process is a dynamic one, and tests and Systems. ed. J Mendel and K Fu. Academic Press: New Conf Artif Intell, Tokyo. 942-950. 1979.treatments made through time are more im- York, 1970. 14. Kulikowski, C, and J Ostroff: Constructing an Ex-

4. Ledley, R, and L Lusted: Reasoning Foundations of pert Knowledge Base for Thyroid Consultation Usingportant than diagnoses. Medical Diagnosis. Science. 130:9-12, 1959. Generalized A.l. Techniques. Proc 4th Annual ComputerWarner claims that the limit to computer- 5. Bleich, H: Computer-Based Consultation on Electro- Applic Med Care. ed. J O'Neill. 175-180. IEEE Computer

aided medical decision making is not com- lyte and Acid-Base Disorders. Amer J Med. 53:285-291, Society: Los Alamitos, California, 1980.1971. 15. Pople, H: INTERNIST - Methods for Structuring

puter hardware or software, but "medical 6. Kulikowski, C: Artificial Intelligence Approaches to the Medical Problem List. Proc 6th Illinois Conf Med In-ware."20 This must be provided by medical Medical Consultation. Proc 4th Illinois Cont Med Infor form Sys, 1980.

care experts. Warner feels that the pro- Sys. Regional Health Resources Center: Urbana, Illinois, 16. Durel, T, and S Weinstein: Medical Information Sys-1979. tems - Problems of Integration. Proc 3rd Annual Com-

gress in computerized medicine will be ex- 7. Myers J, and H Pople: INTERNIST: A Consultative Di- puter Applic Med Care. ed. R Dunn. 292-295. IEEE Com-actly as rapid or as slow as the progress in agnostic Program in Internal Medicine. Proc 1st Annual puter Society: Los Alamitos, California, 1979.medical ware. Computer Applic Med Care. IEEE: New York, 1977. 17. Warner, H: Computer-Assisted Medical Decision

8. Shortliffe, E: Computer-Based Medical Consultations Making. Academic Press: New York, 1979.Although choosing simpler before harder MYCIN. American Elsevier: New York, 1976. 18. Murphy, E: The Logic of Medicine. Johns Hopkins

problems and developing a theory of diag- 9. Andersen, H. and M Barclay: Prediction of Delivery University Press: Baltimore, 1976.

nosis are necessary steps to the success Date in a Computerized Prenatal Record System, Proc 4th 19. Warner. H: Computer-Assisted Medical DecisionAnnual Computer Applic Med Care. ed. J O'Neill. 307-310. Making. Academic Press: New York, 1979.

of computer-aided medical decision mak- IEEE Computer Society: Los Alamitos. California. 1980. 20. Ibid.ing, they are not, in and of themselves, suf- 10. van Melle. W: Domaiii Independenit Production Rule 21. Bush. I: MIS - The Human Connection, Proc 4th

ficient to guarantee success. The human System for Consultation Programs. Proc 6th Intern'I Joint Annual Computer Applic Med Care. ed. J O'Neill. 444-453.Conf Artif Intell. 923-925, 1979. IEEE Computer Society: Los Alamitos. California, 1980.

factor plays a crucial role. The systems 11. Bennett, J. and Goldman: D.CLOT: A Knowiedge- 22. Ibid.must interact gracefully with the users. Based Consultation for Bleeding Disorders. Computer 23. Levy, A: Is Informatics a Basic Medical Science?

In the 1960s and 1970s, the role of the Science Department. Stanford University. Memo HPP-80- MEDINFO. 77:979-981. North-Holland Publ: Amsterdam,user was underestimated. For applications 7. 1980.197

12. Clancey. W. E Shortliffe, and B Buchanan: Intelli- 24. Shortliffe, E: Computer-Based Medical Consulta-with the complexity of medical diagnosis, gent Computer-Aided Instruction for Medical Diagnosis. tions MYCIN. American Elsevier: New York, 1976.

the user must be actively involved in the Proc 3rd Annual Computer Applic Med Care. ed. R Dunn.117-122. IEEE Computer Society: Los Alamitos. California,

operation of the system.21 He must be able 1979. This article is adapted from a paper in Applications ofto manipulate the computer system with- 13. Weiss, S. and C Kulikowski: EXPERT: A System for Computers in Medicine, published in 1982 by IEEE/EMBS;out calling a programmer or learning a new Developing Consultation Models. Proc 6th Intern'l Joint edited by M.D. Schwartz, Ph.D.

