On Dec 3rd 2012 the New York Times published a fabulous article entitled “For Second Opinion, Consult a Computer?”. Science writer, Katie Hafner, also followed it up with a podcast.
Katie Hafner did a great job with this article as it shows how the really smart doctors, like Dr Dhaliwal, use tools like Isabel. I hope that Dr Dhaliwal can be a role model for the “most of us (who) don’t think we need help at diagnosis”.
The quality of the 200 plus comments has been outstanding and is a testament to the NYT and its readership. However, much of the discussion still revolves around the issue of whether the computer is or will be better than the doctor. I believe that the real issue here is not the ‘competition’ between doctor and computer but when the medical profession as a whole will embrace these tools to make them collectively smarter.
Over the 12 years that we have developed Isabel, we have never once thought about whether Isabel could replace the doctor – that was never our intention. We built it as tool to help doctors build a differential diagnosis in the very limited time they have. We wanted to reduce the burden of memory and buy them time to think which, as Dr Dhaliwal says, is their “most important procedure”
For the record, I don’t believe that computers will ever replace the doctor’s role of diagnosis. What I do believe is what has happened since the beginning of human history which is that humans design tools which make them better at doing what they were doing before. So doctors, using computers, will become much better and more reliable diagnosticians. As Don Berwick once said “Genius diagnosticians make great stories, but they don’t make great health care. The idea is to make accuracy reliable, not heroic.”.
I get the greatest pleasure from hearing, for example, how a nurse practitioner using Isabel has diagnosed two patients with cancer that her physician colleagues didn’t think of. The computer, in this case, Isabel has extended her capabilities. Imagine how this could help in places where there is a shortage of medical expertise? It’s wonderful to hear Dr Dhaliwal using Isabel to second check his conclusions even though most of the time he was right and didn’t need to. The important point was that he recognizes the importance of double checking his diagnosis; he is not too proud to check as he knows how easy it is to miss something.
It is estimated that 40,000 to 80,000 Americans die each year from, almost certainly preventable, misdiagnosis. Countless more will experience unnecessary discomfort, pain and worry about an unnecessarily delayed diagnosis. Much of this could be prevented if tools, like Isabel, were widely adopted into routine practice. We need to move the debate on from whether a computer will replace the doctor to asking why these tools aren’t in common use today. Dr Dhaliwal has shown us how easily they can be used, even as an app on the phone. The stakes are too high to worry about whether doctors will be replaced by computers. We will always need doctors and, as medicine gets ever more complex, we need them to be consistently smart - which they can be by using computers. Without them, they have little chance and will be letting us all down just when we need them most.
We have recently enjoyed hear from delighted users about their reactions to and love of the Isabel medical diagnosis tool and iPhone app. Below are some excerpts that simply speak for themselves.
- An FNP student user recently wrote us a email saying, "'Like it' is AN UNDERSTATEMENT! I love the fact that when I enter my data, I already have a list of differential diagnosis, but your Isabel app makes me think outside the box. I get results that I would not have come up with on my own! I don’t think your Isabel diagnosis website takes the place of diagnostic knowledge, but instead allows my knowledge to grow. THANK YOU! I am THOROUGHLY impressed!”
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“The Isabel app has made Isabel so much more accessible because it’s literally in my pocket. The more we can integrate technology into our workflow, the better the efficiency of healthcare. Isabel is a perfect example of that.” -- Paul Manicone, M.D., associate chief, Hospitalist Division, Children's National Medical Center in Washington, D.C., and assistant professor of pediatrics, George Washington University School of Medicine
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“We chose Isabel because it is the best diagnosis support tool on the market. Integrated into our EMR, Isabel is a powerful tool that, in the hands of our qualified pediatricians, will allow us to determine a difficult diagnosis faster.” -- Gary Mirkin, Allied Pediatrics’ Chief Executive Officer
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“Isabel Healthcare released a mobile version that offers Apple-using clinicians additional clinical decision support at the point of care. Subscriptions are available in weekly, monthly, and annual varieties, making it ideal for rotating medical students and occasional users. I’ve used Isabel (via EHR integration) for some time and it’s extremely valuable.” – Joseph Schneider at Baylor Health
To find out more about the Isabel App - visit our App page or see us in the Apple iTunes App Store.
