ISN Informatics Commission, NKF cyberNephrology in the Context of cyberMedicine Moscow Nephrology Update Course May 31, 2002 Kim Solez, M.D.

Slide 2 NKF cyberNephrology/Informatics - A remarkable NKF/ISN innovation! In 1996 an NKF think tank recommended the creation of NKF cyberNephrology, initiated in April ISN Informatics Commission May ‘97. In 1996 an NKF think tank recommended the creation of NKF cyberNephrology, initiated in April ISN Informatics Commission May ‘97. Remarkably insightful, no other voluntary heath organization has had similar technology impact. Earlier Internet initiatives in other health disciplines - dermatology, anesthesiology, and nursing - were individual or institutional efforts. Remarkably insightful, no other voluntary heath organization has had similar technology impact. Earlier Internet initiatives in other health disciplines - dermatology, anesthesiology, and nursing - were individual or institutional efforts. Now as a consequence of this NKF/ISN initiative, nephrology has caught up to and surpassed these other disciplines, now has Internet resources superior to those in any other area! Now as a consequence of this NKF/ISN initiative, nephrology has caught up to and surpassed these other disciplines, now has Internet resources superior to those in any other area!

Slide 3 NKF cyberNephrology/Informatics - A remarkable NKF/ISN innovation! Foreign language content now in French, Spanish, and Arabic. Foreign language content now in French, Spanish, and Arabic. Would like as a consequence of this meeting to also create similar high quality Internet resources in Russian. Would like as a consequence of this meeting to also create similar high quality Internet resources in Russian. Educational content also available on CD-ROM for physicians with low bandwidth Internet connections. Educational content also available on CD-ROM for physicians with low bandwidth Internet connections.

Slide 4 All the More Remarkable Considering Nephrology’s size vs. all of Medicine There are more than 800,000 physicians in the US and only about 5,000 are practicing renal medicine, so nephrologists represents only about 0.6% of total US physicians. There are more than 800,000 physicians in the US and only about 5,000 are practicing renal medicine, so nephrologists represents only about 0.6% of total US physicians. On the other hand, the cost of end stage kidney disease care is very high: 18 billion US dollars per annum in public and private money (source USRDS). This is nearly 2% of the 1 trillion dollar total annual health care budget of the US and rising rapidly. On the other hand, the cost of end stage kidney disease care is very high: 18 billion US dollars per annum in public and private money (source USRDS). This is nearly 2% of the 1 trillion dollar total annual health care budget of the US and rising rapidly.

Slide 5 Surprising that Nephrology is Ahead of Much Larger Disciplines, e.g. Cardiology Topol text on Heart.org has cumbersome registration process, is old (1998), and is mostly just visually uninteresting text on a page, Schrier Atlas is made for web presentation, virtually identical to 2001 text, has powerpoint files for each chapter, every page visually interesting, no registration process! Topol text on Heart.org has cumbersome registration process, is old (1998), and is mostly just visually uninteresting text on a page, Schrier Atlas is made for web presentation, virtually identical to 2001 text, has powerpoint files for each chapter, every page visually interesting, no registration process! Heart.org weekly update inferior to and goes to fewer people than HDCN weekly update. Heart.org weekly update inferior to and goes to fewer people than HDCN weekly update. JointandBone.org similarly inferior to Schrier Atlas and other nephrology resources. JointandBone.org similarly inferior to Schrier Atlas and other nephrology resources.

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Slide 14 NKF New Technologies Division / ISN webpage redesign Beautiful new redesign of NKF kidney.org page for 2002! Beautiful new redesign of NKF kidney.org page for 2002! Chronic kidney disease guidelines now available electronically through efforts of NKF cyberNephrology. Chronic kidney disease guidelines now available electronically through efforts of NKF cyberNephrology. Redesign of ISN website underway: Redesign of ISN website underway:

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Slide 17 Extending Internet knowledge from nephrology to medicine in general! cyberMedicine - New Medicine medicine.org cyberMedicine - New Medicine medicine.org Discipline upgrade from other areas which can learn from nephrology - Critical Care Medicine Discipline upgrade from other areas which can learn from nephrology - Critical Care Medicine cyberMedicine as part of the technology future - search strategies - efficient information retrieval. cyberMedicine as part of the technology future - search strategies - efficient information retrieval.

