Computer evaluation of acid-base disorders

Sharpening clinical decision support alert and reminder designs with MINDSPACE: A systematic review

BACKGROUND

Clinical decision support (CDS) alerts and reminders aim to influence clinical decisions, yet they are often designed without considering human decision-making behaviour. While this behaviour is comprehensively described by behavioural economics (BE), the sheer volume of BE literature poses a challenge to designers when identifying behavioural effects with utility to alert and reminder designs. This study tackles this challenge by focusing on the MINDSPACE framework for behaviour change, which collates nine behavioural effects that profoundly influence human decision-making behaviour: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, and Ego.

METHOD

A systematic review searching MEDLINE, Embase, PsycINFO, and CINAHL Plus to explore (i) the usage of MINDSPACE effects in alert and reminder designs and (ii) the efficacy of those alerts and reminders in influencing clinical decisions. The search queries comprised ten Boolean searches, with nine focusing on the MINDSPACE effects and one focusing on the term mindspace.

RESULTS

50 studies were selected from 1791 peer-reviewed journal articles in English from 1970 to 2022. Except for ego, eight of nine MINDSPACE effects were utilised to design alerts and reminders, with defaults and norms utilised the most in alerts and reminders, respectively. Overall, alerts and reminders informed by MINDSPACE effects showed an average 71% success rate in influencing clinical decisions (alerts 73%, reminders 69%). Most studies utilised a single effect in their design, with higher efficacy for alerts (64%) than reminders (41%). Others utilised multiple effects, showing higher efficacy for reminders (28%) than alerts (9%).

CONCLUSION

This review presents sufficient evidence demonstrating the MINDSPACE framework's merits for designing CDS alerts and reminders with human decision-making considerations. The framework can adequately address challenges in identifying behavioural effects pertinent to the effective design of CDS alerts and reminders. The review also identified opportunities for future research into other relevant effects (e.g., framing).

Lung and general health effects of Toll-like receptor-4 (TLR4)-interacting SPA4 peptide

Background

A surfactant protein-A-derived peptide, which we call SPA4 peptide (amino acids: GDFRYSDGTPVNYTNWYRGE), alleviates lung infection and inflammation. This study investigated the effects of intratracheally administered SPA4 peptide on systemic, lung, and health parameters in an outbred mouse strain, and in an intratracheal lipopolysaccharide (LPS) challenge model.

Methods

The outbred CD-1 mice were intratracheally administered with incremental doses of SPA4 peptide (0.625–10 μg/g body weight) once every 24 h, for 3 days. Mice left untreated and those treated with vehicle were included as controls. Mice were euthanized after 24 h of last administration of SPA4 peptide. In order to assess the biological activity of SPA4 peptide, C57BL6 mice were intratracheally challenged with 5 μg LPS/g body weight and treated with 50 μg SPA4 peptide via intratracheal route 1 h post LPS-challenge. Mice were euthanized after 4 h of LPS challenge. Signs of sickness and body weights were regularly monitored. At the time of necropsy, blood and major organs were harvested. Blood gas and electrolytes, serum biochemical profiles and SPA4 peptide-specific immunoglobulin G (IgG) antibody levels, and common lung injury markers (levels of total protein, albumin, and lactate, lactate dehydrogenase activity, and lung wet/dry weight ratios) were determined. Lung, liver, spleen, kidney, heart, and intestine were examined histologically. Differences in measured parameters were analyzed among study groups by analysis of variance test.

Results

The results demonstrated no signs of sickness or changes in body weight over 3 days of treatment with various doses of SPA4 peptide. It did not induce any major toxicity or IgG antibody response to SPA4 peptide. The SPA4 peptide treatment also did not affect blood gas, electrolytes, or serum biochemistry. There was no evidence of injury to the tissues and organs. However, the SPA4 peptide suppressed the LPS-induced lung inflammation.

Conclusions

These findings provide an initial toxicity profile of SPA4 peptide. Intratracheal administration of escalating doses of SPA4 peptide does not induce any significant toxicity at tissue and organ levels. However, treatment with a dose of 50 μg SPA4 peptide, comparable to 2.5 μg/g body weight, alleviates LPS-induced lung inflammation.

