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Evaluation möglicher Auswirkungen von Expertensystemen in der Medizin
Abstract
Medizinische Experten- und Konsultationssysteme sind wissensbasierte Computerverfahren, die den Arzt bei komplexen Diagnose- und Therapieentscheidungen unterstützen sollen. In einer Studie zur Folgenabschätzung bzw. zum Technology Assessment (TA) solcher Systeme untersuchten wir: Reifegrad, Verbreitung, Diffusionschancen in den nächsten 10–15 Jahren, Aus-, Neben- und Folgewirkungen auf Versorgungsqualität, Kosten der Versorgung, Personaleinsatz, Arzt-Patienten-Verhältnis, Risiken.
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A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16,737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual. The system proved reliable and was used in 75.1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45.6% to 65.3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11.5%). The bad management error rate fell from 0.9% to 0.2%, and the observed mortality fell by 22.0%. The savings made were estimated as amounting to 278 laparotomies and 8,516 bed nights during the trial period--equivalent throughout the National Health Service to annual savings in resources worth over 20m pounds and direct cost savings of over 5m pounds. Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.
In the course of a 6-year development project computer systems for ambulatory medical care are tested. Problem background is the liberally organized health care system of the Federal Republic with some 50,000 practices operating rather individually. Among alternative system concepts with different degrees of centralization, autonomous “doctor’s office computers” have been in the field test for several years in the specialties of urology, ophthalmology, and internal medicine. The application software concentrates on crucial administrative and documentary functions that occur frequently in the daily routine of every practice.
The hardware PDP 11/34, Philips 856 and MICRO I is programmed in MUMPS. It proved to be too expensive for individual practices. In regard to the efficiency there are significant discrepancies between the expectations of the doctors, the paramedical staff, and the actual use of implemented functions. The work load for data acquisition is regularly underestimated, although it affords 80 percent of the system dialog.
While the different cost factors can easily be calculated, it is rather difficult to measure and quantify profits. It is remarkable that all costs of the computer have to be borne by the practice, while all potential advantages are evenly spread over patients, employers, insurance companies, and doctors’ associations. The realization of positive economic effects is blocked by the fact that the practice is accustomed to proved conventional forms of organization which are very flexible, pragmatic and always ready for improvisation. In addition, the legal and contractual environment favours those paper and pencil structures, thus diminishing the advantage of integrated computer-oriented data processing. The trend to group practices and small clinics from 4,000 today to some 20,000 in the mid eighties will play a key role for computer penetration into this market.
Installations of computers in offices of private physicians were evaluated. The tested group involved practices for gynecology, ENT, ophthalmology and general medicine. The study comprised detailed analyses of the functional characteristics of each office before, during and after the computer installation.
An increased systematization of recording and claim processing could be found. Time gain was seen in the processing of documents of new patients and of ‘repeaters’ with updates. Retrieval of administrative data was slightly longer in normal ‘repeaters’ than in the manual process. Frequencies of diagnoses, procedures and various time parameters are reported. The used set of codes or terms is manageable in regard to volume and differentiation in the individual office. In some offices time gain and shift in workload led to an economic gain. General aspects of the experiment are discussed.
The traditional approach to computer-based advice in medicine has been to design systems which simulate a physician's decision process. This paper describes a different approach to computer advice in medicine: a critiquing approach. A critiquing system first asks how the physician is planning to manage his patient and then critiques that plan, discussing the advantages and disadvantages of the proposed approach, compared to other approaches which might be reasonable or preferred. Several critiquing systems are currently in different stages of implementation. The paper describes these systems and discusses the characteristics which make each domain suitable for critiquing. The critiquing approach may prove especially well-suited in domains where decisions involve a great deal of subjective judgement.
Welche finanziellen und praktischen Überlegungen müssen bei der Auswahl eines Systems bedacht werden? Vortrag auf der Systems
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