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Most physicians are learning about the Internet and new technology “on the fly”. Inefficient, unpredictable, leaves gaps.

A short 2-3 hour period of formal teaching with mixed didactic/interactive format and hands on experience can provide enormous benefit. That is the plan of the computer workshops at this meeting.

Slide 22 Ray Kurzweil "Technology is the continuation of evolution by other means.... "Technology is the continuation of evolution by other means.... It is in the nature of exponential growth that events develop extremely slowly for extremely long periods of time, but as one glides through the knee of the curve, events erupt at an increasingly furious pace. And that is what we will experience as we enter the twenty-first century." It is in the nature of exponential growth that events develop extremely slowly for extremely long periods of time, but as one glides through the knee of the curve, events erupt at an increasingly furious pace. And that is what we will experience as we enter the twenty-first century." --Ray Kurzweil - The Age of Spiritual Machines, When Computers Exceed Human Intelligence (a)When computers exceed human intelligence (b)When computers and humans become indistinguishable from each

Slide 23 Arthur C. Clarke "When a scientist states that something is possible, he is almost certainly right. "When a scientist states that something is possible, he is almost certainly right. When he states that something is impossible, he is very probably wrong. When he states that something is impossible, he is very probably wrong. The only way of discovering the limits of the possible is to venture a little way past them into the impossible. The only way of discovering the limits of the possible is to venture a little way past them into the impossible. Any sufficiently advanced technology is indistinguishable from magic." Any sufficiently advanced technology is indistinguishable from magic." -- Arthur C. Clarke's three laws of technology

Slide 24 First Phase of ISN Informatics/NKF cyberNephrology Many accomplishments  discussion groups - NEPHROL, NEPHDEVEL, NEPHKIDS and progeny  WWW sites - virtual attendance at meetings  AJKD Forum  Schrier Atlas  Renal-Tech computer donation project  Internet videoconferencing, wireless connectivity, panoramas. French, Spanish.  WWW site

Slide 25 Support of ISN Programs COMGAN COMGAN RENAL-TECH Computer Donation Project RENAL-TECH Computer Donation Project Video Legacy Project Video Legacy Project ISN Archive ISN Archive Sister Centers Program Sister Centers Program Teaching Resources Teaching Resources Discussion Groups Discussion Groups Assistance to National Societies Assistance to National Societies

Slide 26 Making Full Use of the Favorable Local Environment in Canada Canada is way ahead of the U.S. in the deployment and adoption of next-generation broadband services: The cross-Canada high- speed network backbone, CA*net3, is the world's first national optical research network. Canada is way ahead of the U.S. in the deployment and adoption of next-generation broadband services: The cross-Canada high- speed network backbone, CA*net3, is the world's first national optical research network. In % of Canadian on-line homes have a broadband connection compared to 8.6% in the U.S. Prime Minister Jean Cretien dedicated to making Canadians “the most connected people on earth!”. In % of Canadian on-line homes have a broadband connection compared to 8.6% in the U.S. Prime Minister Jean Cretien dedicated to making Canadians “the most connected people on earth!”. Internet2 Initiative provides enormous dedicated bandwidth between educational institutions for video conferencing etc. Internet2 Initiative provides enormous dedicated bandwidth between educational institutions for video conferencing etc.

Slide 27 New Operating Systems, DataTransmission Formats, Artificial Intelligence Palm computing platform Palm computing platform Macintosh OS 10 Macintosh OS 10 Wireless transmission - AirPort hub Wireless transmission - AirPort hub XML document presentation XML document presentation Artificial Intelligence, Robotics Artificial Intelligence, Robotics

The Great Internet Paradox! The Internet is everywhere … and nowhere. It has become mainstream in everyday life in first world countries, and reaches virtually every nation on earth. On the other hand, just as half the world has yet to make their first phone call, the Internet has not touched the lives of the vast majority of people living on this planet. Only 5 percent of the world’s population is actively using the Internet.

Slide 29 Internet use becomes “mainstream” in even in the Russia! 1.Most health care workers using the Internet. 2.Access becoming faster, cheaper. 3.Computers themselves inexpensive. 4.No longer necessary to type. Voice recognition reaches 98% accuracy and still improving! Internet use becomes “mainstream” in even in the Russia! 1.Most health care workers using the Internet. 2.Access becoming faster, cheaper. 3.Computers themselves inexpensive. 4.No longer necessary to type. Voice recognition reaches 98% accuracy and still improving!