Causes of Shortness of Breath in the Acute Patient: A National Study

BACKGROUND

Dyspnea is a common and ambiguous complaint that results in 3.4 million emergency department (ED) visits annually. While learners may encounter lists of differential diagnoses to consider while in training, often these lists are not empirically based. We sought to establish an evidence-based differential diagnosis for dyspnea and to determine whether normal vital signs can rule out a life-threatening diagnosis.

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2014 for ED visits with a chief complaint of dyspnea and tallied the principal discharge diagnosis. We included 10,170 sampled ED visits by adults with a chief complaint of dyspnea, representing nearly 42 million visits nationally. We then calculated the most common principal discharge diagnoses by age group and the frequency of abnormal respiratory vital signs in cases with life-threatening diagnoses.

RESULTS

The most represented age group was 45 to 64 years (31.6%). Most visits were discharged directly from the ED (57.5%), while 8.1% required admission to an intensive care unit (ICU). The most common diagnosis in patients aged 18 to 44 was acute asthma exacerbation (14.8%). Obstructive chronic bronchitis was the most common specified diagnosis in both patients ages 45 to 64 (11.1%) and patients ages 65 to 79 (12.4%), while congestive heart failure was the most common for patients ages 80 and over (15.9%). Respiratory vital signs were frequently normal in the 44.6% of visits that resulted in a potentially life-threatening diagnosis but corresponded to increased ICU utilization when abnormal.

CONCLUSIONS

For patients with dyspnea, the high utilization of ICUs highlights the importance of an accurate differential. The frequencies established here can be used as pretest probabilities in Bayesian analysis to improve the accuracy of differential diagnosis lists.

An Opening Chapter of the First Generation of Artificial Intelligence in Medicine: The First Rutgers AIM Workshop, June 1975

The first generation of Artificial Intelligence (AI) in Medicine methods were developed in the early 1970's drawing on insights about problem solving in AI. They developed new ways of representing structured expert knowledge about clinical and biomedical problems using causal, taxonomic, associational, rule, and frame-based models. By 1975, several prototype systems had been developed and clinically tested, and the Rutgers Research Resource on Computers in Biomedicine hosted the first in a series of workshops on AI in Medicine that helped researchers and clinicians share their ideas, demonstrate their models, and comment on the prospects for the field. These developments and the workshops themselves benefited considerably from Stanford's SUMEX-AIM pioneering experiment in biomedical computer networking. This paper focuses on discussions about issues at the intersection of medicine and artificial intelligence that took place during the presentations and panels at the First Rutgers AIM Workshop in New Brunswick, New Jersey from June 14 to 17, 1975.

Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems

BACKGROUND

Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems.

OBJECTIVE

To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs.

STUDY DESIGN AND METHODS

We used a modified Delphi approach with a panel of 11 decision support experts to develop a taxonomy of 53 front-end CDS tools. Based on this taxonomy, a survey on CDS tools was sent to a purposive sample of commercial EHR vendors (n=9) and leading healthcare institutions with internally developed state-of-the-art EHRs (n=4).

RESULTS

Responses were received from all healthcare institutions and 7 of 9 EHR vendors (response rate: 85%). All 53 types of CDS tools identified in the taxonomy were found in at least one surveyed EHR system, but only 8 functions were present in all EHRs. Medication dosing support and order facilitators were the most commonly available classes of decision support, while expert systems (eg, diagnostic decision support, ventilator management suggestions) were the least common.

CONCLUSION

We developed and validated a comprehensive taxonomy of front-end CDS tools. A subsequent survey of commercial EHR vendors and leading healthcare institutions revealed a small core set of common CDS tools, but identified significant variability in the remainder of clinical decision support content.

Computer-assisted diagnostic decision support: history, challenges, and possible paths forward

This paper presents a brief history of computer-assisted diagnosis, including challenges and future directions. Some ideas presented in this article on computer-assisted diagnostic decision support systems (CDDSS) derive from prior work by the author and his colleagues (see list in Acknowledgments) on the INTERNIST-1 and QMR projects. References indicate the original sources of many of these ideas.

