by Robin Cook
George noticed Thorn glaring at Langley, who glanced away. George sensed that Langley had been responsible for the overwrite and had essentially screwed up, which was why Zee discovered it.
With an exasperated expression, Thorn turned back to George. “Okay, you suspected a homicide. What were your thoughts up to this point?”
George hesitated.
“Please,” Thorn persisted.
“I thought that someone or some group at Amalgamated had decided to use iDoc to save money.”
“Can you be more specific?”
“I was worried that someone had been using iDoc as a kind of ‘death panel’ and then overwriting the commands to get rid of the evidence.”
Thorn and Langley nodded.
“Again,” Thorn said, “I must commend you on your reasoning and work, but . . . at the same time, I have to tell you that you are wrong.”
George looked at Thorn, puzzled.
“I’ll let Lewis explain what really happened.”
George and Paula leaned forward, their anger and fear momentarily forgotten.
54
MENTAL HEALTH FACILITY
HOLLYWOOD HILLS, LOS ANGELES, CALIFORNIA
MONDAY, JULY 7, 2014, 9:28 A.M.
It was Langley’s turn to clear his throat. “First and foremost,” he began, lowering his voice as if concerned about being overheard, even though the attendants had left the room, “I have to go back to basics. I must be certain that both of you really know what it means for a program to be heuristic.”
George and Paula exchanged a glance. To both of them it seemed a strange way for Langley to start.
“Of course I do, Lewis,” Paula replied. “I’ve been selling that feature to God knows how many people!”
“I’m mostly interested in Dr. Wilson’s answer. But still, selling heuristic and understanding heuristic can be two different things.” He turned to George.
“I have an idea, but I’m not entirely sure I could define it.”
“In its original meaning, ‘heuristic’ denoted a speculative concept that could serve as a guide in the solution of a problem, or a teaching method by which learning takes place through discoveries made by the student himself.”
George and Paula looked at each other for a moment with confusion. Neither understood what Langley was saying. George, in particular, under the circumstances, found Langley’s comments bizarre.
“In computer programming,” Langley continued, “‘heuristic’ means a problem-solving technique that can be described as the ability to take advantage of previous solutions. What I mean is that the application incorporates information and solutions in its database to apply them in future problems, which it had not been originally programmed to solve.” Langley focused on George to see if he was grasping it.
George nodded. It seemed like an awfully complicated way to say that a computer program could learn.
“It was important from the outset that the iDoc algorithm be written to enable it to take advantage of previous cases that it had encountered and to do it quickly. The initial alpha trials gave us an idea of the number of situations that would need a flesh-and-blood medical specialist as backup. To fulfill this need we created what we call the ‘control room.’ The control room is—”
“Paula actually has taken me on a visit to the control room,” George interrupted, hoping Langley would get to the point more quickly.
Langley smiled. “Good. At the outset of the beta test iDoc referred relatively often to the control room for answers, but that number dropped very quickly, meaning iDoc was functioning as planned in a heuristic fashion. In other words, there was a rapid reduction in the number of situations that iDoc didn’t feel capable of handling on its own, demonstrating that it was indeed learning, and learning at a phenomenal rate.” Langley stared at Paula and George, waiting for an acknowledgment that they were keeping up with him.
They both nodded.
“Now, to understand the glitch that occurred, you must know that the algorithm upon which iDoc is based includes a number of subjective issues such as pain and suffering associated with various medical treatments and even with some supposedly preventive testing. Even something simple, like the inability to sleep or eat normally, has been incorporated into iDoc if it is a frequent side effect. What we are essentially talking about here are quality-of-life issues, which are hard to quantify to include for the purposes of digitization. Nonetheless, we tried to incorporate them because we feel strongly that they need to be considered much more in health care decision making than has been done in fee-for-service medicine. And let me mention another variable: cost. The iDoc algorithm is responsibly aware that health care is already taking too big a bite from the GDP and that costs have to come down in order to ensure that health care can be distributed equitably. Am I making sense here?”
Both George and Paula nodded. The phrase it’s not rocket science went through George’s mind.
Langley cleared his throat again. “So here is the truth. No one knowingly used iDoc to kill anyone. The fact that a small number of patients died because of iDoc was a surprise to all of us. What happened was that the iDoc algorithm decided on its own to eliminate certain individuals after taking into consideration the pain and suffering associated with the specific cancer treatments they were facing, the predicted outcome of treatments, and cost consequences. There was no outside interference. In other words, there were no ‘bad guys.’ iDoc made its decision dispassionately with the evidence it already had in terms of the illnesses involved, the treatments available, the suffering that the patients would have to endure, and the cost. And that is basically it.”
There was a prolonged silence. The only sound penetrating the room was the chirping of birds outside the window.
Paula was the first to speak. She was decidedly less angry. “How long has this glitch been known?”
“A week,” Langley answered. “I first received evidence the same day that Amalgamated gave the presentation to potential investors.”
“And what actions have you taken?” Paula asked.
