Naval Submarine Medical Research Laboratory

NSMRL REPORT 1186 1 May 1993

AD-A264 479

STATES 0 0GA toS E

A HISTORY OF COMPUTER-ASSISTED MEDICAL DIAGNOSIS AT

NAVAL SUBMARINE MEDICAL RESEARCH LABORATORY

P. L. Perrotta. LT, MC. USNR

and

E. M. Perkins KII~J

3rA;I 1,3199 D ,

At sA 7 93-11024

Released by

P. K. Weathersby, CAPT, MSC, USN

Commanding Officer

Naval Sibmarine Medical Research Laboratory

Approved for public release; distribution unlimited
A HISTORY OF COMPUTER-ASSISTED

MEDICAL DIAGNOSIS AT

NAVAL SUBMARINE MEDICAL RESEARCH

LABORATORY

Peter L. Perrotta, LT, MC, USNR

and

Ellen M. Perkins

Naval Submarine Medical Research Laboratory

Report 1i 86

Naval Medical Research and Development Command

Work Unit 63706N M0095.005-5010

Approved and released by

P. K. Weathersby, CAPT, MSC, USN

Approved for public release; distribution unlimited
SUMMARY PAGE

PROBLEM

In the 1970's NSMRL was tasked with development of computer assisted diagnostic aids for

Independent Duty Corpsmen serving aboard submarines and other health care practitioners at

remote duty stations.

FINDINGS

This report details the history and development of the nine computer-assisted medical

diagnostic aids at NSMRL.

APPLICATION

This report would be of use to individuals interested in the history of medical diagnostic

product development in the submarine medical community. Several of these programs have

been released by the Commanding Officer of NSMRL for distribution and can be obtained by

request.

ADMINISTRATIVE INFORMATION

This report was completed under Naval Medical Research Development Command Research

Work Unit 63706N-M0095.005-5010, Submarine deployable computer based system for enhancing medical practice, performance, and quality. The views expressed in this report are those of

the authors and do not reflect the official policy or position of the Department of the Navy,

Department of Defense, or the U.S. Government. This report was approved for publication

on 1 May 1993 and designated Naval Submarine Medical Research Report 1186.
ABSTRACT

Independent duty hospital corpsmen assigned to submarines are normally the sole provider

of medical care for the crew. Corpsmen with varying levels of experience and training must

make diagnoses with limited diagnostic tools and without expert consultation. A medical

evacuation (MEDEVAC) can potentially expose a submarine's position, is hazardous to both

the patient and the rescuers, especially in high sea states, and is expensive because it entails the

movement of large numbers of ships, aircraft and men. For these reasons, the Naval Submarine

Medical Research Laboratory (NSMRL) was tasked in the 1970's with developing computerized

diagnostic aids for these corpsmen with the goals of reducing the number of unnecessary

medical evacuations and improving the quality of health care at sea.

This report details the history and development of the computer assisted medical diagnostic

aids at this laboratory and would be of benefit to individuals or Commands interested in

continuing this type of work. Several of these programs have been approved for distribution

by the Commanding Officer, NSMRL, and may be obtained by request.

AOOOS:? !•'tO 10 •---- V.I 

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[Blank Page]

iv
A HISTORY OF COMPUTER-ASSISTED MEDICAL DIAGNOSIS AT NAVAL

SUBMARINE MEDICAL RESEARCH LABORATORY

Independent duty hospital corpsmen as- details in this report are not ,ecorded in any

signed to submarines are normally the sole other retrievable publication.

provider of medical care for the crew.

Corpsmen with varying levels of experience Abdominal Pain Programs

and training must make diagnoses with

limited diagnostic tools, e.g., there are no A survey of the literature in 1979 revealed

radiographic and few laboratory capabilities several computer algorithms developed for

onboard, and the corpsman is without expert evaluation of gastrointestinal complaints inconsultation. A medical evacuation cluding acute abdominal pain, epigastric pain,

(MEDEVAC) can potentially expose a and dyspepsia. One of these, the acute absubmarine's position, is hazardous to both the dominal pain program being developed by Dr.

patient and the rescuers, especially in high sea Timothy de Dombal of the University of

states, and is expensive because it entails the Leeds, England, was determined to meet submovement of large numbers of ships, aircraft marine requirements. de Dombal's program

and men. For these reasons, the Naval Sub- did not require extensive memory which

marine Medical Research Laboratory meant that it could be installed on computers

3 (NSMRL) was tasked with developing com- other than the large main frames of the time

puterized diagnostic aids for these corpsmen It used a Bayesian algorithm to generate diswith the goal of reducing the number of un- ease probabilities and did not require results

necessary medical evacuations and of improv- of laboratory tests to arrive at a diagnosis.

ing the quality of health care at sea. The Bayesian approach incorporates the prior

probability of a disease to guide the interpretaIn 1971, Dr. Rupert Hester of NSMRL tion of signs and symptoms. During the early

reported that the three most common medical 1980's, in cooperation with Dr. de Dombal,

problems encountered aboard submarines re- his program was modified for an active duty

quiring MEDEVAC were abdominal pain, population (young, healthy males who are

chest pain, and psychiatric disturbances1. seen within the first 48 hours of illness) so

With the rapid technical advances of micro- that it could be used by corpsmen at sea on a

computers occurring during the 70's, there Tektronix 4051 desk top calculator with 32 K

was increasing interest in developing com- of memory and a 300 K tape cartridge.

puter-aids to medical diagnosis in both the

civilian and military communities. The After a series of experimental evaluations

United States Navy, in particular, was inter- both at Naval hospitals4 ,

5'6 and at sea, this

ested in producing a system that would assist program was placed on four operational fleet

corpsmen aboard submarines and other health ballistic missile (FBM) submarines for extencare practitioners in remote duty stations. sive at-sea testing in 19797. To ensure use of

This report details the history and develop- the system in a predictable way, preselected

ment of the computer assisted medical diag- crew members were trained to simulate abnostic aids at this laboratory. Many of the dominal complaints and then presented to the

corpsman at some time during the patrol. The
corpsman did not know which cases were sequently, in Miy 1982, training of Squadron

fabricated and which were real. Commanding Medical Officers and Squadron Corpsmen

(CO) and executive (XO) officers participated was begun with the concomitant distribution

in the simulated cases by knowing who the ac- of computer tapes and instructional materials.

tors would be. Individual submarine corpsmen were, in turn,

trained by Squadron medical personnel. In

During this study, nine simulated and four July 1982 , sea trials were initiated with 103

genuine cases of abdominal pain were submarines--52 in a control group and 51 in

evaluated at sea. Following deployment, the the experimental group. The enrollment numcorpsman, CO, and XO of each patrol were bers fluctuated with new additions to the fleet

debriefed at NSMRL. These participants and decommissioning or transfers to the

believed that the simulated cases appeared shipyard. The Control Group was given the

genuine and that this method provided for data sheets, reference manual, and training

realistic evaluation of the system. The program; the Experimental Group received

corpsmen perceived the computer as an aid to, those same items and the computer diagnostic

rather than a replacement for, their clinical program. These sea trials were to last a

judgment and found the program valuable in period of five years.

