Though it is almost four million years since the predecessor of Homo Sapiens first started walking on Terra Firma it is barely 20 years since a new species Homo Computericus evolved. For several millennia it was taken for granted that preventing, diagnosing, treating diseases and maintaining health depended entirely on Man’s innate physical skills. In the last decade it has been shown that computers can be used in clinical practice in a way totally unthinkable earlier. This article will attempt to do some crystal ball gazing and take a look at where Homo Computericus is going in the field of clinical practice. The basis of learning today is to know where the information is available, and have a broad idea of the road which one needs to take even if it is one less travelled by rather than get bogged down by a myriad of inconsequential details. Therefore this article will follow an unconventional method of purely attempting to stimulate the reader without necessarily whetting the appetite!

Advantages of using computers in clinical situations: 

More efficient data gathering  

Provide immediate feedback to patients

Overcomes problems of illegibility

Overcomes problems of inefficient coding of data

Better data quality

Patient evaluation, compared to written tests, may be less daunting than a long test list

Tireless, i.e. the same response irrespective of the time of day

May be cost effective despite Initial capital and costs in updates and maintenance

Health information management (HIM) is concerned with health-related information and the management of systems to collect, store, process, retrieve, analyse, disseminate and communicate information related to the planning, provision, research and evaluation of healthcare services

Hospital Information Systems

Laboratory automation - today almost every single type of laboratory investigation is automated. Large numbers can be done with precision in a cost effective manner.

Imaging – Ultrasound, Digital X rays, 3D Spiral CT, 4 Tesla MRI. PET, SPECT etc will eventually fuse into single multipurpose imaging with image fusion software.

Intranets in large hospitals will be commonplace.

Disadvantages of using computers in clinical situations:

Initial capital outlay for hardware and software

Costs in updates and maintenance

Administrative staff costs, Storage and rooms

Staff training

Patients may decline to use computers or may not have the requisite skills

Use of computers in a patient's home may be impractical

Inhuman!

Best informed patients may become  "cyberchondriacs"

Prolonged clinical encounters due to better informed patients

Information providers trying to manipulate the general public to suit their own clinical or administrative needs . Erroneous information available on the net.

Intangible human skills eg intuition, experience, imagination cannot be duplicated

       Table 1   Computer Assisted Medical Education:

    Table II Palmtops - Clinical Information - Anytime, Anywhere    

 Looks up data on diagnosis of different diseases and its treatment    

 Looks for drug interactions

Stores summaries of sick patients, including their drugs lists

Reminds the doctor of necessity for uncommon investigations Eg an ultrasound for evaluating back ache (abdominal aortic aneurysm !)

Medical programs can be downloaded directly off the Web.

Task schedules alerted with alarm.

Getting hard copies of important documents by connecting to a printer.

Surf websites and  send & receive email – better than a WAP mobile phone.

Address book, schedules,Jotting down notes, tips, ideas.

During lectures and conferences notes can be taken easily, and beamed using the infrared port to colleagues absent in body, or in mind!!.

As much clinical information as required can  be entered.

Blood results can be entered, and brought on Ward Rounds.

Handovers can be printed  and discharge summaries produced.    

Medikit I calculates medical and paediatric parameters, from infusion rates to creatinine clearances, PEFRs to Anion gaps, Ransons Criteria to APACHE 2 scores. It will even work out fluid rates and drug calculations for children dependent on age.

British National Formulary Qcite is a reference manager which organises Medline searches.

MaxSacs program, customisable for any specialty, allows easy OPCS coding of operations, and enables rapid collection of data.

Medinotes is a large compendium of useful information in many specialities.  

Pre-programmed templates and drop-down menus for entering history.

Generating electronic prescriptions. A growing number of companies provide software for PDA-based prescriptions. The doctor picks the drugs and the system knows if it's on the formulary; The PDA then can be placed in its cradle or docking station, from which it sends the prescription to a printer to be faxed to the pharmacy, or sends it electronically to the pharmacist's fax number. Wireless devices that enable real-time synchronization and transmission of information can also be used.

Mobile technology can be used for home health and emergency services. Only two minutes are required to Hot Sync a full week's data into the practice management system.

A physician directory lookup, secure access to confidential patient information, and wireless order processing for books and articles from the medical library is all available on the palmtop.

Easy, ubiquitous access to online health care data.

Proliferation of PDA’s in health care can help break down barriers between clinicians and greater use of I.T. in general.

As of October 2000, 15% of physicians in the UK used handheld devices for reference purposes such as scheduling and checking drug dosages 20% of physicians will be using handheld devices for daily transactions by 2004, predicts a report by WR Hambrecht + Co.