“As soon as we determined what had happened,” Langley continued, “we put an immediate end to what George has termed global dumping commands. Then we wanted to know how it had happened. Our first concern was the same as Dr. Wilson’s, namely the existence of a rogue hacker. But that was immediately ruled out when it became obvious that the dump commands had come from iDoc itself, meaning it was the algorithm that had made the determinations and given the orders.”
“And then what did you do?” Paula asked, taking the words right out of George’s mouth.
“Like I said, we stopped iDoc’s ability to issue dumping commands.”
“The selection of these types of patients . . . was that also stopped?” George asked.
“No. Because we want to look at the cohort of people that iDoc would have terminated along with how iDoc reached its decision, so that we as programmers could in a sense learn from iDoc: a heuristic event in reverse.”
“How many more patients were there besides the four that George discovered?” Paula asked.
“There were eight others, for a total of twelve,” Langley admitted. “There was one more associated with L.A. University Medical Center that Dr. Wilson was not aware of, four associated with Santa Monica University Hospital, and three with Harbor University Hospital.”
“Did all of these result in deaths?” Paula inquired. She sounded like an attorney taking a deposition.
“Yes.”
“Has iDoc identified anyone as fitting the criteria for a global dump since you stopped such a command from being issued?”
“Yes, there have been three of those. Two at L.A. University Medical Center and one at Santa Monica University Hospital.”
“So, these three people are still alive?”
“Yes, but they are
about to undergo very difficult treatments that will severely impact their quality of life with little chance of slowing their respective diseases.”
George interrupted. “I assume iDoc has also identified a group of candidates that would fit the global dump profile that do not have an embedded reservoir to do its dirty work, were it allowed.”
Langley was silent a moment. His eyes flicked toward Thorn. “Yes.”
“How many of those has it identified?”
“I don’t have that exact information available. I can get it for you, though.”
“But that is a good question,” Thorn admitted.
George nodded, then moved on. “Was Zee correct in his assumption that the records of the four cases I investigated had been overwritten to cover up the dump commands?”
“Yes. We did that,” Langley admitted.
“Why did you wipe the patients’ smartphones clean of all data and try to do so with DeAngelis’s phone as well?” George demanded.
“That has been standard procedure since the outset of the beta test. We wipe a phone clean immediately upon confirmation of death. That has nothing to do with the dump commands. It has to do with privacy issues that—”
Thorn interrupted. “Lewis is correct. There was no attempted cover-up with the smartphones. Our damage control was limited to the overwrite of the global-dump commands and their physiological consequences on the servers. And that was to prevent anyone at Amalgamated or our iDoc subsidiary from discovering the glitch. Only the three of us, plus one other individual at Amalgamated, were aware of what happened. Our intent was, and is, to prevent the media from learning what had happened. We know that such information would ignite a media frenzy. Remember what happened when Sarah Palin brought up the subject of ‘death panels.’ And that was only about discussing end-of-life choices with elderly patients. We feel that iDoc is so potentially beneficial to the country and the world that this unfortunate glitch should not derail it. When iDoc’s benefits are known to the world in terms of democratizing medicine and truly focusing on prevention, then dealing with the issue of this glitch can be accomplished without ‘throwing the baby out with the bathwater.’”
Thorn stopped and took a deep breath. Everyone was silent, absorbing Thorn’s impassioned defense of iDoc.
George was the first to speak. “iDoc is going to be good for Amalgamated as well.”
“Absolutely!” Thorn agreed without hesitation. “I want you and Paula to understand that the glitch does not represent any kind of conspiracy on the part of Amalgamated. There was no Amalgamated ‘death panel.’ Nor will there ever be. Frankly, to be perfectly honest, we do not need it.”
“Why didn’t you come directly to George and me instead of snatching us in the middle of the night?” Paula demanded, some of her anger returning. “We could have been seriously injured.”
“I apologize for that. As I mentioned earlier, that decision was made by Butch Gauthier, our security chief. Don’t worry, I’ll be having a word with him very soon. Unfortunately it was one of those situations where the right hand didn’t know what the left hand was doing. The professionals who snatched you had no idea who you were, just that you were dangerous. I understand how you both feel. And for good reason. But keep in mind, the situation was deemed an emergency, which had to be contained as soon as possible. That said, we apologize again.”
Langley and Clayton nodded their heads in agreement.
“In view of what you two have had to endure, we here would like to say that we are prepared to make it up to you if you’re willing to cooperate.”
“What the hell do you mean by ‘cooperate’?” George demanded.
“‘Cooperation’ means that you recognize the glitch for what it was. The deaths of the patients involved are regrettable, as they had no say in the decision. That’s completely contrary to informed consent. But also remember that all of those people were terminal in the very near future and facing considerable pain and suffering with the treatments available, and therefore a very low quality of life.”
George and Paula exchanged a glance of disbelief.
“And if we don’t, as you say, cooperate, what then?” George asked.
Thorn sighed audibly. “That will necessitate a prolonged stay at this rather pleasant facility with no opportunities for outside communication until it is deemed possible for Amalgamated to deal with whatever revelations and accusations you might feel appropriate. In other words, we need to cover our behinds.” He offered a crooked smile along with his attempt at humor.
