MEDICAL DIAGNOSTIC & TREATMENT: Software That Saves Lives

NxOpinion – a real-time diagnostic tool built on Microsoft technology –

promises to provide physicians with timely and relevant information concerning

hundreds of non-chronic illnesses and diseases. This will be offered free in

improverised and countries, rural clinics, teaching, hospitals and emergency

rooms.

Nearly 1,00,000 people die in US hospitals each year due to diagnostic

errors, according to the Agency for Healthcare Research and Quality. After his

friend’s 21-year-old son died in an emergency room as a result of a

misdiagnosis, Michigan pharmacologist Dr Joel C Robertson resolved to create a

technology product that might prevent similar tragedies by helping doctors to

more quickly and accurately assess a patient’s condition. 

"In emergency medicine, you may have only a few minutes to diagnose a

patient and start a treatment," says Joel. "When I reviewed the

medical records on my friend’s son, I uncovered some additional evidence that

likely would have saved his life if it had been available to the doctors who

treated him–but it took me two weeks to dig out the answer.

Dr. Joel C. Robertson, creator of NxOpinion, a real-time diagnostic tool built on Microsoft technology

"That’s when I decided that someone needed to develop a diagnostic

software program that could be made available globally, at little or no cost to

any physician who needs it, and that could be constantly updated by experts from

around the world."

BIRTH OF NEXT OPINION



Joel channeled his vision into the creation of NxOpinion (Nx is short for

"Next"), a real-time diagnostic tool built on Microsoft technology –

and with assistance from Microsoft Research – that promises to provide

physicians with timely and relevant information concerning hundreds of

non-chronic illnesses and diseases.

The non-profit Robertson Research Institute (RRI), which Joel founded in

February 2001, plans to distribute NxOpinion at no cost to doctors and medical

organizations in areas where this type of resource is most needed – such as

impoverished and developing regions, rural clinics and teaching hospitals, and

emergency rooms everywhere. An initial version of the software and associated

database of medical information is slated to launch in fall 2004.

RRI selected Sagestone Consulting Inc, a Microsoft Gold certified partner, to

develop NxOpinion. In turn, Sagestone chose to build the software on a

foundation of Microsoft technologies that includes the .NET Framework, Microsoft

Visual Studio .NET 2003, Microsoft Windows Server 2003 and Microsoft SQL Server.

After two months of setting the vision for NxOpinion, Sagestone began

constructing it in January 2003.

"The Microsoft technology behind this initiative was vital in terms of

its ability to extend the different NxOpinion applications across different

platforms that doctors might use in the field, as well as for its

reliability," says Keith Brophy, CEO of Sagestone. "It allowed us to

create a sophisticated and powerful diagnostic product, yet still make it easy

for even the most non-technical physician to use. This project is a wonderful

affirmation of what you can accomplish with Microsoft’s platform and

tools."

Designed for use on a Pocket PC, Tablet PC or desktop computer, NxOpinion

prompts a physician to enter details about a patient’s condition as if he or

she were describing the case to a colleague. Based upon each new piece of

information, NxOpinion suggests possible ailments and asks for other evidence -

for example, "Have you taken a blood pressure reading in the leg?" –

until the doctor is confident that he or she has pinpointed the most likely

diagnosis and identified a viable treatment option.

EASE OF USE



Physicians can adapt NxOpinion to their skill level, language, level of

available medical resources and preference for Western or Eastern medicine. For

example, if the physician does not have the optimal equipment or expertise to

run a lab test or perform a textbook-perfect medical procedure, NxOpinion can

suggest viable alternatives. Since the .NET Framework and SQL Server store all

their information in Unicode, which is a way of consistently representing

character sets across the world, Sagestone has been able to build multi-language

support into NxOpinion without the added development time and expense



of converting data from one character set to another for each language.

In the Dominican Republic, physicians Dr Maximo Jose Rodriguez Rivera (left) and Dr Alejandro Dominguez Brito use a Tablet PC to field test the user interface of NxOpinion. Oct 2003

"Two of the most important design goals for NxOpinion were to make it

easy for physicians to use and allow them to find any piece of information in

four to five mouse clicks or less," says .Keith "Microsoft Windows

Forms technology allowed us to develop a very rich and interactive interface

that delivers information to the user on one screen. With Windows Forms, we’re

also able to cache a very large and diverse body of medical information right on

the physician’s device for instant retrieval."

The core technology that will enable NxOpinion to intelligently weigh

different pieces of evidence and generate the next logical question or

suggestion is a Bayesian inference engine currently being constructed by the

Sagestone and Microsoft team using the .NET Framework and C# programming

language. Dr. David Heckerman of Microsoft Research, who is one of the foremost

experts in Bayesian decision theory, contributed to the overall design of the

diagnostic engine.

Named for the 18th-century English mathematician Thomas Bayes, Bayesian logic

essentially deals with calculating the statistical probability of different

outcomes based upon prior observations. The NxOpinion diagnostic engine is

programmed to correlate the different pieces of available medical evidence,

compare them to the disease profiles stored in the NxOpinion knowledge base and

use the weightings assigned to each piece of information to generate a

differential diagnosis – a list of potential disease candidates.

WEALTH OF INFORMATION



The technology team completed phase one of the NxOpinion software in October

2003, eight months ahead of schedule and US$150,000 below RRI’s initial $3

million budget. Sagestone developers estimated that building the NxOpinion

applications in the C# programming language on the .NET Framework allowed the

team to complete its work as much as 50 percent faster than if they had used the

Java programming language.