language.Computer systems can be developed

that have user-friendliness. The computer Res stance lessen ngindustry has, however, inadequately in-vested in user-friendly systems.22 Theawareness of the importance of the user in as research ncreasescomplex rriedical applications is fortunate-ly growing. By ADRIANA REYNERIThe need for a science of medical infor- A R N rEYer

mation or a theory of medical diagnosis is EMB Staff Writerneeded to further research in medical diag- omputers have arrived in medicine, EMB Magazine has reviewed the litera-nosis. A. Levy23 and E. Shortliffe24 have ar- and they're here to stay. Though ture and interviewed physicians, engineersgued for the creation of more departments most scientists agree on this, pro- and computer scientists currently re-of medical information science. They feel a fessionals seem to debate most of the oth- searching medical-expert systems. The re-formal emphasis on medical information er issues raised when intelligent machines sults have been compiled into this over-sciences is crucial to the success of com- enter a profession that for centuries has view of developments in computer-aidedputer-aided medical decision making. been regarded as an art. One of the most medical decision-making systems.The development of a theory of medicine controversial and problem-ridden areas is The federal government has been sup-

depends, in part, on the dedication of the the field of automated decision making. porting research on medical computer ap-professionals in that field. The future of The issues in computer-aided medical plications for decades. More recently, thecomputers in society at large will also crit- decision-making systems fall into the National Library of Medicine (NLM), part ofically determine the possibilities for com- broad categories: the appropriateness of the National Institutes of Health (NIH), hasputers in medicine. Developments across the technology, means of knowledge rep- been sponsoring research grants in itsdisciplines will affect the ability of people resentation, cost-effectiveness, useful- Computers in Medicine program. The pro-and computers to fruitfully interact. Most ness, and user friendliness. Obstacles lie gram, initiated 2V/2 years ago, supports re-would predict that these interactions will in the path of further development of medi- search in a broad range of knowledge man-become progressively richer, cal-expert systems. These include short- agement, such as artificial intelligence,

age of funds, problems of language and knowledge representation, and knowledgeReferences: logic, and resistance from the medical utilization, says Peter Clepper, program of-

1.Fryback. 0: Bayes Theorem and Conditional Non-In- communitY. Yet, computers have the PO- ficer.dependence of Data In Medical Diagnoais. Computers tnilt c spwru ol hte- "u ocnrto ih o so hand Biomed Res. 11:423-434, 1978. tnilt c spwru ol hte- "u ocnrto ih o so h

2. Nilsson. N: Learning Machines. McGraw-Hill: New hance the patient-physician relationship basic understanding of how we make upYork, 1965. adices h fiinyo elhcr u id o emk eia ei

3.Viglione, SS: Applications of Pattern Recognition an nraeteefcec fhat-ae ormns, o emk eia eiTechnology. Adaptive, Learning, and Pattern Recognition delivery. sions," Clepper says. "Once we know

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EXJFJ1PUTEFS Iii P1EOIDF1Ethese things, we can adopt them to the point of patient care," Clepper says. "We at the University of Pittsburgh, advancedcomputer-based decision-making sys- don't see any of this as supplanting the art one of the first knowledge-based computertems." of the medical practitioner; rather, it will diagnostic systems that they hope one day"Technology is advancing in enormous augment human powers for the welfare of will contain the entire domain of knowl-

bounds each year," Clepper says. "Yet all." edge in internal medicine. Dubbed INTER-there's difficulty in finding support for Dr. Gwilyn Lodwick, chairman of the de- NIST, the system now contains 550 of thelong-term projects on basic problems. This partment of radiology at the University of projected 750 diseases.type of research needs to be done if the Missouri-Columbia, pioneered one of the Myers, who has practiced internal medi-new technology is to be used appropriate- first computer-aided medical decision-mak- cine since the mid-1930s, has witnessed aly. We feel that as part of NIH we can make ing systems and the first computerized ra- tremendous knowledge explosion. In thethe most significant difference by addres- diology program. He says he feels respon- early 1970s, Myers got the idea to developsing fundamental issues." sible for creating a new, perhaps a vast system to guide the internist in diffi-

