A PRACTICAL COMPUTER PROGRAM

THAT DIAGNOSES DISEASES IN ACTUAL PATIENTS

Carlos Feder & Tomás Feder

A PRACTICAL COMPUTER PROGRAM

THAT DIAGNOSES DISEASES IN ACTUAL PATIENTS

Carlos Feder & Tomás Feder

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

Diagnostic errors occur very frequently; some are disabling or fatal, resulting in liability for the physician. Unawareness, underreported

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

Diagnostic errors occur very frequently; some are disabling or fatal, resulting in liability for the physician. Unawareness, underreported

Physicians order an inordinate number of futile tests, not rationally selected according to a probabilistically determined benefit

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

Diagnostic errors occur very frequently; some are disabling or fatal, resulting in liability for the physician. Unawareness, underreported

Physicians order an inordinate number of futile tests, not rationally selected according to a probabilistically determined benefit

These errors are due to the impossibility to remember or even learn thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc.

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

Diagnostic errors occur very frequently; some are disabling or fatal, resulting in liability for the physician. Unawareness, underreported

Physicians order an inordinate number of futile tests, not rationally selected according to a probabilistically determined benefit

These errors are due to the impossibility to remember or even learn thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc.

Diseases neither learned nor recalled by the physician remain undiagnosed or misdiagnosed

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

Diagnostic errors occur very frequently; some are disabling or fatal, resulting in liability for the physician. Unawareness, underreported

Physicians order an inordinate number of futile tests, not rationally selected according to a probabilistically determined benefit

These errors are due to the impossibility to remember or even learn thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc.

Diseases neither learned nor recalled by the physician remain undiagnosed or misdiagnosed

Problem compounded by time constraints imposed by health insurances (managed care medicine)

ESSENTIAL NEED FOR AN EFFICIENT COMPUTER DIAGNOSTIC PROGRAM

Diagnostic errors occur very frequently; some are disabling or fatal, resulting in liability for the physician. Unawareness, underreported

Physicians order an inordinate number of futile tests, not rationally selected according to a probabilistically determined benefit

These errors are due to the impossibility to remember or even learn thousands of diseases with their corresponding names, symptoms, tests, procedures, causes, mechanisms, etc.

Diseases neither learned nor recalled by the physician remain undiagnosed or misdiagnosed

Problem compounded by time constraints imposed by health insurances (managed care medicine)

Computers can store the contents of many medical texts and swiftly retrieve the needed information anywhere and at any time

EXISTING SO CALLED“COMPUTER DIAGNOSTIC PROGRAMS”

INTERNIST (former Caduceus)

MEDITEL

QMR (Quick Medical Reference)

ILIAD

PKC (Problem-Knowledge Couplers)

ISABEL

DXplain

EXISTING SO CALLED“COMPUTER DIAGNOSTIC PROGRAMS”

INTERNIST (former Caduceus)

MEDITEL

QMR (Quick Medical Reference)

ILIAD

PKC (Problem-Knowledge Couplers)

ISABEL

DXplain

Excellent remainder of unusual diagnoses, but

Unable to pinpoint the disease(s) that actually afflict a specific patient

Considered educational or training tools rather than diagnostic tools

Poorly accepted and seldom used by practicing health care providers

Advantages of our novel computer program

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent

It diagnoses concurrent diseases afflicting simultaneously a specific patient

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent

It diagnoses concurrent diseases afflicting simultaneously a specific patient

It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent

It diagnoses concurrent diseases afflicting simultaneously a specific patient

It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods

It gives primary importance to the cost of obtaining each clinical datum. Our algorithm interprets cost not only as dollar expense, but also considers discomfort and risk of the procedure. Four overall cost categories are established: No Cost, Small Cost, Intermediate Cost, and Great Cost

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent

It diagnoses concurrent diseases afflicting simultaneously a specific patient

It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods

It gives primary importance to the cost of obtaining each clinical datum. Our algorithm interprets cost not only as dollar expense, but also considers discomfort and risk of the procedure. Four overall cost categories are established: No Cost, Small Cost, Intermediate Cost, and Great Cost

