Practical Predictive Analytics and Decisioning Systems for Medicine: Informatics Accuracy and Cost-Effectiveness for Healthcare Administration and Delivery Including Medical Research

software).

Introduction

At the end of 2013, a lot of turmoil developed in the US surrounding implementation of the Patient Protection and Affordable Care Act (ACA). As newspaper headlines at the time illustrated, the American political landscape was chaotic and many people were rather unsettled about the issues around how to organize effective and fair health insurance.

At the same time, new predictive analytics technologies that have fundamentally transformed practically all aspects of life – from CRM (customer relationship management) to general insurance, risk management, demand forecasting, or manufacturing – are only beginning to find applications in health care. It is likely that the impact and benefits of these technologies, once fully applied to optimize the overall performance of the healthcare system, will be as important for the overall quality of health care as structural and legislative reforms of the system. In fact, new developments in predictive analytics and statistical learning will be key to sustainable and successful healthcare reforms.

Significant changes in health care will have to happen. Healthcare costs have been skyrocketing, insurance premiums are increasing rapidly, and the existing healthcare system – like other industries – will have to adjust to leverage new technologies. This situation is reminiscent of the famous Far Side cartoon of the dinosaur convention by Gary Larson (Figure I.1).

Figure I.1 The Dinosaur Convention cartoon by Gary Larson.

Chapter 1 tells the story of King Solon of Ancient Greece, who instituted the seisachtheia, or the shaking off of burdens of the poor. This law was designed to address an inequality in 6th Century BC Greece, where a bankrupt person would become a slave to his rich creditors. In addition to losing their personal freedom, these newly poor people were excluded from healthcare treatment by physicians, who catered only to the rich. This is not unlike medical bankruptcies taking place in the modern world today, where people are tied to the often onerous debt caused by the extraordinary costs of their health care. One of the results of the seisachtheia was formation of the Hippocratic Corpus of medical documents by Hippocrates, which became the standard source of healthcare information for over 2,000 years. Something like the seisachteia is needed in 21st Century American health care – relief from a system that seems to put people into virtual slavery, tying them down with burdensome debt and denying them liberty, the pursuit of happiness, and their lifelong dreams. A new Hippocratic Corpus could be developed using existing technology to link data in a seamless fashion, and create a standard source of healthcare data and actionable information.

Technology exists to create such a new-age Hippocratic Corpus, supporting what we might do with medical data. Technological advancements, however, have far outstripped our ability to analyze and make useful the data in the currently available formats. If the ACA (or its modification, possibly) is able to bring about a digital form of the Hippocratic Corpus of stored medical knowledge, it will be the beginning of a digital Golden Age in medicine and health care.

Currently, our ability to track, and make useful, medical information across the array of institutions and specialist physicians is limited severely by the fragmentation of the healthcare system. Much medical case-specific information is still in medical records that line the shelves of physicians’ offices in paper format. The new and growing capability of our analytical technology combined with the severe lack of case-specific medical data renders our medical establishment as an amnesiac with an enormously high IQ (a powerful non-linear analytical system – our predictive analytical technology), but lacking all five senses, and providing little data to analyze.

In this book, we seek to break that logjam (at least conceptually) by showing readers what can be done using new predictive analytical capabilities with available healthcare data, and lead by examples (tutorials) of ways to get ‘er done (as Larry the Cable Guy is fond of saying). What we can’t do in this book is design the changes in storage systems, security systems, delivery systems, and legal systems (e.g., HIPAA) necessary to make it happen. Those changes will come. All we can do is set the stage with chapters on general concepts of medical decision systems, and present some practical tutorials designed to grease the skids for change to happen.

Evidence Based Medicine (EBM) is an important new paradigm that has not exerted much impact yet. Unlike Evidence Based Guidelines, EBM starts with guidelines and updates them using new information generated by clinical trials, medical journals, academic medical centers, government health institutes, and other authoritative sources of medical knowledge.

One of the biggest challenges to EBM implementation is the set of limitations associated with the gold standard of randomized control trials, including high cost, length of time, and often significant bias; the enormous problem of the lack of access to unpublished (possibly suppressed) data; and the issues of using results that are not applicable very often to the individual patient under treatment. Many practicing physicians realize how little good evidence we have for diagnosis and treatment of patients. If patients knew how much their physicians don’t know, they might not want to see them. We need desperately to know the right test, and the right treatment, for the right patient at the right time. The goal of this book is to explain the enormous power of current technology in the search for evidence, which avoids those problems, and can provide timely, relevant, and practical information to use in the clinic and at the bedside.

The approach of this book is to present a background for the use of predictive analytics in health care, and provide practical tutorials to show how to perform important new tasks in medicine and health care, including the following.

1. Gain new insights into disease pathways and progression.

Predictive analytics technology can provide new information and relationships between diseases and specific patient characteristics. The progression of the disease can be predicted for various treatments. This capability can provide unprecedented choice of treatments for patients by permitting optimization of the analysis of their data to enable the answering of existing questions, project the course of disease progression, generate new insights, and present new questions to analyze.

2. Discover new knowledge and insights in real-life, not just in test tube cultures.

It is one thing to learn new things about diseases in the laboratory, but pathogens may act differently in the outside world. This new knowledge can lead to the discovery of root causes of diseases, and guide treatment of the real problem – not just the laboratory expression of it.

3. Accelerate the pace of medical science.

New technology increases the rate at which new information can be discovered. The faster we can learn new things about diseases and their treatments, the quicker and more effectively we can cure them.

4. Develop a new paradigm of personalized medical diagnosis and treatment.

We must shift our approach from treating the disease to treating the patient. This focus on the particular characteristics of the patient and the individual expression of the disease will lead to treatments optimized closely to the patient, and not just to population averages. The patient can play a vital role in health care.

Organization of This Book – Why We Did It This Way

When encountering the vast power of predictive analytics in medicine for the first time, the temptation is to seize upon a technique and want to try it out immediately. We recognize this great urge, and, rather than squelch it, we want to channel it through to fruition in responsible analysis.