organizing and summarizing data before discussing MEDEVAC decisions with the com- After six months at sea, only two cases of

manding and executive officers. All abdominal pain had been reported to

participants felt that the system assisted in NSMRL 8 . Periodic interviews of Squadron

MEDEVAC and other patient care decisions Corpsmen revealed that the "Control" group

and endorsed its use aboard submarines. Sub- was unhappy with their role of data collection

sequent at-sea trials revealed several limita- without the benefit of the diagnostic program.

tions of the system. Operational access to the The "Experimental" group was unhappy with

Tektronix was limited because of its location the extra paperwork involved in data collecin Sonar spaces and use by other personnel, tion.

primarily Sonarmen. The system was felt to

be clumsy to use because of the antiquated After another 15 months, only 30 cases of

magnetic tape storage system. The users also abdominal pain at sea were reported to

found that the results of the computer analysis NSMRL. Review of the sick call logs and perwere difficult to interpret, and the hard copy sonal communication with the corpsmen disunit failed to provide legible computer prin- closed that 80-90% of the cases went

touts for the majority of cases. It was con- unreported to NSMRL, largely because of the

cluded that before full scale clinical sea trials, increased paperwork. The corpsmen were

the computer system must present diagnoses also concerned that this data would be used

in a format which is more easily interpreted for other purposes, such as to "second guess"

by the practitioner making patient care the corpsman's diagnosis in the event of an addecisions. Finally, user training needed to be verse medical outcome. Personal visits were

improved, made to submarine corpsmen to ease their concerns.

In January 1982, approval was granted by

the Chief of Naval Operations (CNO) for Despite these problems, several subjective

Fleet Test & Evaluation support. Sub- advantages of using this system were noted by

2
the users and researchers. First, the d,-ta sheet of 39 cases), agreement between the computer

was found to be very helpful when used diagnosis and final diagnosis was also 85%,

during collection of clinical information. By and agreement between the practitioner's iniproviding a template, the corpsmen were tial diagnosis and the computer diagnosis was

more likely to gather a more complete history 69% (27 of 39 cases).

and physical examination. Second, the

corpsmen felt that the system was reliable be- During fiscal year (FY) 1985, evaluations

cause the computer's diagnosis supported were initiated to replace the Tektronix

their initial diagnosis at least 75% of the time. machine which was being phased out Navy

Finally, when the computerized diagnostic wide. A decision was made that programs

program was used, it was subjectively ap- would be IBM compatible and run under the

preciated by corpsmen as an aid or adjunct to MS-DOS operating system.

diagnostic problems.

For this reason, the abdominal pain module

Concurrent with the sea trials, in July was programmed using Microsoft Quick1982, a similar study was begun at the Emer- BASIC by Southerland and Fisherkeller10.

gency Room of Naval Hospital Groton, CT Supporting user documentation • • 9 1 1 was also

using physician-collected data . A total of 90 provided. In its present form, version 3.0 of

cases along with supporting documentation the abdominal pain program provides diagnos-

(51 male cases, 39 female cases) were col- tic and treatment suggestions for appendicitis,

lected. For the male data, agreement between cholecystitis, renal colic, perforated duodenal

the practitioner's initial diagnosis and the ulcer, small bowel obstruction, and nonfinal diagnosis was 88% (45 out of 51 cases). specific abdominal pain. This program also

The initial diagnosis of the practitioner was contains a database for the diagnosis of the

the discharge diagnosis noted on the emergen- following disorders associated with female abcy room treatment record. The final diagnosis dominal pain: appendicitis, pelvic inflamwas determined after follow-up with the matory disease, urinary tract infection,

patient by phone at least seven days after the ovarian cyst, ectopic pregnancy, incomplete

emergency room visit. If the patient was ad- abortion, and non-specific abdominal pain.

mitted to the hospital, the final diagnosis was The female only program incorporated the

the discharge diagnosis noted in the patient Bayesian knowledge base developed in

record. Agreement between the computer England (no U.S. Navy data was used), with

diagnosis and final diagnosis was 84% (43 of the diagnosis of dyspepsia categorized as non51 cases), and agreement between the specific abdominal pain. Changes were made

practitioner's initial diagnosis and the com- to the user interface and disease information

puter diagnosis was 88%. For the purposes of and treatment protocols were updated. Correcthis comparison, the computer diagnosis was tions were made to the abdominal pain trainarbitrarily set to be that diagnosis with a calcu- ing cases and a subroutine which generated

lated probability of 50% or greater. standardized medical record entry (SF-600)

form was added. Following these improveAlthough not relevant to the submarine ments, the program was approved for distribuforce, the female data collected was analyzed. tion by the Commanding Officer, NSMRL.

Agreement between the practitioner's initial

diagnosis and the final diagnosis was 85% (33

3
During FY 88, the operational diagnostic dominal pain. In unpublished results, the proprograms (abdominal and chest pain) were gram disagreed with the emergency room

given to the Navy Management Systems Sup- physician in 43% of*',e cases. All three cases

port Office (NAVMASSO) for insertion into of appendicitis were diagnosed incorrectly by

the SNAP II Medical Module to be placed the program, as were 71% of the cases of pelaboard all U.S. Navy vessels on microcom- vic inflammatory disease (PID) and 64% of

puters as per NAVMASSO's timetable. This the cases of urinary tract infection (UTI). The

allows data collection from both submarine program failed to diagnose all 12 cases of apand surface crews. The microcomputers were pendicitis confirmed by pathologic examinaIBM MS-DOS compatible to allow for the tion. It was concluded that the female

widest possible range of microcomputers to abdominal pain module would require further

be utilized. examination and testing before it could be

safely implemented.

In 1988, NSMRL undertook a prospective

study collecting data from the emergency Gynecology Consultant (GYN)

rooms at Naval Hospitals San Diego and

Portsmouth, VA. An apparently large total of Developed during 1990-91 by LCDR

616 cases of abdomir . pain were collected Michael J. Hughey, MC, USNR, this system

from the two facilities. Since this program was designed to provide expert advice to

was designed to initially be deployed on sub- those who treat women with gynecological

marines, it was tested against the 146 male problems and offer guidance in the continuing

cases 12 . Overall diagnostic accuracy of the care of women 14 . This program was

program was found to be 69% compared to developed in response to a medical officer's

the 80% accuracy rate of emergency room dissatisfaction with the female portion of the

physicians. Sensitivity and specificity for dis- abdominal pain (ABDX) program.

tinguishing surgical from non-surgical cases

were 56% and 85% respectively. The study It is designed to assist the corpsman in assuffered from a small number of cases in any sessing gynecological problems with the folbut the non-specific abdominal pain category. lowing limitations:

This report concluded that it was not possible

to access the clinical adequacy of the NSMRL 1) Women who are previously healthy and

abdominal pain diagnostic program based on of childbearing age.

this case data and recommendations for further study were made. Study of the usability 2) Only "common" problems are conof the abdominal pain program was also com- sidered. pletd duing his ime erio13.

pleted during this time period 3) Non-gynecological illnesses are not conThe abdominal pain module for females sidered.

has not been formally validated in a prospective study. In 1990, LCDR Michael Hughey, 4) Surgical complications or trauma are

a reservist and gynecologist, evaluated this not considered.

area by conducting a retrospective review of

medical records at his institution of 97 5) Results may be misleading when the

females, age 17 to 50 presenting with ab- clinical presentation is atypical.

