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A Practical Computer Program That Diagnoses Diseases In Actual Patients

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  • 1. A PRACTICAL COMPUTER PROGRAM THAT DIAGNOSES DISEASES IN ACTUAL PATIENTS Carlos Feder &
  • 2. A PRACTICAL COMPUTER PROGRAM THAT DIAGNOSES DISEASES IN ACTUAL PATIENTS Carlos Feder & Tomás Feder
  • 3. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM
  • 4. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM Diagnostic errors occur very frequently; some are disabling or fatal,  resulting in liability for the physician. Unawareness, underreported
  • 5. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM Diagnostic errors occur very frequently; some are disabling or fatal,  resulting in liability for the physician. Unawareness, underreported Physicians order an inordinate number of futile tests, not rationally  selected according to a probabilistically determined benefit
  • 6. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM Diagnostic errors occur very frequently; some are disabling or fatal,  resulting in liability for the physician. Unawareness, underreported Physicians order an inordinate number of futile tests, not rationally  selected according to a probabilistically determined benefit These errors are due to the impossibility to remember or even learn  thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc.
  • 7. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM Diagnostic errors occur very frequently; some are disabling or fatal,  resulting in liability for the physician. Unawareness, underreported Physicians order an inordinate number of futile tests, not rationally  selected according to a probabilistically determined benefit These errors are due to the impossibility to remember or even learn  thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc. Diseases neither learned nor recalled by the physician remain  undiagnosed or misdiagnosed
  • 8. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM Diagnostic errors occur very frequently; some are disabling or fatal,  resulting in liability for the physician. Unawareness, underreported Physicians order an inordinate number of futile tests, not rationally  selected according to a probabilistically determined benefit These errors are due to the impossibility to remember or even learn  thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc. Diseases neither learned nor recalled by the physician remain  undiagnosed or misdiagnosed Problem compounded by time constraints imposed by health  insurances (managed care medicine)
  • 9. ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM Diagnostic errors occur very frequently; some are disabling or fatal,  resulting in liability for the physician. Unawareness, underreported Physicians order an inordinate number of futile tests, not rationally  selected according to a probabilistically determined benefit These errors are due to the impossibility to remember or even learn  thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc. Diseases neither learned nor recalled by the physician remain  undiagnosed or misdiagnosed Problem compounded by time constraints imposed by health  insurances (managed care medicine) Computers can store the contents of many medical texts and swiftly  retrieve the needed information anywhere and at any time
  • 10. EXISTING SO CALLED “COMPUTER DIAGNOSTIC PROGRAMS” INTERNIST (former Caduceus) MEDITEL QMR (Quick Medical Reference) ILIAD PKC (Problem-Knowledge Couplers) ISABEL DXplain
  • 11. EXISTING SO CALLED “COMPUTER DIAGNOSTIC PROGRAMS” INTERNIST (former Caduceus) MEDITEL QMR (Quick Medical Reference) ILIAD PKC (Problem-Knowledge Couplers) ISABEL DXplain Excellent remainder of unusual diagnoses, but  Unable to pinpoint the disease(s) that actually afflict a specific patient  Considered educational or training tools rather than diagnostic tools  Poorly accepted and seldom used by practicing health care providers 
  • 12. Advantages of our novel computer program
  • 13. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other
  • 14. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other  It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent
  • 15. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other  It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent  It diagnoses concurrent diseases afflicting simultaneously a specific patient
  • 16. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other  It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent  It diagnoses concurrent diseases afflicting simultaneously a specific patient  It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods
  • 17. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other  It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent  It diagnoses concurrent diseases afflicting simultaneously a specific patient  It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods  It gives primary importance to the cost of obtaining each clinical datum. Our algorithm interprets cost not only as dollar expense, but also considers discomfort and risk of the procedure. Four overall cost categories are established: No Cost, Small Cost, Intermediate Cost, and Great Cost
  • 18. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other  It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent  It diagnoses concurrent diseases afflicting simultaneously a specific patient  It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods  It gives primary importance to the cost of obtaining each clinical datum. Our algorithm interprets cost not only as dollar expense, but also considers discomfort and risk of the procedure. Four overall cost categories are established: No Cost, Small Cost, Intermediate Cost, and Great Cost  It anticipates the benefit that each clinical datum would confer to each diagnosis in the differential diagnosis list, by calculating with our mini-max procedure how much it would increase or decrease the current probability of the corresponding diagnosis if the data were found respectively present or absent in the patient
  • 19. Advantages of our novel computer program  It confirms one or more diseases that indeed afflict a specific patient, instead of displaying a long list of potential diagnoses that compete with each other  It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent  It diagnoses concurrent diseases afflicting simultaneously a specific patient  It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods  It gives primary importance to the cost of obtaining each clinical datum. Our algorithm interprets cost not only as dollar expense, but also considers discomfort and risk of the procedure. Four overall cost categories are established: No Cost, Small Cost, Intermediate Cost, and Great Cost  It anticipates the benefit that each clinical datum would confer to each diagnosis in the differential diagnosis list, by calculating with our mini-max procedure how much it would increase or decrease the current probability of the corresponding diagnosis if the data were found respectively present or absent in the patient.  It selects and recommends the probabilistically calculated best cost-benefit clinical data to investigate next in the patient at each diagnostic step, to achieve more efficiently and economically a final diagnosis
  • 20. Advantages of our novel computer program (continues)
  • 21. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies
  • 22. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies  It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences
  • 23. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies  It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences  It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases
  • 24. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies  It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences  It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases  It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis
  • 25. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies  It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences  It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases  It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis  It proposes an easy way to handle synonyms of diagnoses and clinical data
  • 26. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies  It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences  It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases  It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis  It proposes an easy way to handle synonyms of diagnoses and clinical data  It is ease to update
  • 27. Advantages of our novel computer program (continues)  It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies  It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences  It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases  It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis  It proposes an easy way to handle synonyms of diagnoses and clinical data  It is ease to update  Such an algorithm, if successful in medicine, may represent a more general model of reasoning; a paradigm of mental structure and functioning applicable to other inexact disciplines such as law, sociology, politics, defense, or corporate strategy
  • 28. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM
  • 29. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences
  • 30. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available
  • 31. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available 3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources
  • 32. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available 3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources 4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive
  • 33. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available 3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources 4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive 5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers.