A four-phase model of the evolution of clinical decision support architectures

BACKGROUND

A large body of evidence over many years suggests that clinical decision support systems can be helpful in improving both clinical outcomes and adherence to evidence-based guidelines. However, to this day, clinical decision support systems are not widely used outside of a small number of sites. One reason why decision support systems are not widely used is the relative difficulty of integrating such systems into clinical workflows and computer systems.

PURPOSE

To review and synthesize the history of clinical decision support systems, and to propose a model of various architectures for integrating clinical decision support systems with clinical systems.

METHODS

The authors conducted an extensive review of the clinical decision support literature since 1959, sequenced the systems and developed a model.

RESULTS

The model developed consists of four phases: standalone decision support systems, decision support integrated into clinical systems, standards for sharing clinical decision support content and service models for decision support. These four phases have not heretofore been identified, but they track remarkably well with the chronological history of clinical decision support, and show evolving and increasingly sophisticated attempts to ease integrating decision support systems into clinical workflows and other clinical systems.

CONCLUSIONS

Each of the four evolutionary approaches to decision support architecture has unique advantages and disadvantages. A key lesson was that there were common limitations that almost all the approaches faced, and no single approach has been able to entirely surmount: (1) fixed knowledge representation systems inherently circumscribe the type of knowledge that can be represented in them, (2) there are serious terminological issues, (3) patient data may be spread across several sources with no single source having a complete view of the patient, and (4) major difficulties exist in transferring successful interventions from one site to another.

Effects of a decision support system on physicians' diagnostic performance

PURPOSE

This study examines how the information provided by a diagnostic decision support system for clinical cases of varying diagnostic difficulty affects physicians' diagnostic performance.

METHODS

A national sample of 67 internists, 35 family physicians, and 6 other physicians used the Quick Medical Reference (QMR) diagnostic decision support system to assist them in the diagnosis of written clinical cases. Three sets of eight cases, stratified by diagnostic difficulty and the potential of QMR to produce high-quality information, were used. The effects of using QMR on three measures of physicians' diagnostic performance were analyzed using analyses of variance.

RESULTS

Physicians' diagnostic performance was significantly higher (p < 0.01) on the easier cases and the cases for which QMR could provide higher-quality information.

CONCLUSIONS

Physicians' diagnostic performance can be strongly influenced by the quality of information the system produces and the type of cases on which the system is used.

Recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, Computer-based Patient Record Institute, Medical Library Association, Association of Academic Health Science Libraries, American Health Information Management Association, American Nurses Association

In mid-1996, the FDA called for discussions on regulation of clinical software programs as medical devices. In response, a consortium of organizations dedicated to improving health care through information technology has developed recommendations for the responsible regulation and monitoring of clinical software systems by users, vendors, and regulatory agencies. Organizations assisting in development of recommendations, or endorsing the consortium position include the American Medical Informatics Association, the Computer-based Patient Record Institute, the Medical Library Association, the Association of Academic Health Sciences Libraries, the American Health Information Management Association, the American Nurses Association, the Center for Healthcare Information Management, and the American College of Physicians. The consortium proposes four categories of clinical system risks and four classes of measured monitoring and regulatory actions that can be applied strategically based on the level of risk in a given setting. The consortium recommends local oversight of clinical software systems, and adoption by healthcare information system developers of a code of good business practices. Budgetary and other constraints limit the type and number of systems that the FDA can regulate effectively. FDA regulation should exempt most clinical software systems and focus on those systems posing highest clinical risk, with limited opportunities for competent human intervention.

Computer-based clinical decision aids. A review of methods and assessment of systems

During the last three decades a great deal of research has been devoted to the development of integrated clinical decision support systems. This report aims to give a basic understanding of what is required for such a system. By means of a large literature study a survey is given of the major components of computer-based clinical aid systems. The main approaches and several aspects of evaluation of such programs are described. The computer has several inherent capabilities which are suitable for medical problem solving and can help in the formalization of medical knowledge. The components of such systems include the computer database, the reasoning engine and the user interface. The different approaches on which the reasoning engine is built are based on manipulation of information and advocate the use of knowledge to construct a solution to a problem. The information in the mode vary from data-intensive to knowledge-intensive. Assessment of decision support systems is a very important phase in the development of such systems. Evaluation should be made on the accuracy of the program, the nature of the system, the use of the data and the acceptance by the target users. Whatever the model is, its effectiveness will depend on the data with which the program has to work. Acceptance by physicians depends among other things on ease of use of the user interface. Profound changes in the delivery of health care will be induced through the rapid growth of on-line computer communication together with the development of integrated clinical decision support systems and electronic medical records. Notwithstanding the rapid growth of computer technology, computer-aided decision making is in its infancy and real support in daily practice is not yet achieved.