Part 1

Part I of the book really has two sub-parts:

1. Background to healthcare – structure and organizations from which the data needed for effective predictive analytic modeling and decisioning can be obtained

2. The Predictive Analytic process itself.

Part 1 – First Sub-Part

Chapters 1–14 present an introduction to all (or many) of the aspects of health care, including methods like EMR, and organizations such as HIMSS that are part of the medical healthcare landscape. These serve as a very important background to predictive analytics, as it is from these institutions that the data are produced for needed effective data analysis. Throughout Chapters 1–14, the authors allude to the primary principles and practices of predictive analytics to prepare you to do it yourself … responsibly. The tendency for analysts to go off half-cocked in using a new body of techniques will be minimized, if they read these chapters first. Chapter 1 presents the historical background for this book, and it also justifies the notion ensconced in the Affordable Care Act (ACA) to convert medical record to digital format, and make them available to all responsible parties to guide diagnosis and treatment of medical ailments. Chapter 2 presents many of the other reasons we wrote this book, builds the foundation of reasons for the application of information on past cases to the diagnosis of current cases, and presents some disturbing facts about medical research in America today. Chapter 3 explores the rich landscape of medical informatics to set the stage of how this powerful technology can revolutionize medical treatment in the future. Chapters 4–8 describe the standards, the regulatory structure, and the basis for electronic medical records (EMRs). Chapters 10–14 present features of the proper milieu in which EMRs are gathered and used.

Part 1 – Second Sub-Part

Finally, Chapter 15 gets to the nuts and bolts of predictive analytics. It introduces readers to the many powerful predictive analytical (data mining and text mining) techniques that can be employed to gather useful information from mountains of EMRs and other health data.

Part 2

After building a proper foundation for understanding and performing (at least simple) predictive analytical operations with medical data, tutorials and case studies are presented to permit readers to see how predictive analytical techniques can be employed in various analysis and prediction scenarios.

Part 3

The last part of the book, Chapters 16–26, describes some examples of how predictive analytics can be used in administration and the delivery of health care. These include Chapter 16, which summarizes how nurses can use predictive analytics; it is not the exclusive area of researchers and physicians, and Chapter 23, which shows an excellent example of how predictive analytics is applied to the entire organization and operations of the Military Institute of Poland. The success in Poland illustrates the downside of American regulatory constraints; they can get in the way of effective integration of new practices into health care. And this success suggests not that American regulatory structures should be abandoned, but rather that they must be redesigned to capitalize on the powerful capabilities of the new technology of predictive analytics in medicine and health care.

Prologue to Part 1

Outline

Prologue to Part 1

Part 1 Historical Perspective and the Issues of Concern for Healthcare Delivery in the 21st Century

Prologue to Part 1

This book comprises three basic areas:

1. Context and opportunities

2. Practice

3. Theory.

Part 1 is primarily concerned with the first area.

Chapters 1–14 (basic area number one) acquaint the reader with the many facets of health care and explain the various aspects and organizations that, directly or indirectly, affect how medical and healthcare data are captured. These chapters offer the perspectives of history, including where we are at present and where we might be heading. The reader can become grounded in the context of medical research by examining the history, the organizations that arose, the arising needs from our cultural milieu, the attempts at answers to those needs, and where those answers may have fallen short.

Predictive analytics requires data, and good data. It is the task of the data miner to secure those data just as though they were gold. However, data mining is not enough. Predictive analytic methods seek to anticipate good outcomes, and good outcomes for individuals. Predictive models are only as good as the data that are processed by the models. Chapters 1–14 demonstrate the flow of data through history, including the laws that were meant to inhibit and those that were meant to increase the flow. We as researchers must know our context in order to apply our predictive analytic art to the canvas of individual outcomes.

In summary, data (good data) are essential to the precision of predictive analytics. Good data are necessary for unleashing effective models from which excellent decisions can be made.

You, the reader, may wonder why we did not start this book with discussions of predictive analytic algorithms, and predictive analytic models and decisioning. But good decisioning can only come after good modeling, and neither of these can be obtained if one does not have good data as a starting point.

Linda A. Winters-Miner PhD and Gary D. Miner, PhD,

Linda A. Winters-Miner and Gary D. Miner are co-developers of the structure, table of contents, organization, and effective learning formats of not only this book but also the other two books in this mini-series: Handbook of Statistical Analysis and Data Mining Applications (2009) and Practical Text Mining and Statistical Analysis for Non-Structured Text Data Applications (2012).

Part 1

Historical Perspective and the Issues of Concern for Healthcare Delivery in the 21st Century

Outline

Chapter 1 History of Predictive Analytics in Medicine and Health Care

Chapter 2 Why did We Write This Book?

Chapter 3 Biomedical Informatics

Chapter 4 HIMSS and Organizations That Develop HIT Standards

Chapter 5 Electronic Medical Records: Analytics’ Best Hope

Chapter 6 Open-Source EMR and Decision Management Systems

Chapter 7 Evidence-Based Medicine

Chapter 8 ICD-10

Chapter 9 Meaningful Use – The New Buzzword in Medicine

Chapter 10 The Joint Commission: Formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Chapter 11 Root Cause Analysis, Six Sigma, and Overall Quality Control and Lean Concepts: The First Process to Bring Quality and Cost-Effectiveness to Medical Care Delivery

Chapter 12 Lean Hospital Examples

Chapter 13 Personalized Medicine

Chapter 14 Patient-Directed Health Care

Chapter 1

History of Predictive Analytics in Medicine and Health Care

The underlying purpose of predictive analytics in medicine is to predict and direct decision-making in diagnosis and treatment. The central element in this decision-making process is the availability of medical information to serve it. The original medium of this information was the mind of the physician. However, quite early in history, some of this medical head knowledge was committed to writing. The purpose of this chapter is to trace the history of written forms of information storage, to serve as a foundation for the present conversion of it into digital form.