4
Table 1. Scope of Gynecology Program

Clinical Symptoms Clinical Problems

1. Abdominal/Pelvic Pain 8. BCP Problems

2. Vulvar Pain 9. Menstrual Problems

3. Abnormal Bleeding 10. Abnormal Pap Smear

4. No Menstrual Flow 11. IUD Problems

5. Vaginal Discharge 12. Painful Intercourse

6. Itching/Irritation 13. Urination Problems

7. Odor 14. Warts (Condyloma)

15. Venereal Disease

The gynecology program provides help in Conditional probabilities were derived from

15 clinical areas -- 7 clinical symptoms and 8 several hundred adult male patients presenting

clinical problems (Table 1). to hospitals in England and these probabilities

were then analyzed by the Bayesian method

Depending on the selection, the health care to develop a symptom/disease matrix. This

practitioner would be given immediate advice, approach was similar to that used by the abor, in other cases, additional questions may be dominal pain program. The ini:ial program

asked. Treatment protocols, a tutorial, and was tested in a small number of adult male

general guidelines for treating gynecological patients and found to have a low false positive

illnesses are also available to the corpsman. rate for myocardial event (5%). It was also

found that the program could predict death or

At this point, the program has not been en- survival in about 2/3 of all patients. Recomtirely completed and also has not been ap- mendations for management on-board subproved for distribution pending formal marines were also delivered under the

testing. To date, it has only been informally contract.

reviewed by gynecologists and general medical officers. Work on this program at Testing -f de Dombal's algorithm then

NSMRL has been terminated, moved to the United States. In 1982, de

Dombal's model was prospectively tested

Chest Pain Programs against that of one developed by Dr. Goldman

at Brigham & Women's Hospital, Bostont 6

The second diagnostic program was devel- The algorithm developed by Goldman used a

oped to aid the corpsmen in the diagnosis and recursive partitioning model derived from aptreatment of acute chest pain. This program proximately 500 patients seen at Yale-New

was also initiated at the University of Leeds, Haven Hospital prior to the Navy contract.

England by Dr. de Dombal in the early This new model appeared to perform well ,15

1980's and consisted of three modules: with a subgroup of patients similar to that

diagnosis, prognosis, and management of seen in the submarine community (males

acute chest pain. It provided diagnoses in the under age 60 with no prior history of myocar- categories of myocardial infarction, angina, dial infarction or angina). The high senchest infection, and non-specific chest pain. sitivity and specificity of Goldman's model in

5
the diagnosis Mf acute myocardial infarction or female) and considered myocardial infarcwas dependent on simple electrocardiographic tion, angina, chest infection, and non-specific

(ECG) criteria not used by the de Dombal chest pain in the differential diagnosis. Treatmodel. It was suggested that this model could ment suggestions were given for eatch of these

be used as an alternative in a deployed situa- diagnoses. A training module was included to

tion if an ECG was available, test the corpsman's ability to abstract information from simulated patient narratives and a

Between November 1982 and July 1983, a SF-600 generator was added to print medical

brief study was undertaken at the Naval Hospi- record entries based on the patient data

tal, Groton, to determine the corpsmen's entered into the program.

ability to understand and collect data required

by the computer program developed by de Again, the original de Dombal data set was

Dombal . Sixteen Navy Hospital corpsmen used, but a priori data derived from cases seen

performed medical history and physical ex- at Naval Hospitals in the United States were

aminations of 102 patients presenting to the added to the program in hopes of enhancing

emergency room with a chief complaint of diagnostic accuracy. Also, results of

chest pain. They then completed a chest pain electrocardiographic data were included in the

data sheet (no computers were used for data patient data set. A revised database was forcollection) for each patient. It was found that warded by Dr. dc Dombal which provided for

the corpsmen were very accurate in gathering use of ECG data. The user interface was

medical history information but less accurate modified based on the opinions of individuals

in performing physical examinations. "Ac- observing several alternatives. Although this

curacy" was defined as agreement with emer- made the program more user 'friendly,' the

gency room physicians. It ap-eared this type source code became increasingly more comof data collection format may be useful in plex and difficult to modfy. Finally, treatgathering information for the computer as- ment protocols were updated. With changes

sisted diagnostic program. having been made to the knowledge base, this

program would need additional validation,

During April 1984, a preliminary version

of the chest pain program was completed Between May 31, 1988 and September 30.

based on de Dombal's disease/symptom 1988, cases of chest pain were collected

matrix 18. The program would run on a prospectively at the Emergency Rooms of the

Tektronix 4051 computer and was very Naval Hospitals in Portsmouth, VA, Charlessimilar to that produced for the first version of ton, SC, and San Diego, CA, to be used in the

21 the abdominal pain program. This program validation process . The subjects were 132

was not completed for distribution, male and female active duty Navy personnel

or their dependents between the ages of 15

The Tektronix version of the chest pain and 50 who presented with chest pain as a

program was then recoded in Microsoft Quick- chief complaint. Six research technicians

BASIC to run on a PC based system 19 and (two at each hospital) worked consecutive 8-h

released by the CO of NSMRL for distribu- shifts between the hours of 8 a.m. and midtion along with supporting user documenta- night five days a week. When patients

tion2. The program was intended for use in presented to the emergency room with a compatients between the ages of 17 and 79 (male plaint of chest pain, they were interviewed by

6
the technician who described the study and Chest Pain and the

solicited their participation. Patients who Electrocardiogram (ECG)

agreed to participate then signed a consent

form and the technician recorded case history Medical Officers attached to submarine

details while waiting for the physician to ex- squadrons suggested that they would like to

amine the patient. The doctor was asked to have electrocardiographic data available to asverbalize his findings so that the technician, sist both corpsmen and themselves in the diagwho was in the exam room listening, could nosis of chest pain. At this time, chest pain

record the answers on the chest pain data data including ECG tracings were being colsheet. If the physician was too busy to pro- lected for NSMRL by physicians at Naval

vide a complete report, the technician ob- Hospital Groton so that the accuracy of comtained the missing data from the patient's puterized dh:gnosis with and without ECG

emergency treatment record. The research tracings could be compared 22. It was detertechnician was not permitted to interview the mined that there would be sufficient improvepatient without the doctor's permission and ment in diagnostic accuracy to warrant the

would leave the exam room if the patient was inclusion of ECG data (this addition was

uncomfortable. made to the most recent version of the chest

pain program as previously described). HowThe data collected on each patient was ever, the existing ECG recorders were not

later entered into the computer program to ob- deployable because of weight and space contain its diagnosis. Result- of the study straints aboard submarines. Under contract

showed that the diagnostic accuracy (defined with Marquette Electronics, NSMRL cooperaas percentage of correct diagnoses) of the tively developed a portable ECG machne

computer program for the 132 patients was which could be used in conjunction with the