  • 34. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available 3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources 4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive 5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers. 6. Protect health care providers against unfounded malpractice liability
  • 35. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available 3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources 4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive 5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers. 6. Protect health care providers against unfounded malpractice liability 7. Helps to overcome the current well known resistance of physicians to resort to computerized aid for medical diagnosis
  • 36. SOCIOECONOMIC ADVANTAGES OF OUR PROGRAM 1. Reduces significantly the current numerous diagnostic errors and their dismal consequences 2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available 3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources 4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive 5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers. 6. Protect health care providers against unfounded malpractice liability 7. Helps to overcome the current well known resistance of physicians to resort to computerized aid for medical diagnosis 8. Some concepts of our diagnostic program are applicable and necessary to properly implement the current renewed enthusiasm for long needed universal electronic storage of medical records
  • 37. DEMONSTRATION
  • 38. DEMONSTRATION A 32-year-old white female grade-school teacher with recent onset of palpitations. Six months ago she lost her job, followed by nervousness and depression. At that time a complete physical examination and basic lab tests were normal; she was treated with an antidepressant, without improving. Her medical condition gradually worsened and recently the mentioned palpitations added to the clinical picture, motivating the present consultation. The medical examination revealed the following clinical data.
  • 39. CLINCAL DATA PRESENT
  • 40. CLINCAL DATA PRESENT No Cost clinical data Medical History (symptoms) C0072 (palpitations) C0216 (nervousness/anxiety) C0606 (depression) C0050 (fatigue, asthenia) C0109 (sweating, diaphoresis, perspiration) C0161 (weight loss) C0165 (diarrhea) C0010 (dyspnea, breathlessness, shortness of breath) Physical Examination (physical signs) C0078 (tachycardia) C0219 (fine texture of skin/hair) C0224 (exophthalmos) C0490 (conjunctival redness) C0222 (lid lag) C0220 (goiter, enlarged thyroid gland) C0095 (loud first heart sound) C0053 (systolic murmur) C0111 (weakness) C0223 (tremor)
  • 41. CLINCAL DATA ABSENT
  • 42. CLINCAL DATA ABSENT No Cost clinical data Medical History (symptoms) C0498 (male)
  • 43. DIFFERENTIAL DIAGNOSIS LIST D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) D0046 (PANCREATIC HEAD CARCINOMA) total P: 818 total P: 176 ---------- ---------- D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE) D0001 (AORTIC DISSECTION) total P: 640 total P: 169 ---------- ---------- D0012 (PHEOCHROMOCYTOMA) D0007 (PULMONARY EMBOLISM) total P: 364 total P: 157 ---------- ---------- D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) D0026 (INTESTINAL GIARDIASIS) total P: 338 total P: 145 ---------- ---------- D0002 (AORTIC VALVE STENOSIS) D0022 (ULCERATIVE COLITIS) total P: 332 total P: 145 ---------- ---------- D0035 (ROCKY MOUNTAIN SPOTTED FEVER) D0024 (ACUTE INFECTIVE ENDOCARDITIS) total P: 272 total P: 138 ---------- ---------- D0057 (ACUTE MYOCARDIAL INFARCTION WITH MASKED CHEST PAIN) D0038 (SYSTEMIC LUPUS ERYTHEMATOSUS) total P: 183 total P: 132 ---------- ---------- D0005 (ACUTE MYOCARDIAL INFARCTION WITHOUT MASKED CHEST PAIN) D0059 (DIABETIC KETOACIDOSIS) total P: 183 total P: 110 ---------- ---------- D0027 (DISSEMINATED GONOCOCCAL INFECTION) D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) total P: 181 total P: 107 ---------- ---------- D0069 (PANCREATIC BODY-TAIL CARCINOMA) D0034 (PNEUMOCOCCAL PNEUMONIA) total P: 176 total P: 100 ---------- ----------
  • 44. Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 103 G0007 ECHOCARDIOGRAM C0704 (moderate hyperosmolality: 300 – 320 mOsm/mL) C0797 (echocardiogram of atrial septal defect secundum) C0703 (glucose: 250 – 600mg/dL) G0001 MEDICAL HISTORY C0710 (hypertriglyceridemia, triglycerides > 250 mg/dL) G0008 IMAGING: CT AND/OR MRI C0353 (abdominal pain, right lower quadrant) C0711 (hyperlipoproteinemia) C0902 (magnetic resonance colangio-pancreatography for body or tail C0800 (abdominal pain, left lower quadrant) C0679 (plasma D-dimer ELISA) mass) C0799 (abdominal pain, right upper quadrant) C0535 (ANA, antinuclear antibodies) C0901 (magnetic resonance colangio-pancreatography for head) C0246 (abdominal pain, epigastric) C0526 (hypergammaglobulinemia) C0851 (multidetector-row CT with oral contrast for Crohn's disease) C0781 (abdominal pain, left upper quadrant) C0518 (casts) C0834 (positron-emission tomography (PET) for pheochromocytoma) C0697 (inadequate insulin administration) C0496 (latex agglutination test for rocky mountain spotted fever) C0495 (indirect immunofluorescence assay for rocky mountain spotted C0798 (mitral stenosis on cardiac magnetic resonance imaging) C0352 (mucus in stool) C0784 (pancreatic body or tail mass on CT or MRI) C0615 (dysuria) fever) C0682 (multislice spiral chest CT or MRI for pulmonary embolism) C0538 (photosensitivity) C0386 (C-reactive protein) C0670 (liver imaging with CT or MRI: fatty liver) C0533 (pericarditis) C0384 (multiple blood cultures for acute endocardits) C0244 (elevated plasma and urine catecholamines and metanephrines) C0612 (spiral CT scanning for pancreatic head carcinoma) C0215 (hypersensitivity to heat) C0785 (spiral CT scanning for pancreatic body or tail carcinoma) C0486 (onset May-September) C0243 (elevated twenty four-hour urine vanillylmandelic acid) Continues… C0458 (vaginal discharge) C0229 (suppressed TSH) C0401 (urinary tract symptoms, female) C0228 (increased free, uncombined thyroxin, T four or T three) C0400 (urinary tract symptoms, male) C0214 (hypophosphatemia) G0009 SCANNING C0833 (nuclear medicine scintigraphy with MIBG for Continues… Continues… pheochromocytoma) C0157 (lung perfusion scan with ventilation scan: high probability) G0002 PHYSICAL EXAMINATION G0005 RADIOLOGY C0233 (thyroid radionuclide scan) C0864 (urethral discharge) C0680 (Westermark's, Hampton's, and Palla's signs on chest x-rays) C0860 (urethritis) C0338 (quot;string signquot; on x-rays) G0010 ENDOSCOPY C0859 (cervicitis) C0329 (pleural effusion on imaging) C0850 (wireless capsule endoscopy for Crohn's disease) C0853 (small intestine obstruction) C0134 (pulmonary infiltrate on imaging) C0153 (colonoscopy and biopsy for Crohn's disease) C0854 (colonic obstruction) C0330 (pancreatic head mass on abdominal ultrasound) Continues… C0794 (systolic thrill) C0681 (venous ultrasonography with Doppler imaging) C0793 (unequal blood pressures) C0044 (transthoracic aorta ultrasound for aortic dissection) C0702 (Kussmaul respiration) G0011 BIOPSY Continues… C0529 (butterfly, malar rash) C0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion) C0475 (chest dullness at percussion) C0399 (biopsy of small intestine for Giardia lamblia) G0007 ECHOCARDIOGRAM C0402 (tenosynovitis/periarthritis) C0664 (echocardiogram for MI) C0398 (dehydration) C0378 (valvular vegetations on transesophageal echocardiogram) Great cost best cost-benefit clinical data: 14 C0379 (new/worsened regurgitant murmur) C0070 (aortic valve stenosis on echocardiogram) Continues… C0102 (mitral stenosis on echocardiogram) G0010 ENDOSCOPY Small cost best cost-benefit clinical data: 92 C0898 (endoscopic ultrasound and fine-needle aspiration for body) Intermediate cost best cost-benefit clinical data: 33 C0608 (ERCP for pancreatic head carcinoma) G0003 ELECTROCARDIOGRAM Continues… C0377 (abnormal ECG) G0004 LABORATORY TESTS C0120 (myocardial infarction pattern on ECG) C0396 (string test) G0011 BIOPSY C0065 (left ventricular hypertrophy on ECG) C0189 (abnormal glucose tolerance) C0611 (biopsy for pancreatic head carcinoma) C0577 (myocardial infarction pattern on ECG, with masked chest pain) C0786 (biopsy for pancreatic body or tail carcinoma) C0048 (myocardial infarction pattern on ECG, without masked chest G0005 RADIOLOGY pain) C0856 (upper GI series with small bowel follow-through for Crohn's G0013 ANGIOGRAPHY disease) C0787 (pancreatic body or tail mass on angiography) G0004 LABORATORY TESTS C0242 (barium enema for ulcerative colitis) C0047 (aortography) C0867 (nucleic acid urogenital probe tests for gonococcus) C0027 (gastrograffin enema for Crohn's disease) C0071 (aortic valve stenosis on catheterization) C0788 (CA 19-9) C0160 (pulmonary angiogram) Continues… C0705 (plasma ketones ++++) Continues… G0006 ULTRASOUND C0792 (transesophageal ultrasound for aortic dissection) Total: 242
  • 45. PARAMETERS Trim Present No Cost 800 Trim Absent No Cost 800 Trim Present Greater Cost 800 Trim Absent Greater Cost 800 Present Difference Cost 000 Absent Difference Cost 000 Confirmation Threshold 900 Deletion Threshold 100 Cutoff Present 100 Cutoff Absent 900
  • 46. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 35 G0001 MEDICAL HISTORY C0819 (increased troponins with masked chest pain) G0008 IMAGING: CT AND/OR MRI C0353 (abdominal pain, right lower quadrant) C0829 (increased troponins without masked chest pain) C0834 (positron-emission tomography (PET) for pheochromocytoma) C0800 (abdominal pain, left lower quadrant) C0679 (plasma D-dimer ELISA) C0798 (mitral stenosis on cardiac magnetic resonance imaging) C0781 (abdominal pain, left upper quadrant) C0535 (ANA, antinuclear antibodies) C0682 (multislice spiral chest CT or MRI for pulmonary embolism) C0780 (strong analgesics) C0496 (latex agglutination test for rocky mountain spotted fever) C0612 (spiral CT scanning for pancreatic head carcinoma) C0673 (pregnancy) C0495 (indirect immunofluorescence assay for rocky mountain spotted C0785 (spiral CT scanning for pancreatic body or tail carcinoma) C0401 (urinary tract symptoms, female) C0045 (aortic dissection on MRI) fever) C0333 (malabsorption) C0884 (sputum culture for pneumococcus) C0296 (gross blood in stool) C0395 (antigen detection in stool) G0009 SCANNING C0262 (acholic, pale, clay-colored stool) C0833 (nuclear medicine scintigraphy with MIBG for C0384 (multiple blood cultures for acute endocardits) C0215 (hypersensitivity to heat) C0345 (serologic markers for Crohn's disease: ASCA) pheochromocytoma) C0163 (anorexia, loss of appetite) C0852 (serologic markers for ulcerative colitis: pANCA) C0233 (thyroid radionuclide scan) C0127 (arthralgia) C0244 (elevated plasma and urine catecholamines and metanephrines) C0665 (radionuclide imaging: viable myocardium, ventricular eject.) C0004 (chest pain) C0229 (suppressed TSH) C0052 (history of angina pectoris) C0228 (increased free, uncombined thyroxin, T four or T three) G0010 ENDOSCOPY C0107 (diabetes) C0151 (increased bilirubin) C0153 (colonoscopy and