A PROGRESS REPORT ON ARTIFICIAL INTELLIGENCE:
HOSPITAL APPLICATIONS AND A REVIEW OF
THE ARTIFICIAL INTELLIGENCE MARKETPLACE
Lawrence M. Brenkus, M.D.
Arthur D, Little, Inc.
Acorn Park
Cambridge, Massachusetts 02140
ABSTRACT
Artificial intelligence applications
are finally beginning to move from the
university research laboratory into
commercial use. Before the end of the
century, this new computer technology
will have profound effects on our work,
economy, and lives. At present, rela-
tively few products have appeared in
the hospital, but we can anticipate
significant product offerings in in-
strumentation and affecting hospital
administration within 5 years,
Knowledge-based expert systems represent
a new software technology which permits
programs to simulate human expertise
through the use of a large knowledge
base and reasoning methods. These pro-
grams have recently become a topic of
lively interest because of their increas-
ing capabilities, and their recent intro-
duction into the commercial marketplace
as real-world products. The most famous
program of this type operating in the
medical domain is probably INTERNIST, a
diagnostic consulting program developed
at University of Pittsburgh. A test of
its performance was published recently
in the New England Journal of Medicine;
the program performed approximately as
well as the human physicians in solving
difficult CPC cases.
At present, our technology for building
expert systems is still limited. Each
program is a custom effort; no fully
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adequate off-the-shelf system building
tools exist yet, Furthermoref they per-
form adequately only in a narrow domain of
expertise, unlike a human expert who can
often be a generalist. The programs are
also unable to learn and require human
intervention to add new rules to refine
the system. Thus, a fully developed "in-
dustrial strength" expert system is quite
expensive -- commercially useful products
have required about 5 man-years of effort
and about a million dollars expenditure.
(Prototype development is much less costly,
but these figures are typical to develop
a sizeable program with true human exper-
tise in a field.)
Even with these limitations there are many
problems which justify the use of expert
systems technology because of the large
savings which can be realized. Typically
these high-value applications are used
within a company to save money on its in-
ternal operations. Examples already de-
Velop include an expert underwriter for
an insurance firm, a sales adviser who
aids in placing orders correctly, a shop-
floor scheduling expert, and an oil well
instrument interpreter. Each of these
applications involve the "base busine.s"
of the developing company. They are ex-
pected to pay back their development costs
within the first year of use.
While many expert systems like INTERNIST
have been developed by university re-
searchers, none of them have ever been
commercialized or have even moved success-
fully from their original research site.
A simple explanation for this is that the
"doc in a box" represents an ideal re-
search project, but does not offer the
direct cost savings required to be a suc-
cessful commercial expert system. These
academic prototypes were designed to be
used by physicians, but there is little
evidence that doctors even want a stand-
alone diagnostic consulting system. Older
physicians are often threatened by this
"creeping computerization", while younger
doctors will be frustrated by the system's
limitations. Existing diagnostic systems
generally require a great deal of data
to be typed in, and are only "expert" in
a narrow speciality domain. Unfortu-
nately, doctors need help most when a
patient's problem is poorly defined --
should they refer a patient to a cardi-
ologist, a gastronenterologist, or a
"shrink"? Expert systems can't help
them yet for this real-world problem.
Research into diagnostic consulting
systems will continue to be funded in
universities and by the military (who
have a genuine need for distributed ex-
pertise.) We can anticipate steady
progress in this challenging area, but
it is unlikely to be the source of the
first AI products in medicine.
By contrast, application of expert
systems to diagnostic and monitoring
equipment -- using ("intelligent in-
struments") represents an attractive
area for commercial exploitation. In
this area, AI technology is likely to
be cost-effective because it will pro,
duce advantages perceived by the user,
at relatively low costs and with side-
benefits to the manufacturer. A major
problem in a hospital ICU or anesthesia
suite is information overload: too
many monitors watching numerical vital
signs, and only a fallible human watch-
ing the patient. Reviews of anesthesia
mishaps have consistently shown that
human error remains the prime cause.
