1. Informational Resources: Computer-Assisted Instruction, Expert Systems, Health Information Online Chapter 10

2. Education Computers have been used in medical education for more than 40 years. Drill-and-practice software teaches skills requiring memorization. Simulation software puts the student in the situation and requires some action.

3. The Visible Human The Visible Human is a computerized library of human anatomy at the National Library of Medicine (NLM).  From Data to Knowledge—users can see and feel anatomic flythroughs on the Web

4. The Visible Human The Visible Human is a computerized library of human anatomy at the National Library of Medicine (NLM).  Explorable Virtual Human—in development Includes authoring tools to build anatomical models  Virtual Human Embryo—images of embryos sectioned and sliced

5. Figure 10.1a The Visible Human Project gallery. Source: National Library of Medicine, http://www.nlm.nih.gov/research/visible/visible_gallery.html; accessed March 29, 2011.

6. Figure 10.1b The Visible Human Project: Color Cryosections. Source: National Library of Medicine, http://www.nlm.nih.gov/research/visible/photos. html; accessed March 29, 2011.

7. Computer-Assisted Instruction Drill-and-practice for skills requiring memorization Simulation software simulates a complex process  Using text  Using graphics, sound, animation  Using haptics (sense of feel)

8. Computer-Assisted Instruction Hospitals are using electronic informed consent programs:  The electronic consent programs explain the procedures to the patient.  The patient can ask questions and receive answers.  The patient is also informed of risks and benefits.  iMedConsent is used at the VA and at 190 U.S. hospitals.

9. Simulation Software Programs using text—ILIAD Programs using graphics—ADAM Virtual reality simulations  Surgery  Dentistry  Bronchoscopy  Epidural anesthesia  Administer IV  Colonoscopy

10. Figure 10.2 Simulation of a colonoscopy. Source: CAE Endoscopy VR simulator. Reproduced by permission of CAE Healthcare. Copyright © 2011 CAE Healthcare. All rights reserved.

11. Figure 10.3 Simulation of a bronchoscopy. Source: CAE Endoscopy VR simulator. Reproduced by permission of CAE Healthcare. Copyright © 2011 CAE Healthcare. All rights reserved.

12. Patient Simulators Human patient simulators  Programmable mannequins Inhale and exhale Eyes dilate Heart and lung sounds Pulse, blood pressure Can react to medication (barcoded) Can simulate allergic reactions

13. Figure 10.4a BabySim. Source: Courtesy of METI.

14. Figure 10.4b PediaSim. Source: Courtesy of METI.

15. Figure 10.4c A doctor examines iStan. Source: Courtesy of METI.

16. Figure 10.4d Medical personnel examine iStan as an injured football player. Source: Courtesy of METI.

17. Figure 10.4e Emergency medical services (EMS) personnel treat METIman in a virtual emergency. Source: Courtesy of METI.

18. Figure 10.4f Medical personnel treat Airman METIman. Source: Courtesy of METI.

19. Figure 10.4g Nurses examine METIman. Source: Courtesy of METI.

20. Figure 10.4h Nursing students practice on METIman. Source: Courtesy of METI.

21. Figure 10.4i Nursing students practice on METIman. Source: Permission granted, Courtesy of METI.

22. Patient Simulators Using patient simulators  Students can practice: Intubations Needle decompression of pneumothorax Insertion of chest tubes Defibrillation Catheterization

23. Simulated Environments In simulated environments, students can practice in “real-world” situations:  Emergency rooms, with noise and constraints of space  Operating rooms

24. Distance Learning Learning in an environment where student and teacher are not physically face-to-face Use of Internet resources

25. Decision Support: Expert Systems Expert systems—attempt to make a computer an expert in one limited field Expert systems in medicine  MYCIN  INTERNIST  POEMS  Databank for Cardiovascular Disease

26. Decision Support: Expert Systems Expert systems in medicine  Starting in 2009, doctors in New York State emergency departments can use a computer application containing “concise guidelines for starting prompt drug treatment that can reduce the risk of becoming infected” with HIV

27. Decision Support: Expert Systems (Outcomes) The quality of expert systems varies:  In certain areas, specifically, drug use and preventive medicine, these systems have been shown to improve physician performance and, less frequently, improve patient outcomes.  CDS prevent medication errors (incorrect decisions), but their effect on ADEs (harm to patients) is not so clear.