Hot-Sync – simple method of transfer of data from and to computer,

 Table III  Limitations Of Palmtops in Clinical Practice:

   Danger of the device being lost or stolen

   Dependence on the gadget

   Incompatability between two different types of palmtops

   Infra red communication interfering with other devices

   Garbled information if multiple users in the same location use infra red portals

   Colour palm tops require periodic battery change

 VIRTUAL REALITY IN CLINICAL PRACTICE:  

Airline pilots spend weeks in flight-simulators before even seeing a 747. They can also be automatically assessed at the same time. Questions are being asked as to why a trainee surgeon has to acquire skills on a real living patient – exposing the latter to avoidable dangers. This has resulted in major developments in VR for surgical training

The term "Virtual Reality", is itself an oxymoron. Other terms that have been used are Synthetic Environments, Cyberspace, Artificial Reality and Simulator Technology. Virtual Reality (VR) is the most common and “sexiest”. It has caught the attention of the media. Production of realistic 3D sensual model from complex data. CT, MRI, fMRI, MRA, US, Angio, PET, SPECT requires massive data manipulation using Workstations and Minicomputers.

VR comprises a variety of technological advances that allow computers to produce a realistic dimensional and sensual model from complex data, with which humans can then interact and manipulate. The individual is thus ‘immersed’, as if ‘teleported’ into the new world. The visualisation part refers to the computer generating visual, auditory or other sensory outputs to the user of a world within the computer. This world may be a computer assisted design model, a scientific simulation or a view into a database. The user can interact with the world and directly manipulate objects within the world. Some worlds are animated by physical simulations, Interaction and manipulation is possible in this virtual world. VR has particularly been used is in the field of laparascopic and arthroscopic surgery, where the requisite skills required to perform the  procedures entail a steep
learning curve. Model knees that flex and
extend with a realistic skin cover are now available. Acquisition of remote hand-eye coordination and indirect fine motor control within a limited environment is the goal of VR simulation.   To produce the sensory outputs required to generate an impression of reality, a number of different Output Devices may be used.
	VR interactive viewing of the brain

Uses of VR:  Virtual Reality has the distinct advantage of being able to turn an abstract situation into a perceptibly real one . For example a virtual world can be produced where the patient is immersed in their phobic situation, and guided through therapy. VR can provide a safe learning environment for development of skills needed to drive a powered wheelchair.

VR may be utilised in surgery, for planning and assisting. A virtual image is displayed upon the patient over the operative site, A patient in a remote area can be examined by a Physician using a haptic input / haptic output system. Simply put, tactile information can be inputted  at the  source using either a robotic hand or a volumetric sensor, and can be felt by the examiner through a tactile output

Education, Training Simulation Systems

Image Manipulation, Surgical Guidance and Navigation Systems

Telepresence Surgery, Virtual Telemedicine. 

Robotics in clinical practice:

    A robot is a reprogrammable, multifunctional manipulator designed to move material, parts, tools, or specialized devices through various programmed motions for the performance of a variety of tasks.

Improves accuracy or reproducibility, or replaces lost physical abilities

Useful in Interventional Medicine

Useful in Open Surgery, Minimally Invasive Surgery

Useful in Telepresence Surgery

Useful in Prosthetics ,Cybernetics

Useful in CAD-CAM Technology

Using complex 3D image reconstructions, robots can be used to precisely target and deliver therapeutic agents to deep lesions such as neoplasms. This allows pinpoint accuracy in delivery, provided that the image reconstruction is perfect and the registration of patient data to the robot is accurate.

A computer–robot can perform the appropriate bone cuts required to seat a total knee replacement with laser guided accuracy. With robot systems, it is possible to encode this mirror imaging and use a robot to perform the manoeuvres, under operator control. The operator uses a joystick or similar device to manipulate the robot, with this important difference: the operator’s hand movements are ‘real sense’ or equivalent to the instrument movements, and so are intuitive

Robotic surgical systems do not need to be controlled locally. Indeed, it may be more advantageous to be able to control the robot from a distance, for example in remote areas or where there is risk of infection. The main problem with such a system is the bandwidth of the connection between the robot/sensing system and the remote operator

An individual with a Bionic prosthesis may be termed a Cybernetic Organism or Cyborg for short. These are usually replacements for musculoskeletal deficits and take the form of robotic arms or legs. Increasingly sophisticated prostheses have been developed and applied. Examples include powered lower leg prosthesis for amputees, which use pneumatic technology to decrease the effort required whilst walking. The physical interface between patient and prosthesis is paramount in obtaining a good fit, thus restoring optimum function and preventing pressure induced complications. If the patient’s limb stump is precisely digitized into a three dimensional computer model, a computer driven robot can then accurately fashion a matching socket, which will be anatomically correct.

