Diagnostic Decision Support

On May 18th, 1996 I gave a presentation on Diagnostic Decision Support Systems. The text from the slides follows below.

Goals

• basic definitions and concepts
• sense of past and the future
• strengths and limitations
• how to learn more

http://www.nmsr.labmed.umn.edu/~john/acp/

• updated outline and bibliography
• pointers to related Internet resources

Why is this Important

• John Henry and the Steam Shovel
• extending expertise
  • primary care physician
  • consultant
  • physician extender
  • patient
• reducing error (Leape, 1994)

Lessons from Chess

• Garry Kasparov vs. Deep Blue: 3-1-2
• Deep Blue: computational power
• Kasparov: strategy

Definitions - The Descent of Ambition

• Artificial Intelligence: human intelligence, sentience (strong AI)
• Expert System: solve challenging problems, enhance non-expert
• Decision Support: anything that supports a decision.
• Diagnostic Decision Support System

Historical Perspective

• Every time history repeats itself the price goes up. Anonymous.

History -- 1950-69: Great Dreams

• Artificial Intelligence.
• automated ambulatory care
• replacing MDs with paramedical staff and decision aids

History -- 1970-1987: The Age of the Oracle.

• Expert System.
• DxPlain
• Iliad
• QMR

History -- 1988-1996: "The Best of Both Worlds".

• Decision Support
• Narrow domain systems
• Reminders and alerts (active mode)
• Neural networks
• Image processing
• Internet
• Systems

Lessons of History: Wetware vs. Hardware

(Blois 1987)

• the human strength: inventing sense and order, flexible structure, strategy
• the machine strength: never forgets, never tires, details, fast

The Oracles

• Iliad
  • Bayesian
  • 4th year medical student
  • case simulator
• QMR
  • rules and associations
  • enhanced textbook
  • somewhat useful
• DxPlain
  • rules and associations
  • online to web-based
  • server model

Problems with Oracles

• data acquisition
• slow to use
• work flow
• passive mode
• infrequent recognized need

Beyond the Oracles

(1370 citations in current MEDLINE)

• Mid-Range
• Narrow-Domain
• Alerts and Reminders
• Guidelines

Mid-Range

• ClinDerm
• hundreds more ...
• problems: publishing, marketing, distribution, maintenance

Narrow-Domain Systems

• EKG interpretation
• ABG and lipid interpretations
• PAP smears
• drug-drug interactions

Alerts and Reminders

• out-of-range test flagging
• Rind et al, 1994: effective!
  • rising Cr + nephrotoxic meds
  • 21.6 hour earlier dosage change
  • RR injury .45
• HELP system (LDS)

Guidelines

• static: efficient reference material, index
• dynamic + triggered + embedded resembles expert system

Obstacles

(Kassirer,1994)

• $
• work flow and performance
• needs assessment
• standards
• law and the FDA

What's Coming?

• standard ways to represent rules
• electronic medical record
• work-flow
• customized guidelines
• distributed expert systems
• web publication?
• Agents

Lessons from Chess: Next Year

• Kasparov: one year older
• Deep Blue: ?ten times faster
• Man-machine chess

Take Home

• error-reduction
• reminders work
• narrow-domain systems work
• work-flow integration needs EMR
• we'll be getting smarter ...