Medical diagnostic decision support systems--past, present, and future: a threaded bibliography and brief commentary

Articles about medical diagnostic decision support (MDDS) systems often begin with a disclaimer such as, "despite many years of research and millions of dollars of expenditures on medical diagnostic systems, none is in widespread use at the present time." While this statement remains true in the sense that no single diagnostic system is in widespread use, it is misleading with regard to the state of the art of these systems. Diagnostic systems, many simple and some complex, are now ubiquitous, and research on MDDS systems is growing. The nature of MDDS systems has diversified over time. The prospects for adoption of large-scale diagnostic systems are better now than ever before, due to enthusiasm for implementation of the electronic medical record in academic, commercial, and primary care settings. Diagnostic decision support systems have become an established component of medical technology. This paper provides a review and a threaded bibliography for some of the important work on MDDS systems over the years from 1954 to 1993.

The Arden syntax for medical logic modules

The Arden Syntax for sharing medical knowledge bases is described. Its current focus is on knowledge that is represented as a set of independent modules that can provide therapeutic suggestions, alerts, diagnosis scores, etc. The syntax is based largely upon HELP and the Regenstrief Medical Record System. Each module, called a Medical Logic Module or MLM, is made of slots grouped into maintenance, library, and knowledge categories. The syntax has provisions for querying a clinical database and representing time. Several clinical information systems were analyzed and appear to be compatible with the syntax. The syntax has been tested for syntactic ambiguities using the tools lex and yacc. Seventeen institutions are currently in the process of adopting the Arden Syntax for their decision-support systems. A subcommittee of ASTM has been formed to develop standards for sharing medical knowledge bases. The Arden Syntax has been published by ASTM as a initial standard for sharing medical knowledge.

Medical informatics--an Australian perspective

Computers, like the X-ray and stethoscope can be seen as clinical tools, that provide physicians with improved expertise in solving patient management problems. As tools they enable us to extend our clinical information base, and they also provide facilities that improve the delivery of the health care we provide. Automation (computerisation) in the health domain will cause the computer to become a more integral part of health care management and delivery before the start of the next century. To understand how the computer assists those who deliver and manage health care, it is important to be aware of its functional capabilities and how we can use them in medical practice. The rapid technological advances in computers over the last two decades has had both beneficial and counterproductive effects on the implementation of effective computer applications in the delivery of health care. For example, in the 1990s the computer hobbyist is able to make an investment of less than $10,000 on computer hardware that will match or exceed the technological capacities of machines of the 1960s. These rapid technological advances, which have produced a quantum leap in our ability to store and process information, have tended to make us overlook the need for effective computer programmes which will meet the needs of patient care. As the 1990s begin, those delivering health care (eg, physicians, nurses, pharmacists, administrators ...) need to become more involved in directing the effective implementation of computer applications that will provide the tools for improved information management, knowledge processing, and ultimately better patient care.

Computer aided interpretation of acid-base disorders

This paper describes an expert system for the interpretation of acid-base disorders. The target users are residents in training in internal medicine, anaesthesia and intensive care medicine. The program is written in PROLOG and runs on a SUN 3/160 minicomputer. Evaluation of a learning set (N = 202) and a test set (N = 194) has proved that the system's accuracy is acceptable. As a result, the program has recently been put in routine clinical practice.