biopsy for Crohn's disease) C0186 (colonoscopy and biopsy for ulcerative colitis) C0131 (increased ESR) G0002 PHYSICAL EXAMINATION C0033 (leukocytosis) C0794 (systolic thrill) G0011 BIOPSY C0678 (paradoxical bradycardia) G0005 RADIOLOGY C0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion) C0562 (Horner's syndrome) C0042 (abnormal aortic contour on chest x-ray; widening of C0399 (biopsy of small intestine for Giardia lamblia) C0475 (chest dullness at percussion) mediastinum) C0379 (new/worsened regurgitant murmur) C0085 (cardiac enlargement on imaging; usually due to right ventric. Great Cost best cost-benefit clinical data: 7 C0375 (meningism) enlarg.) C0365 (skin lesions) C0086 (increased pulmonary artery and/or vascular engorgement on G0011 BIOPSY C0337 (mouth lesions) imaging) C0332 (intestinal fistulas) C0611 (biopsy for pancreatic head carcinoma) C0248 (jaundice, icterus) C0786 (biopsy for pancreatic body or tail carcinoma) G0006 ULTRASOUND C0238 (funduscopic abnormalities for pheochromocytoma) C0044 (transthoracic aorta ultrasound for aortic dissection) C0147 (tachypnea) G0013 ANGIOGRAPHY C0015 (abdominal tenderness) C0047 (aortography) G0007 ECHOCARDIOGRAM C0018 (fever) C0071 (aortic valve stenosis on catheterization) C0070 (aortic valve stenosis on echocardiogram) C0019 (hypertension) C0090 (atrial septal defect on arteriography) C0102 (mitral stenosis on echocardiogram) C0022 (heart murmur) C0103 (mitral stenosis on catheterization) C0054 (clinical data of advanced age) C0160 (pulmonary angiogram) Intermediate Cost best cost-benefit clinical data: 16 C0055 (delayed second heart sound) C0074 (right ventricular abnormal maximal impulse) Total: 85 C0094 (mitral opening snap) G0005 RADIOLOGY C0856 (upper GI series with small bowel follow-through for Crohn's Small Cost best cost-benefit clinical data: 27 disease) G0006 ULTRASOUND G0004 LABORATORY TESTS C0792 (transesophageal ultrasound for aortic dissection) C0867 (nucleic acid urogenital probe tests for gonococcus) C0788 (CA 19-9) G0007 ECHOCARDIOGRAM C0789 (CA 19-9) C0797 (echocardiogram of atrial septal defect secundum) C0705 (plasma ketones ++++)
  • 47. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 35 G0001 MEDICAL HISTORY C0819 (increased troponins with masked chest pain) G0008 IMAGING: CT AND/OR MRI C0353 (abdominal pain, right lower quadrant) C0829 (increased troponins without masked chest pain) C0834 (positron-emission tomography (PET) for pheochromocytoma) C0800 (abdominal pain, left lower quadrant) C0679 (plasma D-dimer ELISA) C0798 (mitral stenosis on cardiac magnetic resonance imaging) C0781 (abdominal pain, left upper quadrant) C0535 (ANA, antinuclear antibodies) C0682 (multislice spiral chest CT or MRI for pulmonary embolism) C0780 (strong analgesics) C0496 (latex agglutination test for rocky mountain spotted fever) C0612 (spiral CT scanning for pancreatic head carcinoma) C0673 (pregnancy) C0495 (indirect immunofluorescence assay for rocky mountain spotted C0785 (spiral CT scanning for pancreatic body or tail carcinoma) C0401 (urinary tract symptoms, female) C0045 (aortic dissection on MRI) fever) C0333 (malabsorption) C0884 (sputum culture for pneumococcus) C0296 (gross blood in stool) C0395 (antigen detection in stool) G0009 SCANNING C0262 (acholic, pale, clay-colored stool) C0833 (nuclear medicine scintigraphy with MIBG for C0384 (multiple blood cultures for acute endocardits) C0215 (hypersensitivity to heat) C0345 (serologic markers for Crohn's disease: ASCA) pheochromocytoma) C0163 (anorexia, loss of appetite) C0852 (serologic markers for ulcerative colitis: pANCA) C0233 (thyroid radionuclide scan) C0127 (arthralgia) C0244 (elevated plasma and urine catecholamines and metanephrines) C0665 (radionuclide imaging: viable myocardium, ventricular eject.) C0004 (chest pain) C0229 (suppressed TSH) C0052 (history of angina pectoris) C0228 (increased free, uncombined thyroxin, T four or T three) G0010 ENDOSCOPY C0107 (diabetes) C0151 (increased bilirubin) C0153 (colonoscopy and biopsy for Crohn's disease) C0186 (colonoscopy and biopsy for ulcerative colitis) C0131 (increased ESR) G0002 PHYSICAL EXAMINATION C0033 (leukocytosis) C0794 (systolic thrill) G0011 BIOPSY C0678 (paradoxical bradycardia) G0005 RADIOLOGY C0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion) C0562 (Horner's syndrome) C0042 (abnormal aortic contour on chest x-ray; widening of C0399 (biopsy of small intestine for Giardia lamblia) C0475 (chest dullness at percussion) mediastinum) C0379 (new/worsened regurgitant murmur) C0085 (cardiac enlargement on imaging; usually due to right ventric. Great Cost best cost-benefit clinical data: 7 C0375 (meningism) enlarg.) C0365 (skin lesions) C0086 (increased pulmonary artery and/or vascular engorgement on G0011 BIOPSY C0337 (mouth lesions) imaging) C0332 (intestinal fistulas) C0611 (biopsy for pancreatic head carcinoma) C0248 (jaundice, icterus) C0786 (biopsy for pancreatic body or tail carcinoma) G0006 ULTRASOUND C0238 (funduscopic abnormalities for pheochromocytoma) C0044 (transthoracic aorta ultrasound for aortic dissection) C0147 (tachypnea) G0013 ANGIOGRAPHY C0015 (abdominal tenderness) C0047 (aortography) G0007 ECHOCARDIOGRAM C0018 (fever) C0071 (aortic valve stenosis on catheterization) C0070 (aortic valve stenosis on echocardiogram) C0019 (hypertension) C0090 (atrial septal defect on arteriography) C0102 (mitral stenosis on echocardiogram) C0022 (heart murmur) C0103 (mitral stenosis on catheterization) C0054 (clinical data of advanced age) C0160 (pulmonary angiogram) Intermediate Cost best cost-benefit clinical data: 16 C0055 (delayed second heart sound) C0074 (right ventricular abnormal maximal impulse) Total: 85 C0094 (mitral opening snap) G0005 RADIOLOGY C0856 (upper GI series with small bowel follow-through for Crohn's Small Cost best cost-benefit clinical data: 27 disease) G0006 ULTRASOUND G0004 LABORATORY TESTS C0792 (transesophageal ultrasound for aortic dissection) C0867 (nucleic acid urogenital probe tests for gonococcus) C0788 (CA 19-9) G0007 ECHOCARDIOGRAM C0789 (CA 19-9) C0797 (echocardiogram of atrial septal defect secundum) C0705 (plasma ketones ++++)
