History of Health Information Technology in the U.S.History of Clinical Decision

Support SystemsLecture b – Examples of Early CDS Systems

This material Comp5_Unit7 was developed by The University of Alabama Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000023

History of Clinical DecisionSupport Systems

Learning Objectives• Describe various types and structures of clinical decision support (CDS)

systems• Discuss the evolution of clinical decision support from expert system

research• Discuss the changes in focus of clinical decision support from the 1980s to

the present• Discuss the change in architecture and mode of access of clinical decision

support systems from the 1980s to the present• Describe some of the early clinical decision support systems• Discuss the historical challenges in implementing CDS

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Support Systems Lecture b

Examples of Early CDS

• MYCIN• INTERNIST-1/QMR• DXplain• Antibiotic Assistant• Regenstrief CDS

Sources: (Buchanan & Shortliffe, 1984)(Clancey & Shortliffe, 1984)

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MYCIN

• Expert system developed at Stanford• Provided diagnostic and therapeutic advice like an expert

consultant

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MYCIN

• Expert system developed at Stanford• Provided diagnostic and therapeutic advice like an expert

consultant• Infectious diseases

– Diagnosed causal organism – Suggested drug to treat infection

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MYCIN

• Certainty factors• Performed well compared to experts• Model expanded to oncology and other areas

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MYCIN

• Certainty factors• Performed well compared to experts• Model expanded to oncology and other areas• Stand-alone system• Never used in practice

Source: (Wyatt, 1999)

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INTERNIST-1

• Expert system developed at University of Pittsburgh• Diagnosis in Internal Medicine• Captured expert’s knowledge

Source: (Miller, et al., 1982)

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INTERNIST-1

• Expert system developed at University of Pittsburgh• Diagnosis in Internal Medicine• Captured expert’s knowledge• User entered findings and system produced diagnosis

– Controlled vocabulary– Weighted positive and negative findings —evoking

strength, frequency and importance

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Quick Medical Reference (QMR)

• Decision support, not an expert system– Demise of the “Greek Oracle” model

Source: (Miller & Masarie, 1990)

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Quick Medical Reference (QMR)

• Decision support, not an expert system– Demise of the “Greek Oracle” model

• Used the INTERNIST-1 knowledge base• Stand-alone commercial system no longer available• Integrated with Vanderbilt’s EHR• Part of McKesson’s Horizon Expert Orders

Source: (Miller, Masarie & Myers, 1986)

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DXplain

• Diagnostic decision support system developed at Massachusetts General Hospital

• Similar structure to QMR• Stand-alone program

Source: (Barnett, et al., 1987)

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DXplain

• Diagnostic decision support system developed at Massachusetts General Hospital

• Similar structure to QMR• Stand-alone program• 1980s to the present

– 1980s dial up network (AMA/NET)

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1987 Version of Rapid Response

“It requires about two minutes to complete the dial-in sequence to log onto AMA/NET and to connect to the computer located at Massachusetts General Hospital.”

Source: (Barnett, et al., 1987)

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DXplain

• Diagnostic Decision Support System developed at Massachusetts General Hospital

• Similar structure to QMR• Stand-alone program• 1980s to the present

– 1980s dial up network (AMA/NET)– 1990s floppy disks– 2000s Web-based

Source: (Hoffer, et al., 2005)

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Antibiotic Assistant

• Advising and critiquing system for use of antibiotics developed at LDS Hospital, Utah

• Integrated with the LDS Hospital information systems as part of HELP system (Health Evaluation through Logical Processing)

• Provided advice on orders for antibiotics to prevent infections• Currently in use in LDS Hospital and other hospitals part of the

Intermountain Health Care (IHC)

Source: (Haug, et al., 2007)

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Regenstrief CDS

• Developed by informatics experts at the Regenstrief Medical Institute in Indiana and used at multiple hospitals and clinics

• Integrated with the Regenstrief Medical Record System (RMRS)

• Reminder type of CDS• Gradual expansion of rules and sites• Still in existence today

Source: (Mamlin, et al., 2007)

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History of Clinical Decision Support Systems

Summary – Lecture b• Examples of CDS and how they evolved

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History of Clinical DecisionSupport Systems

References – Lecture bReferences • Barnett GO, Cimino JJ, Hupp JA, Hoffer EP. DXplain. An evolving diagnostic decision-support system. JAMA.

1987 Jul 3;258(1):67-74.• Buchanan BG, Shortliffe EH, editors. Rule-based expert systems: the MYCIN experiments of the Stanford

Heuristic Programming Project. Palo Alto (CA): Association for the Advancement of Artificial Intelligence; 1984 Available from: http://www.aaai.org/AITopics/pmwiki/pmwiki.php/AITopics/RuleBasedExpertSystems

• Clancey WJ, Shortliffe EH, editors. Readings in medical artificial intelligence: the first decade. Palo Alto (CA): Association for the Advancement of Artificial Intelligence; 1984. Available from: http://www.aaai.org/AITopics/pmwiki/pmwiki.php/AITopics/ReadingsInMedicalArtificialIntelligence

• Haug PJ, Gardner RM, Evans RS, Rocha BH, Rocha RA. Clinical decision support at Intermountain Healthcare. In: Berner ES, editor. Clinical Decision Support Systems: Theory and Practice. New York: Springer; 2007. p. 159-89.

References continued on next slide.

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History of Clinical DecisionSupport Systems

References – Lecture b

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References, continued

•Hoffer EP, Feldman MJ, Kim RJ, Famiglietti KT, Barnett GO. DXplain: patterns of use of a mature expert system. AMIA Annu Symp Proc. 2005:321-5.•Mamlin BW, Overahage JM, Tierney W, Dexter P, McDonald CJ. Clinical decision support within the Regenstrief Medical Record System. In: Berner ES, editor. Clinical Decision Support Systems: Theory and Practice. New York: Springer, 2007. p. 190-214.•Miller RA, Masarie FE Jr. The demise of the "Greek Oracle" model for medical diagnostic systems. Methods Inf Med. 1990 Jan;29(1):1-2.•Miller R, Masarie FE, Myers JD. Quick medical reference (QMR) for diagnostic assistance. MD Comput. 1986 Sep-Oct;3(5):34-48.•Miller RA, Pople HE, Myers JD. INTERNIST-1: An experimental computer-based diagnostic consultant. N Engl J Med. 1982;307:468-76.•Wyatt JC. The promises and perils of modeling medical reasoning. In: van Bemmel JH, McCray AT, editors. Yearbook of Medical Informatics 1999. Stuttgart: Schattauer Verlag;1999. p. 161-5.