David Zakim’s Medical Revolution

As medical knowledge expanded in the 20th century, medical practice became based on a false premise -- that the physician could somehow keep in his head everything he needed to know in the treatment of his patients. This issue provides an in depth look at the work of David Zakim who remarkably in his  retirement ten years ago began the daunting task of using digital technology to organize and make accessible medical knowledge.  In two lengthy interviews done earlier this year we show how Dr Zakim is using a uniform patient complaint form to take patient history and compile what will become massive databases of patient histories starting with the five most common chronic illness of adults in western societies.  The first clinical trials of the software are beginning in the summer of 2010 in Stuttgart Germany.

The computerized questionnaire uses a decision tree format to guide the patient and physician through medically accepted choices.  Intake is done over the web and the physician will have the basic history and complaint in front of him when the patient enters for consultation.  Eventually massive databases will be gathered which over time will provide clinically valuable records of outcomes.

Dr Zakim is making his software open and public accessible placing all intellectual property in the ownership of his institute for digital medicine to ensure that no single company can claim ownership by attempting to privatize the results,

Before turning to the interview, readers may continue with our much more detailed summary of his work on page 45.  There we place what he is doing in the context of Dr Larry Weeds pioneering expert system work of a generation earlier.

Symposium Discussion

Changes in Internet Architecture  pp. 52-60

Bill St Arnaud posted a paper in Feb 2010 that describes the rise of application content infrastructure.  During the past decade as  the incumbents buttressed their control over the last mile providers of content and applications took advantage of decreases in bandwidth cost to  build their own backbone and push their service towards the edge of the network.  s the incumbents consolidated their stranglehold over the edge, the importance of the connective backbones diminished as service of all kinds built their mesh in the middle.  

St Arnauds points about the ability to push content and service from exchange points and the need forced by the intransigence of the duopoly to me everything as close to the last mile as possible, emphasizes the change in the net away from email and web to all forms of content delivery and cloud computing kinds of applications. 

we summarize some of Van Jacobson’s architectural thinking that underlies these changes and we point out that when the providers are allowed to keep their infrastructure confidential  and proprietary that sound policy making becomes impossible.

FCC’s Title II “lite” Disgrace pp. 61-76

Finally we present a detailed tour of the FCC’s equivocation in the face of its visionless broadband plan.

In looking at what Genachowski has done…. reclassify as Title II but then apologetically saying don’t worry we will be “lite”, we see the significance in Yves Smith’s explanation of financial regulatory failure: “Paradigm breakdown, meaning the elements of the current system are no longer viable, but that is a possibility that no one is prepared to face since the old system seemed to work well for a protracted period. Thus the authorities reflexively put duct tape on the machinery rather than hazard a teardown.”

Fred Goldstein well captured the absurd convolution: “The "Internet" component of a service will not be regulated based on Title I ancillary jurisdiction, but the transmission component is regulated under Title II only to the extent that it provides the nexus to apply Title I ancillary jurisdiction to the Internet component carried atop it.  No other rights are conferred.  But now USF can apply (Section 254), both to tax ISP's and to give subsidies to rural ILECs for providing data services on a non-common-carrier basis.  Verizon and Comcast can pay; CenturyTel and Sandwich Isles can collect.

Most explicitly, Counsel states that the Computer II rules are *not* being reinstated.  ISP's thus do NOT gain access to telco wires.  So you don't gain a choice of ISP's.  It's still a choice of one ISP per wire.  The telcos keep the wires for themselves, and while they must provide "nondiscriminatory" service at "just and reasonable" rates (i.e., sections 201-202), these protections only apply to the transmission services that they ONLY provide TO THEMSELVES.  So they can still screw everyone else, but not themselves.  I'm sure we can all feel good about that.

And the FCC can't regulate Internet content, but the bit-level telecommunications component (the one transmitted without regard for content) can probably be regulated so as to ensure that it looks like what somebody thinks the Internet should look like.  But it's not the Internet; it's the transmission of bits to and from the Internet that must only be provided in a way that the Internet itself is managed the way the FCC wants it to.”



How Dr. David Zakim Is Developing His Clinical Expert Operating System


Editor’s Introduction                                        p. 5

Why Computers Are Necessary to Economically

Sustainable and High Quality Medical Practice                    p. 6

Medicine and Science: Two Different Cultures                    p. 8

How Do You Manage the Knowledge Base?                        p. 10

Investment via a Foundation of Social Conscience                p. 13

An Expert System to Address the Chronic Illnesses of Adults        p. 16

Building Decision Trees for Collection of Patient History            p. 18

Large Databases Likely Will Offer the Key

to What Should be Measured                                p. 21

Goals for the Next Five Years                                p. 24


Part 2 April 2, 2010

We Are Trying to Show What Can Actually Be Done            p.27


The Platform Emulates Thinking of Panels of Experts Viewing the Patient  as a Living Complex System                p. 30

The Structure of the Knowledge System                        p. 32

Strategy by Which to Seed and Grow the Idea                    p. 33

Role of the “Live” Physician                                p. 35

Whither the Physician?                                    P. 36

Trials of CLEOS in Germany in 2010                            p. 37




Underutilization of information and knowledge in everyday medical practice: Evaluation of a computer-based solution       p. 40

Executive Summary

The Progress of the Medical Record from a Mainframe Hierarchy to Decentralized, Edge-Based Intelligence

Larry Weed and the Coupler - The Path from Promis to the Personal Computer and  Increasing Decentralization                p. 45

How to Structure and Formalize the Knowledge Base in a Pre Internet Era                                         p. 46

David Zakim and the Transition to CLEOS as a Next Generation Internet Knowledge Commons Based System        p. 48

Afterward                                                p. 51


Symposium Discussion April May 2010

The New Internet Architecture:  Cloud and Content

Providers Versus the Incumbent’s Last Mile              p. 53


An Abbreviated Summary of Bill St Arnaud’s Architecture Paper        p 54

How ACIs Benefit the Rest of the Internet Ecosystem                p. 56

ACI,  Network Neutrality Challenges, and Last Mile Networks        p. 57

Some State Level Regulatory Implications                        p. 58

Conclusion                                                 p. 59

Postscript                                                p. 60

Putting Duct Tape on Telecom Regulation The Obama FCC

Speaks its Mind                      p. 61

How Does this Translate 18 months after Obama?                p. 62

The Unbearable Lightness of Being or Title II ‘lite‘                p. 64


Executive Summary                                 p. 77