Keywords

Predictive analytics; Medical databases; Best Practice Guidelines; Ancient cultures; Medical records

Chapter Outline

Preamble 5

Background 5

Introduction 6

PART 1: DEVELOPMENT OF BODIES OF MEDICAL KNOWLEDGE 7

Earliest Medical Records in Ancient Cultures 7

Classification of Medical Practices in Ancient and Modern Cultures 8

Medical Practice Documents in Major Ancient World Cultures of Europe and the Middle East 8

Egypt 8

Mesopotamia 9

Greece 10

Medicine in pre-Classical Greece 10

Hippocrates and Classical Greece 11

Ancient Rome 12

Galen 12

Arabia 14

Summary of Royal Decrees of Medical Documentation in Ancient Cultures 15

Effects of the Middle Ages on Medical Documentation 16

Rebirth of Interest in Medical Documentation During the Renaissance 16

The Printing Press 16

The Protestant Reformation 17

Erasmus 17

Human Anatomy 17

Andreas Vesalius (1514–1564) 17

William Harvey (1578–1657) 17

Medical Documentation Since the Enlightenment 18

Medical Case Documentation 18

The Development of the National Library of Medicine 18

PART 2: ANALYTICAL AND DECISION SYSTEMS IN MEDICINE AND HEALTH CARE 19

Computers and Medical Databases 19

Medical Databases 20

Medical Literature Databases 20

Best Practice Guidelines 20

Guidelines of the American Academy of Neurology 21

Postscript 21

References 22

Preamble

The underlying purpose of predictive analytics in medicine is to predict and direct decision-making in diagnosis and treatment. The central element in this decision-making process is the availability of medical information to serve it. The original medium of this information was the mind of the physician. However, quite early in history, some of this medical head knowledge was committed to writing. The purpose of this chapter is to trace the history of written forms of information storage, to serve as a foundation for the present conversion of it into digital form.

Background

The underlying purpose of predictive analytics in medicine is to predict and direct decision-making in diagnosis and treatment of medical and health-related conditions. For the purposes of presenting the history of predictive analytics in medicine, I decided to recount the history of the core of analytical operations – medical information. Therefore, I defined the relevant historical context rather broadly to include all forms of storage and preservation of medical and healthcare information, beginning with written forms.

In the process of researching the history of written medical documentation for the purposes of diagnosis and treatment, I found many examples in history of the mandate of royal leaders (kings and emperors) to gather together current medical and health-related information, and make it available for diagnosis and treatment of common people. This process began among the early Pharaohs of Egypt and the Kings of the Ancient Middle East. But the greatest contribution by far was made by King Solon of Greece, when he commissioned Hippocrates to gather together jealously guarded texts from many independent Greek physicians to form the Hippocratic Corpus of medical documents. This corpus was expanded by the Greek physician Galen, under the commission of the Roman Emperor Commodus, thus creating the body of medical knowledge that remained the standard for almost 2000 years. The processes of maintaining it, however, was neither simple nor direct.

King Chosroes I of Persia supported the Nestorians (a heretical Christian sect), branded as heretics and banished from the Christian church of the Holy Roman Empire. The Nestorians fled eastward and were embraced by Chosroes (and Islam), because both believed that Jesus Christ was not the Son of God but only a prophet. The Nestorians helped to found the university at Jundi Shapur, and to translate the Greek Hippocratic Corpus into Arabic. This great interest of Chosroes preserved the Greek medical texts through the Middle Ages, when many of the Greek and Roman texts were destroyed. The Arabian works were translated into Latin during the Reformation, beginning with Erasmus in 1525, and remained as the standard in medical treatment until the rise of modern medicine at the beginning of the 20th century.

Despite the massive problem with sign-up for the insurance exchanges through the US government website in 2013, and regardless of your political stance today, one thing becomes quite clear in this history of medicine. It is that Obama and his mandate of conversion to digital medical records (in the Affordable Care Act of 2009) is simply following in the footsteps of many rulers in history to collect medical information into an available format (digital now, rather than written) to facilitate diagnosis and treatment of the common people of the day.

Introduction

The goal of this chapter is to provide a foundation in the history of medical practice for the development of decision tools that guide the determination of correct diagnosis and treatment of human ailments. In general terms, these tools can be classified as:

I. Bodies of knowledge that govern the nature of medical diagnosis and treatment

II. Analytical approaches and decision systems that integrate diverse knowledge elements and direct the formation of accepted medical practices.

These two tool types are related, in that the decision systems are based on existing bodies of knowledge available to the physician. In Part 1 of this chapter we will discuss the various types of bodies of knowledge in the history of medicine, and see how they affected the quality and appropriateness of medical treatment. In Part 2, we will discuss various ways that information resident in the bodies of knowledge has been combined, stored, analyzed, and used to express predictions of diagnosis and treatment. Prior to the invention of the computer, analysis and decision-making processes were performed entirely in the most powerful non-linear processing engine in the universe, the human brain – the brain of the physician. Here, we will discuss how computers enable us to build and process complex mathematical predictive algorithms, and deploy them in medical decision systems. We will focus on computers and medical databases, and the development of best practice documents among specialties in Personalized Medicine.

The reason for considering the development of bodies of written medical information in this digital age is to highlight the various types of bodies of medical knowledge and show how they have been used in the past, and to provide guidance for using future medical information in digital form. Bodies of written knowledge are of two types: (1) subject-related documents; and (2) case-related documents. Both of these sources of medical knowledge serve as major components of the knowledge infrastructure of modern medical practice. Proper discussion of medical decision systems today (and in the future) must include an understanding of all of the components of the system of medical practice on which they are built. In addition, discussion of the history of the development of the current medical practice system can yield valuable insights to help us meet the technical and political challenges of today. One such insight provided by the study of medical history is the relationship between past royal decrees and the collection of medical documents together into comprehensive bodies of information for the sake of diagnosis and treatment of all people in a society. This insight is particularly relevant to the challenge by current legislation that requires the digitizing of physician medical case records to form an electronic health record (EHR).

The availability of EHRs and digital medical knowledge databases will provide the foundation required by analytical medical decision and management systems of today and in the future. The overall goal of this book (described more fully in the Introduction to this volume) is to show how to use advanced analytics to build and use a medical decision system that draws upon all available digital sources of information to increase the effectiveness of medical diagnosis and treatment.

Part 1: Development of Bodies of Medical Knowledge

The process of determining the appropriate treatment is conditioned by the training of the physician in medical school plus his or her evaluation of the aspects of the case in relation to:

• Personal experience

• Personal judgment

• Written and/or digital records of medical and healthcare information from previous cases.

Personal experience and personal judgment have always been important factors affecting the success of medical diagnosis and treatment; they must be kept central to the practice of medicine. The third aspect, development and use of records of medical and healthcare information, forms the foundation of responsible medical practice to all members of a society. The various methods and tools used to integrate these three aspects of medical practice characterize the entire history of medical practice.

The recognition of the need to collect and maintain written medical records extends back to the dawn of recorded history. We will confine our discussion to cultures in the West and Middle East. Medicine in Far Eastern cultures developed almost independently from that in the West and Middle East, until medical practices and technology were imported from the West in the 20th century.

