taylor@hplabsc.UUCP (06/20/86)
Computers and Society Digest, Number 7
Friday, December 20th 1985
Topics of discussion in this issue...
The NLS System
The problems of on-line pharmacutical datasystems
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Date: 17 Dec 85 14:36 EST
From: David Potter - McDonnell Douglas <hplabs!DAP.TYM@OFFICE-1>
Subject: The NLS System
Your passing reference in this forum to Doug Engelbart's NLS system prompts me
to wonder if you're aware that NLS still lives? It's currently called AUGMENT,
and is marketed by the Augmentation Systems Division of McDonnell Douglas, of
which I am a member -- our group is the direct descendant of the SRI group
(some of us date back to those days), and Doug himself is still working with us
within MDC.
In fact, this message comes to you from AUGMENT. Which is STILL one helluva
system.
Just thought you might be interested if you didn't know -- lots of folks don't.
Regards -- David
p.s. Usual netland disclaimers do NOT apply. Any opinions expressed herein are
my own, and I am an interested party, my salary being paid by MDC for my work
with AUGMENT.
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Date: Thu, 19 Dec 85 15:51:20 MST
From: hpcnou!dat (Dave Taylor)
Subject: The problems of on-line pharmacutical datasystems
Some interesting philosophical issues have arisen in the current
Risks-Forum discussion that is also of interest to people reading
the Computers and Society group.
First off, the discussion (sorry about the length, but I didn't
feel right digesting it too much);
[ excerpt from Risks Forum 1.29 ]
From: Dave Platt <Dave-Platt%LADC@CISL-SERVICE-MULTICS>
To: Risks Forum
Subject: Risks re computer-compared prescriptions
Recently, an increasing number of pharmacies have been putting greater
amounts of drug information "on line". As I understand it, they will keep
track of all of a particular customer's prescriptions, and will alert the
pharmacist if they should be asked to fill a prescription that conflicts
with any other medication that the customer is taking. The rationale is, I
believe, that if a person is receiving prescriptions from two different
doctors (different specialists, perhaps), then neither of the doctors would
necessarily be aware of the drugs that the other had prescribed, or of any
possible unfortunate interactions between the drugs. Normally, I assume
that the pharmacist would inform the consumer and contact the prescribing
doctor for further instructions.
Several concerns come to mind:
- Where is the database of drug conflicts derived from? Manufacturers'
data files? FDA reports? Articles in recent medical journals? Just
how complete is it?
- Does the database cover only drug-to-drug interactions, or is it more
complete? Might it, for example, contain counter-indication information
for specific drugs (e.g., don't take this if you're pregnant)? How about
reports of unusual symptoms or side effects?
- How "intelligent" (sorry!) is the logic that compares a new prescription
with a person's medical/drug history? Is there any AI/expert-system
capability, or is it simply a look-up-a-list-of-conflicts? Might the
code be capable of, for example, warning a person who's receiving
medication for asthma not to take doses of a specific brand of antibiotic
because that particular brand is preserved with a sulphite compound that
has been reported to trigger asthma attacks in sensitive individuals?
- If a pharmacy advertises their new drug-checking software (and some do
mention it in their ads), are they assuming any degree of responsibility
or liability for either (a) false "conflict exists" warnings that cause
a consumer not to take a necessary drug prescribed for them, or (b)
any failure to alert a customer to a conflict that does exist?
- Will doctors, pharmacists, and/or consumers begin to depend on the
correct functioning systems such as this, at the expense of studying
the issues involved themselves?
This system is one step further away from the doctor and closer to the
consumer; there might be a greater tendency for people to "take it at
its word" rather than simply using it as a tool.
[ Next, an excerpt from Risks Forum 1.30 ]
From: Richard Lamson <RSL@SCRC-STONY-BROOK>
Subject: Risks re computer-compared prescriptions
- Where is the database of drug conflicts derived from? Manufacturers'
data files? FDA reports? Articles in recent medical journals? Just
how complete is it?
That's a very good question. It turns out that the database on drug
interactions is very sparse, even for the simple case of two different
drugs. There are a lot of common combinations which have never been
adequately tested.
- Does the database cover only drug-to-drug interactions, or is it more
complete? Might it, for example, contain counter-indication information
for specific drugs (e.g., don't take this if you're pregnant)? How
about reports of unusual symptoms or side effects?
Again, this database is also very sparse. Many drugs these days carry
the warning that they haven't been tested in pregnant women, and
therefore the physician should think twice (or more) before prescribing
them to pregnant women (or those of "childbearing age", in many cases).
One of the reasons drugs have not been adequately tested during
pregnancy is that manufacturers are frightened of testing them in
pregnant women, and, in fact, many drugs are not tested in "childbearing
age" women at all, just in case they might be or become pregnant during
the study!
