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

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Abstract

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.

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References

  • Adams, I. D., Chan, M., Clifford, P. C., et al. (1986). Computer aided diagnosis of acute abdominal pain: A multicentre study. British Medical Journal (Clinical research ed.), 293, 800–804.

    Article  Google Scholar 

  • Aliferis, C. F., Cooper, G. F., Miller, R. A., Buchanan, B. G., Bankowitz, R., & Giuse, N. B. (1996). A temporal analysis of QMR. Journal of the American Medical Informatics Association, 3, 79–91.

    Google Scholar 

  • Bankowitz, R. A., McNeil, M. A., Challinor, S. M., Parker, R. C., Kapoor, W. N., & Miller, R. A. (1989a). A computer-assisted medical diagnostic consultation service: Implementation and prospective evaluation of a prototype. Annals of Internal Medicine, 110, 824–832.

    Google Scholar 

  • Bankowitz, R. B., McNeil, M. A., Challinor, S. M., & Miller, R. A. (1989b). Effect of a computer-assisted general medicine diagnostic consultation service on housestaff diagnostic strategy. Methods of Information in Medicine, 28, 352–356.

    Google Scholar 

  • Barnett, G. O., Cimino, J. J., Hupp, J. A., & Hoffer, E. P. (1987). DXplain. An evolving diagnostic decision-support system. JAMA, 258, 67–74.

    Article  Google Scholar 

  • Bates, D. W., et al. (2003). Ten Commandments for effective clinical decision support. Journal of the American Medical Informatics Association, 10(6), 523–530.

    Article  Google Scholar 

  • Berner, E. S., Webster, G. D., Shugerman, A. A., et al. (1994). Performance of four computer-based diagnostic systems. New England Journal of Medicine, 330(25), 1792–1796.

    Article  Google Scholar 

  • Berner, E. S., Maisiak, R. S., Cobbs, C. G., & Taunton, O. D. (1999). Effects of a decision support system on physicians’ diagnostic performance. Journal of the American Medical Informatics Association, 6(5), 420–427.

    Google Scholar 

  • Bleich, H. L. (1969). Computer evaluation of acid-base disorders. Journal of Clinical Investigation, 48, 1689–1696.

    Article  Google Scholar 

  • Blois, M. S., Tuttle, M. S., & Sherertz, D. D. (1981). RECONSIDER: A program for generating differential diagnoses. In: Hefferman, H. G. (Ed.). Proceedings of the Fifth Annual Symposium On Computer Applications in Health Care (pp. 263–268). Washington, DC: IEEE Computer Society Press.

  • Collen, M. F. (1995). A history of medical informatics in the United States: 1950 to 1990. Bethesda (p. 489). Amer Med Informatics Assoc: MD. ISBN 0-9647743-0-5.

    Google Scholar 

  • Cooper, G. F. (1986). A diagnostic method that uses causal knowledge and linear programming in the application of Bayes’ formula. Computer Methods and Programs in Biomedicine, 22(2), 223–237.

    Article  Google Scholar 

  • de Dombal, F. T., Hortocks, J. C., Staniland, J. R., & Gill, P. W. (1971). Simulation of clinical diagnosis: A comparative study. British Medical Journal, 2, 575–577.

    Article  Google Scholar 

  • Durack, D. T. (1978). The weight of medical knowledge. New England Journal of Medicine, 298(14), 773–775.

    Google Scholar 

  • Feldman, M. J., & Bartlett, G. O. (1991). An approach to evaluating the accuracy of’ DXplain. Computer Methods and Programs in Biomedicine, 35, 261–266.

    Article  Google Scholar 

  • Friedman, C. P., & Wyatt, J. (1997). Evaluation methods in medical informatics (p. 311). New York: Springer. ISBN 0387942289, 9780387942285.

    Google Scholar 

  • Friedman, C. P., Elstein, A. S., Wolf, F. M., et al. (1999). Enhancement of clinicians’ diagnostic reasoning by computer-based consultation: A multisite study of 2 systems. JAMA, 282(19), 1851–1856.