72%, not significdntly different from the chest pain program. This device measures 12

physician's which was 79%. "Correct" diag- x 81 x 33 inches, weighs 10 pounds, can be

noses were determined in one of two ways. If battery operated, and has all the capabilities of

the patient was admitted, the correct diagnosis the larger MAC-I1 ECG machines. This new

was considered discharge diagnosis. Other- portable ECG machine, the MAC-PC, can be

wise, if the patient was not admitted, a follow- interfaced with the computer and is comup telephone call was made to the patient by a patible with the Computer Assisted Processnurse or physician at least three weeks after ing of Cardiograms (CAPOC) system used by

the emergency room visit to determine if fur- the Tn-Service Medical Information Systems

ther events were consistent with the emergen- (TRIMIS) programs23

cy room final discharge diagnosis. It was

concluded that the computer program was During FY 90 a pilot study was undertaken

able to distinguish myocardial infarc,ion from in cooperation with Marquette Electronics

the other diseases (angina, chest infection, and Inc. and Submarine Squadron Twelve to deternon-specific chest pain) as well as the mine the feasibility of transmitting ECG data

physicians (83% vs 84%).21 via radio waves from submarines. Three

standard Marquette ECG recorders (Mac PC)

were updated to allow transmission of the

ECG by way of a RS232 board on the Mac

7
PC into an IBM compatible computer with an diagnoses was available to the dentist for

RS232 port. A commercially available com- standardization of terminology). Thc diagmunications software (ProComm PlusTm ) noses generated by the computer were cornwas used to transfer the data via the x-modem pared with those of the dentist for 80

protocol. A stored ECG data strip was placed symptomatic patients. Results of the study

on a floppy disk and brought onboard the were favorable (87.5% of cases were exact or

USS John Adams (SSBN 620) where it was logically consistent matches defined as a

transmitted via satellite to Norfolk, VA and "proper diagnosis in the absence of certain

then on to the USS Von Steuben (SSBN 632), diagnostic information not evaluated by the

again via stellite. Upon examination of the system"). Unfortunately, there were no

transmitted file, it was found that the file size trauma-related emergencies to test the system.

and ECG strip readings were unchanged

during transmission. Although these results This program was then reprogrammed in

were encouraging, additional testing would be Microsoft 26 QuickBASICR to run on MS-DOS

required before consideration for deployment. systems , supported with user documentation 7 . The conversion was essentially 'lineDental Pain Program for-line" to keep the knowledge representation

(the "brains" of the program) intact. This

Interest in the design and development cf a knowledge representation was also extracted

system for diagnosis of dental emergencies from the BASIC code during this period 28.

began in the early 1980's at the Naval Dental

Research Institute in Great Lakes, Illinois. Evaluations at the Naval Dental Clinic in

The initial program, written in Apple Basic Groton, CT29 found 83% agreement between

language, was completed and underwent the computer's diagnosis and that of a dentist

preliminary testing. This rule-based system in 32 cases. The "accuracy" of this program

considered 35 trauma and non-trauma related was tested against "classic presentations" of

dental emergencies and provided a differential dental emergencies3 . Basically, 19 dentists

diagnosis of soft tissue lesions based on clini- completed questionnaires, providing eypected

cal appearance. Other modules provided treat- responses after interviewing and examining

ment recommendations and definitions of patients with dental conditions considered by

dental terms which may be unfamiliar to the the program. The program produced the corcorpsman. rect diagnosis 78% of the time when these

"classic" responses were entered. More iraValidation of this program consisted initial- portantly. it appeared the program was able to

ly of review by a group of dentists who simu- distinguish between dental conditions requirlated over 200 dental emergencies which were ing immediate evacuation and those which

then entered into the program . Based on the could be managed safely by an independent

results, minor changes were made to the algo- duty corpsman.

rithm, and this system was then tested in a

large Navy Dental Clinic 25. Dental tech- This program was released during 1990 by

nicians were responsible for first entering the Commanding Officer, Naval Submarine

responses to the computer-displayed ques- Medical Research Laboratory, for distribution.

tions. The patient was tnen referred to a dentist who made a diagnosis (a list of the 35

8
Computer-Supported Assessment entering and checking the results of over 400

and Treatment Consultation for GIS profiles 32. Initial validation was done by

Emotional Crises (CATCEC) six experienced psychiatrists and one clinical

psychologist (two of these were career Naval

Computer-Supported Assessment and officers) who systematically evaluated the

Treatment Consultation for Emotional Crises structured interview, all diagnostic and treat-

(CATCEC), was developed under contract in ment modules, and all glossaries. This valida1982 to Dr. James Hedlund of the Missouri In- tion provided strong expert corroboration of

stitute of Psychiatry. Dr. Hedlund first the diagnostic and treatment procedures.

focused on development of a structured interview that would be problem and treatment This program was also clinically tested in

oriented and appropriate to the psychiatric 60 patients presenting to the psychiatry depart33 training and experience of the corpsman. ment at a Naval hospital . Accuracy CATCEC includes a detailed interview for (defined as agreement between the program's

corpsmen to use in collecting patient informa- and clinician's diagnosis) was 73% (22 of 30

tion, computer-generated patient summaries, cases) of the types of cases which a corpsman

treatment suggestions, four special glossaries, may encounter aboard a submarine. This pro31 and a computer-aided training module . The gram is not in use in the submarine corncorpsman uses a highly structured paper-and- munity.

pencil interview guide, the Groton Interview

Schedule (GIS), to obtain specific information The Submarine Medical Administrative

about the problem including a physical ex- Records and Tickler System

amination of the patient, and available col- (SMARTS)

lateral information or observations. He then

enters this information into the computer and Since 50% or more of a corpsman's time is

obtains a patient summary which gives a prob- spent in keeping administrative records,

able diagnosis and a listing of all related preparing required reports, and maintaining

symptoms. The corpsman may then make continually updated inventories of medical

specific changes or corrections to the data supplies, SMARTS was created in 1985 to fill

entered or obtain treatment suggestions. The most of the requirements for medical record

four glossaries (Emergency Treatment Prin- keeping aboard submarines to allow the

ciples, a Diagnosis and Treatment Glossary, a corpsman more time to carry out his primary

Medications Glossary, and a Glossary of duty of monitorin• and supporting the health

Psychiatric Terms) are available at any time needs of the crew . The initial functions

both on the computer and in hard copy. The supplied by SMARTS were management of

program was designed to be "user-friendly" crew member information files, processing of

with many screen prompts and provisions for radiation health data, preparation of radiation

making changes and corrections easily. health reports, management of medical inventory data, and generation of requisition lists

The diagnostic/treatment modules are for supplies that are on hand below required

primarily rule-based, recording patient infor- quantities or are out-of-date.

mation and comparing it against the diagnosis

and treatment rules. CATCEC's diagnostic Although this program was approved for

and treatment logic were tested by manually release by the Commanding Officer of

9
NSMRL, it has been replaced by SAMS were designed with regard to the available

(Snaps Automated Medical System) which resources and level of expertise of the user.