  • 48. CLINCAL DATA PRESENT No Cost clinical data Medical History (symptoms) C0072 (palpitations) C0216 (nervousness/anxiety) C0606 (depression) C0050 (fatigue, asthenia) C0109 (sweating, diaphoresis, perspiration) C0161 (weight loss) C0165 (diarrhea) C0010 (dyspnea, breathlessness, shortness of breath) C0215 (hypersensitivity to heat) Physical Examination (physical signs) C0078 (tachycardia) C0219 (fine texture of skin/hair) C0224 (exophthalmos) C0490 (conjunctival redness) C0222 (lid lag) C0220 (goiter, enlarged thyroid gland) C0095 (loud first heart sound) C0053 (systolic murmur) C0111 (weakness) C0223 (tremor)
  • 49. CLINCAL DATA ABSENT No Cost clinical data Medical History (symptoms) C0498 (male) C0238 (funduscopic abnormalities for C0353 (abdominal pain, right lower quadrant) pheochromocytoma) C0800 (abdominal pain, left lower quadrant) C0147 (tachypnea) C0781 (abdominal pain, left upper quadrant) C0015 (abdominal tenderness) C0780 (strong analgesics) C0018 (fever) C0673 (pregnancy) C0019 (hypertension) C0401 (urinary tract symptoms, female) C0022 (heart murmur) C0333 (malabsorption) C0054 (clinical data of advanced age) C0296 (gross blood in stool) C0055 (delayed second heart sound) C0262 (acholic, pale, clay-colored stool) C0074 (right ventricular abnormal maximal impulse) C0163 (anorexia, loss of appetite) C0094 (mitral opening snap) C0127 (arthralgia) C0004 (chest pain) C0052 (history of angina pectoris) C0107 (diabetes) Physical Examination (physical signs) C0794 (systolic thrill) C0678 (paradoxical bradycardia) C0562 (Horner's syndrome) C0475 (chest dullness at percussion) C0379 (new/worsened regurgitant murmur) C0375 (meningism) C0365 (skin lesions) C0337 (mouth lesions) C0332 (intestinal fistulas) C0248 (jaundice, icterus)
  • 50. DIFFERENTIAL DIAGNOSIS LIST D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 ---------- D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE) total P: 103 ----------
  • 51. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 2 G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3 G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three) G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram) Intermediate Cost best cost-benefit clinical data: 2 G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging) G0009 SCANNING C0233 (thyroid radionuclide scan) Great Cost best cost-benefit clinical data: 1 G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization) Total: 8
  • 52. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 2 G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3 G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three) G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram) Intermediate Cost best cost-benefit clinical data: 2 G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging) G0009 SCANNING C0233 (thyroid radionuclide scan) Great Cost best cost-benefit clinical data: 1 G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization) Total: 8
  • 53. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 2 G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3 G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three) G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram) Intermediate Cost best cost-benefit clinical data: 2 G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging) G0009 SCANNING C0233 (thyroid radionuclide scan) Great Cost best cost-benefit clinical data: 1 G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization) Total: 8
  • 54. CLINCAL DATA PRESENT No Cost clinical data Medical History (symptoms) Small Cost clinical data C0072 (palpitations) Laboratory Tests C0216 (nervousness/anxiety) C0229 (suppressed TSH) C0606 (depression) C0228 (increased free, uncombined thyroxin, T four C0050 (fatigue, asthenia) or T three) C0109 (sweating, diaphoresis, perspiration) C0161 (weight loss) C0165 (diarrhea) C0010 (dyspnea, breathlessness, shortness of breath) C0215 (hypersensitivity to heat) Physical Examination (physical signs) C0078 (tachycardia) C0219 (fine texture of skin/hair) C0224 (exophthalmos) C0490 (conjunctival redness) C0222 (lid lag) C0220 (goiter, enlarged thyroid gland) C0095 (loud first heart sound) C0053 (systolic murmur) C0111 (weakness) C0223 (tremor)
  • 55. CLINCAL DATA ABSENT No Cost clinical data Medical History (symptoms) C0498 (male) C0238 (funduscopic abnormalities for C0353 (abdominal pain, right lower quadrant) pheochromocytoma) C0800 (abdominal pain, left lower quadrant) C0147 (tachypnea) C0781 (abdominal pain, left upper quadrant) C0015 (abdominal tenderness) C0780 (strong analgesics) C0018 (fever) C0673 (pregnancy) C0019 (hypertension) C0401 (urinary tract symptoms, female) C0022 (heart murmur) C0333 (malabsorption) C0054 (clinical data of advanced age) C0296 (gross blood in stool) C0055 (delayed second heart sound) C0262 (acholic, pale, clay-colored stool) C0074 (right ventricular abnormal maximal impulse) C0163 (anorexia, loss of appetite) C0094 (mitral opening snap) C0127 (arthralgia) C0004 (chest pain) C0221 (thyroid bruit or thrill) C0052 (history of angina pectoris) C0096 (rumbling diastolic murmur) C0107 (diabetes) Physical Examination (physical signs) Small Cost clinical data C0794 (systolic thrill) Echocardiogram C0678 (paradoxical bradycardia) C0102 (mitral stenosis on echocardiogram) C0562 (Horner's syndrome) C0475 (chest dullness at percussion) C0379 (new/worsened regurgitant murmur) C0375 (meningism) C0365 (skin lesions) C0337 (mouth lesions) C0332 (intestinal fistulas) C0248 (jaundice, icterus)