An expert system can integrate the out-
put of many monitors and report a diag-
nostic rather than simply make a measure"
ment. The type of "smart alarm" could
inform the medical care team not only
that something was wrong with the
patient, but what is specifically wrong
and what they should do about it. Fur-
thermore, this type of expert system is
quite practical using today's tools. It
involves only a narrow domain of knowl-
edge, can read data directly from sensors
rather than requiring extensive typing,
and can be implemented using relatively
few rules. As an example, the PUFF
system developed at Stanford was suc-
cessfully prototyped in only a few months
using 60 rules.
Manufacturers will also realize direct
advantages from use of expert system
technology. To stay competitive, a
manufacturer of monitoring or test in-
struments must bring out an improved
product line every 2 or 3 years. Before
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iicroprocessors were available, this
required manufacturers to employ a large
staff of electrical engineers, who would
redesign the new circuits for the improved
instrument. Now that this equipment is
microprocessor based, manufacturers can
produce their next-generation instrument
by making cosmetic changes to the in-
strument's front panel and changing the
software executed by the instrument. As
a result, they now employ a few electrical
engineers and a small army of computer
programmers! The "software bottleneck"
has taken its toll. By contrast, an ex-
pert system can be updated by addition of
new rules rather than by rewriting of an
entire program. This offers a speedier
and more cost-effective approach to
systems development.
One example of an expert system imbedded
in a medical instrument has already
reached the commercial marketplace.
Helena Labs, in conjunction with Rutgers
University, has released an intelligent
protein densitometer, called the
Cliniscan. This laboratory instrument
measures the components of a patient's
serum protein, and prints out a diagnosis
for the patient along with the numeric
values of the protein analysis. Other
instruments under development in univer-
sities include systems for ventilator
management, interpretation of EEG, and
rule-based interpretation of the EKG
(potentially more accurate than conven,
tional signalprocessing approaches);
commercial research in this area is also
active.
Intelligent instruments are also likely to
affect the hospital biomedical engineer.
The high cost of service is a major con-
cern for equipment manufacturers. This
can be reduced drastically by desing-
ing intelligent test-instruments to
"diagnose" faulty equipment in the field.
Westinghouse is actively developing
systems in this area.
To understand the largest opportunity
for AI in the hospital, it is necessary
to look at conventional computer appli-
cations in medicine. Virtually all
hospitals utilize computers for financial
processing. Even a full "hospital in-
formation system" (HIS) is really con-
centrated on administrative scheduling
and logistics issues rather than mani-
pulation of clinical data. In fact, there
has been very limited market acceptance
for Patient Data Management systems or
"paperless chart" systems which focus on
patient care rather than administration.
In sum, only applications that directly
save money can justify the large in-
vestment in data processing systems.
This same logic applies to expert systems
as well as to the older conventional
forms of data processing. The main
application of AI in hospitals within
the next five years will be to support
the administrator. Under cost-plus, the
administrator did not have to be in-
volved in medical decision making. Now
the old methods of chart review will
prove inadequate. Prospective payment
requires prospective monitoring of
costs. Unnecessary tests and excessive
length of stay will no longer raise the
per-diem rate, they will bankrupt the
hospital. Fortunately, expert systems
technology is directly applicable.
Even though systems capable of specify,
ing ideal or optimal medical practice
are still beyond our grasp, it is much
easier to recongnize bad medical prac-
tice. (For example, antibiotics pre-
scribed prophylactically for sur-
gery should not be continued beyond
48 hours.) This type of patient-care
protocol can be developed by working
together with the medical chief-of-staff
and the individual department heads.
The expert system then only acts as a
"passive restraint" to indicate devi
ations from agreed-upon medical
practice.
The first generation of expert systems
imbedded into hospital information
systems began with Homer Warner's
pioneering work at LDS Hospital. This
system, called HELP, is now being com-
mercialized by Control Data Corp.
HELP uses a medical logic system of
decision rules which it applied auto-
matically as new data is available on a
patient. Some of these decision cap-
abilities (such as recognition of poten-
tial drug interactions) are now avail-
able with most HIS systems. The im-
portant feature in HELP is that these
decision rules can be customized by the
user to recognize that prescribed therapy
deviates from agree-upon protocols (with
obvious advantages in preventing un-
necessary costs).
I anticipate the sophistication of
medical expert system support in HIS's
to grow rapidly as a result of the
changes of reimbursement. As these
systems grow more sophisticated, they
will become an "administrative assis-
tant," aiding the administrator with
some of the same skills now being
provided by hospital management con-
sultants.

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