From the very beginning, medical diagnosis and treatment have been essentially prediction problems. Individual treatment specialists in primitive cultures (e.g., medicine men/women) learned to perform their responsibilities from experience and word-of-mouth. There was very little cooperation among them, and sometimes there was animosity. This medical practice environment generated a wide variation in the nature, quality, and availability of techniques in medical practice, and difficulty in the training of new specialists. Five examples are given to show how rulers in ancient cultures have managed these problems with medical care in the past. These examples provide insights into how societal forces generated royal responses to the problems in medical care, how the responses were expressed in specific cultures, and how they can guide us in our response to the challenges in medical and health care that we face in our society today. Our approach to this daunting task will include discussion of the following topics:

1. Earliest medical records in ancient cultures

2. Classification of medical practices in ancient and modern cultures

3. Medical practice documents in major ancient world cultures of Europe and the Middle East

4. Summary of royal decrees of medical documentation in ancient cultures

5. Effect of the Middle Ages on medical documentation

6. Rebirth of interest in medical documentation during the Renaissance.

Earliest Medical Records in Ancient Cultures

There is some controversy about the identification of the earliest manuscript of medical treatments. Many scholars point to the Code of Hammurabi (~1700 BC), containing accounts of various surgery procedures, recommended fees for service, and penalties for malpractice (Sigerist, 1951). But there are earlier Sumerian cuneiform texts that date to the reign of King Ur III (ca. 2100 BC) in the early Babylonian Empire, which contain instructions for medical treatments, without diagnostic information, designed to be used by experts. There are earlier records of spells and incantations among the Pyramid texts, caused to be written by King (Pharaoh) Unas on the walls of his pyramid; he was the last king of the Fifth Dynasty in Egypt (~2300 BC). The text includes many religious spells and incantations aimed at assuring the well-being of the Pharaoh in the after-life. Some evidence exists (if it is valid) that a very early Pyramid text (the Hearst Medical Papyrus, dated about 2500–2000 BC) contained some references to medical treatment (Reisner, 1905). This text mentions the Egyptian god Thoth, who gave the Egyptian physicians healing arts. Herodotus (484–425 BC) collected many documents of Egyptian medical practice, which he called Hermetic books, because he identified the Egyptian god Thoth with the Greek god Hermes (Dawson, 2010). Clemens Alexandrinus (AD 215) collected 42 such Hermetic books on anatomy, illnesses, eye diseases, gynecology, drugs, and surgical instruments (Alexandrinus, AD 215). If any of these Hermetic books existed, none survives (Sigerist, 1951).

Classification of Medical Practices in Ancient and Modern Cultures

Development of medical practice appears to follow a similar pattern in all cultures studied (Sigerist, 1951). The earliest phase of medical practice in a given culture presumes supernatural causes and prescribes spiritual treatments for ailments and diseases (supernaturalistic medicine). The second phase abandons (at least partially) the supernatural medicine approach and accepts the naturalistic medicine approach, in which causes for ailments and diseases are sought among natural causes that can be studied in the natural world. The final phase is scientific medicine, based on accumulated medical informational documents, and results of scientific tests. Most cultures follow the pattern shown in Figure 1.1.

Figure 1.1 The normal course of development of medical treatments in many cultures.

Even though this development trend describes the long-term trend in a culture, it is often the case that these approaches may be practiced at the same time by different segments of the culture (Sigerist, 1951). This was the case for supernaturalistic medicine and naturalistic medicine in Egypt and Mesopotamia. We find elements of naturalistic medicine along with scientific medicine in practice in many cultures today, even in the United States in the form of homeopathic medicine and conventional medicine.

Medical Practice Documents in Major Ancient World Cultures of Europe and the Middle East

Medicine of some sort has been practiced in every ancient culture. In this chapter, we will confine the discussion to the developments of medical practice documents in Europe and the Middle East:

• Egypt

• Mesopotamia

• Greece

• Ancient Rome

• Arabia.

Some naturalistic medical texts were written in China ca. AD 600 (Unschuld, 1985), and in India even earlier than that (Sigerist, 1951 ), but these texts do not appear to represent ideas and relationships to predictive analytics that are not reflected in documents from countries of Europe and the Middle East.

Egypt

Many pyramids in Egypt contain hieroglyphic scripts with medical content, the earliest of which appear on tombs of the Fifth Dynasty, in about 2300 BC (Faulkner, 1969). These scripts contain many incantations and spells designed to help the Pharaoh in his after-life. Concepts of detailed examination, diagnosis, and prognosis (medical treatment) may have arisen in very early Egypt. The Edwin Smith Surgical Papyrus (ca. 1700 BC; see Figure 1.2) contains very detailed descriptions of 48 medical cases involving head and body wounds, sprains, and tumors. Serving as the founder of Egyptology, Breasted (1967) claimed that the Edwin Smith document is composed of a copy of an earlier document dating back to 3000–2500 BC in the form of 69 explanatory notes on the original document. If this document existed, it would be the earliest medical record of surgical information.

Figure 1.2 Edwin Smith papyrus. Reproduced with permission from: http://designblog.nzeldes.com/2011/03/hats-off-to-ancient-egyptian-medicine/

The Ebers Papyrus of 1550 BC is the largest among the most ancient Egyptian medical documents known (Bryan, 1930). It contains over 700 spells and incantations for turning away evil, disease-causing demons. The Hearst Medical Papyrus is thought to date back to 2000 BC or beyond (Reisner, 1905), but some controversy exists about the date.

According to Sigerist (1951), other known Egyptian medical papyri included:

• Kahum Papyrus (1900 BC) – On Gynacology and pregnancy

• London Papyrus (1350 ) – On recipes and incantations

• Berlin Papyrus (1350 BC) – On medical tests, pregnancy and fertility

• Chester Beaty Papyrus (1250 BC) – Drug recipes and diseases.

Herodotus identified the Egyptian god Thoth (mentioned in the Hearst Papyrus) with the Greek god Hermes, the god of healing. We know of many of these works through the writings of Herodotus and Clement of Alexandria. They referred to them as the Corpus Hermiticum, or the Hermetic books. Six of the 42 Hermetic books were on medical subjects of physiology, male and female diseases, anatomy, drugs, and instruments (Zeller, 1886).

Thus it appears that naturalistic and supernaturalistic medicine were practiced side by side in Ancient Egypt, as in Mesopotamia and Greece (see below).

