Computer Applications in Medical Care. Computers in Medical ...

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given the major findings from the history and phy- sic'l examination, and then ... and Fortran on a Digital Equipment Corporation. VAX 11/750 housed in theĀ ...
ABIM COMPUTER-BASED EXAMINATION SYSTEM

David B. Swanson, Ph.D. and George D. Webster, M.D.

American Board of Internal Medicine,Philadelphia,Pennsylvania

We will demonstrate a computer simulation of

given the major findings from the history and phy-

the clinical encounter developed in conjunction

sic'l examination, and then orders laboratory

with the Computer-Based Examination (CBX) Project

and investigative procedures, begins drug thera-

at the American Board of Internal Medicine (ABIM).

pies, requests surgical procedures, and observes

Over the past ten years, this research and devel-

the impact of his/her patient management selections

opment project has investigated the potential of

on the patient's "condition" as it evolves over

computer-based testing for use in the ABIM Certi-

simulated case time.

fying, Examination in internal medicine.

apies are ordered, the patient model simulates

drug-drug, drug-test, and test-test interactions

a

The CBX system includes three programs:

as appropriate.

case entry program, a case review program, and a test administration program.

When multiple tests and ther-

The cases are programmed to pre-

sent reasonable clinical complications:

The first uses a

these may

menu-driven data base management system for entry

evolve naturally or result from mismanagement of

and revision of case material. The case review system provides a mechanism for automatically

the case.

running through numerous prespecified methods for

downhill clinical course.

"managing" the simulated "patient" and verifying

time, choice of ambulatory or inpatient management,

The physician must react to complica-

tions appropriately or, as in real life, face a

Passage of simulated

The

use of the intensive care unit, "stat" ordering of

test administration program is what we propose to

laboratory tests, and other features of the clini-

that the computer model behaves as intended.

exhibit at SCAMC.

This program simulates the

cal environment are under the physician's control.

clinical encounter, including a physiological

The simulation currently contains over 800

model of the patient, a broad arsenal of drug and

therapies and laboratory tests.

non-drug therapies, and simulated laboratory faci-

sponses (primarily changes in laboratory test

lities through which the clinical course of patients

values) of a normal 31-year-old male

with a variety of disease entities is depicted.

ed therapies are built into the patient model.

The simulated patient's clinical course is altered

Cases are constructed by supplementing these normal

over time as a function of the physician-user's

clinical responses with case-specific information

management decisions.

The physician is initially

0

1983 IEEE

to the includ-

which details the response of the simulated

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0195-4210183/0000/0458$01.00

The clinical re-

patient's disease to various appropriate and inappropriate management strategies.

The latter

information specifies the response of the patient to the most likely therapeutic choices,

with normal clinical responses used to model the less likely choices.

A very simple physiological

model is constructed for each case.

Management

activities affect the physiological status of the patient through this model, with laboratory test values indexed to physiological status. Every effort is made to insure that the simulated

patient responds to management in the same way that a real patient would, thus providing an accurate simulation of the clinical decision

making environment for testing purposes. The CBX programs are implemented in Pascal

and Fortran on a Digital Equipment Corporation VAX 11/750 housed in the Philadelphia offices

of the ABIM.

The demonstration will consist of

a terminal linked via telephone line to the VAX

system.

CBX cases will be available for SCAMC

participants to "manage".

The latest version of

the system differs substantially from the prior ones in its "user-friendly", menu-driven interface

for examinee-computer interactions, in the use of

physiological modelling as a basis for determining therapeutic impact on laboratory tests, and in the

"production system" control structure for implementation of the event-driven simulation.

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