Health

AI Order for Health Care May Bring Patients, Doctors Closer

Published

3 years ago

November 10, 2023

Nov. 10, 2023 – You may have used ChatGPT-4 or one of the other new artificial intelligence chatbots to ask a question about your health. Or perhaps your doctor is using ChatGPT-4 to generate a summary of what happened in your last visit. Maybe your doctor even has a chatbot doublecheck their diagnosis of your condition.

But at this stage in the development of this new technology, experts said, both consumers and doctors would be wise to proceed with caution. Despite the confidence with which an AI chatbot delivers the requested information, it’s not always accurate.

As the use of AI chatbots rapidly spreads, both in health care and elsewhere, there have been growing calls for the government to regulate the technology to protect the public from AI’s potential unintended consequences.

The federal government recently took a first step in this direction as President Joe Biden issued an executive order that requires government agencies to come up with ways to govern the use of AI. In the world of health care, the order directs the Department of Health and Human Services to advance responsible AI innovation that “promotes the welfare of patients and workers in the health care sector.”

Among other things, the agency is supposed to establish a health care AI task force within a year. This task force will develop a plan to regulate the use of AI and AI-enabled applications in health care delivery, public health, and drug and medical device research and development, and safety.

The strategic plan will also address “the long-term safety and real-world performance monitoring of AI-enabled technologies.” The department must also develop a way to determine whether AI-enabled technologies “maintain appropriate levels of quality.” And, in partnership with other agencies and patient safety organizations, Health and Human Services must establish a framework to identify errors “resulting from AI deployed in clinical settings.”

Biden’s executive order is “a good first step,” said Ida Sim, MD, PhD, a professor of medicine and computational precision health, and chief research informatics officer at the University of California, San Francisco.

John W. Ayers, PhD, deputy director of informatics at the Altman Clinical and Translational Research Institute at the University of California San Diego, agreed. He said that while the health care industry is subject to stringent oversight, there are no specific regulations on the use of AI in health care.

“This unique situation arises from the fact the AI is fast moving, and regulators can’t keep up,” he said. It’s important to move carefully in this area, however, or new regulations might hinder medical progress, he said.

‘Hallucination’ Issue Haunts AI

In the year since ChatGPT-4 emerged, stunning experts with its human-like conversation and its knowledge of many subjects, the chatbot and others like it have firmly established themselves in health care. Fourteen percent of doctors, according to one survey, are already using these “conversational agents” to help diagnose patients, create treatment plans, and communicate with patients online. The chatbots are also being used to pull together information from patient records before visits and to summarize visit notes for patients.

Consumers have also begun using chatbots to search for health care information, understand insurance benefit notices, and to analyze numbers from lab tests.

The main problem with all of this is that the AI chatbots are not always right. Sometimes they invent stuff that isn’t there – they “hallucinate,” as some observers put it. According to a recent study by Vectara, a startup founded by former Google employees, chatbots make up information at least 3% of the time – and as often as 27% of the time, depending on the bot. Another report drew similar conclusions.

This is not to say that the chatbots are not remarkably good at arriving at the right answer most of the time. In one trial, 33 doctors in 17 specialties asked chatbots 284 medical questions of varying complexity and graded their answers. More than half of the answers were rated as nearly correct or completely correct. But the answers to 15 questions were scored as completely incorrect.

Google has created a chatbot called Med-PaLM that is tailored to medical knowledge. This chatbot, which passed a medical licensing exam, has an accuracy rate of 92.6% in answering medical questions, roughly the same as that of doctors, according to a Google study.

Ayers and his colleagues did a study comparing the responses of chatbots and doctors to questions that patients asked online. Health professionals evaluated the answers and preferred the chatbot response to the doctors’ response in nearly 80% of the exchanges. The doctors’ answers were rated lower for both quality and empathy. The researchers suggested the doctors might have been less empathetic because of the practice stress they were under.

Garbage In, Garbage Out

Chatbots can be used to identify rare diagnoses or explain unusual symptoms, and they can also be consulted to make sure doctors don’t miss obvious diagnostic possibilities. To be available for those purposes, they should be embedded in a clinic’s electronic health record system. Microsoft has already embedded ChatGPT-4 in the most widespread health record system, from Epic Systems.