Mesopotamia

The earliest medical text in Mesopotamia (associated with King Ur III, ca. 2100 BC) contained instructions for treatments of patients without diagnostic information, intended for use by experts only (Oppenheim, 1962). It is unclear whether the Babylonians were the first to document the concepts of detailed examination, diagnosis, and prognosis (medical treatment), or whether they just imported them from the Egyptians. In either case, enough medical knowledge was accumulated by the Middle Babylonian period (1532–1000 BC) to support separate texts for diagnosis and treatment.

During his reign at the end of this period, King Adad-apla-iddina (1068–1047 BC) decreed that existing medical records be collected to form a corpus of 40 tablets, referred to as the Diagnostic Handbook. Some of these tablets in the handbook listed treatments based on the number of days the patient had been sick (Tablets 15 and 16) and the pulse rate (Tablet 21). This and other similar numerical information used to compose diagnoses may represent the first bioinformatics models in medicine. We can see this same integration of medicine and numbers in the Sakikku, a large medical treatise of about 40 tablets divided into 5 parts (Neugebaur, 1957). Part II enumerates symptoms of diseases according to color, temperature, and movements of body parts. Part III describes treatments that were prescribed as a function of numerical information from observations described in Part II, combined with specific information about the disease course, phase, and amelioration/aggregation relative to the time of day.

Sumerians used a symbol for not in the place of zero, as a placeholder in their sexigecimal number system based on 16, rather than 10 (Kaplan, 2000). For example, the number 2013 was represented by a string of symbols for 2, followed by the symbols for not, 1 and 3. They did not understand the concept of zero (that came later from the Moors in 11th century Europe), but they could do geometry with this system. There is evidence to suggest that they understood the geometry of the Pythagorean Theorem 1000 years before Pythagoras (Oppenheim, 1962; Kaplan, 2000). Evidence of this rather sophisticated number system combined with their detailed medical knowledge suggests that diagnoses based on the Sakikku were quantitative. To that extent, one of the roots of predictive analytics in medicine extends back to ancient Babylonia.

A vast collection of over 30,000 clay tablets was found in Nineveh and gathered into a library by Ashurbanipal, successor to King Sennacherib (Polastron, 2007). Over 700 of these tablets contained medical information. The tablets were distributed in many rooms according to a classification methodology. This library was the not the first if its kind, but it is the first known collection having most of the attributes of a modern library (Johnson, 1970) This collection was a great interest of Ashurbanipal; he was not above conquest to obtain new additions to it. To this extent, we can view that his collection arose from a royal mandate, and it serves as a second example of the collection of medical texts by royal decree.

The Babylonian medical tradition continued in practice until about 200 BC, after which it dropped out of awareness of medical practitioners. This decline of the Babylonian medical tradition in Asia Minor was contemporary with the rise of the Hippocratic Corpus in ancient Greece. Maybe these two events were related.

Greece

Medicine in Pre-Classical Greece

The cultural mindset and world-view in place can greatly affect the course of development of concepts and practices in a culture, sometimes in multiple directions. We can see two good examples of this human response phenomenon in the development of medical practice in the Greek history (and another one in Rome – see below). Beginning in about 600 BC, medicine became organized around two centers of the same supernaturalistic world-view: (1) the temple cult worship of the god-man Asclepius (a man who was elevated to the status of a god); and (2) the philosophy of the man Pythagoras.

1. Asclepius was a demi-god in Greek mythology, son of the god Apollo and a mortal mother, Coronis. He became the god of medicine, and his followers held that aliments and diseases could be healed by prayers and sacrifices, particularly in the temples erected for that purpose. Homer included a man named Asclepius in his story of the Iliad, as a physician to wounded men at the battle of Troy. In later years, he became elevated to the status of a god.

2. Pythagoras strived to create a balance among opposing forces acting on people. He quantified these forces with numbers, and analyzed these numbers (in terms of arithmetic) to guide medical treatments in terms of numbers. One of his treatments was to prescribe harmonic frequencies and music to treat human conditions. He invented instruments, and with the use of sound and vibration he was able to bring an individual’s attention to the awareness of their Divine Nature in order to facilitate the healing process. Pythagorus was a Renaissance man, in that his ideas ruled Philosophy, Mathematics, and Music, as well as Medicine, throughout the Golden Age of Greece (~550–300 BC).

Both of these forms of supernaturalistic medicine were practiced contemporaneously in Greece beginning about 600 BC and extending to about 450 BC, when a new approach was introduced by Empedocles via his philosophy (Sigerist, 1951). The previous belief system based on the philosophy of Parmenides held that the senses are not reliable, and that medical diagnosis and treatment should be found in supernaturalistic practices. Empedocles disagreed by stating that our senses are indeed a reliable guide to truth. He introduced the concept that all things were composed of four elements: Earth, Air, Fire, and Water. This belief was the first example of atomistic thinking in the Greek culture. This burgeoning culture permitted such philosophical disagreement, and the stage was set for Hippocrates (460–370 BC), who formulated the principle of the true mixture of elements. These elements (he called them humors) were black bile, yellow bile, phlegm, and blood. They were different from the four elements of Empedocles, but they followed the same philosophy of atomism (Empedocles) and balance (Pythagorus). Hippocrates believed that ailments and disease were caused by the wrong balance of the four humors; therefore, he sought medical treatments that restored the balance of humors to form the true mixture for human health. Naturalistic medicine had arrived in ancient Greece.

The result of this philosophical disagreement and the medical practices that it induced relegated supernaturalistic medical practice to the Asclepian temple, and Hippocratic practices to outside the temple (Sigerist, 1951). Thus, in Classical Greece, supernaturalistic medicine was practiced almost side by side with naturalistic medicine, following two very different world-views. We see reflections of this same tension today between homeopathic (or holistic) medicine practiced in a world-view dominated by modern scientific medicine, which developed from the naturalistic medicine on which homeopathic medicine is based. This similarity between ancient Greece and modern America of simultaneous practices arising from different world-views supports Solomon’s claim that …there is nothing new under the sun (Eccl. 1:9).

