INVESTIGATING POSSIBILITIES AND PROBABILITIES OF BIOMEDICAL INFORMATICS (BMI): BEYOND BIOLOGY AND INFORMATION by Rodney W. Sappington A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland April 2014 © 2014 Rodney W. Sappington All Rights Reserved Abstract My work focuses on how medicalized minds and bodies are refashioned through the concepts and technologies of Biomedical Informatics (BMI). I attempt to make visible objects of informatics that mark the human as a digital machine operating among and within computerized agencies, artificial intelligence, and what has been termed Big Data correlation. Specifically, the anthropological puzzle that I investigate focuses on the BMI imagination and its implicit and implemented effects upon doctors as operators, patients as sites, and informaticians as technicians of “new” medicine in a world of expanding computerized data that shifts and refashions the human care encounter. I argue that the contemporary of BMI has a far wider organizing effect upon healthcare and medicalized bodies than previous aspirations based on computer technology as mere tools in medicine. Through a rapid development and deployment of intelligent databases and computerized networks, BMI is currently restructuring modes of clinical care. As a set of scientific practices, it is reconstituting earlier medical informatics of the 1970s, 1980’s, 1990’s and pushing these modes of care in different directions. Such restructurings come in contact with non-human operations of medico-scientific systems of knowledge and through programmable expressions that impinge upon doctors’ deliberations through everyday encounters with patients. I approach these puzzles and clinical experiences through the figure of an informatics body that frames emergent arrangements of computerized algorithms, organization, disease, genomics, and therapeutic order. As an informatics body, the human falls under questions embedded in this deeper convergence of medical digitalization. Complex computerizations and algorithmic forms that are designed to bring clinical improvement are giving rise to ii unanticipated effects that are refashioning the body of the patient and the mind of the physician in ways that have been under-examined. In futures of biomedicine that I investigate, an informatics-based medicine, the figure of the human in the continuum of care is constantly being reengineered and redeployed. Throughout my investigation I ask what acts, human and non-human, possess the possibility of therapeutic improvement and can bring other things to life that do not originate in current therapeutic order? I suggest that systems of machine agency that are targeting and monitoring for disease and health are reconstituting who and what has access to care, as well as access to decision agency among intelligent and computerized care data. iii Acknowledgements For my mother and father, with abiding love and respect, as you have taught me to journey into worlds seen and unseen And to my wife Laima and my daughter Kaia, who have taught me to always embrace love with awareness and light This dissertation could not have been possible without the emotional and intellectual encouragement of many people. My friends and colleagues at the Johns Hopkins University Department of Anthropology were always a standard against which I measured my insights and hopes for a kind of anthropology that could enter the technical areas of Biomedical Informatics. I specifically wish to thank Professor Veena Das, Chair of my dissertation committee, for instructing me at key times in the development of my research. I have been very fortunate to have her as mentor, providing abiding support and encouragement over the time I have known her from my days at the New School for Social Research and later at Johns Hopkins. Over the years, Dr. Das has consistently showed me that examining new medical technologies reveals some of the most pressing societal and human challenges that anthropology faces today. Professor Jane Guyer always opened her office and her ideas to me. She was creatively engaged in my research progress and ideas as they developed towards the new potentials of computerized data in biomedicine. Professor Aaron Goodfellow has provided me with a level of insight and editorial questioning that comes very seldom and has both improved my work and clarified my thinking. I was very fortunate to have remarkable physicians, clinicians, business leaders, and experts in the field of BMI who have been generously insightful and giving of their time. iv Without them I would have had very little perspective regarding the deeper effects and affective dimension of computerization and Big Data upon healthcare. My family in