build on the data to aid in diagnosis, treatment, research.	Smart phone technology and the rapid pace of product development and iteration means the next generation of IT minded doctors (US/India or any other global player) can be expected to move quickly into the crowd-sourcing concept  Medical Culture at large makes a baseline assumption that the doctor, the professional, contains sacred knowledge.This project tries to break in and take some of the power away from the dominant culture, which can be threatening. If dermatologists feel threatened there is easy risk of blowback such as being accused of being unsafe for patients. Michigan Iphone app: screen self for skin cancer w/ free iphone app. VisualDx - made and marketed exclusively for physicians. However, a conceptual step could lead to a patient version for submitting images and the organization already has infrastructure, connections, and momentum. patientslikeme.com - already exists, brand recognition, is crowd sourcing patient support groups. Contains 1,000+ conditions, and 156,241 patients when last accessed.

The Potential Exists

People like to share photos. 
The challenge becomes getting the right context (age/gender/associated symptoms), the right label (diagnosis), the right amount of accuracy and pixel clarity to any uploaded image.

Online Databases - the purpose of the the sites compiled here seem to be mainly informational/educational. Dermnet, Dermatlas from Hopkins, and DermIS seem to me more aimed at at educating medical professionals. Visualdx is one product of the company Logical Images. Their images can only be accessed through their apps.

Visualdx 
- Private entity. A for-profit owned by parent company Logical Images. Sells online and app program to doctors/nurse/medical practitioners to help increase accuracy of diagnosis by provided images of common skin conditions.
- Containing "25,898 unique images"

Dermnet 

- Founded in 1998 by Thomas Habif, MD. The "largest independent photo dermatology source dedicated to online medical education though articles, photos and video."

- Per the site, "more than 23,000 images, Dermnet.com contains the largest number of dermatology images online"

Dermatlas from Johns Hopkins

- Founded by Dermatologist from Johns Hopkins, the "purpose of this WWW site is to enable health care professionals, parents, and patients to access high quality dermatology images for teaching purposes"

- Images submitted by and large from healthcare professionals 

- Contains, "13,052 images from 628 contributors"

DermIS a collaboration between University of Heidelberg and University of Erlangen

- Claiming to be the, "the largest dermatology information service available on the internet." but without reported numbers on their site that I was able to fine.

Several other sites which do not report where they images were obtained from nor how many images are in the collection are include: Skin Cancer and Benign Tumor Image Atlas from Loyola University and Dermatologic Image Database from University of Iowa

Seems like the a robust database currently contains between 10,000 - 20,000 mark. 

 __________________________________________________________________________________________

By Comparison:

Flickr reports to have 6 billion uploaded images.

searching for images tagged "skin" on Flickr yields --  307,554 uploads

Searching for "eczema" on Google Images results in -- 3,850,000 results

With regards to capacity for pictures, this post speaks to the large volume of images on the internet, reporting 140 billion photos hosted on Facebook.

It's All In The Name - Good Incorporated

The reason this blog is called A Doctor for Good is due in part to the gentle yet persistent suggestions of my lovely wife. I was hesitant about this title because without the context it can easily comes across as arrogant on my part. The word Good, in A Doctor for Good carries a double entendre throughout this entire endeavor. I am a doctor, and with this medium will attempt to catalogue a vision for a healthier society. The project described in the first post is part of that vision. However, the roots of my passion for change run deeper than solving health challenges alone.

Below is a White Paper I first wrote as a medical student around 2006 based on an idea that I first had as an undergraduate. The white paper is an attempt to lay out a vision for a new kind of enterprise. This type of venture was a unique type of undertaking in my mind when I first had the thought in college. I later came to find out this kind of entrepreneurial arrangement was gaining wide attraction, and had been around for some time. The idea, now commonly referred to as social entrepreneurship or social business, has been implemented in the real world with notable success by the Grameen Bank and Dr. Muhammad Yunus.

The reason the project is called Good Incorporated is thanks to a good friend of mine, Joel Wright. On a laid back Friday afternoon in his dormitory room on Hendrix College campus a group of friends were hanging out. I described to them this rough idea formalized in the white paper below. After hearing my thesis Joel said, that sounds like good…incorporated. The name stuck. That has been the title of this project for about a decade.

It is important to me to include this idea up front. I see the project described in the first post is a building block in a larger economic and social pyramid. Every time I think about the title of this blog, I think about Good as noun with potential for a concrete reality in terms of the concepts and abstractions below.

White Paper

Good Incorporated

The Goal, and why the world needs us to do this

Enabling our generation to sustain its standard of living and ensuring others have the opportunities to do the same.

We live in an age of vast and ever growing wealth. The recent global economic slowdown merely represented a shrinking of overall economic growth, rather than an absence of it. Never in our history have we been so interconnected with the peoples and cultures that live such vast distances from us. Efficiencies in population and material transport have allowed entrepreneurs access to global labor and consumer markets. This shrinking of borders has been exploited in ways that take the global standard of living to unbelievable new heights. This has been detailed nicely in works such as The World is Flat and Hot, Flat, and Crowded by Thomas Freidman. The advent and propagation of information technology is further contributing to the narrowing of economic and social gaps. Unfortunately, a large number of global citizens have been “left-out” of this interconnected, rich world. This means that they have not had a similar opportunity to partake in the creation of individual or community prosperity to the same degree.

