Implementing RECONSIDER, a Diagnostic Prompting ... - NCBI - NIH

Implementing RECONSIDER, a Diagnostic Prompting Computer System, at the Georgetown University Medical Center*t BY NAOMI C. BROERING, Director, Biomedical Information Resources Center and Medical Center Librarian

MILTON CORN, Dean, School of Medicine WILLIAM R. AYERS, Associate Dean, School of Medicine PAULINE MISTRY, Program Manager, IAIMS Georgetown University Medical Center 3900 Reservoir Road, N. W. Washington, D.C. 20007 ABSTRACT

MEDICAL INFORMATION SCIENCE AT GEORGETOWN RECONSIDER, a computer program for diagnostic At Georgetown, medical informatics is considprompting developed at the University of California, San Francisco, has been implemented at the Georgetown ered essential for preparation of the modern physiUniversity Medical Center as part of the Integrated cian. Exposure to computers has permeated the Academic Information Management System Model student's educational experience in a variety of Development grant project supported by the National settings and (classroom, library, clinical environLibrary of Medicine. The system is available for student use in the Biomedical Information Resources Center of ment). With IAIMS serving as a catalyst, an even the Dahlgren Memorial Library. Instruction on use of the more concentrated effort is currently underway to computer system is provided by the library and instruc- integrate computers in existing courses. tion on medical use of the knowledge base is directed by For over five years students have been using the faculty. The implementation, capabilities, enhancements such as the addition of Current Medical Informa- computers in the fully automated library. They tion and Terminology (5th ed.), and evaluation of the have gained extensive bibliographic search experisystem are reported. ence through the online catalog and the miniMEDLINE System0t. They have used the library's collection of over seventy-five computer-assisted IN 1985 Georgetown University Medical Center instructional (CAI) programs for independent received a three-year grant from the National study and self-assessment. They have been taught Library of Medicine to develop a pilot Integrated to use personal computers (PCs) in the library's Academic Information Management System computer laboratory, which was converted in 1986 (IAIMS) at the medical center. The pilot IAIMS into the Biomedical Information Resources Center has five component projects, one of which is in (BIRC) with a computer classroom and open work education. In this component each of three schools stations. The BIRC has over fifty-five PCs of a (medicine, dentistry, and nursing) has undertaken mixed variety-IBM, Apple, Macintosh, and a computer-based educational project. The ration- AT&T machines. The Personal Information Manale for the educational component is to expose agement for Medical Students (PIMMS) program, students to special computer applications in their a software package developed at Georgetown, has profession, to raise their level of computer compe- been introduced to students for maintaining pertency, and to prepare them for lifelong learning. sonal notes [2], and more recently Nutriquest, a commercially available educational package, has been used to teach nutrition and dietary concepts in *This project is supported in part by NIH Grant No. patient management as partial requirement for the 5G09LM04392-02 from the National Library of Medi- second year clinical nutrition program. cine. tBased on a presentation given at the Eighty-seventh Annual Meeting of the Medical Library Association on May 19, 1987, Portland, Oregon.

Bull. Med. Libr. Assoc. 76(2) April 1988

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A project is underway to integrate microcomputinto the newly revised pathology course. During clinical rotations in the third and fourth year, students are exposed increasingly to computerized diagnostic and laboratory systems. Their awareness of a fully automated hospital is especially heightened at Georgetown where a sophisticated hospital information system (HIS) is in place. For patient security reasons, "hands off" is the necessary approach for the HIS. Plans for 1988 include a clinical workstation project to introduce students to automated patient record applications. Projected in the future are special simulated learning software programs to further broaden the students' clinical ers

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RECONSIDER School of Medicine and the Library As a diagnostic decision making tool, RECONSIDER fills a gap in the medical information science experiences provided at Georgetown. The RECONSIDER project is a cooperative endeavor between the library and the school of medicine, which concentrates on developing clinical problemsolving skills and deemphasizing the need for memorization by using computers as memory extenders. In 1985, RECONSIDER was selected as an appropriate computer program for the IAIMS experiment.