It anticipates the benefit that each clinical datum would confer to each diagnosis in the differential diagnosis list, by calculating with our mini-max procedure how much it would increase or decrease the current probability of the corresponding diagnosis if the data were found respectively present or absent in the patient

Advantages of our novel computer program It confirms one or more diseases that indeed afflict a specific patient, instead of

displaying a long list of potential diagnoses that compete with each other

It rules in diagnoses evoked by clinical data present, but also rules out those diagnoses that are not viable, based on sensitivity of clinical data absent

It diagnoses concurrent diseases afflicting simultaneously a specific patient

It calculates accurately the probability of each diagnosis with our novel mini-max procedure, instead of applying inexact Bayes formula or other methods

It gives primary importance to the cost of obtaining each clinical datum. Our algorithm interprets cost not only as dollar expense, but also considers discomfort and risk of the procedure. Four overall cost categories are established: No Cost, Small Cost, Intermediate Cost, and Great Cost

It anticipates the benefit that each clinical datum would confer to each diagnosis in the differential diagnosis list, by calculating with our mini-max procedure how much it would increase or decrease the current probability of the corresponding diagnosis if the data were found respectively present or absent in the patient.

It selects and recommends the probabilistically calculated best cost-benefit clinical data to investigate next in the patient at each diagnostic step, to achieve more efficiently and economically a final diagnosis

Advantages of our novel computer program (continues)

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences

It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences

It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases

It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences

It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases

It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis

It proposes an easy way to handle synonyms of diagnoses and clinical data

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences

It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases

It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis

It proposes an easy way to handle synonyms of diagnoses and clinical data

It is ease to update

Advantages of our novel computer program (continues)

It recommends a set of best cost-benefit clinical data to be investigated simultaneously in the patient, based on diverse heuristic strategies

It can display selected partial lists that render the diagnostic task more economic and manageable, without compromising the accuracy of the result. It accomplishes this through parameters that can be set at diverse values and through abridged output files, giving the user the choice to select the ones that fit best his or her preferences

It includes complex clinical presentation models in the database, which list associations among diseases, such as causes, complications, and other relations, precluding overlooking associated diseases

It deals with interactions between concurrent diseases or drugs that mask important clinical data of the primary disease, precluding the improper ruling out of the corresponding diagnosis

It proposes an easy way to handle synonyms of diagnoses and clinical data

It is ease to update

Such an algorithm, if successful in medicine, may represent a more general model of reasoning; a paradigm of mental structure and functioning applicable to other inexact disciplines such as law, sociology, politics, defense, or corporate strategy

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources

4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources

4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive

5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers.

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources

4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive

5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers.

6. Protect health care providers against unfounded malpractice liability

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources

4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive

5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers.

6. Protect health care providers against unfounded malpractice liability

7. Helps to overcome the current well known resistance of physicians to resort to computerized aid for medical diagnosis

SOCIOECONOMIC ADVANTAGESOF OUR PROGRAM1. Reduces significantly the current numerous diagnostic errors and their dismal

consequences

2. Saves specialist consultations; important in emergencies and in underdeveloped areas were specialists are not available

3. Reduces significantly the number of futile tests and procedures, by recommending the best cost-benefit clinical data to investigate next in a patient. This saves expense, risk, and discomfort for the patient and saves social medical resources

4. On the other hand, if best cost-benefit function proves probabilistically that a diagnostic procedure is absolutely necessary, it will force managed care organizations and insurers to authorize such procedures, otherwise curtailed for being expensive

5. Facilitates and improves utilization reviews by hospitals, laboratories, and other providers.

6. Protect health care providers against unfounded malpractice liability

7. Helps to overcome the current well known resistance of physicians to resort to computerized aid for medical diagnosis

8. Some concepts of our diagnostic program are applicable and necessary to properly implement the current renewed enthusiasm for long needed universal electronic storage of medical records

DEMONSTRATION

DEMONSTRATION

A 32-year-old white female grade-school teacher with recent onset of palpitations. Six months ago she lost her job, followed by nervousness and depression. At that time a complete physical examination and basic lab tests were normal; she was treated with an antidepressant, without improving. Her medical condition gradually worsened and recently the mentioned palpitations added to the clinical picture, motivating the present consultation. The medical examination revealed the following clinical data.