Medical telemetry:

Measurement of physiological parameters at a distance from the patient by cable, or by wireless technology.

Biosensors are electrical components which detect physiological parameters and convert them to digital values e.g. a pulse oxy meter probe to   detect the saturation of capillary blood

ECG, temperature, oxygen saturation, BP and respiration.

Fetal cardiography Sleep apnoea alarms in Sudden Infant Death Syndrome

Dedicated radio-frequency spectrum with sufficient bandwidth.

Artificial intelligence in Clinical practice:

A System giving expert advice, understanding “natural” computer languages, speaking like humans and recognising complex patterns like handwriting is an AI system.

AI models for medical imaging, cardiac, electrical, biomechanical behaviours, circulatory dynamics and renal function are available.

Receiving and processing visual, auditory and tactile sensation is a major function of intelligence. Intelligence, however cannot be broken down to its constituent parts – the whole being greater than the sum of its parts.

Useful AI Programs include expert systems, natural language and neural networks.

An expert system can solve real world problems by following the same IF/THEN rules a human expert follows. A software knowledge engineer interviews one or several experts and encodes their thinking process into the software knowledge base. The IF/THEN rules become expert software knowledge frames. Expert systems are useful for simple medical diagnosis and problem solving. Natural language software is the branch of AI that focuses on enabling computers to understand spoken or typed language. A neural network is a digitized model of a human brain, simulated in the binary memory of a personal computer. A neural network is made up of artificial neurons, connected to each other by weights indicating the strength of the connection. As a neuron becomes energized by input, it fires, sending a digital message to other neurons. There are hundreds or even thousands of these inter-linked neurons, arranged in layers, and all together they form a neural network, capable of learning from experience.

Programs may be designed to serve as consultants on complex problems where outstanding feats of pattern recognition are required

AI may overcome human factors like data overload, vigilance, varying expertise and human error.

Decision support system:

·         Decision-making is a complex process based on the evaluation of available data. Decision making ideally should be based on hard evidence which takes into account every possible factor. In clinical practice this is often based on “Intuitive reasoning” (an oxymoron?) based on one’s “experience”.  Consensus decision by a committee with different types of experts treating the same disease in different ways may be preferable to unilateral biased decisions. With state of the art neural networks it should be possible to design an intelligent system which could give correct unbiased weightage to different influencing factors and arrive at a scientifically valid conclusion

·         How can a system ‘make decisions’? Can a decision be equated to choosing between one of many alternatives.  Does a Decision Support System (DSS) merely sort things into ‘either-or’ categories? Can a Neural Network mimic human ways of looking at data?  Will the Bayesian methods of calculating the probability of different outcomes suffice? Is ‘Conditional Probability’ (A way of relating the probability of an event to the presence of certain factors) evaluation the answer? In clinical decision-making, there may be an information overload with irrelevant facts. How does one separate the wood from the trees?  Can a DSS help one make better decisions? A DSS need not be a rival but can be yet another aid with the physician still continuing to call the shots.

·         Will it be possible to precisely identify specific characteristics, which could predict suitability for a specific treatment? Which technique should be used to identify these factors?  Does the technique matter? It is not always a matter of two different answers - the techniques of the DSS and “clinical judgement” may be different routes to the same answer. Categorizing data should yield more information and this should make a difference

A Neural network which is the heart (or rather the brain!) of a DSS should simulate the biological way of connecting many artificial ‘neurons’ and training the network to recognise patterns. The optimal arrangement of the ‘nodes’ (or neurons) and training strategy are important.  Neural Networks consist of a series of linked ‘nodes’, linked to form a network. Nodes have layers –input and output layers. Simple networks have no intervening layers. Activation of each node occurs once its threshold is reached, and this is determined by the summation of its inputs. Each input is also ‘weighted’, so that some inputs are more important than others. A decision node can be deleted if it doesn’t matter in practical terms which option is taken.  The danger of this approach is that we are determining before hand what information may be useful and what may not be useful.  It might then be difficult to include some new item of information into the decision making process. One of the strengths of Neural Networks, is integrating multiple pieces of ‘low-value’ information.

Conclusion:  

We have come a long way since the Abacus was first thought of. To one trained in the BC era (Before Computers) the future is sometimes frightening. Many of us desperately cling to the present not realising that we have already become the past.  The only thing that is constant in the universe is change and we have to accept it, and the problem with the future is that it is always ahead of schedule. At the same time we should realise that “a fool with a tool is still a fool”. Technology in search of an application is not the answer. Let us not become slaves of technology but continue to be the master, never forgetting that no supercomputer of the future can ever match the human brain whose circuits will always remain a mystery.