The Health 2.0 Conference in Berlin Germany is approaching and will be held on November 6-7, 2012. The conference will host Speakers Tim Kelsey, the Executive Director of Transparency and Open Data for the UK Government, and Peter Levin, the Senior Advisor to the Secretary and CTO at the US Department of Veterans Affairs. This international event will host these among the 75 speakers from 25 different countries at Health 2.0 Europe 2012.
The Latest Tech featured in 45 live technology demos, from up-and-coming companies, like Universal Doctor, PatientsCreate, and Isabel.
Jason Maude will speak and demo Isabel's medical diagnosis tool on November 6 at 1:30PM in the Participative Workflow session of Health 2.0. View a full agenda of the event.
Isabel Diagnosis spotlight on: Ebola Virus
Article Summary
Ebola is an aggressive virus and requires swift diagnosis, medical attention and containment. Mobile diagnosis applications and clinical decision support can be of great help to assist clinicians in diagnosis and treatment, as mobile access has the distinct advantage over desktop programs in countries that lack onging power sources.
Ebola causes severe viral hemorrhagic fever and death results in 25%-90% of cases. Ebola first appeared in 1976 and primarily occurs in remote villages in Central and West Africa near tropical rainforests. Since 1976 there have been regular outbreaks of the various strains of Ebola, as can be seen from the World Health Organization below:
Table: Chronology of major Ebola haemorrhagic fever outbreaks (as of May 2012)
|
Year
|
Country
|
Virus subtype
|
Cases
|
Deaths
|
Case fatality
|
|
2011
|
Uganda
|
Ebola Sudan
|
1
|
1
|
100%
|
|
2008
|
Democratic Republic of Congo
|
Ebola Zaire
|
32
|
14
|
44%
|
|
2007
|
Uganda
|
Ebola Bundibugyo
|
149
|
37
|
25%
|
|
2007
|
Democratic Republic of Congo
|
Ebola Zaire
|
264
|
187
|
71%
|
|
2005
|
Congo
|
Ebola Zaire
|
12
|
10
|
83%
|
|
2004
|
Sudan
|
Ebola Sudan
|
17
|
7
|
41%
|
|
2003
|
Congo
|
Ebola Zaire
|
35
|
29
|
83%
|
|
(Nov-Dec)
|
|
2003
|
Congo
|
Ebola Zaire
|
143
|
128
|
90%
|
|
(Jan-Apr)
|
|
2001-2002
|
Congo
|
Ebola Zaire
|
59
|
44
|
75%
|
|
2001-2002
|
Gabon
|
Ebola Zaire
|
65
|
53
|
82%
|
|
2000
|
Uganda
|
Ebola Sudan
|
425
|
224
|
53%
|
|
1996
|
South Africa (ex-Gabon)
|
Ebola Zaire
|
1
|
1
|
100%
|
|
1996
|
Gabon
|
Ebola Zaire
|
60
|
45
|
75%
|
|
(Jul-Dec)
|
|
1996
|
Gabon
|
Ebola Zaire
|
31
|
21
|
68%
|
|
(Jan-Apr)
|
|
1995
|
Democratic Republic of Congo
|
Ebola Zaire
|
315
|
254
|
81%
|
|
1994
|
Cote d'Ivoire
|
Ebola Ivory Coast
|
1
|
0
|
0%
|
|
1994
|
Gabon
|
Ebola Zaire
|
52
|
31
|
60%
|
|
1979
|
Sudan
|
Ebola Sudan
|
34
|
22
|
65%
|
|
1977
|
Democratic Republic of Congo
|
Ebola Zaire
|
1
|
1
|
100%
|
|
1976
|
Sudan
|
Ebola Sudan
|
284
|
151
|
53%
|
|
1976
|
Democratic Republic of Congo
|
Ebola Zaire
|
318
|
280
|
88%
|
World Health Organization, Ebola hemorrhagic fever factsheet, No. 103
Uganda Ebola Outbreak
Uganda is currently experiencing a 2012 outbreak of the Ebola Sudan strain which started in July, and so far 16 people have died and a total of 165 people in the region are currently being observed for signs of the disease.
