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.Click image for high-res version.
EDITORS' UPDATE, June 24, 2004 -- Based on more current information provided by the Robertson Research Institute, several details -- including a projected date for delivery of the NxOpinion software and plans for additional development phases of the software -- have been updated or corrected in this article.
REDMOND, Wash., Jan. 21, 2004 — Nearly 100,000 people die in U.S. 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 neuropharmacologist 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 Robertson. "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.
"That's when I decided that someone needed to develop a diagnostic decision-support 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."
Robertson 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 Robertson 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, and rural clinics. An initial version of the software and associated database of medical information is slated to launch in 2005.
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.
Sample screenshots illustrate how NxOpinion helps physicians rapidly formulate medical diagnoses and treatment options.Click image for high-res version.
"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, chief executive officer 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 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.
Physicians can adapt NxOpinion to their skill level, language and level of available medical resources. 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 capability into NxOpinion without the added development time and expense of converting data from one character set to another for each language.
"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 three mouse clicks or less," says Brophy. "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 the18th-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.
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, a 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.
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 the RRI team expands and members in different regions of the United States and other countries create new disease profiles, they will be 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.
When NxOpinion is released, 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. Swanson 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.
Dr. Joel C. Robertson, creator of NxOpinion, a real-time diagnostic tool built on Microsoft technology.Click image for high-res version.
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 Robertson. "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 future phases of 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, medical director for NxOpinion.
Bates 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 Swanson. "We watched how they performed certain actions, listened to their questions about the interface and noted the places where they struggled."
The doctors especially valued NxOpinion's search engine 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 Swanson. "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 future 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. RRI plans 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 Robertson, "it's measured not in dollars but in the lives we're going to help save."