The expanding influence of computers on society is being felt in medicine as well. Essentially all hospitals and clinics depend on computers for administrative and financial functions and for providing access to clinical data. Most physicians have been exposed to the powerful available systems for searching the biomedical literature by computer. Modern imaging techniques depend on computers for image generation, small computers have become mandatory elements in the research laboratory, and information systems are becoming vital topics for medical education. The clinical community has long anticipated the day when computers would be able to assist with diagnosis and with making decisions about patient management. Examples show that technology increasingly will provide physicians with clinically useful decision-support tools. This chapter describes some of the issues in building such systems and in making them easily available, clinically useful, and broadly acceptable.
About 30 years ago, the first research programs for medical diagnosis were shown to be highly accurate in their diagnostic predictions. Why have such systems resisted widespread implementation and acceptance in the intervening years? The barriers reflect the subtleties of the medical practice environment and the increasing recognition that good advice from such programs cannot ensure their use and acceptance. Confounding the implementation efforts have been logistical constraints, the sometimes awkward mechanics of computer use, confusion about whether such programs are intended to be tools for rather than competitors with clinicians, and a pervasive belief that computers do not really "understand" medicine and therefore cannot be expected to reach complex expert decisions. Early successes largely reflect an increased understanding of the importance of such issues and a gradual change in physician attitudes regarding computers and their potential for a beneficial clinical role.
Efforts to construct effective medical decision-support tools are closely tied to research into the nature of medical knowledge and its use for problem solving. Psychologic studies have taught us that medical expertise involves the application of factual knowledge and skills in using hypotheses to guide data collection. This important distinction between what is true and how to do things has had a profound effect on the development of computer-based advice tools. The research has also affected medical education, demonstrating that it is as important to teach decision-making skills and techniques for knowledge use as it is to expose students to the factual basis of medical practice. The Need for Assistance With Clinical Decision Making
Knowing how to find the information needed for clinical decision making is as important as trying to memorize it. Innovations such as MEDLINE are a tribute to the way in which computers can be used to help physicians and others to find the information that they need to make good decisions. Computers have superb memories, but until recently, there has been little they could do with pieces of text information other than display them. Modern programs contain detailed clinical information and have the knowledge to help users to determine how that information should be applied. As computer-based tools offer this kind of expertise, physicians have begun to consult programs to obtain reasoned advice about diagnosis and management of specific cases, while the ultimate decision-making roles are maintained for provider and patient. Obstacles to the Effective Introduction of Decision-Support Systems
Experience in applying computers in medicine over two decades has shown that logistical...