    Article  Google Scholar 

  • Fryback, D. G. (1978). Bayes’ theorem and conditional nonindependence of data in medical diagnosis. Computers and Biomedical Research, 11, 423–434.

    Article  Google Scholar 

  • Giuse, N. B., Bankowitz, R. A., Giuse, D. A., Parker, R. C., & Miller, R. A. (1989a). Medical Knowledge Base Acquisition: The Role of Expert Review Process in Disease Profile Construction. Proceedings of Thirteenth Annual Symposium on Computer Applications in Medical Care (pp. 105–109). Washington, DC: IEEE Press.

  • Giuse, N. B., Giuse, D. A, & Miller, R. A. (1989b). Medical knowledge base construction as a means of introducing students to medical informatics. Proceedings of the International Symposium on Medical Informatics and Education (pp. 228–232). Victoria, BC.

  • Giuse, D. A., Giuse, N. B., & Miller, R. A. (1990). Towards computer assisted maintenance of medical knowledge bases. Artificial Intelligence in Medicine, 2, 21–33.

    Article  Google Scholar 

  • Giuse, N, B, Giuse, D. A, Bankowitz, R. A., & Miller, R. A. (1993a). Comparing contents of a knowledge base to traditional information sources. Proceedings of the Seventeenth Annual Symposium on Computer Applications in Medical Care. Washington DC: McGraw-Hill, Nov. 1993.

  • Giuse, D. A., Giuse, N. B., & Miller, R. A. (1993b). Consistency enforcement in medical knowledge base construction. Artificial Intelligence in Medicine, 5, 245–252.

    Article  Google Scholar 

  • Giuse, N. B., Giuse, D. A., Miller, R. A., Bankowitz, R. A., Janosky, J. E., Davidoff, F., et al. (1993c). Evaluating consensus among physicians in medical knowledge base construction. Methods of Information in Medicine, 32, 137–145.

    Google Scholar 

  • Giuse, D. A., Giuse, N. B., & Miller, R. A. (1995). Evaluation of long-term maintenance of a large medical knowledge base. Journal of the American Medical Informatics Association, 2, 297–306.

    Google Scholar 

  • Gorman, P. N., & Helfand, M. (1995). Information seeking in primary care: How physicians choose which clinical questions to pursue and which to leave unanswered. Medical Decision Making, 15(2), 113–119.

    Article  Google Scholar 

  • Gorry, A. (1968). Strategies for computer-aided diagnosis. Mathematical Biosciences, 2, 293–318.

    Article  Google Scholar 

  • Gorry, G. A., & Barnett, G. O. (1968). Experience with a model of sequential diagnosis. Computers and Biomedical Research, 1, 490–507.

    Article  Google Scholar 

  • Horrocks, J. C., McCann, A. P., Staniland, J. R., Leaper, D. J., & de Dombal, F. T. (1972). Computer-aided diagnosis: Description of an adaptable system, and operational experience with 2, 034 cases. British Medical Journal, 2(5804), 5–9.

    Article  Google Scholar 

  • Hupp, J. A., Cimino, J. J., Hoffer, E. F., Lowe, H. J., & Barnett, G. O. (1986). Explain-A computer-based diagnostic knowledge base. In: Proc Fifth World Conference on Medical Informatics, MEDINFO 86 (pp. 3117–3121). Amsterdam: North-Holland.

  • Kingsland, L. C. III, Sharp, G. C., Kay, D. R., Weiss, S. M., Roeseler, G. C., & Lindberg, D. A. B. (1982). An expert consultant system in rheumatology: AI/RHEUM. Proc Sixth Ann Symp Comput Appl Med Care (pp. 748–752).

  • Kingsland, L., Sharp, G., & Capps, R. (1983). Testing of a criteria-based consultant system in rheumatology. In J. van Bemmel, M. Ball, O. Wigertz, et al. (Eds.), Proceedings of MEDlNFO-83 (pp. 514–517). Amsterdam, The Netherlands: North-Holland.