28. Decision Support: Expert Systems (Outcomes) The quality of expert systems varies:  Outcomes were improved on the use of deep vein thrombosis (DVT) prophylaxis. Results with diabetes were mixed. Diagnostic CDS do remind doctors to consider more options and diagnoses.

29. Health Information on the Internet Information is of varying quality  Code of conduct suggested by health care professionals: Disclose sponsorship Distinguish between science and advertising Allow feedback

30. Health Information on the Internet The digital divide  Internet use is not spread equally through our society  The biggest differences are by age, income, and education  Many Americans with disabilities lack access to the Internet

31. Medical Literature Databases MEDLARS (Medical Literature Analysis and Retrieval System)—collection of 40 computerized databases maintained by NLM; free via Internet. Includes:  MEDLINE—complete database of articles  SDILINE—recent additions to MEDLINE  AIDSLINE—database of information on AIDS

32. Medical Literature Databases MEDLARS (Medical Literature Analysis and Retrieval System)—collection of 40 computerized databases maintained by NLM; free via Internet. Includes:  CANCERLIT—database of information on cancer  MedlinePlus—database of health care information for consumers

33. Figure 10.5a Army and Air Force posters from the 1940s. Source: Courtesy of the National Library of Medicine.

34. Figure 10.5b Army and Air Force posters from the 1940s. Source: Courtesy of the National Library of Medicine.

35. Figure 10.6 MedlinePlus is a database maintained for consumers. Source: Courtesy of the National Institutes of Health.

36. Databases of Drug Information Medi-Span Clinical Pharmacology ClinicalTrials.gov CenterWatch

37. E-mail Patients want it as a way to communicate with their own health care providers. Few health care providers make it available:  Problems of privacy, liability, time

38. E-mail By 2013, The American Recovery and Reinvestment Act of 2009 calls for including secure e-mail between doctors and patients as part of the EHR. In a Kaiser Permanente study in CA, the more a patient with diabetes or hypertension e-mailed the doctor, the more the patient improved.

39. Self-Help on the Web Innumerable sites offer help for any medical or psychiatric condition, many with disclaimers that they are not responsible for the accuracy of the information. Some sites also offer prescription drugs.

40. Support Groups on the Web Starbright World is for seriously ill children. Some of the bigger patient networks include: PatientsLikeMe, Health Central, Inspire, CureTogether, and Alliance Health Network. Diabetic Connect has 140,000 members.

41. Support Groups on the Web The Internet allows virtual communities to develop, which support people with very rare conditions, making face-to- face support impossible.

42. Judging the Reliability of Information on the Internet Is there information about the author? Is the author reliable? Are the sources reliable? Are the sources of funding revealed? Are there conflicts of interest? Is the information current? Read critically!

43. Health-Related Smartphone and Tablet Computer Apps Fitness: diet and exercise Medications and side effects Lab test results What do symptoms indicate? Monitoring heart rate

44. Health-Related Smartphone and Tablet Computer Apps Fast Food calorie counter KidsCheckup T2 Mood Tracker And many more

45. Figure 10.7 MedlinePlus is available on mobile phones. Source: Courtesy of the National Library of Medicine.

46. Self-Help Software Mayo Clinic Family Health Book on CD- ROM Doctor's Book of Home Remedies Medical House Call

47. Computers and Psychiatry Computers are used in diagnosis and treatment:  CIDI (Composite International Diagnostic Interview) screens for depression and anxiety  CIDI-Auto—self-administered using a computer

48. Computers and Psychiatry Computers are used in diagnosis and treatment:  Several programs are used to treat anxiety and depression  Internet-based therapy (Interapy) for posttraumatic stress disorder

49. Computers and Psychiatry Online screening programs for anxiety and mood disorders have been “generally equivalent” to assessment by a therapist.

50. Computers and Psychiatry The use of virtual reality in therapy (cybertherapy):  Exposure to threatening virtual situation for phobias  Exposure to virtual bars for alcoholics  Exposure to virtual slot machines for gamblers  Exposure to virtual social situations for people with social anxiety disorder

51. Computers and Psychiatry Some experiments have shown that the advice does have an effect on actual behavior in the real world. Researchers are also attempting to use virtual people to improve the ability of autistic children to think and talk while surrounded by others.

52. Computers and Psychiatry Other uses of computers and software in psychiatry:  Angelina and SimCoach are virtual therapists  Use of avatars to increase awareness of others' points of view  Use of programs in the treatment of drug addiction