Slide 30 The World is Changing - Now! September 26, 2000 New Hewlett Packard CEO Carly Fiorina stated that the world is now entering the "renaissance of the information age" -- a time when emerging technologies and an "always-on Internet" could transform human experience and entire industries. "This world is clearly emerging before our eyes," "The shifts ahead, the opportunities ahead are massive." February 2, 2001 Cars that alert their owners when stolen, tracking thief location. (CNN) September 26, 2000 New Hewlett Packard CEO Carly Fiorina stated that the world is now entering the "renaissance of the information age" -- a time when emerging technologies and an "always-on Internet" could transform human experience and entire industries. "This world is clearly emerging before our eyes," "The shifts ahead, the opportunities ahead are massive." February 2, 2001 Cars that alert their owners when stolen, tracking thief location. (CNN)

Slide 31 The World is Changing - Now! February 1, 2001 The Media Development Loan Fund, backed by some of the world's largest philanthropies including the MacArthur and Soros foundations, lends money at low interest rates to news organizations in developing countries and helps them use technology to facilitate the flow of information…. Rather than beam their reports via satellite, the stations transmit audio and text files via the Internet, creating a network that covers most of the country. February 1, 2001 The Media Development Loan Fund, backed by some of the world's largest philanthropies including the MacArthur and Soros foundations, lends money at low interest rates to news organizations in developing countries and helps them use technology to facilitate the flow of information…. Rather than beam their reports via satellite, the stations transmit audio and text files via the Internet, creating a network that covers most of the country.

Slide 32 The World is Changing - Now!... continued November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor.

Slide 33 The World is Changing - Now! … continued - The “Digital Divide” November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. At a gathering of world leaders who adhere to "third way" politics, Clinton said one of the greatest domestic problems facing developed countries is the "digital divide" that gives those who have computers an enormous advantage over those who do not. At a gathering of world leaders who adhere to "third way" politics, Clinton said one of the greatest domestic problems facing developed countries is the "digital divide" that gives those who have computers an enormous advantage over those who do not.

Slide 34 The World is Changing - Now! … Solutions to “Who has time!” November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. Feb Former Labor Secretary Robert Reich “The Future of Success”. Quit job when youngest son asked “wake me up when you get home no matter what time it is so I know you are there.” Internet driven economy, frenzied lives, less security “race without a finish line”. Digital age allows you more time to yourself, more work can be done at home. Digital butler or agent performs searches for you at night learning from what you liked in previous searches. Personalized newspaper in the morning. Feb Former Labor Secretary Robert Reich “The Future of Success”. Quit job when youngest son asked “wake me up when you get home no matter what time it is so I know you are there.” Internet driven economy, frenzied lives, less security “race without a finish line”. Digital age allows you more time to yourself, more work can be done at home. Digital butler or agent performs searches for you at night learning from what you liked in previous searches. Personalized newspaper in the morning.

Slide 35 The Internet in Europe, Asia, and the Middle East - including Russia November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. Up until now there have been three main barriers to Internet use in Europe, Asia, and Middle East: 1. Cost (Much higher than in North America and quite heterogeneous) 2. Lack of high speed Internet access (Often nothing faster than standard modem or ISDN) 3. Language (because most Internet activity is in English it may seem like a very foreign and not-very-attractive culture) Up until now there have been three main barriers to Internet use in Europe, Asia, and Middle East: 1. Cost (Much higher than in North America and quite heterogeneous) 2. Lack of high speed Internet access (Often nothing faster than standard modem or ISDN) 3. Language (because most Internet activity is in English it may seem like a very foreign and not-very-attractive culture)

Slide 36 The Internet in Europe, Asia, and the Middle East - Solutions! November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. 1. Cost - Communications reform. Flat rate. 2. High speed Internet access DSL and cable modem coming, faster than ISDN and cheaper! 3. Language - Increasing success with non-English resources on the Internet. 1. Cost - Communications reform. Flat rate. 2. High speed Internet access DSL and cable modem coming, faster than ISDN and cheaper! 3. Language - Increasing success with non-English resources on the Internet.