Traditional multi-national companies have not championed that neglected population because those markets, and those consumers, are not as profitable. Their business models and corporate charters are structured  in such a way to create dis-incentive towards engagement with economically disadvantaged communities.  Good Incorporated believes that the opportunity to participate in a globalized world should be offered to any individual regardless of their station at birth. We seek to do this because we believe that by sharing in the exchanges of culture, history, language, know-how, and ideas, we are in a better position to mutually enrich each other. Globalization and its contiguous economic opportunities doesn't have to be a rich man’s only party. Empowering others to take part in their local and global economies can have beneficial effects on the sustainability and promulgation of overall global prosperity. However, it will require us to muster a change in perspective. Today the traditional business world is working from a specific and one-sided paradigm. What we are seeking to do through Good Incorporated is fundamentally change the paradigm. It is the underlying belief that profit, economic sustainability, and the social good are not mutually exclusive pursuits. It is that belief which distinguishes this endeavor from the traditional conceptualization of business while at the same time distancing itself from the work currently categorized as charity/foreign aid/humanitarian.

Will this even work?

Yes, it will work. We know it will work is because the model of economies of scale has already been proven feasible as a traditional business structure. [In this context feasible = profitable]. An example business model to look at is Wal-Mart. Laying aside valid critiques of some of Wal-Mart’s policies towards its employees, the second largest grossing company in the U.S.A. was Wal-Mart in 2012. Understand that, and then consider the population that is the Wal-Mart client base? The answer: the middle socio-economic classes of American society. Wal-Mart took something: in this case household consumer goods and sold it at a price (and overall profit margin) low enough where American consumers could buy. The model works at a 3% profit margin because of economies of the scale. Those left out to globalization are the poor/middle classes around the world. Imagine a product or service that can be provided at X cost. Imagine a prime client base consisting of those currently left out from globalization. Since traditional enterprise currently are not catering to or heavily pursuing that market, there is ample opportunity for a huge market share. Based on the possible market, and the economy of scale, X would have the potential decrease to a fraction of its original cost. What we are talking about is on the scale of pennies a day. But, like Wal-Mart, if you sell enough units that it only costs you 1/2 a penny and you collect 1 penny, doing that millions of times a day you are still a viable economic entity.

Why Profit?

Profit is important because it underpins structural economic validity and sustainability. It is not the only operating goal, but it is a necessary part of operations. The way we currently structure aide to those left out of globalization looks more like a band-aid. Donated foreign aid money only goes so far as the amount pledged and the length of time it is promised. It functions, or has functioned, more as a superficial patch to the problem. Redistribution of wealth through foreign aid has been around for a long time, but is it sustainable?

Counter that image with the concept of capitalism. It is the argument of this white paper that capitalism as it is currently operationalized globally does not work for the majority of the world’s people. Bear in mind when writing about a global scale, that includes the U.S. population. Why are they left out? Why is capitalism not producing gains for a larger portion of the population? The answer to this goes back to the current world views regarding capital production and charity or social welfare, and suggests a need to a paradigm shift.

The current globalized form of capitalism could have left out many of world’s poor for 1 of several reasons: 1) It could be that capitalism is inherently an unjust system and wherever it is implemented will always proffer inequality. Or, 2) as Good Incorporated believes; capitalism leaves out many because the pursuit of profit is not currently mindful of social well-being. Additionally, socially beneficial pursuits such as those advocated by civic organizations or communities of faith are reliant on donated money, which as alluded to above, comes and goes with a whim and brings its own shackles. A Good Incorporated endeavor is pursuit of the good cause coupled with profit, however minuscule,  as a necessary requirement for the continuation of the project. Profit is viewed a means to provide feedback to the organization about the efficacy of execution of its core mission without wasting energies away from the core project in order to address fund raising or other inefficient efforts.

People who deeply care about others and want to make social change their life's work in this world don’t become CEOs and go into traditional business; they tend towards careers like social work. Pursuit of the social the well-being of your fellow man has not been a quality traditionally associated with a capitalist. It could be argued that a new word is needed for this coupled concept. We seek a new type of entrepreneurship. We seek to take our profits and feed them back into communities. Similarly, the aim is to use profit not as a means of extracting wealth-but rather creating value for people and communities. What if a global corporation acted like a mom and pop store? What if altruistic/socially minded people were at the helm of dynamic Fortune 500 companies? 

Background creates context

A crop germinates in a context where the conditions allow. The ideas herein have been ruminating in my mind for some time. With this blog, the intention is sketch out my own background to enable the reader to understand where I am coming from. I hope to use this writing to further refine the ideas which have stayed locked in the silo of my own mind for too long.