CLINCAL DATA PRESENT

CLINCAL DATA PRESENTNo Cost clinical dataMedical History (symptoms)C0072 (palpitations)C0216 (nervousness/anxiety)C0606 (depression)C0050 (fatigue, asthenia)C0109 (sweating, diaphoresis, perspiration)C0161 (weight loss)C0165 (diarrhea)C0010 (dyspnea, breathlessness, shortness of breath)Physical Examination (physical signs)C0078 (tachycardia)C0219 (fine texture of skin/hair)C0224 (exophthalmos)C0490 (conjunctival redness)C0222 (lid lag)C0220 (goiter, enlarged thyroid gland)C0095 (loud first heart sound)C0053 (systolic murmur)C0111 (weakness)C0223 (tremor)

CLINCAL DATA ABSENT

CLINCAL DATA ABSENTNo Cost clinical dataMedical History (symptoms)C0498 (male)

DIFFERENTIAL DIAGNOSIS LIST

D0011 (HYPERTHYROIDISM, GRAVES' DISEASE)total P: 818----------D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE)total P: 640----------D0012 (PHEOCHROMOCYTOMA)total P: 364----------D0003 (ATRIAL SEPTAL DEFECT SECUNDUM)total P: 338----------D0002 (AORTIC VALVE STENOSIS)total P: 332----------D0035 (ROCKY MOUNTAIN SPOTTED FEVER)total P: 272----------D0057 (ACUTE MYOCARDIAL INFARCTION WITH MASKED CHEST PAIN)total P: 183----------D0005 (ACUTE MYOCARDIAL INFARCTION WITHOUT MASKED CHEST PAIN)total P: 183----------D0027 (DISSEMINATED GONOCOCCAL INFECTION)total P: 181----------D0069 (PANCREATIC BODY-TAIL CARCINOMA)total P: 176----------

D0046 (PANCREATIC HEAD CARCINOMA)total P: 176----------D0001 (AORTIC DISSECTION)total P: 169----------D0007 (PULMONARY EMBOLISM)total P: 157----------D0026 (INTESTINAL GIARDIASIS)total P: 145----------D0022 (ULCERATIVE COLITIS)total P: 145----------D0024 (ACUTE INFECTIVE ENDOCARDITIS)total P: 138----------D0038 (SYSTEMIC LUPUS ERYTHEMATOSUS)total P: 132----------D0059 (DIABETIC KETOACIDOSIS)total P: 110----------D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS)total P: 107----------D0034 (PNEUMOCOCCAL PNEUMONIA)total P: 100----------

Data Cost Procedure Quantity

No Cost best cost-benefit clinical data: 103

G0001 MEDICAL HISTORYC0353 (abdominal pain, right lower quadrant)C0800 (abdominal pain, left lower quadrant)C0799 (abdominal pain, right upper quadrant)C0246 (abdominal pain, epigastric)C0781 (abdominal pain, left upper quadrant)C0697 (inadequate insulin administration)C0352 (mucus in stool)C0615 (dysuria)C0538 (photosensitivity)C0533 (pericarditis)C0215 (hypersensitivity to heat)C0486 (onset May-September)C0458 (vaginal discharge)C0401 (urinary tract symptoms, female)C0400 (urinary tract symptoms, male) Continues…

G0002 PHYSICAL EXAMINATIONC0864 (urethral discharge)C0860 (urethritis)C0859 (cervicitis)C0853 (small intestine obstruction)C0854 (colonic obstruction)C0794 (systolic thrill)C0793 (unequal blood pressures)C0702 (Kussmaul respiration)C0529 (butterfly, malar rash)C0475 (chest dullness at percussion)C0402 (tenosynovitis/periarthritis)C0398 (dehydration)C0379 (new/worsened regurgitant murmur) Continues…Small cost best cost-benefit clinical data: 92