In 1982, grants for the NLM's Computers idiosyncratic, medical language of signs cult problems.in Medicine program will total $2.5 million. foranalyzing X-ray images. "The human brain can only deal with sev-The funds are distributed to 20 research Lodwick is the inventor of MARS, the en hypotheses at one time. The difficultcenters across the country. Computer sci- Missouri Automated Radiology System, problems often have several dozen possi-ence represents a great opportunity for ex- that supports the diagnosis of rare bone tu- ble hypotheses."ploitation of our growing store of health mors and indicates proper management of The difficult problems in internal medi-knowledge, Clepper says. Research results more than 90 percent of the cases. Lod- cine require more information than a physi-to date justify a certain amount of cautious wick began building his diagnostic model cian could ever store. It takes the physicianoptimism. in the early 1950s, when he began analyz- a long time to sequentially process a largeTwo reasons contribute to Clepper's op- ing X-rays of bone tumors by constructing number of hypotheses, Myers says. In the

timism. The medical community, especially image-processing models. process, he might easily overlook a possi-the younger, "computer-literate" segment In the early 1960s, Lodwick originated bility. The computer, which has a hugeof physicians, is more and more accepting his computer-aided diagnostic system, memory, can consider multiple hypothesesof computer systems, Clepper says. Also, based on these image-processing models. at once. It could store all knowledge in in-microcomputers are making computer as- In the late 1970s, Lodwick revised his mod- ternal medicine.sistance more available and more afforda- el after reading Is Human Memory Obso- Though many problems remain to beble to clinicians. lete? by Harvard professor of pyschology, solved, computer-aided decision-makingOn a less positive note, Clepper says, Dr. W.K. Estes. The article led to Lodwick's systems will enhance the practice of medi-

overstated accomplishments from past adoption of "chunking" theory, which cine, Myers says. The systems will de-em-computer research have led to some skep- states that humans process several sepa- phasize the simple memory and recall in-ticism about future applications. For this rate bits of information as a single mes- volved in medicine and re-emphasize theand other reasons, physicians frequently sage. role of the physician as an expert dataexpect more than the state of the art is ca- Four to eight pieces of information are gatherer.pable of, Clepper says. the maximum that the mind can accept at "The systems will free the physicianNor do all computer scientists under- one time, yet physicians use an average of from arduous routine memory tests and

stand clinical realities. 22.8 discrete pieces of information to diag- leave him more time to interact with the pa-Computer scientists have their own dis- nose bone tumors. Lodwick has identified tients," Myers says. "The impersonality in

ciplinary framework, which does not al- more than 33 different signs of tumor. "I medicine is time-related. Expert systemsways accommodate biomedical nuances. combined these into a pattern of signs," he make medicine more personal."Traditionally, physicians have not been says. One of the divisions of MIT's Laboratorymathematically oriented, so that interdisci- Lodwick's final model is based on four for Computer Science, the "Clinical Deci-plinary dialogues with computer scientists types of information: degree of bone de- sion-Making Group" receives its majorhave often been frustrating. struction; location, size and shape of the funding from the NLM.At NLM, "we feel that we can make a sig- tumor; proliferation of reparative bone; and The group researches basic core issues

nificant contribution by bringing together presence of tumor bone. The model uses in knowledge representation. Dr. Peter Szo-these two domains," says Clepper, adding 52 separate question-and-answer groups to lovits, director, maps out the areas of basicthat when mutual understanding has been make a diagnosis. The answers are ana- research.established between the two groups, work lyzed according to a Bayesian system of Diagnostic programs should have acan progress. probabilities, sense of self, Szolovits says. This way aWhen the professionals are exposed to The MARS system represents a success- system can reason not only with what it

the complexities of the other's world, they ful hybrid of Bayesian and artificial intelli- knows but about what it knows, asking it-become intrigued and want to continue ex- gence applications to a subspecialized self, "Have made a diagnostic error, or isploring it, Clepper says. The development area of medicine. It provides useful infor- this really anew disease?"of computer diagnostic systems is a young mation to physicians possessing only a "This is the most difficult, but the mostand exciting field. Especially exciting is general knowledge. The system not only fun area in artificial intelligence research,"the growth of computerized medical expert works as a physician extender, but it can Szolovits says.systems. also serve as an educational device. The group is also devising a program"They distribute knowledge right to the Dr. J. Myers and Dr. H. Pople, professors that will explain to a non-computer person |