About Ebola and Symptoms
Ebola in humans occurs due to close contact of blood, secretions, organs or other bodily fluids of infected animals. Infection in Africa has been caused by the handling of infected chimpanzees, gorillas, fruit bats and monkey found dead or ill in the rainforest.
Once transferred to the human population it then spreads via human-to human transmission resulting from close contact with blood, secretions and bodily fluids of infected people. It has been found that transmission from infected semen can occur up to seven weeks after clinical recovery from Ebola. Funeral ceremonies where the mourners have direct contact with the deceased person who has had Ebola can also result in transmission.
The signs and symptoms of Ebola hemorrhagic fever can include:
- Sudden onset of high fever
- chills
- headaches
- myalgia
- anorexia
- intense weakness
- vomiting
- diarrhea
- maculopapular rash
- abdominal pain
- low white cell count
- low platelets
- elevated liver enzymes
The incubation period (time of infection to onset of symptoms) is between 2 and 21 days.
Other differential diagnoses to consider with similar symptoms to Ebola include:
- Malaria
- Typhoid
- Shigellosis
- Cholera
- Leptospirosis
- Plague
- Rickettsiosis
- Relapsing fever
- Meningitis
- Hepatitis
- Other viral hemorrhagic fevers
Treatment of humans infected with Ebola is intensive supportive care to prevent multiorgan failure developing. Patients are frequently dehydrated and need intravenous fluids and replacement of electrolytes. No specific treatment or vaccine is yet available for Ebola hemorrhagic fever and so infected animals should be culled and their carcasses destroyed which will reduce the animal to human transmission. Human to human transmission can be reduced by ensuring that during an Ebola outbreak that public health messages are distributed.
Containing Ebola
Close physical contact with Ebola patients should be avoided and health care workers are at high risk of contracting Ebola during an outbreak due to the nature of their jobs and stringent infection control measures should be adhered to including gloves, wearing protective clothing and regular hand washing along with careful disposal of body fluids. Communities should be advised on how to handle the deceased during an outbreak and to seek advice from Health care workers on these issues.
To contain Ebola outbreaks, it is important is to recognize the possibility that Ebola could be a cause of a patient's presenting symptoms when no outbreak is currently declared and the patient doesn’t have all of the core symptoms expected. Many of the symptoms of Ebola are similar to other, more common diseases, but Ebola in Central and West Africa should remain on the differential diagnosis list if the patient presents with some of the symptoms mentioned above until a definitive answer is found.
Isabel’s Clinical Decision Support System reminds health care workers of the possibility of Ebola being a cause, as it allows the differential disease output to be sorted to specific diseases which are seen in Central or West Africa.
Implementing Mobile Diagnosis Support
In developing countries such as Sub-Saharan Africa, it is difficult to implement access to clinical decision support systems requiring desktop computers due to the lack of infrastructure not place. Health care workers are minimally trained and tend to have a ratio of 1 doctor to 7000 patients and many of the patients live in very remote settings; so a patient could spend a good part of their day travelling to make contact with a health care worker who is normally overworked and cannot spend too long with each patient. During an outbreak of a disease like Ebola, the resources are drained even further due to the need to diagnose and treat early to prevent further deaths and to try to contain the disease. The hospitals tend to have limited power supplies which are unstable and power can be lost regularly, so the facilities should be used for life saving equipment rather than running desktop computers. In Sub-Saharan Africa applications like Isabel can be delivered on mobile applications which overcome many of these issues, including not having to have a power source permanently available. Mobile devices allow the application to be used away from the hospital or clinic base so it does not require the hospital's power source. Mobile applications at the clinics also allow information access for other health professionals who are seeing the patient, including Nurses and Pharmacists. It is also possible to disseminate up to date public health information via the disease information page and ensure that the health professional has the most accurate information and advice to give patients, helping to ensure the outbreak is contained and quickly eliminated.