Slide 37 Bandwidth considerations November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. The Internet in high bandwidth environments: Only 35% of human communication is words. With Internet video conferencing can capture gestures, body language, inflections of the voice, facial expression etc. plus share images, documents, software applications with "shared white board" or complete remote control of other computer! Requres 56 K modem or faster connection. Allows telemedicine/telepathology. The Internet in high bandwidth environments: Only 35% of human communication is words. With Internet video conferencing can capture gestures, body language, inflections of the voice, facial expression etc. plus share images, documents, software applications with "shared white board" or complete remote control of other computer! Requres 56 K modem or faster connection. Allows telemedicine/telepathology.

Slide 38 Bandwidth considerations November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. The Internet in low bandwidth situations: Web site educational content can be placed on CD-ROMs cheaply and easily so sites can be accessed without going to the World Wide Web. -based low bandwidth discussion has been enormously successful in nephrology and transplantation while WWW-based discussion has not. So potentially everyone has access to the Internet resources that have proven most valuable. The Internet in low bandwidth situations: Web site educational content can be placed on CD-ROMs cheaply and easily so sites can be accessed without going to the World Wide Web. -based low bandwidth discussion has been enormously successful in nephrology and transplantation while WWW-based discussion has not. So potentially everyone has access to the Internet resources that have proven most valuable.

Slide 39 Few Countries Out of Reach! November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. Almost all countries can benefit from Internet-based discussion. connectivity has reached almost everywhere. Very few exceptions: Countries lacking Internet access include only Afghanistan, Angola, Cape Verde, the Comoros Islands, Equatorial Guinea, Libya, Mauritania, São Tome and Principe, Somalia and Western Sahara. Almost all countries can benefit from Internet-based discussion. connectivity has reached almost everywhere. Very few exceptions: Countries lacking Internet access include only Afghanistan, Angola, Cape Verde, the Comoros Islands, Equatorial Guinea, Libya, Mauritania, São Tome and Principe, Somalia and Western Sahara.

Slide 40 "We strongly believe that better telecommunications will enhance our ability to deliver improved quality of life, electronic health and learning services to previously disadvantaged areas in the continent". President Nelson Mandela in an address to the Africa TELECOM 98 Exhibition and Forum Johannesburg 4-9 May 1998 "We strongly believe that better telecommunications will enhance our ability to deliver improved quality of life, electronic health and learning services to previously disadvantaged areas in the continent". President Nelson Mandela in an address to the Africa TELECOM 98 Exhibition and Forum Johannesburg 4-9 May 1998

Slide 41 Factors Influencing Second Phase of ISN NKF cyberNephrology onward Digital photography now inexpensive and superior/equal to film photography. Video panoramas, 3D panoramas Video panoramas, 3D panoramas “Virtual microscope” panoramas “Virtual microscope” panoramas Books with “digital paper” pages Books with “digital paper” pages Circuits that combine digital and analog signaling just as the human brain does Circuits that combine digital and analog signaling just as the human brain does Human-centered rather than machine- centered computing, near perfect voice recognition Human-centered rather than machine- centered computing, near perfect voice recognition

Slide 42 Factors Influencing Second Phase of ISN/NKF cyberNephrology - Continued Gene chip DNA Microarrays for instant genetic diagnosis Gene chip DNA Microarrays for instant genetic diagnosis The wearable computer, digital clothing The wearable computer, digital clothing The bioartificial kidney The bioartificial kidney Evolution of new ethical standards for e- health Evolution of new ethical standards for e- health Quantum computing Quantum computing Optical switching/Optical Internet Optical switching/Optical Internet Nanomachines/near molecular level organ repair in disease Nanomachines/near molecular level organ repair in disease

Slide 43 Why not talk about distant future of technology/cyberNephrology? Because if Ray Kurzweil is right and people and machines will be indistinguishable from each other in 2099, what will be the relevance of nephrology then? Because if Ray Kurzweil is right and people and machines will be indistinguishable from each other in 2099, what will be the relevance of nephrology then? Machines/computers don’t have kidneys ! Machines/computers don’t have kidneys !

So follow our progress and remember: “Any sufficiently advanced technology is indistinguishable from magic.”