    Google Scholar 

  • Lau, L. M., & Warner, H. R. (1992). Performance of a diagnostic system (Iliad) as a tool for quality assurance. Computers and Biomedical Research, 25, 314–323.

    Article  Google Scholar 

  • Ledley, R. S., & Lusted, L. B. (1959). Reasoning foundations of medical diagnosis. Science, 130, 9–21.

    Article  Google Scholar 

  • Leigh, T. M., Young, P. R., & Haley, J. V. (1993). Performances of family practice diplomates on successive mandatory recertification examinations. Academic Medicine, 68(12), 912–918.

    Article  Google Scholar 

  • Lindbeg, D. A. B., Rowland, L. R., Buch, C. R. Jr., Morse, W. F., & Morse, S. S. (1968). CONSIDER: A computer program for medical instruction. Proc Ninth IBM Med Symp.

  • Lipkin, M., & Hardy, J. D. (1958). Mechanical correlation of data in differential diagnosis of hematological diseases. JAMA, 166, 113–123.

    Google Scholar 

  • Madlon-Kay, D. J. (1989). The weight of medical knowledge: Still gaining. New England Journal of Medicine, 321(13), 908.

    Google Scholar 

  • Masarie, F. E., Jr., Miller, R. A., & Myers, J. D. (1985). INTERNIST-I PROPERTIES: Representing common sense and good medical practice in a computerized medical knowledge base. Computers and Biomedical Research, 18, 458–479.

    Article  Google Scholar 

  • Miller, R. A. (1984). Internist-1/CADUCEUS: Problems facing expert consultant programs. Methods of Information in Medicine, 23, 9–14.

    Google Scholar 

  • Miller, R. A. (1990). Why the standard view is standard: People, not machines, understand patients’ problems. Journal of Medicine and Philosophy, 15, 581–591.

    Google Scholar 

  • Miller, R. A. (1994). Medical diagnostic decision support systems past, present, and future. Journal of the American Medical Informatics Association, 1, 8–27.

    Google Scholar 

  • Miller, R. A. (1996). Evaluating evaluations of medical diagnostic systems. Journal of the American Medical Informatics Association, 3, 429–431.

    Google Scholar 

  • Miller, R. A. (1997). A heuristic approach to the multiple diagnoses problem. In E. Keravnou, C. Garbay, R. Baud, & J. Wyatt (Eds.), Artificial intelligence in medicine, proceedings of AIME 97. Lecture notes in artificial intelligence series, #1211 (pp. 187–198). Berlin: Springer.

    Google Scholar 

  • Miller, R. A., & Gardner, R. M. (1997). Summary recommendations for responsible monitoring and regulation of clinical software systems. Annals of Internal Medicine, 127(9), 842–845.

    Google Scholar 

  • Miller, R. A., & Masarie, F. E., Jr. (1989). Use of the quick medical reference (QMR) (R) program as a tool for medical education. Methods of Information in Medicine, 28, 340–345.

    Google Scholar 

  • Miller, R. A., & Masarie, F. E., Jr. (1990). The demise of the “greek oracle” model for medical diagnostic systems. Methods of Information in Medicine, 29, 1–2.

    Google Scholar 

  • Miller, R. A., & Masarie, F. E. (1992). The Quick Medical Reference (QMR) Relationships function: Description and evaluation of a simple, efficient “multiple diagnoses” algorithm. Proc MEDINFO 92 (pp. 512–518). Geneva, Switzerland.

  • Miller, R. A., & Schaffner, K. F. (1982). The logic of problem-solving in clinical diagnosis: A course for second-year medical students. Journal of Medical Education, 57, 63–65.

    Google Scholar 

  • Miller, R. A., Pople, H. E., Jr., & Myers, J. D. (1982). INTERNIST-1, an experimental computer-based diagnostic consultant for general internal medicine. New England Journal of Medicine, 307, 468–476.

    Article  Google Scholar 

  • Miller, R. A., Schaffner, K. F., & Meisel, A. (1985). Ethical and legal issues related to the use of computer programs in clinical medicine. Annals of Internal Medicine, 102, 529–536.