~ Mandy Tomlinson, Isabel Quality Assurance Director
The
Isabel diagnosis tool touts an extensive database of conditions for differential diagnosis support, and we often will test its accuracy with real patient cases from the New England Journal of Medicine.
About the Isabel Diagnosis Challenge
The New England Journal of Medicine (NEJM) publishes interesting presentations of common diseases and unusual cases in the Clinical pathology Conference (CPC) series. These cases are educational and can pose diagnostic challenges even to the expert physicians at the Massachusetts General Hospital.
Using the clinical features of these cases you can evaluate your own diagnostic skills and compare your diagnostic performance to that of the physicians at MGH. If you are registered with Isabel as a client or have a free-trial subscription, you can use the diagnosis reminder system and run through some scenarios to get a list of likely suspects. Clicking on a diagnosis will take you through to various knowledge sources and links available from within Isabel.
Today's Case
NEJM 12:18
Demographic: Male, 35y, Neckpain, Hoarseness, Dysphagia, North America
Clinical features:
- right sided neck pain
- dysphagia
- hoarseness
- teeth pain radiating to ear
- blurred vision
- unsteadiness
- difficulty moving tongue to the right
- right horner’s syndrome
STOP! Before you read further, create your own differential diagnosis.
Differential Diagnoses considered by the MGH panel: Transient ischemic attack
Final Diagnosis of the case according to NEJM and Isabel: Villaret’s syndrome (ipsilateral paralysis of the 9th thrpugh 12th cranial nerves and cervical sympathetic fibers) due to a carotid-artery dissection and an associated aneurysm.
Was the final diagnosis given by the Isabel system: Yes, Carotid artery dissection under arterial aneurysms in Vascular
Modern Healthcare recently interviewed Isabel Healthcare founder Jason Maude regarding the Isabel diagnosis decision support application.
Modern Healthcare Article -- Bridging a gap: Support systems link docs with diagnoses, developers.”
By Joseph Conn. June 9, 2012.
Read the full article at ModernHealthcare.com: http://www.modernhealthcare.com/article/20120609/MAGAZINE/306099953#
How can clinicians find the right diagnosis faster using an iPad?
Clinicians nationwide are harnessing the power the new Isabel diagnosis "App" -- now available on iPad and iPhone -- with easier access to the powerful web-based Isabel diagnosis checklist system. The Isabel App enables physicians, nurse practitioners and other clinicians using iPhone, iPad or iTouch mobile devices to determine diagnoses and treat patients faster at the point of care. The Isabel app recently made Apple's App Store's (iTunes) list of top grossing apps in the Medical category.
Subscribers can now consult the app on their iPad/iPhone while on rounds at the bedside or at any location when needing to solve diagnostic challenges. Having Isabel available anytime and anywhere makes it practical for physicians to instantly check their patients' diagnoses and therefore reduce the risk of missing an important diagnosis.
The first release of the Isabel App is available for download from iTunes Apple's App Store and offers three purchase levels -- weekly, monthly and annual -- to accommodate various user cases. The weekly subscription is $2.99 in order to make it viable for the occasional user.
App Features include: a robust database of more than 6,000 pediatric and adult diseases, 'Don't miss' diagnosis alerts for physicians, links to a customizable list of well-known mobile web reference resources to rapidly identify and determine diagnosis, and the ability to share results with colleagues or include them in medical notes.
In 2011, Paul Manicone, M.D., associate chief, Hospitalist Division, Children's National Medical Center in Washington, D.C., and assistant professor of pediatrics, George Washington University School of Medicine, spearheaded the effort to integrate the tool into clinical workflows of select residents and faculty researchers for eventual widespread use.
Dr. Manicone works in a tertiary care referral center where many patients (from infants to young adults) have medically complex conditions or are referred by other providers because they are difficult to diagnose. "My job as a pediatric hospitalist is to field cases with diagnostic uncertainty, so for me Isabel was attractive early on," he said.