Lithuania and godchild Kasparas have all been that unique source of perspective that I hope always reminds me that when I am puzzled by the “machine” in everyday life, I am reminded to reach out and care for others. My deep gratitude goes to Laima Serksnyte, who constantly offered me her scholarship, reminding me always to ask how I may contribute to and stay grounded in the human while I may venture-off in search of non-human horizons of biomedicine and care. v Table of Contents Introduction: Anthropological Encounters with Biomedical Informatics (BMI) ............................1 Conceptions of information and BMI Biopower: why BMI exceeds biopolitics Anthropology and Informatics Dissertation Structure My Ethnographic Direction: Setting-out to Encounter BMI Anthropological Contributions to the Investigation of BMI I. Emergence of The Science and Practice of Contemporary of Biomedical Informatics: A Review of Foundational Debates in JAMIA ...................................................................................19 Contemporary of Biomedical Informatics (BMI): Ethnography of JAMIA Origins and Qualities of Emergence in Biomedical Informatics The Concept of “Emergence” Origins of Computational Reason – An Attempt at a Cohesive Scientific Discipline What is a Problem in BMI – Problem-Solutions Scenarios of “Use” and Information Infrastructure Where Is the Science? Majesty of the Empirical: Shifts to accommodate a new mode of science Artificial Intelligence Notions of Failure and Error in Biomedical Informatics Temporalities of Error and Failure in Clinical Computational Reasoning The Becoming Patient Conclusion: What kind of BMI Future is Being Imagined through the Figure of Doctor and Patient? II. Savage Mind In The Modern: Culture, Cybernetics, and Information Theory .........................60 Introduction: Lévi-Strauss and Geertz debate on Mind Geertz: An onslaught of incommersurabilities Turning to Lévi-Strauss: La Pensee Sauvage, Scientific Objectivity and Colonialism Idea of Mind as Reflexive Site of the Modern: Cultural Modernism, “Entropology” and Colonialism Entropology: problems of mind and colonialism Notes on the Early Influence of Artificial Intelligence and Cybernetics Cybernetics: Lively systems and technical potentialities Conclusion: Homo sapiens and Cybernetic Brain III. Medical Reasoning and The Machines of Data: Contemporary and Historical Antecedents Deepening Anthropological Encounters ........................................................................................92 Introduction: Opening Anthropology to Informatics Objects and Origins Computers “in” Medicine: Promises and Boundaries of Biomedical Problems Effects of implementation: Ethnographic examples Organizing Potentialities of BMI: Informatics in Relation to Big Data Big Data Correlation vi William Osler’s Aequanimitas Mind: Possibilities and Actualities of Medical Reasoning of the Physician in 20th Century Scientific Medicine Conclusion: Cartesianism and Mathematical Conceptions of an Informatics Body The Divine Machine: The Calculable and Vital Medicalized Body IV. Case Study of Biomedical Informatics Objects: Concepts, Implementations, and Aspirations ...................................................................................................................................125 Introduction to Ethnography of BMI–Overview of Problematic: What are BMI objects? My field sites: General notes on locations Method of fieldwork Connecting Issues across Field Sites: Artifacts, Effects, and Notions of Training and Use Cases of Andrew, Samuel, Ethan, and Irene: Organizing Dimensions of Computerized Clinical Information Systems Myths and ideas of systems–the case of Andrew Notions of efficiency and medical efficacy: the case of Samuel The case of Ethan: informatics representations in Pathology The case of Irene–bargaining and negotiating a future of a Community Health Center Irene’s puzzle: Big Data Concluding Ethnographic Observations V. Conclusion: Configuring Futures of BMI–Ongoing Emergence and Sites of Informatics .....157 BMI’s Continued Emergence and Organization Post-Human and figures of informatics ‘Irma’ as an ethnographic figure ‘Irma’ as a site of informatics and Big Data correlation Anticipation and Consequence of the Continued Emergence of BMI Anthropological Relevance: Machine-Human Interaction Conclusion: Computing the Incomputable and Homo Digitus References ....................................................................................................................................179 vii Introduction: Anthropological Encounters with Biomedical Informatics (BMI) Conceptions of information and BMI This dissertation explores ideas and practices of Biomedical