"Sagestone’s project management experience as a Microsoft partner is

what has enabled this project to succeed so dramatically," says Mike

Swanson, Senior Consultant in the Microsoft Consulting Services group who worked

closely with the NxOpinion team.

"Considering how ambitious and complex the NxOpinion initiative is, what’s

even more impressive is that Sagestone delivered a product that has had zero

known defects to date." He adds that the Sagestone developers created an

architecture that makes NxOpinion’s functionality very easy to extend in the

future.

Sample screenshots illustrate how NxOpinion helps physicians rapidly formulate medical diagnoses and treatment options

Another team of physicians and researchers at RRI is in the process of

populating the NxOpinion medical knowledge base with disease profiles composed

of the latest data from major medical journals and numerous other sources.

This takes place in the NxOpinion Content Creator, a companion application

that employs a Microsoft SQL Server database to organize, store and deliver the

content. Each disease profile will include information such as common symptoms,

the frequency with which they appear and the types of lab results associated

with that ailment – with each piece of information



assigned a weighting by the RRI medical experts. The NxOpinion diagnostic engine
will apply those weightings in determining which course of action to recommend

to a physician in a given case.

As RRI team members in different regions of the US and other countries create

new disease profiles, they are centrally housed in a Microsoft Windows Server

2003 infrastructure at RRI headquarters in Michigan. Microsoft .NET Remoting

technology allows the Content Creator application to be distributed among team

members in different locations.

Individual team members log into the Content Creator, which is a Windows

Forms application, and enter their disease profile information, which is then

pulled into the centralized knowledge base by means of .NET Remoting.

NXOPINION FOR RURAL AREAS



When NxOpinion is released later this year, users will receive a current

edition of the medical knowledge base and be able to periodically update their

version with the latest published information by downloading files from the RRI

Web site or a CD.

Mike says this so-called "smart client" approach to storing the

medical knowledge base on a user’s machine, rather than requiring NxOpinion to

continually retrieve disease profiles over the Internet, will allow physicians

to get answers faster and not rely on having Web access from where they’re

working.

NxOpinion’s ability to draw upon continually updated medical information

and its use of Bayesian logic to fuel an ongoing dialogue with the user are

among the most striking advantages over other diagnostic software programs that

rely on static content, says Joel.

"Sagestone and Microsoft have done an amazing job of building

intelligence and flexibility into this software," he says. "When a

doctor opens up NxOpinion, the first impression is, ‘Wow – this is exactly

how I think.’"

For that reason, RRI also expects NxOpinion to become a highly effective

teaching resource for medical students, interns and residents. "Rather than

merely supplying answers and telling the user what to do, NxOpinion can serve to

lead a resident further down the right path in questioning patients and coming

up with options," says Dr. Mark Bates, a family physician leading the RRI

team that is creating disease profiles for NxOpinion.

Mark adds that even the most experienced physicians are hard-pressed to stay

current on the full spectrum of available medical knowledge, much of which can

now be downloaded from the Internet by patients who then want their doctor to

help interpret what they’ve read.

"As a family physician, I’ve got to be able to answer more questions

than ever," he says. "If NxOpinion can help a doctor to focus on the

questions that are most important and clarify a clinical situation faster, then

it will be a tremendously valuable tool."

The development team put NxOpinion’s usability to the test in November 2003

by asking a group of twelve doctors in the Dominican Republic to experiment with

the diagnostic application and provide feedback over a three-day period.

"We told them only that this was a diagnostic tool, gave them a list of

tasks and let them go for it," says Mike. "We watched how they

performed certain actions, listened to their questions about the interface and

noted the places where they struggled."

POSITIVE USER FEEDBACK



The doctors especially valued NxOpinion’s search engine, the option to

switch between Spanish and English, and the software’s ability to prompt them

with potential next steps or questions to pursue.

"It surprised us to see just how easy they found the product to

use," adds Mike. "Everybody in the room was able to accomplish all of

the tasks on our list, and this included some doctors who said they were pretty

computer-phobic." Sagestone plans to weave their experiences and

suggestions for improvement into the second phase of NxOpinion development as

well as continue gathering input from other users.

"The physicians whom we most want to reach with NxOpinion initially are

the ones working in small, isolated communities and villages," says

Robertson. "Often, they’re the only doctor for miles around, and they don’t

have access to laboratory equipment or specialists in all these different areas

of medicine. Because of its unique ability to mirror the way these physicians

think, adapt to their real-life working conditions and prompt them with new

ideas to consider, NxOpinion has the potential to save thousands of lives a

year."

RRI has raised more than $9 million in philanthropic contributions to cover

initial development of the NxOpinion end-user application, the NxOpinion Content

Creator and the Bayesian diagnostic engine. Additional phases - such as

distributing the NxOpinion software, amassing new disease profiles and treatment

information, translating content into other languages and building enhanced

functionality–are expected to last through 2007 and cost roughly $30 million.

Donations will continue to provide about two thirds of that total. Joel says

the institute plans to generate additional income through selling copies

NxOpinion at a low cost to physicians, hospitals, universities and other

organizations that can afford to pay for it.

"If just three percent of our potential market pays a very nominal price

for this software, we should be able to not only remain self-sufficient but also

grow and expand NxOpinion every year," he says.

RRI representatives plan to enlist the help of other charitable organizations

in distributing the software in disadvantaged areas, and the institute also

hopes that a few major technology equipment manufacturers will step forward to

provide free or discounted computer hardware for physicians who need it to run

NxOpinion.

"When I think about the return on investment for NxOpinion," says

Joel, "it’s measured not in dollars but in the lives we’re going to

help save."

Source: www.microsoft.com