Crowd Wisdom for Diagnosis?

Ted.E.Palen at KP.ORG Ted.E.Palen at KP.ORG
Thu Jul 18 18:22:22 UTC 2013


Great discussion.
As medical student I did a rotation with Frank Naeymi-Rad while he was 
developing the intelligent medical record.  In this early system as the 
user inputted symptoms and physical exam findings (in a codified manner) 
it was running DxPlain, Iliad, and QMR in background.  When you finished 
inputting your data a list of diagnoses was presented in order of 
probability.  That was 30 years ago.  Unfortunately, as Dr Papier points 
out, these types of systems were not widely incorporated into electronic 
medical records.  But imaging if EMR user interfaces for data entry was 
improved and  if patients entered their own data, and this data was feed 
to systems like IBMs Watson, Visualdx, or similar systems how much better 
our cognitive diagnostic abilities could be.  In addition, as more data is 
collected the systems could become "smarter."  They could also suggest 
appropriate additional diagnostic or treatments based on the evidence, 
cost-effectiveness, and track clinical outcomes.  Could this result in 
being able to do "real-time" comparative effectiveness research.

We have come a long way since my experience with the intelligent medical 
record but unfortunately we are still not using these kinds of tools and 
capabilities to actually change the way medicine is practiced.

Ted E. Palen, PhD MD, MSPH | Physician Investigator | Institute for Health 
Research | Kaiser Permanente Colorado
Physician Manager for Clinical Reporting | Medical Cost Management| 
Colorado Permanente Medical Group
( 303-614-1215 | 7 303-614-1305 | * ted.e.palen at kp.org

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From:   Art Papier MD <apapier at LOGICALIMAGES.COM>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   07/18/2013 12:07 PM
Subject:        Re: Crowd Wisdom for Diagnosis?



Yes clinical decision support, and using tools at the time of action, 
instead of relying on memory alone needs to be taught and adopted widely. 
Wonderful systems like Dxplain, Iliad, QMR, PKC  were developed 30 years 
ago or more, but never widely adopted.  Kahneman asserts that System 2 
thinking is hard and humans don’t like to spend much time really thinking 
and being analytical.  Humans actually prefer to not use their brain to 
think, process and solve!  It is too difficult Kahneman argues, we are 
lazy and prefer quick, blink type judgements.  In thinking about 
diagnostic CDS, we need to realize that the output of diagnostic CDS 
cannot increase cognitive burden, it must make answers more obvious.  So 
yes we need to create and teach to systems that help the clinician 
capacity to remember and process, but we must focus on the output of CDS, 
these systems must relieve cognitive burden and make it easier to see 
answers.   For anyone on the list that is curious about a different 
approach to CDS please visit www.visualdx.com  VisualDx has a 98% renewal 
rate at hospitals, is used in over half of US medical schools, and over 
1500 hospitals and large clinics.   Ten of thousands of clinicians use 
VisualDx to assist in pattern recognition and diagnosis.   Here is just 
one example of how CDS is used in busy work environments 
http://www.visualdx.com/user-stories/gonococcemia  Please feel to contact 
me off the list with research questions or collaborative ideas.
 
Art Papier MD, Logical Images, 
Associate Professor of Dermatology and Medical Informatics
University of Rochester
 
From: Hoffer, Edward P.,M.D. [mailto:EHOFFER at PARTNERS.ORG] 
Sent: Wednesday, July 17, 2013 2:01 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: Crowd Wisdom for Diagnosis?
 
I would suggest hat rather than trust to serendipity - ie, someone on the 
list might have some useful ideas - that doctors with a puzzling case 
should avail themselves of computer-based clinical decision support 
systems such as DXplain (visit dxplain.net) or Isabel.  These have been 
well-proven to be useful in improving one's differential diagnosis.
 
Ed
 
Edward  P Hoffer MD
MGH Lab of Computer Science

From: Peggy Zuckerman [peggyzuckerman at GMAIL.COM]
Sent: Wednesday, July 17, 2013 12:27 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: Crowd Wisdom for Diagnosis?
Dr. Zamir's suggestion that doctors who are puzzled by a diagnosis and 
turn to this or similar sites could solve some of the errors  that occur. 
Frankly, I am more concerned about the doctor who has made a misdiagnosis, 
and has no idea that he has done so.
 
Thus the need for the patient to search out more input into the unresolved 
issue.  There is little information on the impact of misdiagnosis, but 
many in this community have personal experience with this.  Multiply that 
tenfold and you get a sense of the cost to our society.
 
A friend sums this up in the simple question that floats in the mind of 
every frustrated patient, "How do I know if my doctor knows what he is 
talking about?".
 
Peggy Z
 
On Wed, Jul 17, 2013 at 7:35 AM, Timothy Krohe <tkrohe1 at gmail.com> wrote:
Agree with Dr Zamir the better utility of posting to physicians-only 
services . 
 
While my goal is not to provide a plug,  this type of assistance happens 
regularly on sermo.com .  In frequent posts,   a physician  describes a 
case,  requests help AND usually provides feedback to enhance learning. 
All posts are visible to all physicians, so there are glimpses of "how 
(other) doctors think".  Access is free to licensed physicians.  The 
website has MANY other humor/stress release/political/administrative 
postings as well so is not purely clinical and you need to sift for the 
clinically useful posts.
 
In the DoD, there is a worldwide teleconsult service that emails requests 
for help , often from the outlying combat or isolated bases. A large group 
of specialists/internists from the larger military hospitals have 
responsibility to respond quickly with comments/recommendations.   Very 
collegial and supportive for those docs/corpsmen/NPs/PAs providing care in 
isolated area. Access obviously limited to DoD.
 
I have enjoyed and learned (and I hope helped other MDs) from both 
systems.  No fees for the reqeuster in either.
 
TL Krohe MD General Internal Medicine
 
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