    Google Scholar 

  • Miller, R. A., Masarie, F. E., & Myers, J. D. (1986a). “Quick medical reference” for diagnostic assistance. MD Computing, 3, 34–48.

    Google Scholar 

  • Miller, R. A., McNeil, M. A., Challinor, S., Masarie, F. E., & Myers, J. D. (1986b). Status report: The INTERNIST-1/quick medical reference project. Western Journal of Medicine, 145, 816–822.

    Google Scholar 

  • Nash, F. A. (1954). Differential diagnosis: An apparatus to assist the logical faculties. Lancet, 1, 874.

    Article  Google Scholar 

  • Newell, A., & Simon, H. A. (1972). Human problem solving. Englewood Cliffs, NJ: Prentice Hall.

    Google Scholar 

  • Newman-Toker, D. E., & Pronovost, P. J. (2009). Diagnostic errors—The next frontier for patient safety. JAMA, 301(10), 1060–1062.

    Article  Google Scholar 

  • Nordyke, R. A., Kulikowski, C. A., & Kulikowski, C. W. (1971). A comparison of methods for the automated diagnosis of thyroid dysfunction. Computers and Biomedical Research, 4(4), 374–389.

    Article  Google Scholar 

  • Osheroff, J. A., Forsythe, D. E., Buchanan, B. G., Bankowitz, R. A., Blumenfeld, B. H., & Miller, R. A. (1991). Physicians’ information needs: An analysis of questions posed during clinical teaching in internal medicine. Annals of Internal Medicine, 114, 576–581.

    Google Scholar 

  • Parker, R. C., & Miller, R. A. (1989). Creation of a knowledge base adequate for simulating patient cases: Adding deep knowledge to the INTERNIST-1/QMR knowledge base. Methods of Information in Medicine, 28, 346–351.

    Google Scholar 

  • Pauker, S. G., Gorry, G. A., Kassirer, J. P., & Schwartz, W. B. (1976). Towards the simulation of clinical cognition. Taking a present illness by computer. American Journal of Medicine, 60(7), 981–996.

    Article  Google Scholar 

  • Pearl, J. (1987). Evidential reasoning using stochastic simulation of causal models. Artificial Intelligence, 32, 245–252.

    Article  Google Scholar 

  • Pople, H. E., Jr. (1982). Heuristic methods for imposing structure on ill-structured problems: The structuring of medical diagnostics. In P. Szolovits (Ed.), Artificial intelligence in medicine (pp. 119–190). Boulder, Co: Westview Press. AAAS Symposium Series, no. 51.

    Google Scholar 

  • Pople, H. E., Myers, J. D., & Miller, R. A (1975). DIALOG: A model of diagnostic logic for internal medicine. In: Proceedings of the fourth International Joint Conference on Artificial Intelligence (pp. 848–855). Cambridge, Massachusetts: MIT Artificial Intelligence Laboratory Publications.

  • Porter, J. F., Kingsland, L. C., I. I. I., Lindbeerg, D. A., et al. (1988). The AI/RHEUM knowledge-based computer consulatant system in rheumatology. Performance in the diagnosis of 59 connective tissue disease patients from Japan. Arthritis and Rheumatism, 31, 219–226.

    Article  Google Scholar 

  • Ramnarayan, P., Kapoor, R. R., Coren, M., Nanduri, V., Tomlinson, A. L., Taylor, P. M., et al. (2003). Measuring the impact of diagnostic decision support on the quality of clinical decision making: Development of a reliable and valid composite score. Journal of the American Medical Informatics Association, 10(6), 563–572.

    Article  Google Scholar 

  • Ramnarayan, P., Tomlinson, A., Kulkarni, G., Rao, A., & Britto, J. (2004). A novel diagnostic aid (ISABEL): Development and preliminary evaluation of clinical performance. Studies in Health Technology and Informatics, 107(Pt 2), 1091–1095.