RECONSIDER is a diagnostic prompting system that responds to a set of clinical findings by listing diseases that might be considered in differential diagnosis. It uses the computer as an aid to memory, not a substitute for human judgement [ 1]. In 1985, Dr. Marsden S. Blois, developer of RECONSIDER at the University of California at San Francisco (UCSF), was asked if Georgetown could use his program for this missing educational experience. Not only did he respond affirmatively, but he provided software for the IAIMS experiment and Georgetown then began serious planning for the project. The goal was to "transport" RECONSIDER to Georgetown for use in the second year clinical problem solving course. An IAIMS cooperative project was designed to be administered by the library and the school of medicine. The school assumed responsibility for developing class assignments, monitoring student progress, and teaching concepts about the use of knowledge systems such as RECONSIDER. The library was responsible for solving technical issues, establishing an appropriate facility with sufficient workstations, and training students to use this computer system.

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The Knowledge Base The original knowledge base for RECONSIDER is an online version of Current Medical Information and Terminology (CMIT), 4th edition AMA (1971) [3]. The latest version based on CMIT 5th edition (1981), implemented in August 1987, is being tested at Georgetown [4]. Everything in the RECONSIDER system is disease based. The CMIT knowledge base contains 3,262 disease definitions in a structured natural language text used by physicians. Each disease is described by its major clinical characteristics, including etiology, symptoms, and signs. The system accepts core clinical findings and responds with an ordered list of diseases best matched with the clinical indications. Since it is based on CMIT, it masquerades as a knowledge system, but technically it is a high-level, full-text retrieval system. RECONSIDER uses indexed files to link entered terms to diseases quickly. The diseases are ranked on the frequency of "hits" for terms entered into the database. The system responds within seconds. Terms entered can be refined to search only certain contexts or subheadings in the CMIT text, and the files include a handcrafted thesaurus of over 15,000 synonyms. Searches can be broadened or narrowed by the terms selected for input [5,6]. The system's contents are good for inductive reasoning, i.e., "I want to know what is going on," which helps students integrate what they learn. RECONSIDER is also useful in clinical cases as a checklist or a reminder of possible diseases to consider in the diagnosis [7].

Using RECONSIDER The RECONSIDER applications software contains basic user tools and commands so it can respond to clinical findings and lists diseases that might be considered in a differential diagnosis. The system includes instructions on use, the CMIT subheadings, a synonym dictionary, help in entering terms, and help screens. Single terms, i.e., "findings/symptoms," may be entered and the system begins to search for diseases which match the terms. (Figure 1). When the terms are entered, RECONSIDER does not make a diagnosis; it merely provides reminders of relevant diseases that should be considered. As a prompting tool it helps students make a transition from findings to diseases for differential diagnosis. The system does not know whether a disease is common or uncommon and its operational mode is transparent to the user. To refine a search the user can input multiple findings. The match of diseases Bull. Med. Libr. Assoc. 76(2) April 1988

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TECHNICAL ASPECTS Three stages were established for the library's technical role: hardware/software installation, user training, and evaluation of sytem use. The first stage included developing hardware/software modifications, acquiring sufficient microcomputers for student use, and developing training materials. It took about one year to accomplish these tasks. Hardware and Software At UCSF, RECONSIDER functions on a DEC VAX computer using the 4.3 UNIX operating system. At Georgetown it was originally converted

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unknown whether it would function properly. A different version of the operating system added to the problem because a common denominator at the system level needed to be found. A nine-track tape of the UCSF version was developed that could be read by an AT&T 3B15. Then, a compatible electronic mail package was used to transfer the programs to a 3B2. Because the information was not in ACSII format, the data had to be transferred bit by bit. Only ten megabytes of data were transferred, and although preparation was time consuming, the machine operation took only six to eight hours. One of the project objectives was to add a few user-friendly routines to the original system without touching the source code. The system design and structure of the software limited the extensiveness of user-friendly enhancements. Enhancements were completed within two weeks at UCSF and the programs were sent to Georgetown, loaded in the AT&T 3B2, and tested by the technical staff. After technical evaluations were conducted and acceptance acknowledged, plans were made for a technical training session.

