Office Technology
Software for Symptoms

To the several doctors who examined three-year-old Isabel Maude in 1999, her malady at first seemed to be a routine case of chicken pox. But the fever wouldn't drop, her skin had developed a bluish discoloring and she complained of increasing pain.

Eventually rushed to the emergency room, the toddler spent two months in the hospital -- half that time in intensive care -- suffering from multiple organ failure and cardiac arrest brought on by toxic shock syndrome and necrotizing fasciitis (sometimes called the "flesh eating" disease).

Isabel's brush with death was a life-changing experience for her father, Jason Maude. He eventually left his career as an insurance company's investment manager in London to become one of the founders of a venture that makes software designed to help physicians make diagnoses. Mr. Maude believes that "diagnostic-decision support software," which aims to reduce misdiagnoses by presenting physicians with a full array of possible conditions, might have made all the difference for his daughter.

"We all know computers are better at remembering things than we are," he says.

A New Prescription

Perhaps, but for the most part, such DDS programs haven't been what the doctor ordered. Many physicians consider such programs too time-consuming or cumbersome, or not helpful enough to be worth the investment. Proponents of the software say the problem is also with the doctors themselves: Physicians, they say, prefer to rely on their own experience and training, and are reluctant to use computers in making judgments.

"DDS has remarkably little market share or presence," says Thomas Handler, a physician and research director at Gartner Inc., a technology consulting firm based in Stamford, Conn. Many agree with his assessment that such programs simply haven't proved to be more adept at diagnosis than physicians are on their own. Medicine, Dr. Handler says, "is really an art."

The result is that while estimates vary, the consensus is that no more than 2% of doctors in the U.S. use diagnostic-support software.

But advocates of the software believe that, at last, its time is coming. The current generation of diagnostic tools is more powerful. Many doctors, meanwhile, are becoming more comfortable with computer technology in their practices, with the growing use of electronic medical records and computerized ordering of drugs and medical tests.

At the same time, pressure is building from regulators, insurers and patients for more-efficient health care, and getting diagnoses right quickly is one way to cut the cost and improve the quality of treatment. "Medicine is looking for answers" just as everyone else is, says Charles Burger, an internist in Bangor, Maine, who has used diagnostic-support software for years. "At some point in time, a system like this is going to be in universal use."

Life, Death and Discomfort

Missed diagnoses don't always involve emergency rooms and life-or-death situations. A family doctor, for instance, might misread a chronic condition. Consider the intestinal disease called celiac sprue. If it goes undiagnosed, this disease can lead to malnutrition, osteoporosis and increased risk of some kinds of cancer, besides persistent discomfort.

But while it is estimated to affect more than two million people in the U.S. and Canada, it is often misdiagnosed because symptoms vary widely from patient to patient, according to the Canadian Celiac Association.

"Any of the statistics you want to look at tell us that we are doing a lousy job" in general of quickly making correct diagnoses, says Dr. Burger. Diagnostic-support software can be a big help in sorting through the myriad possible causes of a patient's symptoms, he says. "Are the tools perfect?" says Dr. Burger. "No, but they are getting better all the time."

Most of today's DDS programs work in a similar fashion: The physician enters basic data about the patient, such as age and sex, along with the patient's symptoms. The program then lists various diseases and conditions to consider, sometimes ranking them by likelihood or organizing them by medical category -- gastroenterology, cardiology, oncology, etc. The systems also enable doctors to look up background material, such as articles from medical journals with the latest disease research.

These programs often suggest maladies that aren't always obvious even to experienced physicians. Consider the case of a 10-year-old boy who came to an emergency room after suffering from nausea and dizziness for two weeks. Harold Cross of Beaufort, S.C., the attending emergency-room physician, says the case was puzzling because the boy had a good appetite, no abdominal pain and only one headache over the two-week period. Dr. Cross found no other physical or neurological problems.

To aid in the diagnosis, Dr. Cross turned to software from Problem-Knowledge Coupler Corp., based in Burlington, Vt. A common thread emerged among the possible causes the program suggested for each of the boy's symptoms: trouble in the back portion of the brain. Dr. Cross ordered an MRI scan, which revealed a tumor in the back of the boy's brain. "My personal knowledge of the literature and physical findings would not have prompted me to suspect a brain tumor," Dr. Cross says. The tumor was removed two days later.