The purpose of this blog is to lay out a vision. In the book Where Great Ideas Come From, Steven Johnson describes something he calls a slow hunch. This is the process by which ideas take a long time to go from acorn to oak. I have always had an interest in writing, it is a way in which I find that I am able to refine a thought. This public diary may prove more helpful on a personal level, forcing me to clearly articulate a vision, than it will be for the reader. I am putting it in the public space because I believe these personal interests may have broader appeal.

My Background
I was born in Mississippi, son of a single mother. For the first 11 years of my life I lived with my mom in the southwest corner of Arkansas, USA. When I was 11, my mother took a job as teacher with the Department of Defense Dependents Schools. This is the organization that hires teachers for schools on U.S. military bases overseas. These schools where children of U.S. military members attend school. She left a job teaching kindergarten in the United States and we moved to Japan first. After 2 years we moved to Seoul, South Korea. I spent 8th through 10th grade living in Seoul. We moved again, and for junior and senior year of high school we lived in Mons, Belgium. After high school, I returned to Arkansas to attend university. I went to a small liberal arts college in central Arkansas which was geographically close to my father. I completed medical school in Washington, D.C. Today, I am in my 3rd year of postgraduate clinical medical training (termed residency in the U.S., house officer in the British system) in family medicine in North Carolina.

Concept: The value of the crowd.
Project 1, a foundation in a mental pyramid
I have known Zach since high school. He and I have grown in friendship since that time. I had breakfast with Zach at a Panera several years ago and described an idea for using cell phones to identify dermatologic skin abnormalities. Smart phones have reached sophistication with a combination of camera, processing power, and internet connectivity that enable this to move out of the realm of science fiction. The idea is for a cell phone to take a picture of a skin lesion and use artificial intelligence algorithms which would correctly identify the diagnosis. To imagine how this would work, picture an episode of CSI (Crime Scene Investigators). During the crime solving music montage there is screen shot of a computer with fingerprints cycling rapidly through the screen until the correct match is made. The criminal is caught! I have also seen this on the silver screen with scenes of facial recognition technology with the computer successfully picking out the right face. This is not science fiction, airports are currently using the technology. This article about facial recognition for airport security is almost a decade old. The cognitive leap to replacing faces with skin pictures is a short distance. A dermatologist in training spends time gaining exposure to thousands of mental images of abnormal skin (along with associated data points of gender, age, other symptoms, etc) and cataloguing that information attached to a “correct” diagnosis. An algorithm will search the submitted image for characteristic qualities (like the ID points on fingerprints) and produce a diagnosis, or list of probable diagnosis - in the same way a human physician operates. In fact, a version of this concept is operational as a medical device. A machine, Melafind, can detect a cancer in a specific type of small pigmented skin lesion better than a trained Dermatologist. The idea was to expand this to any type of skin lesion, not just something that was a potential melanoma.

Zach became interested in this idea. Our Panera coffee shop breakfasts continued sporadically. Zach emailed me and said he was having trouble locating a skin image database that would be  sufficient in size to attempt such a project. The problem is that there exists no publically available skin image database. In order to “teach” an algorithm what the important characteristics of skin lesions are, you need a large set of photographs that are tagged with an answer, a diagnosis. Those types of image collections are all private. They exist either as proprietary collections, or they are in the possession of the academy for research or teaching purposes. Without the database, it is not possible to begin the development of this algorithm.

This was a daunting set back. The energy had stalled forward progress. The next link in the development of the concept was exposure to the ideas of Clay Shirky. The ideas, freely available on the internet, have shaped my appreciation for the potential of collaborative solutions. One of the things I hear in his work is this idea that the answers to problems which emerge from the crowd are more robust and have more potential. Organizing a truly crowd-sourced answer in a pre-internet world was virtually impossible. The internet, which is estimated to have penetration to a third of the global population, enables the the concept. One  widely used example of this methodology is Wikipedia. The challenge which Wikipeda addresses via the crowd is how to organize/update/and disseminate current and historical information on broad range of current and historical topics. The efficacy of the new method is punctuated by the passing of an old method which was previously used to address this challenge. Encyclopedia Britannica announced that it will stop print publication this year. Similarly, Twitter and social media are challenging the professional journalistic class in answering the question of how society keeps itself informed. For exposure to these ideas, I owe Professor Shirky an enormous debt of gratitude.

How Society Keeps itself healthy - A Professional class of Doctors - Can the crowd compete?

Zach and I met at Panera yet again. The barrier to forward progress was a current image database system characterized by proprietary images, locked away, unavailable for public use. This was an impediment that was scuttling a grand scheme to bring the power of technology to bear for improved health. The next conversation was full of questions. Since we don’t have access to a skin database how can we get the volume of necessary images to proceed? Could we get people to actually submit pictures of their own skin? What if we tried to crowd-source a database of skin images with diagnoses? On a technical level -how could we guarantee the quality of images submitted? Is this even legal? How can we protect the identity and personal health information of willing participants? Will this work?

We don’t yet know the answers to those questions yet. But with a low barrier to entry and a strong conviction in the belief that others will understand the potential of what we are trying to do, we are going to try.

In the posts that follow I will elucidate answers to those questions as well as architect the pyramid, for which Project 1 is a first building block, a proof of concept.