    Google Scholar 

  • Ramnarayan, P., Winrow, A., Coren, M., Nanduri, V., Buchdahl, R., Jacobs, B., et al. (2006). Diagnostic omission errors in acute paediatric practice: Impact of a reminder system on decision-making. BMC Medical Informatics and Decision Making, 6, 37–39.

    Article  Google Scholar 

  • Ramsey, P. G., Carline, J. D., Inui, T. S., Larson, Lo. Gerfo. J. P., Norcini, J. J., & Wenrich, M. D. (1991). Changes over time in the knowledge base of practicing internists. JAMA, 266(8), 1103–1107.

    Article  Google Scholar 

  • Shiffman, R. N. (1995). Guideline maintenance and revision. 50 years of the Jones criteria for diagnosis of rheumatic fever. Archives of Pediatrics and Adolescent Medicine, 149(7), 727–732.

    Google Scholar 

  • Shortliffe, E. H. (1976). Computcr-based medical consultations: MYCIN. Artificial Intelligence Series. New York: Elsevier Computer Science Library.

    Google Scholar 

  • Statnikov, A., Aliferis, C. F., Tsamardinos, I., Hardin, D., & Levy, S. (2005). A comprehensive evaluation of multicategory classification methods for microarray gene expression cancer diagnosis. Bioinformatics, 21(5), 631–643.

    Article  Google Scholar 

  • Stead, W. W., Haynes, R. B., Fuller, S., Friedman, C. P., et al. (1994). Designing medical informatics research and library–Resource projects to increase what is learned. Journal of the American Medical Informatics Association, 1(1), 28–33.

    Google Scholar 

  • Szolovits, P., Patil, R. S., & Schwartz, W. B. (1988). Artificial intelligence in medical diagnosis. Annals of Internal Medicine, 108, 7.

    Google Scholar 

  • Warner, H. R., Jr. (1989). Iliad: Moving medical decision-making into new frontiers. Methods of Information in Medicine, 28, 370–372.

    Google Scholar 

  • Warner, H. R., Toronto, A. F., Veasey, L. G., & Stephenson, R. A. (1961). Mathematical approach to medical diagnosis. JAMA, 177, 75–81.

    Google Scholar 

  • Warner, H. R, Haug, P., & Bouhaddou, O., et al. (1987). ILIAD as an expert consultant to teach differential diagnosis. In: Proceedings of the Twelfth Annual Symposium on Computer Applications in Medical Care (pp. 371–376). New York: IEEE Computer Society Press.

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Acknowledgments

Disclosure of (Non) Conflicts of Interest: Dr. Miller previously received royalties from the University of Pittsburgh in recognition of his work there in authoring the Quick Medical Reference (QMR)® program and knowledge base for diagnostic decision support in Internal Medicine; he donated most of those royalties to charity. The program is no longer being sold. Dr. Miller receives royalties from Vanderbilt University based on Vanderbilt’s commercialization of the WizOrder CPOE system, and the Star electronic health record system, both of which he helped to develop. The majority of income from licensing these systems goes directly to Vanderbilt School of Medicine, per se. Dr. Miller does not own stock in, or serve as an employee or officer of, any of those vendors’ companies. Work on INTERNIST-1 and QMR has been supported over the years by NIH grants from DRR and NLM; grants from Paul Mongerson and his CAMDAT Foundation; and, by internal funding from the University of Pittsburgh. In addition to the author, major contributors to the INTERNIST-1 and QMR projects include: Jack D. Myers, MD; Harry E. Pople, Jr., PhD; Griff Smith, PhD; Zachary Moraitis, MD; Craig Dean; Casey Quayle; Chuck Olson, PhD; Fred E. Masarie, Jr., MD; Nunzia B. Giuse, MD, MLS; Dario A. Giuse, Dr. Ing; Richard A. Bankowitz, MD; and numerous medical students and faculty members from the University of Pittsburgh and other institutions.

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Miller, R.A. Computer-assisted diagnostic decision support: history, challenges, and possible paths forward. Adv in Health Sci Educ 14 (Suppl 1), 89–106 (2009). https://doi.org/10.1007/s10459-009-9186-y

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