G0003 ELECTROCARDIOGRAMC0377 (abnormal ECG)C0120 (myocardial infarction pattern on ECG)C0065 (left ventricular hypertrophy on ECG)C0577 (myocardial infarction pattern on ECG, with masked chest pain)C0048 (myocardial infarction pattern on ECG, without masked chest pain)

G0004 LABORATORY TESTSC0867 (nucleic acid urogenital probe tests for gonococcus)C0788 (CA 19-9)C0705 (plasma ketones ++++)

C0704 (moderate hyperosmolality: 300 – 320 mOsm/mL)C0703 (glucose: 250 – 600mg/dL)C0710 (hypertriglyceridemia, triglycerides > 250 mg/dL)C0711 (hyperlipoproteinemia)C0679 (plasma D-dimer ELISA)C0535 (ANA, antinuclear antibodies)C0526 (hypergammaglobulinemia)C0518 (casts)C0496 (latex agglutination test for rocky mountain spotted fever)C0495 (indirect immunofluorescence assay for rocky mountain spotted fever)C0386 (C-reactive protein)C0384 (multiple blood cultures for acute endocardits)C0244 (elevated plasma and urine catecholamines and metanephrines)C0243 (elevated twenty four-hour urine vanillylmandelic acid)C0229 (suppressed TSH)C0228 (increased free, uncombined thyroxin, T four or T three)C0214 (hypophosphatemia) Continues…

G0005 RADIOLOGYC0680 (Westermark's, Hampton's, and Palla's signs on chest x-rays)C0338 ("string sign" on x-rays)C0329 (pleural effusion on imaging)C0134 (pulmonary infiltrate on imaging)C0330 (pancreatic head mass on abdominal ultrasound)C0681 (venous ultrasonography with Doppler imaging)C0044 (transthoracic aorta ultrasound for aortic dissection) Continues…

G0007 ECHOCARDIOGRAMC0664 (echocardiogram for MI)C0378 (valvular vegetations on transesophageal echocardiogram)C0070 (aortic valve stenosis on echocardiogram)C0102 (mitral stenosis on echocardiogram)

Intermediate cost best cost-benefit clinical data: 33

G0004 LABORATORY TESTSC0396 (string test)C0189 (abnormal glucose tolerance)

G0005 RADIOLOGYC0856 (upper GI series with small bowel follow-through for Crohn's disease)C0242 (barium enema for ulcerative colitis)C0027 (gastrograffin enema for Crohn's disease) Continues…G0006 ULTRASOUNDC0792 (transesophageal ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAM

C0797 (echocardiogram of atrial septal defect secundum)

G0008 IMAGING: CT AND/OR MRIC0902 (magnetic resonance colangio-pancreatography for body or tail mass)C0901 (magnetic resonance colangio-pancreatography for head)C0851 (multidetector-row CT with oral contrast for Crohn's disease)C0834 (positron-emission tomography (PET) for pheochromocytoma)C0798 (mitral stenosis on cardiac magnetic resonance imaging)C0784 (pancreatic body or tail mass on CT or MRI)C0682 (multislice spiral chest CT or MRI for pulmonary embolism)C0670 (liver imaging with CT or MRI: fatty liver)C0612 (spiral CT scanning for pancreatic head carcinoma)C0785 (spiral CT scanning for pancreatic body or tail carcinoma) Continues…

G0009 SCANNINGC0833 (nuclear medicine scintigraphy with MIBG for pheochromocytoma)C0157 (lung perfusion scan with ventilation scan: high probability)C0233 (thyroid radionuclide scan)

G0010 ENDOSCOPYC0850 (wireless capsule endoscopy for Crohn's disease)C0153 (colonoscopy and biopsy for Crohn's disease) Continues…

G0011 BIOPSYC0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion)C0399 (biopsy of small intestine for Giardia lamblia)

Great cost best cost-benefit clinical data: 14

G0010 ENDOSCOPYC0898 (endoscopic ultrasound and fine-needle aspiration for body)C0608 (ERCP for pancreatic head carcinoma) Continues…