One challenge for any chatbot is that the records contain some wrong information and are often missing data. Many diagnostic errors are related to poorly taken patient histories and sketchy physical exams documented in the electronic health record. And these records usually don’t include much or any information from the records of other practitioners who have seen the patient. Based solely on the inadequate data in the patient record, it may be hard for either a human or an artificial intelligence to draw the right conclusion in a particular case, Ayers said. That’s where a doctor’s experience and knowledge of the patient can be invaluable.

But chatbots are quite good at communicating with patients, as Ayers’s study showed. With human supervision, he said, it seems likely that these conversational agents can help relieve the burden on doctors of online messaging with patients. And, he said, this could improve the quality of care.

“A conversational agent is not just something that can handle your inbox or your inbox burden. It can turn your inbox into an outbox through proactive messages to patients,” Ayers said.

The bots can send patients personal messages, tailored to their records and what the doctors think their needs will be. “What would that do for patients?” Ayers said. “There’s huge potential here to change how patients interact with their health care providers.”

Plusses and Minuses of Chatbots

If chatbots can be used to generate messages to patients, they can also play a key role in the management of chronic diseases, which affect up to 60% of all Americans.

Sim, who is also a primary care doctor, explains it this way: “Chronic disease is something you have 24/7. I see my sickest patients for 20 minutes every month, on average, so I’m not the one doing most of the chronic care management.”

She tells her patients to exercise, manage their weight, and to take their medications as directed.

“But I don’t provide any support at home,” Sim said. “AI chatbots, because of their ability to use natural language, can be there with patients in ways that we doctors can’t.”

Besides advising patients and their caregivers, she said, conversational agents can also analyze data from monitoring sensors and can ask questions about a patient’s condition from day to day. While none of this is going to happen in the near future, she said, it represents a “huge opportunity.”

Ayers agreed but warned that randomized controlled trials must be done to establish whether an AI-assisted messaging service can actually improve patient outcomes.

“If we don’t do rigorous public science on these conversational agents, I can see scenarios where they will be implemented and cause harm,” he said.

In general, Ayers said, the national strategy on AI should be patient-focused, rather than focused on how chatbots help doctors or reduce administrative costs.

From the consumer perspective, Ayers said he worried about AI programs giving “universal recommendations to patients that could be immaterial or even bad.”

Sim also emphasized that consumers should not depend on the answers that chatbots give to health care questions.

“It needs to have a lot of caution around it. These things are so convincing in the way they use natural language. I think it’s a huge risk. At a minimum, the public should be told, ‘There’s a chatbot behind here, and it could be wrong.’”

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Health

Putting a Hole in Our World

Published

2 years ago

May 17, 2024

Desk Report

May 10, 2024 – When we’re young, we take our macula for granted. At the center of our retina – the deepest layer of the eye that’s chock-full of photoreceptors and that confers color to our world – the macula is like a high-resolution camera. As light hits our eyes, the retina’s macula recasts our world in a bloom of color with astoundingly high visual sharpness.

But as you age, your vision dulls. What once stood out sharply becomes foggy, like condensation on a windowpane. After some time, a coal-black smudge or cloudy circular area begins to affect your central vision.

This effective blind spot widens over time if left untreated. What remains is a “macular hole” in the center of your retina.

This unfortunate series of events marks the advanced stage of age-related macular degeneration, a dangerous retinal disease that affects about 20 million people in the U.S., and nearly 200 million people worldwide.

And it’s not getting better. Estimates are that by 2040, the disease may affect nearly 300 million people worldwide. We are very limited in our ability to treat or prevent it. Read on for what to know.

First, What Causes Age-Related Macular Degeneration?

AMD’s causes are varied, and whether it will affect you is mostly determined by age and genetics, said Marco Alejandro Gonzalez, MD, an ophthalmologist and vitreoretinal specialist in Delray Beach, FL.

Because of the different cocktails that we have in terms of our genetic makeup, some people’s photoreceptor cells in the macula “basically start to shut down,” he said.

AMD’s development involves over 30 genes, and if you have a first-degree relative – parent, sibling, child – who has the disease, you’re three times more likely to get it, too.

Gonzalez explained how the expected rise to 300 million cases by 2040 is due mostly to improved diagnostic tools, along with the fact that the world is getting older and living longer. (Usually, an optometrist can detect signs of AMD during a routine eye exam.)