Diagnosis of complex acid-base disorders: physician performance versus the microcomputer

Patients with acid-base disturbances that are often complex frequently present to the emergency department. The sometimes hectic nature of the ED can preclude the appropriate quantitative analysis required by these disorders, especially when mixed disturbances are present. A computer program using generally accepted acid-base and electrolyte formulae was developed for use on the Apple II+ or IBM-PC microcomputer. Each of a series of 35 acid-base disturbances incorporating single, double, and triple disorders was correctly identified by the computer in less than 45 seconds. Problem sets based on the same 35 disturbances were presented to 21 physician-subjects at various levels of training from the emergency medicine, internal medicine, pediatrics, surgery, and family practice specialties. Although the physicians were given unlimited time and the necessary formulae to reach a diagnosis, they were requested to perform their analyses in the same fashion used in the ED. Although times varied widely, no physician spent more than five minutes on any problem. The physician correct response rates were 86%, 49%, and 17% for single, double, and triple disorders, respectively. The primary disorder correct response rate was 89% for double disorders and 94% for triple disorders. The primary and secondary disorder correct response rate was 58% for triple disorders. The data suggest that the microcomputer may be beneficial in the rapid assessment of complex disorders.

Applications of an inexpensive microcomputer for the general radiologist

Computer programs of interest to the general radiologist have been written by the author and others for an inexpensive microcomputer. Most of these programs are in the public domain and include: computer-assisted diagnosis; computer-assisted medical education; Bayesian analysis, general statistical analysis; word processing; and radiographic image analysis. Previously, computerized functions such as these have been limited to those with access to a large institutional computer. Due to the general availability of inexpensive microcomputers, the average radiologist or group can now afford the many benefits a computer can add to the practice of radiology.

Computer consultation in neurology: subjective and objective evaluations of the "NEUROLOGIST" system

NEUROLOGIST is a computer system for clinical consultation in neurology. The system's strategy is patterned after the 'localize first' paradigm of the expert neurologist. The system gives explanations of its conclusions, including drawings of neurologic lesions. It currently covers 130 diagnoses and is readily expandable. In this paper the NEUROLOGIST system is described and results of objective and subjective evaluations are presented and discussed. Directions for improvement and expansion of the present system are outlined.

Computer assisted diagnosis and computer consultation in neurology: preliminary testing of diagnostic accuracy for the neurologist system

The Neurologist system is a computer program for consultation in clinical neurology which employs human-like reasoning in diagnosis, covers a broad diagnostic domain, has the capacity to explain strategies and conclusions and is readily expandable. Neurologist employs the strategy of first localizing a neurologic disease, then uses these data as well as mode of disease onset, rapidly to focus on a limited number of diagnostic possibilities which are then sequentially investigated. This paper presents the results of the preliminary assessment of Neurologist's diagnostic accuracy. For a set of 30 test cases, the system's leading diagnosis was correct in 77%, and separation of correct and incorrect diagnostic hypotheses was excellent. Further evaluations of the system are in progress.

The historical development of the concepts of diagnosis and prognosis and their relationship to probabilistic inference

The concepts of diagnosis and prognosis are central to the intellectual basis of modern medical practice. These concepts are rooted in philosophical ideas which were introduced by the ancient Greeks. They were also influenced by the growth of scientific understanding following the Renaissance; and the more recent discipline or probability theory. The relative importance of these histological developments are discussed and suggestions are made about the possible nature of future developments.

Initiatives toward effective decision making and laboratory use

Escalating health care costs constitute a public issue of paramount importance today, Among the leading growth factors in this rise is the cost of hospital services, notably laboratory services. With respect to the clinical laboratory, rising costs appear to be almost entirely attributable to expanding utilization and introduction of new services. The clinical laboratory has gone through a technological revolution in two decades that has changed it from a largely manual to a highly automated system of great speed and capacity. This change had produced a change in the style of providing services, a change that includes the provision of quantities of unsolicited data. A parallel change in the style of use of the laboratory has taken place on the part of patient care physicians from a relatively sparing, problem oriented use pattern to a relatively lavish, data oriented one. These reciprocal changes have transformed medicine, in the United States, at least, into a relatively high laboratory use culture. Abandonment of the new technology and return to a simpler, more primitive laboratory world would be a drastic and most inappropriate response to the new situation. Furthermore, arbitrary measures such as rationing, quotas, and tariffs are, if enacted, almost certain to fail. The most effective long term strategies, though more demanding of time and effort, lie through modification of physician behavior through the pathways of education and research. Education and research initiatives now in progress can in time influence laboratory use patterns of physicians at all career levels, improving the logic of test use and providing more strategic, prudent, and cost effective overall laboratory utilization practices. These approaches will require much improved communication between laboratory and bedside and a new intense involvement of laboratory physicians and scientists in the tasks of helping to improve the use of laboratory tests and laboratory data.