Now with the Isabel app on his iPhone, Dr. Manicone easily opens it during rounds or at home. "The app has made Isabel so much more accessible because it's literally in my pocket. The more we can integrate technology into our workflow, the better the efficiency of healthcare. Isabel is a perfect example of that."
Dr. Manicone noted the app helped him and other clinicians diagnosis central nervous system tuberculosis, a relatively rare contagious bacterial infection, in a teenager returning from India. "We entered the symptoms and when TB came to the top of the checklist, we were surprised, but it made us proceed with the work-up and mindset to determine the type of brain infection that she could have. Ultimately the tuberculosis diagnosis was confirmed and we were able to get her therapy started right away," he said.
Another experienced Isabel user is Napoleon Knight, M.D., medical director of hospital medicine and associate medical director of quality at Carle Foundation Hospital and Physician Group in Urbana, Ill. The physician accesses the Isabel app on his iPad when seeing patients in the hospital emergency department.
"I have used the computer version of Isabel and have always found it incredibly helpful. This app makes using Isabel on my iPad that much more convenient and easier to use and a more valuable product for me because I want that knowledge at my fingertips while standing in the patient's room," said Dr. Knight. "The app's checklist will make you smarter in thinking of diagnoses that you might not have thought about otherwise. Medical professionals will find great value in that."
The launch of the Isabel App carries personal significance for Isabel Healthcare founder Jason Maude. In July 1999, Maude suffered a nightmare when his then 3-year-old daughter Isabel was nearly fatally misdiagnosed by her local hospital. Clinicians missed correctly diagnosing necrostizing fasciitis, a flesh eating disease, forcing Isabel to spend three weeks in intensive care fighting for her life. He turned his personal near tragedy into a new life mission by creating Isabel Healthcare to provide a practical tool to help clinicians worldwide do the best job possible diagnosing patients right the first time so they receive the proper treatment immediately.
"Research has shown that approximately 15 percent of all diagnoses are wrong. A recent survey of over 6,000 doctors showed that 47 percent of clinicians encounter cases of diagnostic error at least monthly and 96 percent of them believe that they are preventable," said Maude.
#12:1. The Isabel tool touts an extensive database of conditions for differential diagnosis support, and we often will test its accuracy with real patient cases from the New England Journal of Medicine.
About the Isabel Diagnosis Challenge
The New England Journal of Medicine (NEJM) publishes interesting presentations of common diseases and unusual cases in the Clinical pathology Conference (CPC) series. These cases are educational and can pose diagnostic challenges even to the expert physicians at the Massachusetts General Hospital.
Using the clinical features of these cases you can evaluate your own diagnostic skills and compare your diagnostic performance to that of the physicians at MGH. If you are registered with Isabel as a client or have a free-trial subscription, you can use the diagnosis reminder system and run through some scenarios to get a list of likely suspects. Clicking on a diagnosis will take you through to various knowledge sources and links available from within Isabel.
Today's Case
Demographic: Male, 82 yrs, North America
Clinical features:
- Skin lesions on hand
- dog bite
- hand erythema
- violaceous bullous
- hand lesion
- urticarial and purpuric rash on torso
- thrombocytopenia anemia
- leukocytoclastic vasculitis
- weight loss
- intermittent diarrhea
STOP !
Before you read further, construct your own:
- Complete differential diagnosis
- Final diagnosis
Differential Diagnoses considered by the MGH panel: Sweet’s syndrome
Final Diagnosis of the case according to NEJM: Pyoderma gangrenosum due to myelodysplastic syndrome
Differential Diagnoses of the case as given by Isabel: Sweet’s syndrome under Neutrophilic dermatoses in Rheumatology
Was the final diagnosis given by Isabel:
Yes, Pyoderma gangrenosum under Neutrophilic dermatoses in Rheumatology
The Isabel tool touts an extensive database of conditions for differential diagnosis support, and we often will test its accuracy with real patient cases from the New England Journal of Medicine.