Eye experts still struggle to stop AMD’s most harmful sign – the cause of those muddy, milky, or even coal-colored circles in your central vision: geographic atrophy.

Geographic atrophy can occur in either of the two forms of age-related AMD: “dry” AMD and “wet” AMD.

Nearly every case of AMD begins as the dry kind, affecting 80% to 90% of AMD patients.

Retinal disease expert Tiarnán Keenan, MD, PhD, offered a vivid image of geographic atrophy for those who have dry AMD.

“As time passes, the circular patches of GA expand like a brushfire, taking more and more vision with it, often to the point of legal blindness,” he said.

A researcher in the Division of Epidemiology and Clinical Applications at the National Eye Institute, Keenan recently led a study that tested the efficacy of the antibiotic minocycline in slowing geographic atrophy expansion in dry AMD. The study operated on the grounds that the body’s immune system could be at play in developing the disease.

When your body’s immune system is overactive, microglial cells (central nervous system immune cells) can get into the sub-retinal space and possibly eat away at the macula and its sensitive photoreceptors.

Though minocycline had been shown to reduce inflammation and microglial activity in the eye in diabetic retinopathy, it didn’t slow the expansion of geographic atrophy or vision loss in patients with dry AMD during Keenan’s study.

When asked if microglial activity could have very little to do with the atrophy expansion, Keenan said it’s something to consider: “Maybe microglia are just there as bystanders clearing up the debris … so inhibiting them is less likely to slow down progression.”

In future drug trials, “maybe it’s possible the minocycline or another approach to target microglia would be helpful, but it would be needed in combination with some other therapy and be ineffective by itself,” he said.

Two Sides of the Same Disease

In dry AMD, Gonzalez compares macular degeneration to the loss of pixels on a screen. “Some of those pixels burn out … and that’s the way you lose vision classically in the dry form.”

Wet AMD is a more progressive form of the disease. It causes abrupt vision loss due to abnormal blood vessel growth.

“If you don’t treat wet AMD quickly, it’s game over,” warned Gonzalez. “Wet macular degeneration is the quicker process of vision loss because these blood vessels wreak havoc.” These new blood vessels bleed, causing fluid to build in the macula, which ultimately leads to scarring.

Gonzalez shed light on why wet AMD develops. “The wet form, for some reason, is the body’s last-ditch effort to try to kind of ‘help’ a dying macula. … When these blood vessels start to grow under the retina, they quickly destroy the architecture of the macula.”

Stopping the Bleeding in Wet AMD

Though wet AMD is rarer, it’s more treatable than dry AMD. Signs and symptoms can be eased with various therapies injected into the eye.

Putting it simply, Gonzalez said these therapies to treat wet AMD “all basically do the same thing. They make these new blood vessels regress temporarily before they cause damage to the macula.”

The injected medication clears away those blood vessels and restores the architecture of the macula. People can recover some vision in this way, but it’s only a temporary tune-up, and shots must be given as often as once a month.

“Degeneration of the cells is still the main problem. You’re not stopping that. But degeneration itself is a lot slower than actual vision loss associated with these blood vessels.”

The Struggle in Developing New Treatments

According to Keenan, “nobody has been able to stop geographic atrophy from happening” in either form of AMD. “So, that’s the main work in the field with trials.”

In December 2023, the FDA approved two new drugs: Syfovre and Izervay, both of which only slow geographic atrophy. Degeneration still happens, regardless.

Keenan explained how these two new drugs are “complement inhibitors … given by injection into the eye once a month or so.”

“Complement” refers to the body’s complement pathway, a trigger that activates a cascade of proteins in enhancing immune response.

Clinical trials showed Syfovre slowing the rate of geographic atrophy by up to 22% over 2 years, and Izervay up to 14% over 1 year.

Though these drugs are a new weapon against this troublesome affliction, they aren’t without their complications.

“Anytime you give an injection in the eye, there’s always the risk of an infection because you’re introducing something from the outside. So that’s the biggest risk,” explained Gonzalez.

An infection is uncommon, but potentially devastating, as you can lose your eye altogether. There’s also the chance of a damaging reaction to the shot.

“You have to pick and choose your patients,” said Gonzalez. “Not everybody is a good candidate for those new shots … and the patient is never going to see better. … It’s a harder sell than the ones for wet AMD.”