At this point, you may be wondering how all of this relates to the history of predictive analytics. The reason is related to the biggest problem with early Greek medicine, even in its naturalistic state – its fragmentation, the lack of standardization, and the cure of both. Many early Greek medical texts included much biological and medical information and described treatments for ailments and diseases, but they were scattered throughout the country in many different locations under the control of different physicians. Similarly, most medical treatment information today is scattered in the offices of individual physicians. The solution to the problem in ancient Greece (see below) followed that in Mesopotamia, and it pre-shadows the solution to the modern problem in the USA mandated by the Affordable Care Act (ACA) in 2010. This solution involved the collection and standardization of medical information, which became the basis for responsible medical practice in Classical Greece; it may become so in America. If it is true that those who ignore the mistakes of the past are bound to repeat them (actually a misquote of a work by George Santayana), then it is logical to expect that some solutions to present problems can be found in history. This is true of the history of Mesopotamia, and Greece. It came about in ancient Greece in the following manner.

There was a serious problem in Athens, one of the two dominant city-states in the 5th century BC (along with Sparta). The then current form of democracy generated serious inequities among the people, resulting an environment of strong social unrest. They elected Solon, a statesman and poet, as king, to restructure the early democracy of Athens to reduce these inequities, and bring a measure of civil peace to the city-states. At that time, repressive laws forced the poor into slavery to the rich. Solon designed an economic program called the seisachteia (shaking off of burdens) to release the lower classes from the burden of debt to those in the wealthy classes (Hammond, 1961). By canceling and reducing debts and abolishing a system of mortgage which had turned many poor landowners into virtual slaves, Solon significantly reduced the huge social and economic gap between the rich and the poor – the source of the social unrest. His concern to elevate the miserable state of the poor led Solon to decree that all medical texts be gathered together into one corpus, making them available to everyone, including the poor. This job was commissioned to the physician Hippocrates.

Hippocrates and Classical Greece

Hippocrates organized existing medical texts (and wrote some of them) in an attempt to integrate the previous philosophical concepts of Empedocles (the four elements), Philistion (the body is separate from the soul, and must be treated as such), and Diogenes (the soul, or the pneuma, is the vehicle of life; Wellmann, 1901) (see Figure 1.3). This group of documents included detailed discussions of brain, lungs, heart, liver, and blood, together with recommended treatments, and became known as the Hippocratic Corpus (about 400 BC). The corpus was composed of about 60 documents, and it represented the first widely distributed and integrated repository of medical information in the world that contained guides to diagnoses and treatments of ailments and diseases. A previous example of this sort of repository in the form of the Babylonian Sakikku documents written on clay tablets and stored in a royal library, was relatively inaccessible to common people.

Figure 1.3 Roman coin of the first century AD from the island of Cos (birthplace of Hippocrates) showing his bust as of about 377 BC. (see why this Roman coin is important in the discussion of Roman medicine below). Source - British Museum, Coins and Medals catalogue number: GC18p216.216.

Specific volumes of the Hippocratic Corpus were devoted to the four humors: black bile, yellow bile, phlegm, and blood. In this regard, Hippocrates followed the general approach of Empedocles, explaining medical illnesses as an imbalance between the four basic elements, but the elements in medicine were the four humors. Other volumes covered information and treatment regarding fractures, head wounds, gynecology, epidemics, obstetrics, ophthalmology, the heart, the veins, and bones. Hippocrates also used tools. He mentions using a rectal speculum (Figure 1.4) to observe a rectal fistula (Volume iii, p. 331).

Figure 1.4 Rectal specula of the type used by Hippocrates. Reproduced with permission from: www.hsl.virginia.edu/historical/artifacts/roman_surgical/

Particularly relevant to the history of predictive analytics is that this repository of knowledge and practices arose largely due to concern for the poor in Greece (as it did in Mesopotamia). We see a reflection of this concern today in the current controversy over access to health information and health care in America. Evidently, our concern today is not purely a modern phenomenon – its roots extend back to ancient Greece and even to the cradle of civilization in Mesopotamia.

Ancient Rome

By winning the Second Punic War in 201 with the victory over Hannibal of Carthage, Rome was transformed from a relatively loose confederacy into a permanent, expansionary war machine (Muhlberger, 1998; www.nipissingu.ca/department/history/muhlberger/2055/l33anc.htm). One result of this unification was a push to declare war on Macedon. Why do that? Rome was very busy with consolidation of its new territory in Gaul (Spain and France), and rebuilding Italy after devastation of the war with Hannibal. Two reasons were offered by Eckstein (1987): (1) Rome was just coming to the aid of one of its allies being attacked by King Philip V of Macedon (even though it appears that Rome’s emissaries engineered it); and (2) Rome had become a conscious imperialistic power in the Mediterranean world, and lusted for conquest of Greece. Muhlberger (1998) claims that these two theories tend to divide those who like the Romans from those who don’t.

For whatever reason, Greece was conquered in a short space of about 60 years, and the existing social structure of Greece crumbled and became largely Roman. Along with this transformation, much of Greek medical literature and art was pushed aside and ignored. This purge included the Hippocratic Corpus, because early Romans believed that divination was the way to cure illnesses. In other words, they were stuck on supernaturalistic medicine. Then, along came Claudius Galen.

Galen

Claudius Galen (AD 131–201) (Figure 1.5) was a Greek physician from Pergamum, who went to Rome, and then studied at the famous medical school in Alexandria, Egypt. He was trained in the medicine of Hippocrates, and he revived interest in the Hippocratic Corpus (Sigerist, 1951). He stressed clinical observation of patients, during which he examined patients very closely to make his diagnosis and prescribe what he thought was the appropriate treatment. In his practice, he accepted the Hippocratic view that disease was the result of an imbalance between the four humors, and developed treatments aimed at restoring the normal balance among these humors. Galen adopted many of the medical instruments described by Hippocrates. Figure 1.6 shows some bone levers that may have been used to lever fractured bone into place.

Figure 1.5 Bust of Galen. Reproduced with permission from the US Library of Congress.

Figure 1.6 Various bone levers in use at the time of Galen. Reproduced with permission from: www.hsl.virginia.edu/historical/artifacts/roman_surgical/

Jealousy by Galen’s rivals, and prejudice against Greeks among the Romans, caused him to flee Rome in AD 166, but he returned at the request of the Emperor Commodus. Because he served as the personal physician to Commodus, and later to Septimus Severus, he could work freely. The tide of imperial opinion turned so strongly back to Hippocrates and his work that a coin was minted with his portrait (see Figure 1.3); on the reverse side is shown the serpent entwined staff of Asclepius, which many centuries later was incorporated into the symbol of the American Medical Association and the logo of the World Health Organization. Mintage of this coin demonstrates the change in attitude of the Romans toward Greek medicine, fueled by Galen’s success under the imperial aegis. We can view this revival of interest in the Hippocratic Corpus as the fourth example of a royal mandate for the collection and dissemination of medical documents for the benefit of the people.