A study published in the February 2005 issue of Casebook, a journal published by the United Kingdom's Medical Protection Society, tested the diagnostic software called Isabel -- Mr. Maude's project -- against 88 cases where doctors had missed the correct diagnosis or had made a delayed diagnosis.

It found that the choices offered by the software included the correct diagnosis for 69% of those cases. (The software is sold by Isabel Healthcare Ltd. and Isabel Healthcare Inc., the two commercial subsidiaries of the U.K.-based Isabel Medical Charity.)

So why hasn't diagnostic software found more of a market? Some doctors say it takes too much time to enter extensive patient data into some systems. "If your HMO allows you 10 and a half minutes to see a patient, how are you going to do this?" asks David Goldmann, a physician who serves as vice president and editor in chief of the Physicians' Information and Education Resource, a guide to clinical care published by the American College of Physicians in Philadelphia.

MEDICAL SCREENING: A look at Massachusetts General Hospital's DXplain software

Others worry about the potential for mistakes whenever computers are involved in medicine. For example, the March 9 issue of the Journal of the American Medical Association is filled with articles about errors in the computerized ordering of drugs and medical tests by physicians. Isabel Healthcare seeks to soothe such concerns by calling its program "diagnosis reminder" software -- to emphasize that diagnostic software leaves the final decision up to the doctor.

There are financial considerations as well. A doctor pays $750 a year to subscribe to Isabel, for example, while a hospital pays $180 per bed. But the majority of the roughly 700,000 practicing physicians in the U.S. are self-employed.

"These are small-business people," says David C. Kibbe, a doctor who is the health information-technology director for the American Academy of Family Physicians in Leawood, Kan. "They've got to pay the bills" like any other small business, he says. "Margins [in family practice] are very narrow to begin with," leaving scant room for discretionary spending on information-technology systems.

"The cost-benefit ratio has not been there for doctors," says Kirk Loevner, chief executive officer at Epocrates Inc., a San Mateo, Calif., company that makes so-called clinical-decision support software, which also helps doctors research symptoms and diseases but doesn't analyze multiple symptoms like DDS programs do.

Still, there are signs that these diagnostic systems may gradually gain a wider following. The increased use of personal digital assistants, or PDAs, and other handheld computers by doctors could boost the market for diagnostic software. More than half of U.S. doctors use one of these devices regularly, according to a study by the American Medical Association and Forrester Research Inc. of Cambridge, Mass.

And some DDS programs, including Isabel, can be used on PDAs as well as desktops. Doctors may be more favorably inclined toward these programs if they don't have to be tied to their desks to use the software. Meanwhile, some makers of diagnostic programs are trying to address doctors' financial concerns. The home page for Isabel Healthcare, for example, has an "ROI calculator" that doctors can click on to consider the potential return on an investment in Isabel -- including the possibility of avoiding malpractice cases.

The growing adoption of electronic medical records also presents an opportunity for makers of diagnostic software. The DXplain software developed by Massachusetts General Hospital in Boston can be linked to electronic medical records, automatically prompting doctors, for example, about potential causes for abnormal results in a patient's latest lab tests.

"Diagnostic support systems will be more widely used when we can link [more of] them" with electronic medical records, says Octo Barnett, a professor of medicine at the Harvard Medical School and senior scientific director of the Laboratory of Computer Science at Massachusetts General.

Also, Dr. Barnett suggests, as the profession becomes more accustomed to using other forms of health-care information technology, like electronic medical records and computerized ordering of medications and tests, some of the resistance to diagnostic software will fade.

Meanwhile, diagnostic-support programs have benefited from greater input from doctors in their development, as well as from the latest advances in software. The Isabel diagnostic tool, for instance, uses powerful software from U.K.-based Autonomy Corp. to analyze the vast amount of medical information that provides the basis for diagnoses of multiple symptoms. Isabel's use of Autonomy's pattern-recognition technology is a key reason why the program is able to find the most likely matches between symptoms and diseases, says a recent report by Forrester.

"Hopefully, someday these systems won't be a burden to be borne by the physician community, but a tool to be embraced," says Eric Brown, a vice president at Forrester.