A Common Protective Measure

Keenan and Gonzalez both have a fair degree of confidence in reducing the risk of AMD with vitamin therapy.

As a bit of background on how vitamins were found to act as a sort of preventive measure, Gonzalez said, “In the early and late ‘90s, there were series of studies which were called the age-related eye disease studies.” These are now referred to as AREDS 1 and AREDS 2.

Researchers proved that a certain cocktail of vitamins slowed down degeneration. The most is a combo of antioxidants: vitamins C and E and lutein and zeaxanthin, all of which are in the AREDS 2 formula.

People who took these vitamins had a lower chance of losing their vision over the next 2 to 5 years. “[The combo] seems to be complementary and additive … with a combined treatment effect of 55% to 60%, an excellent safety record, and very low cost,” Keenan said.

Gonzalez recommends the AREDS 2 formula of vitamins to every patient of his. “It’s such an easy thing to take, and the downside is minimal.”

Unfortunately, if your genes make you more likely to have the condition, a change in diet or vitamin use could have no effect.

Dire? Possibly. But not all is lost in this fight.

Vigilance with AMD and What to Do Next if You’re Diagnosed

Gonzalez is adamant in educating his patients before time has run out on treating AMD. Recognition is key. “The most common reason a lot of these people get to me ‘too late’ is they don’t realize there’s a problem.”

He explained a typical scenario: “Let’s say you have macular degeneration in both eyes at different stages. One of your eyes starts developing wet macular degeneration … so the better eye takes over and you may not notice there’s a problem.”

Even after a patient is diagnosed with AMD, they usually see a specialist only twice a year. Gonzalez often tells his patients to cover one of their eyes to make sure their vision is intact in both eyes. “You’ll be able to pick up on subtle differences” in each eye, he said.

This type of self-care and vigilance can be the difference between successfully living with and treating the disease for the rest of your life, and trying to get help when it’s simply too late.

For wet AMD, as mentioned before, a round of injections is basically what everyone does. Without quick, invasive treatment, the point of no return approaches rapidly.

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Health

Federal Experts Talk Bird Flu ‘What Ifs’ in WebMD Live Event

Published

2 years ago

May 17, 2024

Desk Report

May 16, 2024 – Multiple U.S. agencies are working to contain the recent bird flu outbreak among cattle to prevent further spread to humans (beyond one case reported in early April) and use what we learned before, during, and after the COVID-19 pandemic to keep farm workers and the general public safe.

Fingers crossed, the bird flu will be contained and peter out. Or the outbreak could continue to spread among dairy cattle and other animals, threatening the health and livelihoods of farmers and others who work with livestock.

Or the virus could change in a way that makes it easier to infect and spread among people. If this happens, the worst-case scenario could be a new influenza pandemic.

With so many unknowns, WebMD brought together experts from four federal agencies to talk prevention, monitoring, and what the “what ifs” of bird flu might look like.

Communication with the public “about what we know, what we don’t know, and ways you and your family can stay safe is a priority for us at CDC,” said Nirav D. Shah, MD, JD, the CDC’s principal deputy director. “We at the federal level are responding, and we want the public to be following along.”

People should consult the websites for the CDC, FDA, U.S. Department of Agriculture (USDA), and the Administration for Strategic Preparedness and Response (ASPR) for updates.

It is essential to not only stay informed, but to seek trusted sources of information, Shah said during “Bird Flu 2024 – What You Need to Know,” an online briefing jointly sponsored by the CDC and WebMD.

An ‘Experimental Hamburger’

If one take-home message emerged from the event, it was that the threat to the general public remains low.

The retail milk supply is safe, although consuming raw or unpasteurized milk is not recommended. “While commercial milk supply is safe, we strongly advise against drinking raw milk,” said Donald A. Prater, DVM, acting director for the FDA’s Center for Food Safety and Applied Nutrition.

As for other foods, thoroughly cooked eggs are less risky than raw eggs, and the nation’s beef supply remains free of the virus as well.

For years, federal inspectors have purchased and tested meat at retail stores, said Eric Deeble, DVM, USDA deputy assistant secretary for the Office of Congressional Relations. So far, H5N1, the virus behind bird flu, has not been detected in beef.