EMB MAGAZINE JUNE 1982 23

EOEJPFUTEFS Iii IllEIJIEJIFEwhat it's doing. Other basic problems that medicine. It could be conceivable that pe- that doctors opposed applications thatthe group is attacking include: developing tients get better medical service for more threatened their professional role. At thea program that creates more understand- money," Szolovits says. Or, it could be con- same time, the doctors feared being leftable English and screens non-essential in- ceivable that patients will get better medi- behind in a developing field.formation; creating a program that can rea- cal service for less money, if expert sys- Shortliffe concludes that doctors are ac-son causally by working on two levels, tems can fulfill a monitoring role to prevent cepting of computer assistance that willassociative and detail-representational; de- error, raising red flags when a procedure improve the quality of patient care. Theyveloping a program that can represent doesn't seem reasonable. worried, however, that centralized data sys-changes over time; and devising a program Though scientists building these sys- tems will invite government intervention.that can emulate the way people deal with tems feel computers will become invalua- They also objected on ethical grounds,uncertainty. ble diagnostic tools, many practicing phy- claiming that certain tasks are not appro-The group is applying their research in a sicians oppose computer-aided diagnosis. priate for computers and that analysis of

few areas. These include electrolyte im- Arguments against adopting the technolo- human decision making will debase man-balance, cancer therapy and digitalis treat- gy range from, "So you're trying to replace kind.ments. us; how long will it take?" to less emotion- However, the medical community's re-Though most of the group's research is ally-based concerns about health policy sistance seems to be lessening, just as the

far from application, Szolovits has given and ethics. enthusiasm of artificial intelligence re-some thought to the cost benefits of the Though researchers stress that comput- searchers burgeons.automated decision-making systems. He ers will aid physicians, not replace them, "The intellectual problems are terrific,feels there are indications that the systems some doctors perceive computers as a trying to formulate what is known aboutmay prove cost-effective. For one, as hard- threat to their practices. science and medicine," says Szolovits.ware becomes cheaper, it will become part Physicians swearing by Apollo, Asclepi- "The challenge of medical artificial sys-of a physician's equipment repertoire, used us, Hygenia and Panaceia to keep their pa- tems is that they deal with real problemsfor billing, patient scheduling, and form tients from "harm and injustice" are con- that have their own life. It's very easy toprocessing. The only costs will be devel- cerned with the effects of artificial see if you're actually solving something."opment, which will amortize over the num- intelligence systems on the quality of Szolovits continues, "It's a very youngber of people who use the systems, and health care. field. Everyone's excited. The number ofmaintenance. Stanford University's Dr. Ed Shortliffe, problems far exceeds the number of peo-

"It certainly seems conceivable that the surveying physicians' attitudes toward di- ple to solve them."systems will raise and lower the cost of agnostic systems found, not surprisingly,

How you gonna keep 'emdown in the lab?

Computer's value not limited to large practicesBy RALPH ROSENBERG, M.D.

Enosburg Falls, VermontMA y first experience with computers the next two were clinical. The bookwork most important items would stick after be-

was in college in 1964. This brief was straightforward. We were expected to ing relearned several times.encounter involved some lab exer- learn vocabulary and basic principles of hu- My first serious experience with the re-

cises in a freshman physics course. It was man biology, pathology, diagnosis, and sponsibilities and problems of patient carenot very exciting and made little impres- treatment. A large quantity of information came in 1970 during the third year of medi-sion on me. began to appreciate the po- was presented, but we were only expected cal school. was assigned a patient, andtential value of computers in medical to learn enough to pass the exams. Some was expected to do a "workup" under theschool after being exposed to the prob- of us wondered whether the parts that supervision of a resident physician. Forlemsof patient care. slipped through would be missed some- me, this was a disturbing experience.The curriculum of the medical school day. We were reassured that we could easi- found that the material had learned from

attended was divided into two main sec- Iy look things up if we needed more infor- the textbooks and lectures during the first|tions. The first two years were bookwork; mation on a particular subject and that the two years did not adequately address many

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