  • 56. DIFFERENTIAL DIAGNOSIS LIST D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 1000
  • 57. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 0 Small Cost best cost-benefit clinical data: 0 Intermediate Cost best cost-benefit clinical data: 0 Great Cost best cost-benefit clinical data: 0 Total: 0
  • 58. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 35 G0001 MEDICAL HISTORY C0819 (increased troponins with masked chest pain) G0008 IMAGING: CT AND/OR MRI C0353 (abdominal pain, right lower quadrant) C0829 (increased troponins without masked chest pain) C0834 (positron-emission tomography (PET) for pheochromocytoma) C0800 (abdominal pain, left lower quadrant) C0679 (plasma D-dimer ELISA) C0798 (mitral stenosis on cardiac magnetic resonance imaging) C0781 (abdominal pain, left upper quadrant) C0535 (ANA, antinuclear antibodies) C0682 (multislice spiral chest CT or MRI for pulmonary embolism) C0780 (strong analgesics) C0496 (latex agglutination test for rocky mountain spotted fever) C0612 (spiral CT scanning for pancreatic head carcinoma) C0673 (pregnancy) C0495 (indirect immunofluorescence assay for rocky mountain spotted C0785 (spiral CT scanning for pancreatic body or tail carcinoma) C0401 (urinary tract symptoms, female) C0045 (aortic dissection on MRI) fever) C0333 (malabsorption) C0884 (sputum culture for pneumococcus) C0296 (gross blood in stool) C0395 (antigen detection in stool) G0009 SCANNING C0262 (acholic, pale, clay-colored stool) C0833 (nuclear medicine scintigraphy with MIBG for C0384 (multiple blood cultures for acute endocardits) C0215 (hypersensitivity to heat) C0345 (serologic markers for Crohn's disease: ASCA) pheochromocytoma) C0163 (anorexia, loss of appetite) C0852 (serologic markers for ulcerative colitis: pANCA) C0233 (thyroid radionuclide scan) C0127 (arthralgia) C0244 (elevated plasma and urine catecholamines and metanephrines) C0665 (radionuclide imaging: viable myocardium, ventricular eject.) C0004 (chest pain) C0229 (suppressed TSH) C0052 (history of angina pectoris) C0228 (increased free, uncombined thyroxin, T four or T three) G0010 ENDOSCOPY C0107 (diabetes) C0151 (increased bilirubin) C0153 (colonoscopy and biopsy for Crohn's disease) C0186 (colonoscopy and biopsy for ulcerative colitis) C0131 (increased ESR) G0002 PHYSICAL EXAMINATION C0033 (leukocytosis) C0794 (systolic thrill) G0011 BIOPSY C0678 (paradoxical bradycardia) G0005 RADIOLOGY C0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion) C0562 (Horner's syndrome) C0042 (abnormal aortic contour on chest x-ray; widening of C0399 (biopsy of small intestine for Giardia lamblia) C0475 (chest dullness at percussion) mediastinum) C0379 (new/worsened regurgitant murmur) C0085 (cardiac enlargement on imaging; usually due to right ventric. Great Cost best cost-benefit clinical data: 7 C0375 (meningism) enlarg.) C0365 (skin lesions) C0086 (increased pulmonary artery and/or vascular engorgement on G0011 BIOPSY C0337 (mouth lesions) imaging) C0332 (intestinal fistulas) C0611 (biopsy for pancreatic head carcinoma) C0248 (jaundice, icterus) C0786 (biopsy for pancreatic body or tail carcinoma) G0006 ULTRASOUND C0238 (funduscopic abnormalities for pheochromocytoma) C0044 (transthoracic aorta ultrasound for aortic dissection) C0147 (tachypnea) G0013 ANGIOGRAPHY C0015 (abdominal tenderness) C0047 (aortography) G0007 ECHOCARDIOGRAM C0018 (fever) C0071 (aortic valve stenosis on catheterization) C0070 (aortic valve stenosis on echocardiogram) C0019 (hypertension) C0090 (atrial septal defect on arteriography) C0102 (mitral stenosis on echocardiogram) C0022 (heart murmur) C0103 (mitral stenosis on catheterization) C0054 (clinical data of advanced age) C0160 (pulmonary angiogram) Intermediate Cost best cost-benefit clinical data: 16 C0055 (delayed second heart sound) C0074 (right ventricular abnormal maximal impulse) Total: 85 C0094 (mitral opening snap) G0005 RADIOLOGY C0856 (upper GI series with small bowel follow-through for Crohn's Small Cost best cost-benefit clinical data: 27 disease) G0006 ULTRASOUND G0004 LABORATORY TESTS C0792 (transesophageal ultrasound for aortic dissection) C0867 (nucleic acid urogenital probe tests for gonococcus) C0788 (CA 19-9) G0007 ECHOCARDIOGRAM C0789 (CA 19-9) C0797 (echocardiogram of atrial septal defect secundum) C0705 (plasma ketones ++++)
