| Date post: | 14-Dec-2014 |
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Health & Medicine |
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Evidence Farming1: Implications for Open
ArchitectureIda Sim, MD, PhD
Director, Center for Clinical and Translational Informatics
University of California San FranciscoMay 5, 2011
1With thanks to Rich Kravitz MD, UC Davis and Naihua Duan, Columbia
Rephrasing “Does it Work?”
(Complexes of) Exposures
Outcomestrength of association?
individual
population
Increased breastfeedingText4Baby
Current Approaches: RCT
• Tests prespecified interventions and outcomes• To confirm a hypothesis at the population level• Strong internal validity• Problems: slow to set-up, expensive, short-
term, lack relevance to the real world
ER visits at 1 year
50 people population
100 people
ER visits at 1 year
50 people
Asthma App
Usual Care
Exposures Outcomes?
population
Current Approaches: Data Mining
• Exposures and outcomes from care process systems
• To generate hypotheses at the population level • Problems: limited to data collected, weak internal
validity (data not complete or systematic)
EHR
AppsDec 13, 2009
Guilt
Child care
Worst after school drop-off
AT&T
Current Approaches: N-of-1 Studies
• Within-subject multiple crossover• Only formal method for determining
individual treatment effectiveness• Problems: complicated to set up, analysis
is difficult, little known, not widely used
individual
peak flowpeak flow
Usual Care
Asthma app
Asthma app
Usual Care
Asthma app
Usual Care
Evidence Extraction
• Evidence is something to be extracted from the care process– mining it from the data– directly manipulating the care
process with rigid and pre-defined protocols
Evidence Strip Mining
Evidence Farming
Hay, et al. J Eval Clin Prac 14(2008):707-713.
Rooting for Evidence
Exposures Outcomes?
Industrial Evidence Farming
ER visits at 1 year
50 people population
100 people
ER visits at 1 year
50 people
Asthma App
Usual Care
Personal Evidence Gardens
individual
peak flowpeak flow
Usual Care
Asthma app
Asthma app
Usual Care
Asthma app
Usual Care
Personal Evidence Gardens
individual
dancing
Flovent PRN
Flovent
Flovent
Flovent PRN
Flovent
Flovent PRN
dancing
Crowdsourcing What Matters
• (Complexes of) Exposures– does chocolate trigger (my) asthma?– testing common regimens (ACEI, statin, b-
blocker), complementary medicines
• (Complexes of) Outcomes– what outcomes do patients care about?
Evidence MacrosystemRooting for Evidence
Industrial Evidence Farming
Personal Evidence Gardens
Exposures Outcomes?
individual
dance
Flovent PRN
Flovent
Flovent
Flovent PRN
Flovent
Flovent PRN
dance
ER visits at 1 year
50 people population
100 people
ER visits at 1 year
50 people
Asthma App
Usual Care
How can we scale evaluation?
Stovepiped mHealth
• Health apps built independently– little data sharing
and interoperability
• Limits efficiency and impact of quality mHealth
Internet Hourglass Model
• Standardize and make open the “narrow waist”
• Reduces duplication, spurs community innovation, supports commercial and non-profit uses
OpenmHealth.org
Estrin DE, Sim I. Science; 330: 759-60. 2010.
• The waist should support the evidence macrosystem
OpenmHealth.org
Open Architecture for an Evidence Macrosystem
• Modules for usage analytics– # of text messages, # of sessions, etc.
• Rooting for (glocal) evidence– data sharing with shared syntax and semantics
• Industrial farming, e.g., with RCTs– modules for informed consent, randomization,
adaptive treatment strategy, mixed methods, etc.
• Personal evidence gardening, e.g., N-of-1– modules for scripting and analyzing
individualized N-of-1 protocols, etc.
Open Architecture for an Evidence Macrosystem
• Social media for discovery of exposures and outcomes that matter
• Shared libraries of validated measures and instruments (e.g., PROMIS) – measures that get at finer-grained
mechanisms based on theoretical models of change, etc.
QuickTime™ and a decompressor
are needed to see this picture.
Goal for mHealth Evidence
• A learning community coupled with an open architecture for broad, rapid, and iterative dissemination of evaluation methods and findings that matter