“Do you think you can actually get away with keeping us locked up?” Paula asked.
“Yes, of course. If pressed, we can manufacture evidence for addiction problems that require treatment. Something in that vein,” he said with a flip of his hand.
“People will look for us!” Paula said with disbelief.
“We’ll deal with that. Although we know that neither one of you will be missed by your employers for a few days.” Thorn glanced at George. “Well, for you, George, it’s a bit longer than a few days, isn’t it? Anyway, that’s a usual source of questions apart from local family or intimate relationships, which neither of you have.”
Paula looked at George as if to say, This is crazy.
George turned to Langley. “You’ve described the glitch that killed the patients as a spontaneous creation by the algorithm. And you also stated that it has only been temporarily blocked rather than removed.”
Langley nodded in the affirmative but Thorn interrupted.
“Let me anticipate your concerns. As I mentioned earlier, Amalgamated is in direct negotiations with CMS to provide iDoc to all Medicare and Medicaid beneficiaries. Part of their due diligence is to allow the URI, or Universal Resource Initiative, to monitor the test. URI is a clandestine agency under the aegis of the IPAB, or Independent Payment Advisory Board, which is in turn mandated by the Affordable Care Act. While the URI was performing their due diligence, they detected the glitch almost the same time as we did.”
George remembered that Zee had stated that one of the high-anonymity proxy servers was located in Maryland. It was the government association that had spooked Zee.
“Among other things,” Thorn continued, “the URI has been tasked with looking into the rationing of medical care in the last months of life, particularly for Medicare.”
Paula and George’s faces reflected their horror.
Noting their reactions, Thorn said, “Some kind of limitation or rationing has to be considered to control runaway costs. Most industrialized countries already ration medical care at the end of life, but it is, on occasion, associated with favoritism if not out-and-out corruption. The fact that iDoc made an unexpected venture into a form of rationing was looked upon by the URI with interest. They like the fact that it is totally and completely nondiscriminatory. They have specifically asked us not to rectify the glitch but merely to block the global-dump command. In short, they do not want to terminate the people selected, but they want them selected, perhaps to put them on a different track, which has yet to be specified.
“So to answer your question,” Thorn went on, looking directly at George, “the glitch has not been removed, in the sense that it is still collating the data. It is still selecting people according to its logic, but not terminating them.”
George and Paula exchanged yet another glance, a bit overwhelmed by what they had been hearing.
“Listen,” Thorn continued, “as I said, Amalgamated and the rest of the health insurance industry do not need ‘death panels.’ It is the country and the world that need some rational approach to end-of-life care. Amalgamated will not promote any particular methodology. If the government wants it as part of the Medicare-iDoc package, then that is the government’s decision, not ours.”
Thorn looked down the table at Clayton, who took the cue. “Cooperation on your part will bring oth
er benefits, George,” Clayton said. “I will have you reinstated as a fourth-year resident. The charges of HIPAA violations will be dropped immediately. I’m sure you’re aware that a number of health care professionals have been convicted of similar violations and are now in prison.”
“Likewise, the hacking charges against you will also be dropped,” Thorn added. “You will also be given stock in Amalgamated to compensate you for having the initial conceptual idea for iDoc. And you, Paula, will be given additional stock added to your already sizable holding.”
George leveled a gaze at Thorn. “That sounds like a bribe.”
“Think of it as appropriate compensation. There will be time in the future for both of you to voice your feelings about the iDoc algorithm, but only after iDoc has been given its final FDA approval and has been at least distributed nationally.
“George, your second contribution is that you have underlined our need to correct iDoc sooner rather than later, saving iDoc from a media frenzy that might have put off its adoption for years. Amalgamated owes you a vote of thanks.”
George and Paula both appeared shell-shocked.
“Now,” Thorn said, “if you don’t have any more questions, we will let you discuss the situation in private. Then you can let us know how you feel about what has been said.”
George wasn’t done. “I do have another question. Was Amalgamated responsible for my friend Zee’s death?”
55
MENTAL HEALTH FACILITY
HOLLYWOOD HILLS, LOS ANGELES, CALIFORNIA
MONDAY, JULY 7, 2014, 9:58 A.M.
Thank you for asking,” Thorn replied. “I meant to bring up the issue earlier, as we were certain you assumed that we were, but we weren’t, at least not directly. What happened was we hired professionals to monitor you, to find out exactly what you knew or suspected, then Zee Beauregard entered the picture. We assumed he was helping you, especially when he managed to break into our iDoc servers. When he suddenly bolted early Saturday morning, we knew we had to follow him and bring him here along with you. He was trailed as he drove north, and we would have picked him up when he stopped. Unfortunately, that was not the way things worked out. Somehow he realized that he was being followed, and he apparently panicked. He pushed his car to unsafe speeds. I was told that it was an old vehicle. We believe he just lost control of the car and hit the concrete abutment of an overpass.”
