Assembling the Black Box of Healthcare in India
By Sandhya Mishra
One of the more recent and famous metaphors that I’ve come across is the parallels of safety in Aviation and Healthcare. From once being infamously called a deathbed with many flights ending in disaster to becoming one of the most secured forms of travel, Airlines today have become a touchstone for safety practices for the rest of the industries.
The embedded airline culture encourages to be open and honest about mistakes. It is about creating systems and cultures that enable organizations to learn from errors, rather than being threatened by them, says Mathew Syed in his famous book.
Though many healthcare experts call it a dubious analogy that claims to oversimplify a complex problem of healthcare, many others have already taken this metaphor a step further. A growing number of healthcare institutions have hired professional pilots as aviation consultants to train their staff on how to apply aviation safety principles to their work. However, the enthusiast didn’t stop here, the story is about how black box concept of aviation got emulated in healthcare.
What is black box?
Mr Paresh Lokwani, Aviation Pilot with one of the leading Indian Airlines, says “Black Box also known as the ‘Flight Data Recorder, is an instrument which records all the activities of the airplane during its flight. It can withstand shock and temperature as high as 11000°C, is traceable for 30 days after an accident and its beep can be traced by the investigators from a distance as far as about 2-3 Kilometers.
In today’s world, Digital Flight recorder plays an important role. Airlines monitor data of all the flights and limits are set depending on manufacturer as well as airline. If any limit exceeds then the pilots are informed and subsequent actions are taken depending upon severity. Also trend can be monitored so that training can be planned accordingly to stop such outpace and safety is improved.”
Mr Paresh Lokwani, Aviation Pilot
He shares an example where data from black box suggested a design modification of aircraft to accelerate the safety, he says, “After B737 Max crash of Lion Air, investigators analyzed the black box data to know the last crucial information regarding airplane as well as final conversation in cockpit before accident & thereby recommended modifications of the conceived flawed design of the aircraft with some adaptation in training of Pilots, all these are awaiting rigorous flight test and re-certification of Aircraft to be back to flying.”
Black Box concept in Healthcare
Industries with a perceived higher risk, such as the aviation and nuclear industries, have a much better safety record than health-care. This can be reckoned with the fresh stats of 2019 that say the fatal accident rate for large commercial flights is 0.18 per million flights vis-a-vis more than 3000 death per million patients due to a preventable medical accident. This is equivalent to two jumbo jets falling out of the sky every 24-hours.
The Black Box medicine works in a similar fashion in terms of improving safety of patients. The artificial intelligence software ‘learns’ from the massive healthcare data it is made to ingest. The black box then help these data get a life by making sense out of it and ‘teaching’ health practitioners to adapt to best practices or treatment to yield best outcomes.
The black box concept in healthcare is a budding area that aims to cover the entire pathway of patient, right from admission to post-operative care to recovery at home. Any data that’s of operational importance will be visualised by the black box and presented to the management. The Black Box will analyse the data throughout the care pathway and determine the efficacy of different medical procedures on certain types of patients. Here, the role played by AI is very crucial in monitoring the medical procedures in real time and predict the possible outcomes in case there is a mistake at any step and how to proceed further with best possible solution.
Ethical or Legal Challenges
Aditya Mishra, Practicing Lawyer at Bombay High Court, says, “Machine learning do have the capacity to perceive knowledge, make sense of all the data that is fed into it, generate predictions or decisions. However, there are worries around that AI has no standard ways to communicate how it’-s tool are working to arrive at decisions (and hence the term ‘Black Box’). Even if you have AI Robot in place, doctors still have primary responsibility to prescribe and make final clinical decision. With several entities working together, any wrong diagnosis, wrong treatment or poor treatment outcome, could give rise to a systemic hitch. The question is, who will be held accountable or liable? The doctor, developer or opaque AI robot?
Then there are privacy/security concerns over the data amassed to feed robot, which could be subjected to personal discrimination towards patient or malevolent competitive advantage by companies. Though anonymization of data can address some concerns, reverse tracking is still possible. This also has the potential for discrimination by Health Insurers in terms of health coverage or denial of insurance to those with known health risks or genetic predispositions.
Aditya Mishra, Practicing Lawyer at Bombay High Court
As on date, India does not have any legal framework in place for data protection but soon, we may expect one considering the recent PDP Bill tabled in Parliament on Dec 2019.
The development of Black Box medicine will require significant incentives beyond what is offered by the healthcare. The creative firms tend to underinvest in information goods which is ‘non-excludable’ because they cannot fully appropriate their value. The Section 3(k) in The Patents Act, 1970 exempts algorithms from being patented. Having the right intellectual property regime in place can encourage innovation.”
How to implement it?
Surgical black box, an original version of black box in healthcare, synchronizes a patient’s physical data with video and audio recordings of an operation. Over the years, there has been a rising adoption of surgical black box especially overseas. When asked about its implementation in India, Dr Vivek Desai, Founder and Managing Director of Hosmac, says, “The black box medicine is unprecedented in Indian healthcare. Our hospitals do not even videotape the surgeries done in OT except for few who does it for their own internal quality control measure.”
Dr Vivek Desai, Founder and Managing Director of Hosmac India Pvt. Ltd.
He is a strong advocate of recording surgeries. He says it is the best approach to enable doctors watch their performance and improve it. Dr Desai’s statement is strongly backed by a study which confirms that many error-event go unnoticed by surgical team while operating the case only to be identified later when reviewed.
Dr Desai says, “When there are video surveillances in and around the hospital working round the clock, I don’t see a reason why operation theatres not have one? There are OT light available pre-installed with cameras fully capable of capturing the procedure. Besides, as a patient, I have the right to know what has been done on me.”
“A statute or legislation that makes cameras mandatory in OT, probably can make the surgical black box gain popularity in India in future. Further, it will be consumer and insurance driven,” he concludes.