contains this type of administrative function. For example, the modules make conservative

assumptions when certain information is not

Medical Tickler System available (e.g., radiographs). Treatment

recommendations were modified based on the

Also created in 1985, this program was a resources available in the submarine environcomputerized version of a medical tickler ment and capabilities of the Independent Duty

filing system for use by corpsmen aboard sub- Corpsman.

marines and designed to increase the

corpsman's productivity while decreasing his There have been several methods of vatidaadministrative workloat 36'

37 . The program tion of these diagnostic modules. Tht

enabled a corpsman to track the crew penetrating abdominal and chest injury

members' immunization dates, physical exam module has been tested by entering apdates, and other requirements of the general proximately 400 theoretical cases of penetrathealth maintenance programs in effect on sub- ing trauma Treatment recommendations

marines. Along with SMARTS, this program were compared to actual care given to patients

was also canceled in favor of the SAMS sys- with common presentation of both abdominal

tem being developed by NAVMASSO. and chest trauma. The recommendations

were found to be "acceptable" but specific

Trauma Modules results are not available. The hospital version

of the abdominal/chest module has been in

A computer-based trauma program was use at the Trauma Center of the Medical Coldeveloped during the late 1980's to assist with lege of Pennsylvania where about 85 cases

the management of patients with multiple in- had been entered through 1990. Again, 38 juries . The system was initially designed to results have not been published. The upper

be used by hospital-based physicians trained extremity module has also received testing

in Advance Trauma Life Support (ATLS). against 25 common presentations of upper exThe expert system was rule based utilizing tremity injury.

both forward and backward chaining. A user

could enter sign and symptom data directly or The trauma programs developed at

be prompted for clinical information by the NSMRL have not been approved for fleet use.

program. The program then provided specific Neither of the programs modified for subprotocols for management of injured patients. marine corpsmen have been field tested or

evaluated against a series of actual prospec- This knowledge-base was then modified tive or retrospective cases. The display forby emergency room physicians for use in the mat of the penetrating wound module was

submarine force primarily by independent evaluated from a human-factors standpoint in

duty corpsman who would not have access to 198841. The interface was compared with

hospital facilities. Two separate knowledge that of the available chest and abdominal pain

bases were delivered. One dealt with manage- programs. Recommendations such as to use

ment b of penetrating 39 injuries of the chest and of color to highlight information were made

abdomen and the other considered injuries to make the trauma interface consistent with

40 to the upper extremities . These programs that of the other programs.

10
Efforts at the end of FY 92 within this diag- This program has not been approved for

nostic domain were taking place primarily at distribution pending validation of the

Northwest Research in Seattle, Washington. knowledge base. Over 1000 case descriptions

Specifically, a rule-based expert system for from Navy and civilian hospital records were

the evaluation and intervention of closed head collected to assist in verifying the module but

injury is under evaluation, they were not in a format that could be used

by the program. The program has been inforEye Disease Program mally evaluated by several optometrists and

ophthalmologists, but it has not been rigorousCreated in FY 90, this is a rule-based pro- ly tested against actual cases.

gram generated using the EXSYSTM (Expert

System Development Package) system4 2 . It Medical Practice Support System

provides diagnostic assistance for eye disor- (MEPSS)

ders (Table 2).

In FY 90, the development and testing of

This program also provides a help system existing and future stand-alone modules used

to ensure easy and accurate use of the know- by submarine corpsmen was redirected to a

ledge base and graphics, including drawings cooperative effort involving NSMRL, Naval

and photographs to illustrate clinical concepts, Health Research Center (NHRC), and Johns

and a complete description of each illness des- Hopkins University. The goal of this effort

cribed along with treatment recommendations. was to develop a broadly capable computerbased medical system called MEPSS (MediTable 2. Diagnoses considered by Eye Module

Acute angle closure glaucoma Dislocation of the lens

Acute iritis Hash burn

Allergic conjunctivitis Gonococcal conjunctivitis

Bacterial conjunctivitis Herpes simplex keratitis

Blepharitis Hordeolum

Chalazion Hyphema

Chronic iritis Inclusion conjunctivitis

Contact lens tear Ocular foreign body

Contact lens deposit Orbital blowout fracture

Contact lens induced superior limbic keratitis Penetrating injury

Contact giant papillary conjunctivitis Pneumococcal corneal ulcer

Contact lens solution allergy Retinal detachment

Contact lens inversion Rupture of the globe

Corneal abrasion Subconjunctival hemorrhage

Corneal foreign body Traumatic iritis

Viral conjunctivitis

11
cal Practice Support System). MEPSS Submarine Group Two (CSG 2) in Groton,

provides its users with computer-assisted CT; and Submarine Group Ten (CSG 10) in

medical diagnostic support, a large medical Kings Bay, GA.

library, access to the Navy's CAMIS system,

medical record keeping, and the ability to On delivery to the test sites, NSMRL staff

communicate with data sources outside the provided a demonstration of the system's

medical unit. MEPSS is integrated to share capabilities along with brief initial training. It

data between the record keeping and diagnos- was expected that the system would be usable

tic modules. A prototype version was with a minimum amount of formal instrucdemonstrated at the 15th Annual Symposium tion. Reference materials pertaining to the

on Computer Apslications in Medical Care in operation of the system were provided. The

November 1991 . Usability testing resulting computers were to remain at each site for apin recommendations to increase the ease of prox- imately three months. Medical personuse and acceptance of this system has also nel who used the system either as part of their

been completed44. routine or to only evaluate the system were requested to complete a standardized questionBlack Boat Alpha Configuration naire.

During FY 92, NSMRL commenced a System Hardware

joint study with the Public Health Service The system hardware was selected during

(PHS) to develop a computer-based medical the fall of 1991 jointly by NSMRL and PHS.

information system for use by Navy and PHS Specifically, the hardware was sized to fit on

medical personnel stationed in isolated areas. the newer SSBN's. The system included a

The goals of this project were to provide an in- large internal hard drive to accommodate additegrated system with the following tional software either developed or procured

capabilities: 1) diagnostic decision support or from commercial medical software providers.

an aid to clinical decision making, 2) storage In addition to the large hard drive, the system

and retrieval of a large amount of current included an internal CD-ROM (Compact Diskmedical and operational material, 3) adminis- Read Only Memory) drive. The CD-ROM

trative support functions, and 4) continuing was selected as the mass storage device to be

medical education. It was felt that the most used in the evaluation of electronic medical

important use of the system was as an educa- reference systems and other medical data

tional tool that could be used by the corpsmen bases. The computer workstation consisted of:

as a means of maintaining and increasing their

skills. - 80386-33 MHz CPU with 64kb Cache - Standard AT case with 5 drive bays

A computer system was configured with - 4 MB RAM (80ns) expandable to

hardware and software that would be eval- 16Mb on motherboard

uated in operational settings. Three identical - 330Mb SCSI Hard Disk Drive

prototype computer systems were configured - 1.2Mb, 5.25" Teac Floppy Drive

and delivered to separate operational test sites - NEC 680Mb Internal SCSI CD-ROM

for evaluation during the spring of 1992. Drive

These test sites included: The Naval Undersea - 250Mb Internal Tape Drive

Medical Institute (NUMI) in Groton, CT; - 9600/2400 Internal Sendfax/Modem

12
- 14 Inch Super VGA Monitor a differential diagnosis for analysis. The pro-

- Hewlett-Packard LaserJetTM fIP gram occupies approximately 30Mb of hard

Printer disk space. - Logitech Space-Saver Mouse

b. Reference Material. Medical referSoftware Components: ences are located on both CD-ROM disks and

the computer's hard drive. The CD-ROM's

a. Diagnostic System. The medical supplied by CMC Research Inc. under the

decision support tool at the heart of this trade name DiscPassageTM included the

software configuration was the program "1989-1991 Year Books of Medicine" from

TM DxPlain . This program was developed by Year Book Medical Publishers, Inc., the

the Massachusetts General Hospital "American Family Physician" by the

Laboratory of Computer Sciences as a con- American Academy of Family Physicians,

tinuing medical education tool. This program and the "New England Journal of Medicine"

was only available on mainframe computers were supplied.

