1. History of Health Information Technology in the U.S. History of Clinical Decision Support Systems Lecture 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

2. History of Clinical Decision Support Systems Learning Objectives 2 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 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture b

3. Examples of Early CDS MYCIN INTERNIST-1/QMR DXplain Antibiotic Assistant Regenstrief CDS Sources:(Buchanan & Shortliffe, 1984) (Clancey & Shortliffe, 1984) 3Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

4. MYCIN Expert system developed at Stanford Provided diagnostic and therapeutic advice like an expert consultant 4Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

5. 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 5Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

6. MYCIN Certainty factors Performed well compared to experts Model expanded to oncology and other areas 6Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

7. 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) 7Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

8. INTERNIST-1 Expert system developed at University of Pittsburgh Diagnosis in Internal Medicine Captured expert’s knowledge Source:(Miller, et al., 1982) 8Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

9. 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 9Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

10. Quick Medical Reference (QMR) Decision support, not an expert system –Demise of the “Greek Oracle” model Source:(Miller & Masarie, 1990) 10Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

11. 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) 11Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

12. DXplain Diagnostic decision support system developed at Massachusetts General Hospital Similar structure to QMR Stand-alone program Source:(Barnett, et al., 1987) 12Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

13. 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) 13Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

14. 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) 14Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

15. 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) 15Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

16. 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) 16Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

17. 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) 17Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

18. History of Clinical Decision Support Systems Summary – Lecture b Examples of CDS and how they evolved 18Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b

19. History of Clinical Decision Support Systems References – Lecture b 19Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b References 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 [updated year month day; cited year month day]. Available from: http://www.aaai.org/AITopics/pmwiki/pmwiki.php/AITopics/ReadingsInMedicalArtificialIntelligencehttp://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.

20. History of Clinical Decision Support Systems References – Lecture b 20Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Health IT Organizations Lecture b 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.