  • 59. Abridged Global Overview G0006 ULTRASOUND C0233 (thyroid radionuclide scan) No Cost best cost-benefit clinical data: 35 C0044 (transthoracic aorta ultrasound for aortic dissection) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) D0001 (AORTIC DISSECTION) total P: 818 G0001 MEDICAL HISTORY total P: 169 present total P: 1000 C0353 (abdominal pain, right lower quadrant) present total P: 1000 D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) G0007 ECHOCARDIOGRAM total P: 818 total P: 107 C0070 (aortic valve stenosis on echocardiogram) absent total P: 0 absent total P: 35 D0002 (AORTIC VALVE STENOSIS) G0010 ENDOSCOPY C0781 (abdominal pain, left upper quadrant) total P: 332 C0153 (colonoscopy and biopsy for Crohn's disease) D0069 (PANCREATIC BODY-TAIL CARCINOMA) present total P: 1000 D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) total P: 176 D0002 (AORTIC VALVE STENOSIS) total P: 107 present total P: 800 total P: 332 absent total P: 0 D0069 (PANCREATIC BODY-TAIL CARCINOMA) absent total P: 0 C0186 (colonoscopy and biopsy for ulcerative colitis) total P: 176 D0022 (ULCERATIVE COLITIS) Continues… absent total P: 26 total P: 145 G0002 PHYSICAL EXAMINATION Intermediate Cost best cost-benefit clinical data: present total P: 1000 C0794 (systolic thrill) 16 D0022 (ULCERATIVE COLITIS) D0002 (AORTIC VALVE STENOSIS) G0005 RADIOLOGY total P: 145 total P: 332 C0856 (upper GI series with small bowel follow-through for Crohn's absent total P: 0 present total P: 651 disease) G0011 BIOPSY C0678 (paradoxical bradycardia) D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) C0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion) D0007 (PULMONARY EMBOLISM) total P: 107 D0035 (ROCKY MOUNTAIN SPOTTED FEVER) total P: 157 present total P: 1000 total P: 272 present total P: 500 G0006 ULTRASOUND present total P: 1000 D0034 (PNEUMOCOCCAL PNEUMONIA) C0792 (transesophageal ultrasound for aortic dissection) D0035 (ROCKY MOUNTAIN SPOTTED FEVER) total P: 100 D0001 (AORTIC DISSECTION) total P: 272 present total P: 649 total P: 169 absent total P: 64 Continues… present total P: 1000 C0399 (biopsy of small intestine for Giardia lamblia) Small Cost best cost-benefit clinical data: 27 G0007 ECHOCARDIOGRAM D0026 (INTESTINAL GIARDIASIS) G0004 LABORATORY TESTS C0797 (echocardiogram of atrial septal defect secundum) total P: 145 C0867 (nucleic acid urogenital probe tests for gonococcus) D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) present total P: 1000 D0027 (DISSEMINATED GONOCOCCAL INFECTION) total P: 338 D0026 (INTESTINAL GIARDIASIS) total P: 181 present total P: 1000 total P: 145 present total P: 1000 D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) absent total P: 8 C0229 (suppressed TSH) total P: 338 Continues… D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) absent total P: 0 Great Cost best cost-benefit clinical data: 7 total P: 818 G0008 IMAGING: CT AND/OR MRI C0834 (positron-emission tomography (PET) for pheochromocytoma) G0013 ANGIOGRAPHY present total P: 1000 C0047 (aortography) C0228 (increased free, uncombined thyroxin, T four or T three) D0012 (PHEOCHROMOCYTOMA) D0001 (AORTIC DISSECTION) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 364 total P: 169 total P: 818 present total P: 1000 present total P: 1000 absent total P: 0 C0798 (mitral stenosis on cardiac magnetic resonance imaging) D0001 (AORTIC DISSECTION) G0005 RADIOLOGY D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE) total P: 169 C0042 (abnormal aortic contour on chest x-ray; widening of total P: 780 absent total P: 6 mediastinum) present total P: 1000 C0090 (atrial septal defect on arteriography) D0001 (AORTIC DISSECTION) D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE) D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) total P: 169 total P: 780 total P: 338 absent total P: 54 absent total P: 0 present total P: 1000 C0085 (cardiac enlargement on imaging; usually due to right ventric. G0009 SCANNING D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) enlarg.) C0833 (nuclear medicine scintigraphy with MIBG for total P: 338 D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) pheochromocytoma) absent total P: 0 total P: 338 D0012 (PHEOCHROMOCYTOMA) Continues… absent total P: 101 total P: 364 Total: 85 absent total P: 27
  • 60. Abridged Data Cost Procedure Quantity No Cost best cost-benefit clinical data: 2 G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3 G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three) G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram) Intermediate Cost best cost-benefit clinical data: 2 G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging) G0009 SCANNING C0233 (thyroid radionuclide scan) Great Cost best cost-benefit clinical data: 1 G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization) Total: 8
  • 61. Abridged Global Overview No Cost best cost-benefit clinical data: 2 Intermediate Cost best cost-benefit clinical data: 2 G0002 PHYSICAL EXAMINATION G0008 IMAGING: CT AND/OR MRI C0221 (thyroid bruit or thrill) C0798 (mitral stenosis on cardiac magnetic resonance imaging) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) D0004 (MITRAL STENOSIS) total P: 671 total P: 103 absent total P: 408 present total P: 1000 C0096 (rumbling diastolic murmur) D0004 (MITRAL STENOSIS) D0004 (MITRAL STENOSIS) total P: 103 total P: 103 absent total P: 0 present total P: 176 G0009 SCANNING Small Cost best cost-benefit clinical data: 3 C0233 (thyroid radionuclide scan) G0004 LABORATORY TESTS D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) C0229 (suppressed TSH) total P: 671 present total P: 1000 D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 total P: 671 present total P: 1000 absent total P: 0 D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 Great Cost best cost-benefit clinical data: 1 absent total P: 0 G0013 ANGIOGRAPHY C0228 (increased free, uncombined thyroxin, T four or T three) C0103 (mitral stenosis on catheterization) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) D0004 (MITRAL STENOSIS) total P: 671 total P: 103 absent total P: 0 present total P: 1000 G0007 ECHOCARDIOGRAM D0004 (MITRAL STENOSIS) C0102 (mitral stenosis on echocardiogram) total P: 103 D0004 (MITRAL STENOSIS) absent total P: 0 total P: 103 present total P: 1000 Total: 8 D0004 (MITRAL STENOSIS) total P: 103 absent total P: 0