until placed on the Black Boat systems.

DXplainTM continues to be used on This particular reference system was

mainframe computers where personal com- selected after independent duty corpsmen

puter users access the mainframe through were asked to compare several competing sysmodems4. DXplain 's knowledge base is tems in terms of functionality and ease of use.

extremely large, consisting of over 2000 dis- The corpsmen felt that DiscPassageTM was

ease descriptions and greater than 4700 the most usable of the programs tested. This

patient descriptors. (sipns, symptoms, program also retrieved text considerably faster

laboratory tests, etc) . The program covers than the other programs.

more diseases than are discussed in most

textbooks of medicine. However, as noted by DiscPassageTM allows a user to search ref-

.TM its developers, DXplain may be incomplete erence material on CD-ROM's utilizing

in certain areas. For example, there is only a simple boolean logic. A user may search for

limited coverage of dermatologic diseases, titles of articles, topics, or for individual

where diagnosis often deLends on the visual words contained in the text.

appearance of the lesion . The knowledge

base is continuously updated based on com- So that additional references could be

ments of users who are experts in various placed on the system, the Public Health Serareas of medicine. vice purchased the rights to utilize the CMC

Research Inc. DiscPassageTM search engine.

DXplain operates by allowing a user to After converting medical and operational

enter clinical terms such as signs, symptoms, documents into an ASCII format, NSMRL

physical findings, and laboratory results. and PHS succeeded in indexing and interfacBased on this clinical complex, the program ing these materials with the CMC Research

then produces a ranked list of diseases as- search engine. Two additional reference texts

sociated with these findings. The user may were placed on the hard drive of the Black

also request information on a particular dis- Boat computer. These were the "General

ease, request information about diseases as- Medical Officers Manual" and "Communicable

sociated with a particular finding, and submit Diseases in Man."

13
c. Utility Software. The utility software of the Black Boat Alpha configuration. All of

consists of work station software, proprietary the programs tested were compatible with the

general-purpose commercial software, and other software on the system. These

Department of Defense software. Specific programs include:

utilities included:

1. Micromedix's CCISTM (Computerized

Clinical Information System) - This CDWork Station Software: ROM was installed by Micromedix for

evaluation. CCIS TM provides several

- Micronetics standard MUMPS Version modules which are particularly strong in

3.0.0 the area of emergency medicine.

- MS-DOS, Version 5.0 (distributed by

Phoenix) 2. Teton Data System's STAT!-REFTM -

SJUMBO Tape Backup software A Window's based CD-ROM which con-

(Colorado Memory Systems) tains both medical texts and journals. Of

-Quick Link sItwaM Communica- special interest to corpsmen were the

tions/rFAX sotware (Practical various Lange textbooks in topics such as

Peripherals) emergency medicine, internal medicine, -Device Drivers for SCSI Host Adapter adgnrlsrey

(Data Technology Corporation)

- Utilities and Device Drivers for Orchid Pro~siger I VG adater3. SAMS (Snaps Automated Medical Sys- ProDesigner II VGA adapter

- Utilities and Device Drivers for the tem) Version 7.0 - The most recent release

Logitech Trackball of SAMS was successfully integrated

- Utilities and Device Drivers for the Z- under the Black Boat shell. This program

Nix Mouse provided additional administrative

capability to the informatics system.

Proprietary General-Purpose Commercial Additional enhancements were considered

Software: during the trial. Several Navy specific medical and operational medical reference

WordPerfectT, Version 5.1 materials (including various instructions and

- PC ToolsTM Version 7.1 manuals) were identified as of potential

- Laplink Pro , Release 4 benefit if transferred to electronic media. A

longitudinal medical record which could track

Department of Defense Software: individual medical encounters would be an important function if it could be successfully in-

- HMCM (Hazardous Material Control tegrated with the other modules. Training

and Management) capabilities of the system could be expanded

- HMIS (Hazardous Materials Informa- without a large effort. With the increasing

tion System) popularity of Microsoft WindowsTM over the

Enhancements. past year, this program deserves consideration

Enhanever int. pas a way of standardizing the user interface. Several additional products underwent

preliminary evaluation during the test period

14
Initial Evaluation. ly, it has not been feasible for a small research

Through feedback obtained from a small facility to upgrade and maintain these

number of questionnaires returned and per- programs properly.

sonal communication between the investigators and the users, broad generalization Much of the difficulties encountered in the

can be made concerning the alpha-configura- development of medical diagnostic aids (a

tion. Most users approved of the hardware problem not unique to the military) occur

design and felt that the system was capable of during the validation phase. It is necessary to

providing a continuing medical education obtain a large amount of high qualit, clinical

function. The users were unanimous in their data to test these programs. This is both a

desire for medical reference materials on CD- time consuming and expensive process that is

ROM or other mass-storage devices. There often not considered in the long-range develcontinues to be resistance to the use of diag- opment planning of these programs. The

nostic pro ams, but when a system such as validation procedure is imperative and diagDXplain is presented as an education aid, nostic programs should not be distributed

there is much greater acceptance. Involve- before this process has been satisfactorily

ment of the end-users in every phase of completed.

development would lead to greater approval

of any medical informatics system. This Future efforts in this area should conproject ended with the termination of this centrate on the delivery of updated and

work-unit at the end of FY 92. relevant medical information to health care

practitioners in remote duty station. AdvanConclusions ces in high capacity electronic media have

made storage and delivery of vast amounts of

This report outlined the history of com- medical and operational information possible,

puter assisted medical diagnosis at NSMRL and prospects for the future are even brighter.

and presented major results of these efforts. Tools (software and hardware) to speed the

A historical record would be useful to in- development of diagnostic systems are availdividuals interested in tracing the develop- able. By incorporating existing technology,

ment of these systems in the submarine the high costs of independent development

community because several areas are poorly and long time periods between program condocumented. ception and delivery can be lowered. Endusers must be involved in all stages of the

All work occurring under this work unit development cycle to ensure success and acwas terminated at the end of FY 92 for many ceptance of any diagnostic system.

reasons. Although several of these programs

have been released by the Commanding Of- References

ficer of NSMRL, they have not been approved for general distribution by a higher 1. Hester, R. (1971). Provisional medical

authority such as the Surgeon General of the statistics for personnel attached to

Navy. Therefore, it has not been possible to nuclear powered submarines: FY66-69

distribute these programs on a widespread (NSMRL Report 674). Groton, CT:

basis, resulting in frustration for program Naval Submarine Medical Research

managers, users, and developers. Additional- Laboratory.