Clinical judgment and computers

The increasingly frequent application of formal methods, including algorithms and computer programs, to processes that are ordinarily viewed as judgmental seems to be a source of both promise and unease for physicians. A consideration of some of these methods suggests that it may be helpful to attempt to distinguish carefully between judgment and computation. Medical care involves a complex of inferential processes, any of which may be performed as judgments, and some of which may be carried out as a computation. My purpose here is to identify the latter cases. The empirical evidence suggests that such a demarcation is feasible. The most important question appears not to be "Where can we use computers?" but "Where must we use human beings?" Until this matter is more thoroughly explored, tension between physicians and computer advocates will persist.

Clinical information system for junior doctors

The effect of a computer-based clinical information system is described. The information system, called House Officer Information and Scheduling System, was designed to guide junior medical staff in their decisions about the investigation of common medical problems. By comparing the management of similar groups of patients at two hospitals it is demonstrated that the system influences decisions concerning investigations. In particular, the least common condition reviewed was most affected.

Computer use in diagnosis, prognosis, and therapy

Computers are used to influence diagnostic and therapeutic decisions. The computer's information-handling capabilities allow it to serve as a reliable extension of the physician's memory and expander of the physician's information and synthesized knowledge resources. Computers have been used to facilitate decisions through organization of patient data, improved classification of patients, decision analysis in clinical settings, and simulation of expert clinical reasoning. Computer programs are more successful in narrow, constrained, single arenas of medicine with much underlying pathophysiologic understanding and where decisions are based largely on hard laboratory data. New models of synthetic reasoning that simulate expert clinical behavior show promise of supporting complicated decisions concerning problems of multiple diseases. All systems are confronted by problems of consensus and authority of the underlying information used.

Towards the simulation of clinical cognition. Taking a present illness by computer

Remarkably little is known about the cognitive processes which are employed in the solution of clinical problems. This paucity of information is probably accounted for in large part by the lack of suitable analytic tools for the study of the physician's thought processes. Here we report on the use of the computer as a laboratory for the study of clinical cognition. Our experimental approach has consisted of several elements. First, cognitive insights gained from the study of clinicians' behavior were used to develop a computer program designed to take the present illness of a patient with edema. The program was then tested with a series of prototypical cases, and the present illnesses generated by the computer were compared to those taken by the clinicians in our group. Discrepant behavior on the part of the program was taken as a stimulus for further refinement of the evolving cognitive theory of the present illness. Corresponding refinements were made in the program, and the process of testing and revision was continued until the program's behavior closely resembled that of the clinicians. The advances in computer science that made this effort possible include "goal-directed" programming, pattern-matching and a large associative memory, all of which are products of research in the field known as "artificial intelligence". The information used by the program is organized in a highly connected set of associations which is used to guide such activities as checking the validity of facts, generating and testing hypotheses, and constructing a coherent picture of the patient. As the program pursues its interrelated goals of information gathering and diagnosis, it uses knowledge of diseases and pathophysiology, as well as "common sense", to dynamically assemble many small problem-solving strategies into an integrated history-taking process. We suggest that the present experimental approach will facilitate accomplishment of the long-term goal of disseminating clinical expertise via the computer.

Computer-aided instruction at the Ottawa General Hospital

We have reviewed our experiences with the first systematic use of CAI at the University of Ottawa Medical School. The Bleich acid-base and electrolyte program was employed by senior clinical clerks in the Department of Medicine during the past year using APL version of the program, an IBM 360-65 computer linked by acoustic coupler to the typewriter-style IBM 2741 terminal. We have been impressed with the importance of: (1) minimizing technical difficulties, (2) enhancing the teaching capacity of the program (as opposed to its consultant function) and (3) carefully ensuring that the user understands its limitations. This pilot project in clinical CAI has identified problems which will likely be experienced in other medical centres and has suggested important areas for further development.