About the Isabel Diagnosis Challenge
The New England Journal of Medicine (NEJM) publishes interesting presentations of common diseases and unusual cases in the Clinical pathology Conference (CPC) series. These cases are educational and can pose diagnostic challenges even to the expert physicians at the Massachusetts General Hospital.
Using the clinical features of these cases you can evaluate your own diagnostic skills and compare your diagnostic performance to that of the physicians at MGH. If you are registered with Isabel as a client or have a free-trial subscription, you can use the diagnosis reminder system and run through some scenarios to get a list of likely suspects. Clicking on a diagnosis will take you through to various knowledge sources and links available from within Isabel.
Today's Case
Demographic: Female, 90 yrs, North America
Clinical features:
- ptosis
- high white cell count
- dysphagia
- hoarseness
- general fatigue
- dysarthria
- head drop
- respiratory failure
- mediastinal widening
STOP !
Before you read further, construct your own:
- Complete differential diagnosis
- Final diagnosis
Differential Diagnoses considered by the MGH panel:
Cavernous carotid aneurysm
Final Diagnosis of the case according to NEJM:
(i) Thymoma (ii)Paraneoplastic myasthenia gravis
Differential Diagnoses of the case as given by Isabel:
Cavernous carotid aneurysm under Arterial aneurysms in Vascular
Was the final diagnosis given by Isabel:
Yes. 1) Thymoma under Thymic Neoplasms in Respiratory and 2) Myasthenia Gravis in Neuromuscular
Full case: NEJM case 39
A
n independent study on diagnosis decision support tools in medical education recently conducted by the Children’s National Medical Center and The George Washington University School of Medicine in Washington, DC, investigated these areas:
-
The use of the Isabel diagnosis decision support tool in pediatric patients to reduce diagnostic errors in challenging, published patient cases, and
-
The affect of students’ training and years of experience on Isabel’s performance.
Patient cases for the study were selected from the case-based learning textbook “Pediatric Complaints and Diagnostic Dilemmas,” constructed from The Children’s Hospital of Philadelphia Senior Rounds.
Teaching Diagnosis Skills: Medical education teaches medical students the classic signs and symptoms of common diseases and disorders. As they become house officers and then faculty, their learning progresses by working up cases with similar elements to ones they have seen before by recognizing common symptom patterns in diseases. This process allows them to learn the exceptions to the norm which occur and to diversify their knowledge so they move from pattern recognition to pattern deviation of those signs and symptoms -- and therefore they develop a list of diagnoses to investigate, eventually narrow down to find the final diagnosis and treat the patient successfully. The cases in the book are based on common complaints, but they evolve to become challenging diagnostic dilemmas with many of the final diagnoses being rare.
Study Components:
-
25 cases were selected and 4 investigators (4th year medical student, pediatric resident, senior faculty, junior faculty) selected five keywords from each case. They all reviewed the same cases and were blinded to the final diagnosis.
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Age, gender and the five keywords were entered into Isabel and the final diagnosis was then measured on the results page
-
Investigators level of training, complexity of keyword phrasing and success rate by diagnosis were examined
Outcome: Isabel included the correct diagnosis in 64% of the cases entered. To assess the results, the investigators’ training levels were split into lower level of training (4th year medical student and pediatric resident) and the higher level of training (junior and senior faculty). Higher level of training was associated with increased performance by Isabel which may be explained by the higher levels of training extracting the more pertinent keywords from the cases in order to arrive at a final diagnosis.
The study demonstrated that Isabel may help in avoiding premature closure and reduction of diagnostic errors and also assist education in all levels of training to help put together the key clinical features extracted from cases and convert them into a list of diagnoses which can be evaluated and worked up with ease.
The Study Continues: The study team is continuing their work with Isabel including collecting data in weekly senior rounds and entering key features into Isabel at these rounds to help assist their diagnoses workup. Isabel has already had an impact as the case below was presented and helped them arrive at the final diagnosis of TB meningitis which they hadn’t considered prior to bringing the case to the senior round.
Further information on this study was presented at The Diagnostic Error in Medicine Conference – October 2011.
~~Written by: Mandy Tomlinson, Quality Assurance Director, Isabel Healthcare