15
2. Rogers, W. H., Ryack, B. L., and Moeller, 8. Osborne, S. F. (1983). ComputerL-assisted

G. (1979). Computer-aided Medical diagnosis for abdominal pain: Interim

Diagnosis: Literature review. Internation- Report -July 1982 - September 1983

alJournal of Biomedical Computing,, 10, (NSMRL Report 1012). Groton, CT:

267-289. Naval Submarine Medical Research

Laboratory.

3. de Dombal, F. T., Leaper, D. J., Staniland,

J. R., McCann, A. P., and Horrocks, J. C. 9. Osborne, S. F. (1985). Evaluation of a

(1972). Computer-aided diagnosis of computer-assisted diagnosis program fo)r

acute abdominal pain. British Medical acute abdominal pain with physician-colJournal, 2. lected data (NSMRL Report 1003).

Groton, CT: Naval Submarine Medical Re4. Henderson, J. V., Moeller, G., Ryack, B. L., search Laboratory.

and Shumaik, G. M. (1978). Adaptation

of a computer-assisted diagnosis program 10. Southerland, D. G., and Fisherkeller, K. D.

for use by hospital corpsmen aboard (1989). ABDX- A decision support sysnuclear submarines. In Proceedings of tern for the management of acute abthe Second Annual Symposium on Corn- dominal pain - Version 3.0 - PROGRAMputer Applications in Medical Care. MER'S MANUAL (NSMRL Report 1148).

Washington, DC: Nov 5-9, 1978. Groton, CT: Naval Submarine Medical

Research Laboratory.

5. Robinson, K. D., Ryack, B. L., Moeller, G.,

Post, R., and Schroeder, W. (1983). A 11. Caras, B. G., Southerland, D. G., and

computer-based diagnostic/patient Fisherkeller, K. D. (1989). ABDX- A

management system for isolated environ- decision support system for the managements. Methods of Information in ment of acute abdominal pain - Version

Medicine, 22, 131-134. 3.0 - USER'S MANUAL (NSMRL Report

1146). Groton, CT: Naval Submarine

6. Ryack, B. L., Henderson, J. V., Moeller, G., Medical Research Laboratory.

Robinson, K. D., Post, R., and Schroeder,

R. W. (1979). An evaluation of a com- 12. Perrotta, P. L., and Stetson, D. M. (1992).

puter based medical diagnostic/informa- Trial of a Computer Based Program for

tion system for nuclear submarines. In the Diagnosis of Abdominal Pain in Males

Proceedings of the 107th Annual Meeting (NSMRL Report 1181). Groton, CT:

of the American Public Health Associa- Naval Submarine Medical Research

tion (pp. 57). Laboratory.

7. Henderson, J. V., Ryack, B. L., Moeller, G., 13. Chouinard, E. F., Ryack, B. L., and Stetand Post, R. (1981). Use of a computer- son, D. M. (1991). A Comparison of the

aided diagnosis system aboard patrolling Usability of Three Versions of a ComFBM submarines: Initial at-sea trials puterized Medical Diagnostic Assistance

(NSMRL Report 938). Groton, CT: Program for Abdominal Pain (NSMRL

Naval Submarine Medical Research Report 1172). Groton, CT: Naval SubLaboratory. marine Medical Research Laboratory.

16
14. Hughey, M. C. (1991). Gynecology Con- 21. Luria, S. M., Southerland, D. G., and

sultant - User's Manual and all accom- Stetson, D. M. (1990). Clinical trial of a

panying documentation - Version GC6. computer diagnosis program for chest

Unpublished manuscript, pain (NSMRL Report 1162). Groton, CT:

Naval Submarine Medical Research

15. de Dombal, F. T. (1978). Computer-Aided Laboratory.

system for Diagnosis, Prognosis and

Management of Chest Pain in a Deployed 22. Osborne, S. F., and Fisherkeller, K. D.,

Situation in Previously Healthy Adult (1984). ECG Interpretation Training ProMales (USN Contract No. N68171/78/ gram - Reference Manual (NSMRL

C/857). St. James' Hospital, Leeds, UK Report 1022). Groton, CT: Naval Submarine Medical Research Laboratory.

16. Goldman, L. (1980). FinalReport, Diagnosis and Management of Deployed 23. Ryack, B. L. (1989). A Portable ECG ReAdults with Chest Pain (ONR Contract corder for Shipboard Use. Military

N00014-80-C-0675). Boston, MA: Medicine, 154, 184.

Brigham and Women's Hospital.

24. Rails, S. A., Southard, T. E., and Cohen,

17. Fisherkeller, K. D., Moeller, G., Ryack, B. M. E. (1986). A system for computer-asL., and Goudy J. (1984). An evaluation of sisted dental emergency diagnosis.

the ability of Navy corpsmen to collect Military Medicine, 151, 639.

chest pain data from patients (NSMRL

Report 1016). Groton, CT: Naval Sub- 25. Rails, S. A., Cohen, M. E., and Southard,

marine Medical Research Laboratory. T. E. (1986). Computer-assisted dental

diagnosis. Computer applications in den18. Decora, M., and Fisherkeller, K. D. tistry. Dental Clinics of North America,

(1984). Computer assisted diagnosis of 30(4), 697-712.

chest pain: Preliminary Manual (NSMRL

Report 1019). Groton, CT: Naval Sub- 26. Fisherkeller, K., Burgess-Russotti, C.,

marine Medical Research Laboratory. Rails, S., and Hamilton, D. (1989). A

computer assisted program for the

19. Caras, B. G., Fisherkeller, K. D., and management of acute dental pain - User's

Southerland D. G. (1989). MEDIC - Manual (NSMRL Report 1143).Groton,

CHEST PAIN: A decision support pro- CT: Naval Submarine Medical Research

gram for the management of acute chest Laboratory.

pain: User's Manual (NSMRL Report

1144). Groton, CT: Naval Submarine 27. Burgess-Russotti, C., Fisherkeller, K., and

Medical Research Laboratory. Southerland, D. (1990). A computer assisted program for the management of

20. Caras, B. G., Fisherkeller, K. D., and acute dentalpain - Programmer's Manual

Southerland, D. G. (1989). MEDIC - (NSMRL Report 1156). Groton, CT:

CHEST PAIN: A decision support pro- Naval Submarine Medical Research

gram for the management of acute chest Laboratory.

pain: Programmer's Manual (NSMRL

Report 1147). Groton, CT: Naval Sub- 28. Fisherkeller, K., Burgess-Russotti, C., and

marine Medical Research Laboratory. Hamilton, D. (1989). Documentation for

17
the computer assisted diagnostic program CT: Naval Submarine Medical Research

for dentalpain (NSMRL Memo Report Laboratory.