[ Finally, an exerpt from Risks Forum 1.31 ]
From: "Elizabeth Willey" <ELIZABETH%MIT-OZ@MIT-MC.ARPA>
Subject: Pharmacy systems
About the pharmacy systems: people are essentially lazy. They will
certainly become dependent on a computer program that tells them conflicts
and stop noticing the conflicts themselves! Unless you formatted the program
as a teacher, too: PHARMACIST, TWO OF THIS PATIENT'S CURRENTLY PRESCRIBED
MEDICATIONS WILL REACT BADLY WITH THE NEW PRESCRIPTION. CAN YOU TELL ME
WHICH ONES?
[Added by the Risks Forum Moderator:
"Sorry. I did not know the answer, but I did not want to admit it
<because I understand that some crusader like Ralph Nader has
Trojan-horsed your program and is surveying how many pharmacists
don't know the answers>. Unfortunately, the patient died
yesterday of side-effects."
(Prototypical pharmacist's reply)
]
From: Brint Cooper <abc@BRL.ARPA>
Subject: Re: Risks re computer-compared prescriptions
Risks of putting prescriptions "on-line" must be compared to the risks
of NOT putting them on-line;i.e., to the risks of doing things as they
now are done. It is tempting to compare them to the risks of doing
things as we wish they were done, but this is unrealistic.
Now let's consider Dave Platt's well-founded concerns, keeping in mind
that it is ALREADY the responsibility of the pharmacist to protect the
patient/consumer from harmful drug interactions and the like:
The database of drug conflicts comes from wherever it now comes
from. Package inserts (or the PDR) contain some of this information;
this is mandated by law. Even if the automated database is less
complete than the present human-maintained database, an automated system
is much more likely to consult every relevant item. A human can forget!
Information beyond drug-drug interactions should be included if this
is within the responsibility of the pharmacist. Otherwise, it should not be
unless the medical and pharmaceutical professions consciously decide
otherwise. Programmers should not redefine the practice of the professions
of others.
Clearly, the first step is a non-intelligent database system.
The example of an asthmatic taking another med containing sulphites
should be covered by the database on medicine-medicine interactions.
Regarding degrees of responsibility, if the sources of
information in the database are the same as at present, and if the
pharmacist is using the database as a "decision aid," then I don't see
how anyone's responsibility has been changed by a change in
recordkeeping systems.
> - Will doctors, pharmacists, and/or consumers begin to depend
> on the correct functioning systems such as this, at the expense of
> studying the issues involved themselves?
My problem with this question is that it assumes that doctors,
pharmacists, and consumers presently study the issues involved. To the
extent that an automated system provides a professional with free time,
it will enable him/her to spend more time studying. But an automated
system is not necessarily good or bad for anyone's habits!
Sure! People may come to rely on an automated Physician's Desk
Reference (tm), but many people take their pharmacist's word as gospel
right now. And too many pharmacists spend so much time as business
managers selling cosmetics, stationary, motor oil, jewelry, books, and
flowers that their "expertise" is anything but. At least a
well-functioning database doesn't "forget" what it has learned.
Brint
[ end of excerpts! ]
I think that the interesting issues include:
1 Are we again falling into the Computer Omniscience pitfall?
Are on-line databases really ever going to be good enough that
we'd really rely on them for our health, and indeed, our very
lives?
2 This seems like it opens up a whole new avenue of exploration
for violations of privacy - employers will be able to query
the (inevitable) centralized pharmacutical database to find
out what drugs their employees are on and consequently what
diseases and problems the employees have (like taking Methadone
to try to kick a Heroin addiction...) (probably a more reason-
able scenario would actually be for a government agency (friendly
or otherwise) to do it). The question arising is - What IS
legitimitely private and what should be accessable by agencies
with a 'need-to-know'?? (and who decides if the 'need to know'
is valid???)
3 It seems we're moving back to the classed society bit again,
too - those that have access to the information and those
that don't...are we elevating pharmacists to being more
than they currently are? (For example a pharmacist with a
computerized system could tell someone that "Oh! Your husband
is taking <drug-name> for venereal disease...you did know that
didn't you??" and so on...(information is a valuable commodity,
even in seemingly innocuous situations)
4 What of the responsibility issues, too? As people who work on
and create new computer systems we are responsible for the
correct functioning of our systems, like it or not. With a
system like this what happens if the program is slightly wrong
and it will report two drugs as being compatible when in fact
they're absolutely deadly together...??
5 The issue of Doctors and Pharmacists becoming dependant on the
system to the point of atrophying their own skills is an interesting
problem also. What exactly is the delimiting point where the
computer becomes knowledgeable enough that we can legitimately
begin to depend on it for this sort of information without any
inherent dangers?? Just how far are we willing to go???
6 Finally, what of peoples reactions to this?? Are people going
to accept without a murmer having their pharmacutical records
"on-line"? What about after the inevitable 'teenage whiz kid'
breaks in and messes it all up?
There are many more issues, needless to say!
I encourage people to comment on this and to start a full-fledged
discussion of the issues involved.
-- Dave "I don't take drugs" Taylor
The Moderator
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