Galen continued to add to the Hippocratic Corpus by writing many books and treatises himself. He was affected greatly by prominent Greek philosophers, including Aristotle and Plato. He took aspects from each Greek school of thought and combined them with his original thinking. In this manner, Galen viewed medical practice as interdisciplinary. This attitude is seen clearly delineated in his book, The Best Physician is also a Philosopher. In this regard, Galen presaged the approach of modern scientists and thinkers, in which important ideas of many schools of thought are combined to help explain complex systems in the world (see Nisbet et al., 2009). The books that he collected and wrote were still being used in the Middle Ages and, for many medical students, they were the primary source of information on medicine, particularly in the Arab world (Swain, 1996).

The Roman poet Horace quipped that "Graecia capta ferum victorem cepit et artis intulit agresti Latio (Greece, the captive, took captive her savage conqueror and brought her arts into rustic Rome" – Horace, ca. 14 BC, Epistles 2.1.156–157). What did Horace mean by that statement? The most common interpretation is that even the Romans realized that while Rome vanquished Greece militarily, Greece captivated the great interest of rustic Romans in the arts and sciences, and in the process civilized her. It might be said that Greece was the cradle of Western civilization, and that Rome was simply the vehicle that brought it into all of Europe over the roads built by the Romans. One of the most influential men in that process was Galen the physician. It may not be an overstatement to say that Galen brought Rome (and hence all of Europe) out of supernaturalism and into naturalistic medicine almost single-handedly, and the direct effect of his work on the practice of medicine persisted until the 20th century AD. The spirit of Hippocrates lives on in the Hippocratic Oath taken by every physician before entering into practice in America.

Arabia

The development of Arabian medicine is closely related to the history of Islam. In 622, Mohammed united the warring tribes of Arabia through a common religious and social system (Shanks and Al-Kalai, 1984). Medicine of the early Islamic and Umayyad period (661–750) was largely supernaturalistic, which included three principal treatments: (1) administration of honey; (2) blood-letting through collection in a cup; and (3) cautery (sealing blood vessels with fire).

A rather curious sequence of events happened in the Eastern Orthodox Christian church, which brought Greek and Roman medicine into the Arab world and maintained it until the 16th century:

1. As Bishop of Constantinople, Nestorius denied that Mary was the Mother of God, and was excommunicated at the Council at Ephesus in 431. Nestorius died shortly thereafter, but his followers fled east and founded the Nestorian Church, several medical schools, and a Nestorian center at Nisibis in Arabia.

2. The Persians at Nisibis warmly embraced the schools and the Nestorian center, and King Chosroes I founded the university at Jundi Shapur, which combined Indian philosophy with the Greek medicine brought by the Nestorians in their school. This action can be considered as another example of collection of medical documents by royal decree, but the purpose was for education, not the provision of medical care to the poor.

3. With the defeat of Heraclius, Emperor of the Eastern Roman Empire, the Arabs expanded their empire under the Umayyad Caliphate. This became an age of reawakening of Greek arts and medicine, and ushered in a second golden age of Greek culture.

Even though (or maybe because) Nestorius was branded as a heretic by the Eastern Orthodox Church, Nestorians were accepted in the Arab world as a Christian sect. Several other Christian men and families were also instrumental in the vending of Greek medical arts to the Arab world. Eight generations of the Christian Syriac-speaking Bakhtishu’ family served as court physicians to the caliphs in Baghdad from about AD 770 to 1050 (Savage-Smith, 1994). These men were instrumental in translating Greek medical texts into Arabic. During this period, the Baghdad House of Wisdom (Bayt al-Hikmah) was founded to encourage the collection (in the form of a library) and translation of Greek works into Arabic. The most prodigious scholar in this library was Hunayn ibn Ishaq al-’Ibadi, another Syriac-speaking Christian, who translated almost all of the Greek medical works, half of Aristotle’s works, and even the Jewish Septuagint. Arabs of the Golden Age of Arab culture were not at all adverse to Jewish and Christians literature existing in their midst, and they appear to have even promoted translations of it. Ishaq also included 95 Syriac and 34 Arabic versions of Galen’s works. Figure 1.7 shows two pages of Ishaq’s Arabic translation of Galen’s introductory treatise on the skeletal system. Note that this book and other books up to the invention of the printing press were handwritten. Today, it is difficult for us to imagine the monumental impact of the printing press on the dissemination of knowledge throughout the world.

Figure 1.7 A very rare copy of Hunayn ibn Ishaq’s Arabic translation of Galen’s introductory treatise on the skeletal system, On Bones for Beginners, known in Latin as De ossibus ad tirones, NLM MS P26, open at folios 62b–63a, the beginning of the treatise. Reproduced with permission from the National Library of Medicine.

The importance of Arabian medicine lies not in its originality (which it does not have), but in that it was the vehicle that faithfully preserved the knowledge and arts of the Greeks by translating them into Arabic through Syriac versions. A major consequence of these translations is the preservation of the content of the Greek manuscripts. During the Renaissance, European scholars had no access to the original Greek texts, and so they translated the Arabic source into Latin, the European scholarly language of the day. The availability of the Hippocratic Corpus and other Greek medical documents in the Latin language made them readily available to Western scholars. It is interesting to note that this process was facilitated in the Arab world largely by Christians, who vended the preserved Greek medical and scientific works to Christian Europe, thus paving the way for the development of modern science and medicine.

Summary of Royal Decrees of Medical Documentation in Ancient Cultures

Because of the tension among individual medical treatment specialists in ancient cultures, and the lack of uniformity among them, many ancient rulers sought to codify, standardize, and disseminate medical information in the form of written records to aid in medical diagnosis and treatment for all people in their societies. Many of these official documents exist today, and together they form the context in which modern medical records developed. These standardized documents were mandated by past rulers, because they would not have been developed apart from official mandates (cf. the previous discussion of Kings Adad-apla-iddina and Ashurbanipal in Mesopotamia, King Solon in early Greece, Commodus Caesar in Rome, and King Chosroes I of Persia).