M89-1). Groton, CT: Naval Submarine

Medical Research Laboratory. 35. Tappan, D. V. (1987). Technical information concerning SMARTS: A multilevel

29. Fisherkeller, K., and Beaudry, R. (1989). database system for performing medical

Evaluation of a computer-assisted dental administrative tasks aboard submarines

diagnostic system by Navy hospital (NSMRL Report 1099), Groton, CT:

corpsmen (NSMRL Report 1141). Naval Submarine Medical Research

Groton, CT: Naval Submarine Medical Re- Laboratory.

search Laboratory.

36. Southerland, D. G. (1986). MEDICAL

30. Fisherkeller, K., and Beaudry, R. (1989). TICKLER: A User's Manual (NSMRL

Accuracy of a computer assisted program Report 1083). Groton, CT: Naval Subfor "classic" presentations of dental pain marine Medical Research Laboratory.

(NSMRL Report 1136). Groton, CT:

Naval Submarine Medical Research 37. Southerland, D. G. (1988). TICK

Laboratory. PROGRAMMER'S MANUAL (NSMRL

Report 1106). Groton, CT: Naval Sub31. Hedlund, J. L., Vieweg, B. W., and Cho, marine Medical Research Laboratory.

D. W. (1987). Computer consultation for

emotional crises: An expert system for 38. Clarke, J. R., Cebula, D. P., and Webber,

"non-experts." Computers in Human Be- B. L. (1988). Artificial intelligence: a

havior, 3, 109-127. computerized decision aid for trauma.

Journal of Trauma, 28, 1250-1254.

32. Robinson, K. D., Moeller, G., and Ryack,

B. L. (1983). The observation ofpsycho- 39. Clark, J. R., and Webber, B. L. (1989).

pathology: The performance of corpsmen Computer-Aided Management ofAccidencompared to experienced physicians tal Injuries in Isolated Environments:

(NSMRL Report 964). Groton, CT: Penetrating Injuries of the Chest and AbNaval Submarine Medical Research domen (Technical Report submitted to

Laboratory. NSMRL, ONR Contract N 000014-86-K3444-00002). Pennsylvania: Medical

33. Ryack, B. L., Noddin, E. M., Stetson, D. College of Pennsylvania.

M., and Luria, S. M. (1992). A Clinical

Test of the Computer-Supported Treat- 40. Clark, J. R., and Webber, B. L. (1990).

ment and Consultation for Emotional Computer-Aided Management ofAccidenCrisis Program (CATCEC) (NSMRL tal Injuries in Isolated Environments: InReport 1177). Groton, CT: Naval Sub- juries of the Upper Extremities (Technical

marine Medical Research Laboratory. Report submitted to NSMRL, ONR Contract N 00129-89-C-0006). Pennsylvania:

34. Tappan, D. V. (1987). SMARTS: A mul- Medical College of Pennsylvania.

tilevel database system for performing

medical administrative tasks aboard sub- 41. Fisherkeller, K. (1989). Evaluation of the

marines -- A training and reference Display Format of Clarke's Trauma Promanual (NSMRL Report 1098). Groton, gram for Wounds to the Abdomen

18
(NSMRL Memo Report 38-1). Groton,

CT: Naval Submarine Medical Rese• rch

Laboratory.

42. Newacheck, J. (1991). Computer-aided

Ocular Assessment: Programmer's

Manual (NSMRL Report 1173). Groton,

CT: Naval Submarine Medical Research

Laboratory.

43. Stetson, D. M., Eberhart, R. C., Dobbins,

R. W., and Pugh, W. (1990, May). Medical Support for the Isolated Practitioner:

Naval Medical Practice Support System.

Paper presented at the 1990 American

Society for Information Sciences MidYear Meeting, Washington, DC.

44. Chouinard, E. F. (1992). An Evaluation

of the Usability of the MEPSS Prototype

Decision Support Program for Abdominal

Pain with Two User Populations

(NSMRL Report 1180). Groton, CT:

Naval Submarine Medical Research

Laboratory.

45. Elkin, P. L., McLatchey, J., Packer, M.,

Hoffer, E., Cimino, C., Studney, D., and

Barnett, G. 0. (1989). Automated Batch

Searching of MEDLINE for DXplain.

SCAMC, 436-440.

46. Hupp, J. A., Cimino, J. J., Hoffer, E. P.,

Lowe, H. J., and Barnett, G. 0. (1986).

DXplain - A Computer-Based Diagnostic

Knowledge Base. MEDINFO 86, 117-

121.

47. Barnett, G. 0., Cimino, J. J., Hupp, H. A.,

Hoffer, E. P. (1987). DXplain - An

Evolving Diagnostic Decision-Support

System. Journal of the American Medical

Association, 258(1), 67-74.

19
[Blank Page]

20
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6a. NAME OF PERFORMING ORGANIZATION 6b. OFFICE SYMBOL 7a. NAME OF MONITORING ORGANIZATION

Naval Submarine Medical (ItApplcable) Naval Medical Research and Development Research Laboratory Command

6c. ADDRESS (City, State, Zip Code) 7b. ADDRESS (City, State, Zip Code)

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11 TITLE (Include Security Classificaton)

A historry of computer-assisted medical diagnosis at Naval Submarine Medical

Research Laboratory

12. PERSONAL AUTHOR(S)

Peter L. Perrotta and Ellen M. Perkins

13a. TYPE OF REPORT 13b. TIMECOVERED 14. DATEOFREfORT(Y;lffb 01Zi14 15. PAGECOUNT

FROM -TO__ 1993 May 01 20

16. SUPPLEMENTARY NOTATION

17. COSATI CODES 18. SUBJECT TERMS (Continue on reverse if necessary and identify by biock number)

FIELD GROUP SUB-GROUP Computer-assistod diagnosis; _Exper systema ; Agtificials fl intelligence; Diagnostic systeas; MetIcal A iagnosis

19. ABSTRACT (Continue on reverse if necessary and identify by block number)

Independent duty hospital corpsmen assigned to subxprines ore normally the sole proviler of medlcaj are for the crew. Corpsq.n w:tItvaryXng levels of

e~perience and training q ust make djagqoses witb limited aiagnostic tools and without expert 4onsu ta top. A medical evacuation (MEDEVAC) can potentially ex.posV a sup armne-s position, is hazardous to both the natiei.t ahd the rescuers, especially in high sea statee, and is expensive because it entails the movement of large nlumbI, rs of ships aircraft and men. For these r~asons, the Nav4l

Submarie Medical R•searc• Laborotorya (NSMRL) was tasked in the 1970's with

developing computerized diagnostic a &0 for these qorpsmen with tIhe goals of

reducinig he number of unnecessary ni.Aical evacuations and improving the quality of health care at sea.

This report Jetails the history and development of the ccmputer a~sssted medical diagnostiq aids at this lap~ra~ory .and would be of benefit to individuals or Comffiands interested in c9ntil.uing this type of work. Several of these proqrams have been approved for distribution by triL Commanding Officer, NSMRL, ahd May be

obtained by request.

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