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nical training included systems operation and long term maintenance, for which Georgetown assumed future responsibility. The staff needed briefing on UNIX systems as well as a working knowledge of the programs. RECONSIDER was implemented for student use on two computer systems: three AT&T 3B2 microprocessors and one AT&T 3B15 minicomputer. Eight terminals were installed in the BIRC: six in the computer workstation area and two in the computer classroom. Development of a training manual by library staff was the next step. This included developing introductory information, describing the search functions, defining terms for use and contexts (or subheadings) for refining searches, explaining use of the synonyms, and completing special system features such as the sorted list of diseases and histograms. Screen displays were included for each system function [9]. Once completed, 200 copies were printed and bound for student use. The training manuals, which contain exercises and practice routines, were useful for the initial orientation session. After initial instruction, each student is given a RECONSIDER quick reference card in order to use the system independently. The manuals remain in the BIRC for use at the next training session. The library is currently working with the faculty on instruction for the spring 1988 semester.

Evaluation The final stage is to gather data and to evaluate system use. Sufficient data are not yet available for analysis, but a study is planned for year three of the IAIMS project. The evaluation process will cover not only user behavior and satisfaction, but also system functions and hardware performance. The evaluation will cover the recent system update to the CMIT 5th edition knowledge base, and transfer of the software programs to a more powerful minicomputer, the AT&T 3B15. This computer, linked to the IAIMS local area network, enables remote access to RECONSIDER by more simultaneous users than the 3B2 microprocessor system. It also provides a natural backup system to the 3B2s available in the BIRC's computer lab.

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CONCLUSION Introduction of knowledge systems in the library environment is a new development that is beyond the traditional services expected by users. To transfer a system like RECONSIDER from the developer's computing department to an operational library setting requires technical expertise, time, and resources that should not be underestimated. Success of such a project requires teamwork: a committed staff, adequate resources from the library director, and supportive faculty. The faculty must be willing to invest considerable effort in integrating use of such systems in their courses to make a project of this complexity worthwhile. REFERENCES 1. Blois MS, Sherertz DD, Tuttle MS. Evaluating, devel-

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oping and maintaining RECONSIDER. Proceedings of the 1st AMIA Congress on Medical Informatics. San Francisco, CA May 2-5, 1982:305-6. Ayers WR, Bagdoyan HE, Broering NC. PIMMS: personal information management for medical students. Presented at the National Symposium on Microcomputers in Health Care Education at the University of Nebraska Medical Center, Omaha, Nebraska, Apr 1-2, 1985. (Abstract). Gordon B, ed. Current medical information and terminology, 4th ed. Chicago: American Medical Association, 1971. Finkel JA, ed. Current medical information and terminology, 5th ed. Chicago: American Medical Association, 1981. Blois MS, Tuttle MS, Sherertz DD. RECONSIDER: a program for generating differential diagnoses. Proceedings, 5th Annual Symposium on Computer Applications in Medical Care, Heffernan HG, SJ, Washington, D.C., November 1981:263-8. Blois MS, Sherertz DD, Kim H, et al. RECONSIDER: an experimental diagnostic prompting program. UCSF ACP Computer Workshop 1983. Med Info Sci 1983:7-24. Erlbaum M. Presentation at RECONSIDER training session at Georgetown University. August 20-21, 1986. Nelson SJ, Blois MS, Tuttle MS, et al. Evaluating RECONSIDER - a computer program for diagnostic prompting. J Med Syst 1985; 9(5/6):379-88. Adams JL, Broering NC, Anderson S. RECONSIDER user guide. Washington, D.C.: Georgetown University, 1987.

Received August 1987; accepted November 1987.

Bull. Med. Libr. Assoc. 76(2) April 1988