The USDA took testing a step further and recently cooked ground beef from dairy cows in their lab. Using what Deeble described as an “experimental hamburger,” the agency showed cooking beef to 165 F or higher kills the virus if it ever becomes necessary.

The federal government now requires all cattle be tested and be free of bird flu virus before crossing any state lines. The government is also reimbursing farmers for veterinary care and loss of business related to the outbreak, and supply personal protective equipment (PPE) like gloves, masks, and face shields to workers.

Vaccination Not Recommended Now

Federal scientists know enough about H5N1 virus to create vaccines against it quickly if the need arises. It’s more about planning ahead at this point. “Vaccines are not part of our response right now,” said David Boucher, PhD, director of infectious diseases preparedness and response at the Administration for Strategic Preparedness and Response.

If the virus changes and becomes a bigger threat to people, “we have the building blocks to produce a vaccine,” Boucher added.

An event attendee asked if the seasonal flu shot offers any protection. “Unfortunately, the flu shot you got last year does not provide great protection from the avian flu,” Shah responded. “It might do a little bit … but that is the vaccine for seasonal flu. This is something more novel.”

Treatments Stockpiled and Ready

Antiviral medications, which if given early in the course of bird flu infection could shorten the severity or duration of illness, are available now, Shah said. The dairy farmer who was infected with bird flu earlier this year responded to oseltamivir (Tamiflu) treatment, for example.

When it comes to bird flu symptoms, the fact that the only infected person reported so far this year developed pink eye, also known as conjunctivitis, is interesting, Shah said. Officials would have expected to see more typical seasonal flu symptoms, he added.

“Influenza is not a new virus,” Boucher said. “With this strain of influenza, we are not seeing any genetic markers associated with resistance to antivirals. That means the antivirals we take for seasonal influenza would also be available if needed to treat H5N1.”

ASPR has stockpiled Tamiflu and three other antivirals. “We do have tens of millions of courses that can be distributed around the country if we need them,” he added.

“Influenza is an enemy we know well,” Boucher said. That is why “we have antivirals ready to go now and many types of PPE.”

Science in Action

The feds intend to stay on the case. They will continue to monitor emergency department visits, lab test orders, and wastewater samples for any changes suggesting a human pandemic risk is growing.

“While we’ve learned a great deal, there are still many things we do not know,” Deeble said.

Shah added, “As in any outbreak, this is an evolving situation and things can change. What you are seeing now is science in action.”

For the latest updates on bird flu in the United States, visit the CDC’s H5N1 Bird Flu: Current Situation Summary website.

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Health

Federal Experts Talk Bird Flu ‘What Ifs’ in WebMD Live Event

Published

2 years ago

May 16, 2024

Desk Report

Or the virus could change in a way that makes it easier to infect and spread among people. If this happens, the worst-case scenario could be a new influenza pandemic.

With so many unknowns, WebMD brought together experts from four federal agencies to talk prevention, monitoring, and what the “what ifs” of bird flu might look like.

People should consult the websites for the CDC, FDA, U.S. Department of Agriculture (USDA), and the Administration for Strategic Preparedness and Response (ASPR) for updates.

An ‘Experimental Hamburger’

If one take-home message emerged from the event, it was that the threat to the general public remains low.

As for other foods, thoroughly cooked eggs are less risky than raw eggs, and the nation’s beef supply remains free of the virus as well.

Vaccination Not Recommended Now

If the virus changes and becomes a bigger threat to people, “we have the building blocks to produce a vaccine,” Boucher added.

Treatments Stockpiled and Ready

ASPR has stockpiled Tamiflu and three other antivirals. “We do have tens of millions of courses that can be distributed around the country if we need them,” he added.

“Influenza is an enemy we know well,” Boucher said. That is why “we have antivirals ready to go now and many types of PPE.”

Science in Action

The feds intend to stay on the case. They will continue to monitor emergency department visits, lab test orders, and wastewater samples for any changes suggesting a human pandemic risk is growing.

“While we’ve learned a great deal, there are still many things we do not know,” Deeble said.

Shah added, “As in any outbreak, this is an evolving situation and things can change. What you are seeing now is science in action.”

For the latest updates on bird flu in the United States, visit the CDC’s H5N1 Bird Flu: Current Situation Summary website.

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