From this viewpoint, we can understand some of the force behind the laws of modern countries that enable the collection and standardization of medical records in one place (e.g., the National Health Service of the UK in 1948; and in the United States, the Medicare Act of 1965 and the Affordable Care Act (ACA) of 2010. In addition, this historical context might lead us to believe that further centralization and standardization of medical and healthcare information in the USA is inevitable. This shadow of this inevitability lies particularly heavy on many physicians in the USA today, who must convert their written medical records to digital format during the next several years (a provision of the ACA) or lose increasingly large proportions of their Medicare reimbursements. Some medical specialties (e.g., dermatology) require handwritten figures of the body to be included in physicians’ notes, documenting locations of skin problems. While these diagrams do not currently exist in electronic clinical data entry programs, they could be created by graphics routines that permit annotation of locations of past treatments – but these graphic routines may be slow in the development of software programs to implement digital record-keeping.

Due to the cost of digitizing and the initial lack of required software features available (i.e., graphics), some physicians will choose to delay document conversion and incur the cost of reduced Medicare reimbursements. Others who can do it will bite the bullet and do it as expeditiously as possible. But all practicing physicians will do it, eventually, as costs decline and the richness of software features increases. This conclusion is formed simply by the recognition that the realities of human nature and our need for medical care will interplay with the political and pragmatic realities in today’s society in ways similar to those that occurred in other societies in the past. Technology that controls how it is done changes over time; human nature and basic human needs do not.

One of the themes of this book is the need to maintain current levels of personalized medicine AND provide electronic health records (EHRs) for use in diagnosis and treatment by all physicians. Only in this way can we leverage the power of predictive analytics to guide diagnosis and treatment across the entire landscape of medical practice in America. Certainly, it will be traumatic to convert all physician written records to digital format, but is can, and indeed must, be done. That is the modern expression of the pattern we can see in history of rulers mandating the collection and standardization of medical records at many times in the past.

Despite significant differences between the Democratic and Republican agendas on domestic affairs in American politics, it is clear that it is the Democratic political force that is driving this conversion. It appears that the administrations of Lyndon B. Johnson (the Medicare Act) and Barack Obama (the ACA) are just following in the footsteps of many ancient rulers to standardize bodies of medical information and medical care, and make benefits based on them available to all citizens.

Effects of the Middle Ages on Medical Documentation

Between the fall of Rome (in 476, according to Gibbon, 1906) and the Renaissance (beginning in the 14th century), the development of medical knowledge came to a halt and was kept alive primarily in Arabia. In Europe, much of the knowledge of the Greeks and Romans was lost. The reason appears to be that Europeans (and particularly the early Britons) despised Rome, and destroyed or covered up anything pertaining to Rome – even Greek culture and knowledge promoted by Rome after Commodus. This disparagement and destruction of all things Roman after the fall of Rome paralleled the destruction by early Romans of all things of Greece after its conquest. Only in the Arab world were Greek and Roman medical documents preserved (see above). This situation prevailed for almost 1,000 years, up to the Renaissance.

Rebirth of Interest in Medical Documentation During the Renaissance

The Renaissance was marked by two pivotal events that served to begin the breakdown of the stasis and the mindset controlled by the thinking of the Middle Ages: (1) the printing press, and (2) the Reformation (Eisenstein, 1991).

The Printing Press

The use of movable type was invented in China in 1048, but the concept of movable type did not surface in Europe until Gutenberg combined that concept with the screw press (Figure 1.8). This kind of press was used previously for wine and olive pressing, but Gutenberg was the first to adapt that technology to printing.

Figure 1.8 Johannes Gutenberg and his printing press. Reproduced with permission from: Michael Halbert, Inkart.com.

Thomas Carlyle (1836) quipped in his novel, Sartor Resartus, that He who first shortened the labor of copyists by device of movable types was disbanding hired armies, and cashiering most kings and senates, and creating a whole new democratic world: he had invented the art of printing.

The effect of growing prosperity in the 15th century promoted the rise of literacy. Combined with the spread of Renaissance thinking, increased literacy moved many people to want to read. The invention of the printing press by Gutenberg in 1440 permitted the dissemination of new ideas quickly and accurately in written form, and permitted this expanding body of readers the opportunity to learn and adopt new ideas of the Renaissance.

The Protestant Reformation

The breakdown of the absolute control of religious and philosophical thinking in Europe by Luther and Calvin led to the introduction of new ideas into society. Luther and Calvin returned the Church to the primacy of the Bible. All doctrines of the Catholic Church were rejected unless sanctioned directly by the Bible, and the purity of the Bible was based on Arab translations of the Greek Texts, retranslated back into Greek. This awakening of interest in the Greek language prompted a parallel response in medical science (Porter, 1997).

The combination of the printing press, the consequent rapid spread of Renaissance thinking, and new ideas fueled by the Reformation generated a social climate that encouraged an increasing body of scientific and medical inquiry. Erasmus (1466–1536) drew upon both of these pivotal events to lead Europe back to the Greek medical works of Hippocrates and Galen.

Erasmus

Erasmus was a former monk who left his monastery to lead European scholarship for more than three decades, and established Greek as the standard for literary and theological studies (Porter, 1997). He translated the Arabian versions to produce the first modern Greek edition of the Hippocratic Corpus of books in 1525. The Reformation, dawning at the same time, spurred Erasmus to throw off the constraints of the Church that taught men to avoid invading the sanctity of the human body in the study of anatomy. The huge success of the reintroduction of Galen’s medical works fueled Renaissance natural philosophers to become more inquisitive about human bodies. Thus, the stage was set by the availability of the printing press, and the loosened ties to the Church, for Erasmus to turn inquisitive minds towards a renewed interest in human anatomy.

Human Anatomy

The recovered Greek Texts supported the idea that ancient medicine was the right approach, and that scholars were the rightful guardians and interpreters of it (Porter, 1997).

Andreas Vesalius (1514–1564)

Vesalius was a Flemish anatomist who dissected the bodies of executed prisoners (human vivisection was still taboo at that time). He wrote many books on anatomy, including De humani corporis fabrica (On the fabric of the human body; see Figure 1.9). Despite his respect for ancient Greek medicine, his detailed drawings helped to correct some misconceptions of Galen and the Greek physicians, who dissected only animal bodies (Porter, 1997).

Figure 1.9