  • 62. WHAT HAPPENED SO FAR ?  The theory behind our diagnostic system, its terminology, principles, and operation were first published in 2006
  • 63. COMPUTERIZED MEDICAL DIAGNOSIS: A NOVEL SOLUTION TO AN OLD PROBLEM INITIAL CONCLUSION OF DIAGNOSTIC QUEST? CLINICAL DATA COLLECTION AND SYNONYM HANDLING CONCURRENT DIAGNOSES CLINICAL DATA MATCHING BEST COST-BENEFIT CLINICAL DATUM NEXT TO INVESTIGATE CREATION OF CLINICAL DATUM LISTS Step 1. Select clinical data not yet investigated in the patient CREATION OF Step 2. Organize clinical data not yet DIFFERENTIAL DIAGNOSIS LIST investigated according to cost category, diagnosis, PP value, and S CALCULATION OF PROBABILITY OF DIAGNOSES. MINI-MAX PROCEDURE Step 3. Recommend a new clinical datum as best clinical datum Step 1. Process assuming it present clinical data present Step 4. Recommend a new clinical Step 2. Process clinical data absent datum as best clinical datum assuming it absent Step 3. Create clinical data pairs Step 4. Create clinical data pair MASKING tables Step 5. Calculate partial P that SIMULTANEOUS RECOMMENDATION OF each clinical data pair SEVERAL BEST COST-BENEFIT confers to each diagnosis CLINICAL DATA Step 6. Create mini-max tables SAFETY CHECK FOR RISK FLAGGED DIAGNOSES AND CLINICAL DATA Step 7. Determine total P of the diagnosis SAFETY CHECK FOR RELATED CLINICAL ENTITIES Step 8. Update differential diagnosis list CLINICAL PRESENTATION Carlos Feder 2006
  • 64. WHAT HAPPENED SO FAR ?  The theory behind our diagnostic system, its terminology, principles, and operation were first published in 2006  A patent is pending  The computer program that runs our algorithm was written by Tomás Feder in 2007  This computer program provided a prototype, instrumental in confirming essentially all our novel ideas, enabling to challenge real clinical cases of individual patients and the theories behind, with excellent diagnostic results; it broadened our understanding of the medical diagnostic process, dissipating earlier uncertainties, enabling the discovery of new functions and eliciting ideas that opened an entire new realm in this field. So many are the simplifications, additions, and codes that execute new functions, that they justified writing a new book that we published in 2008
  • 65. A PRACTICAL COMPUTER PROGRAM THAT DIAGNOSES DISEASES IN ACTUAL PATIENTS Carlos Feder &
  • 66. WHAT HAPPENED SO FAR ?  The theory behind our diagnostic system, its terminology, principles, and operation were first published in 2006  A patent is pending  The computer program that runs our algorithm was written by Tomás Feder in 2007  This computer program provided a prototype, instrumental in confirming essentially all our novel ideas, enabling to challenge real clinical cases of individual patients and the theories behind, with excellent diagnostic results; it broadened our understanding of the medical diagnostic process, dissipating earlier uncertainties, enabling the discovery of new functions and eliciting ideas that opened an entire new realm in this field. So many are the simplifications, additions, and codes that execute new functions, that they justified writing a new book that we published in 2008  Our prototype includes so far 60 diseases in its database, and diagnoses beautifully real patients afflicted by any of such diseases
  • 67. WHAT NEXT?  Our diagnostic system, in order to accomplish all the envisioned benefits, must have its database integrated with all currently known diseases, all their clinical data and corresponding sensitivities. All complex clinical presentation models, which lists related diagnoses must be created and also included in the database. This task requires the cooperation of a team of medical specialists.  Our computer program is not a fancy program that opens colorful windows clicking on menus or icons, but it satisfies all requisite functions of the algorithm and works efficiently and accurately. This program would benefit from some cosmetic improvement by an experienced professional programmer, able to make it more glamorous and attractive.  We hope that Google or somebody else may help and support us with this project.
  • 68. WHAT NEXT?  Our diagnostic system, in order to accomplish all the envisioned benefits, must have its database integrated with all currently known diseases, all their clinical data and corresponding sensitivities. All complex clinical presentation models, which lists related diagnoses must be created and also included in the database. This task requires the cooperation of a team of medical specialists.  Our computer program is not a fancy program that opens colorful windows clicking on menus or icons, but it satisfies all requisite functions of the algorithm and works efficiently and accurately. This program would benefit from some cosmetic improvement by an experienced professional programmer, able to make it more glamorous and attractive.  We hope that Google or somebody else may help and support us with this project.
  • 69. WHAT NEXT? Our diagnostic system, once implemented with all known diseases and clinical data, is expected to provide invaluable diagnostic benefits to patients, physicians, nurses, health insurance companies, malpractice lawyers, and the entire medical establishment
  • 70. Thank you for your attention

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