Pediatric Informatics: Computer Applications in Child Health (Health ...

12 Diagnostic Decision Support 173
(as determined by a plausibility score assigned by consensus of the study’s clinical
coinvestigators). The effect was greater for medical students than residents and
greater for residents than faculty, suggesting a role for these systems in education.
This study used two other systems, QMR and Iliad, both of which are no longer
available, as the MDDSS.
A validated composite score that holds promise for evaluating the usefulness
of MDDSS 42 weighs the quality of differential diagnoses and management plans
(including further testing and treatment) on a user’s lists generated both before and
after use of the MDDSS. The score rewards both relevance and comprehensiveness
of differential diagnosis and management plans. The reliability and validity of this
measure is based on data from 71 subjects on six simulated cases, however it is not
clear how the MDDSS affected the subjects’ before and after results.
12.6.2 Developing MDDSS: Scope, Vocabularies,
Level of Detail
MDDSS developers face several challenges in regard to medical vocabularies.
The classification and nomenclature of diseases and findings are not always clear
(in the context of decision-making). Scope decisions, which diseases and findings
to include (and exclude), can be controversial. Many MDDSS programs have
specific names for entities such as “Pneumococcal Pneumonia” and “Mycoplasma
pneumonia,” in their disease vocabularies and will list all pneumonias in their differential
lists when pertinent clinical findings are entered, even if the data available
do not yet support a specific type of pneumonia. This approach confers advantages
to both the developers and the users. Using specific disease names prevents such
systems from needing several hierarchical layers of disease vocabulary and the
corresponding knowledge relating more specific diseases to higher level disease
processes. Also, the end-level diagnostic reminders displayed may be more useful
in helping the clinician build a differential diagnosis than would be a higher level
term. “Lumpers” and “splitters” have a fertile field for discourse in the area of
MDDSS. For example, in designing a diagnostic reminder system for general pediatrics,
it may not be initially clear if a diagnosis list should include “ADHD” alone or
“ADHD inattentive type,” “ADHD hyperactive type” and “ADHD combined type.”
12.6.3 Using MDDSS: Education
The Liaison Committee on Medical Education 43 lists two educational objectives
that are relevant to teaching diagnostic skills to medical students:
ED-28: “Evaluation of problem solving, clinical reasoning, and communication
skills”