G0011 BIOPSYC0611 (biopsy for pancreatic head carcinoma)C0786 (biopsy for pancreatic body or tail carcinoma)

G0013 ANGIOGRAPHYC0787 (pancreatic body or tail mass on angiography)C0047 (aortography)C0071 (aortic valve stenosis on catheterization)C0160 (pulmonary angiogram) Continues…Total: 242

PARAMETERS Trim Present No Cost 800 Trim Absent No Cost 800 Trim Present Greater Cost 800 Trim Absent Greater Cost 800 Present Difference Cost 000 Absent Difference Cost 000 Confirmation Threshold 900 Deletion Threshold 100 Cutoff Present 100 Cutoff Absent 900

Abridged Data Cost Procedure QuantityNo Cost best cost-benefit clinical data: 35

G0001 MEDICAL HISTORYC0353 (abdominal pain, right lower quadrant)C0800 (abdominal pain, left lower quadrant)C0781 (abdominal pain, left upper quadrant)C0780 (strong analgesics)C0673 (pregnancy)C0401 (urinary tract symptoms, female)C0333 (malabsorption)C0296 (gross blood in stool)C0262 (acholic, pale, clay-colored stool)C0215 (hypersensitivity to heat)C0163 (anorexia, loss of appetite)C0127 (arthralgia)C0004 (chest pain)C0052 (history of angina pectoris)C0107 (diabetes)

G0002 PHYSICAL EXAMINATIONC0794 (systolic thrill)C0678 (paradoxical bradycardia)C0562 (Horner's syndrome)C0475 (chest dullness at percussion)C0379 (new/worsened regurgitant murmur)C0375 (meningism)C0365 (skin lesions)C0337 (mouth lesions)C0332 (intestinal fistulas)C0248 (jaundice, icterus)C0238 (funduscopic abnormalities for pheochromocytoma)C0147 (tachypnea)C0015 (abdominal tenderness)C0018 (fever)C0019 (hypertension)C0022 (heart murmur)C0054 (clinical data of advanced age)C0055 (delayed second heart sound)C0074 (right ventricular abnormal maximal impulse)C0094 (mitral opening snap)

Small Cost best cost-benefit clinical data: 27

G0004 LABORATORY TESTSC0867 (nucleic acid urogenital probe tests for gonococcus)C0788 (CA 19-9)C0789 (CA 19-9)C0705 (plasma ketones ++++)

C0819 (increased troponins with masked chest pain)C0829 (increased troponins without masked chest pain)C0679 (plasma D-dimer ELISA)C0535 (ANA, antinuclear antibodies)C0496 (latex agglutination test for rocky mountain spotted fever)C0495 (indirect immunofluorescence assay for rocky mountain spotted fever)C0884 (sputum culture for pneumococcus)C0395 (antigen detection in stool)C0384 (multiple blood cultures for acute endocardits)C0345 (serologic markers for Crohn's disease: ASCA)C0852 (serologic markers for ulcerative colitis: pANCA)C0244 (elevated plasma and urine catecholamines and metanephrines)C0229 (suppressed TSH)C0228 (increased free, uncombined thyroxin, T four or T three)C0151 (increased bilirubin)C0131 (increased ESR)C0033 (leukocytosis)

G0005 RADIOLOGYC0042 (abnormal aortic contour on chest x-ray; widening of mediastinum)C0085 (cardiac enlargement on imaging; usually due to right ventric. enlarg.)C0086 (increased pulmonary artery and/or vascular engorgement on imaging)

G0006 ULTRASOUNDC0044 (transthoracic aorta ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAMC0070 (aortic valve stenosis on echocardiogram)C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 16

G0005 RADIOLOGYC0856 (upper GI series with small bowel follow-through for Crohn's disease)

G0006 ULTRASOUNDC0792 (transesophageal ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAMC0797 (echocardiogram of atrial septal defect secundum)

G0008 IMAGING: CT AND/OR MRIC0834 (positron-emission tomography (PET) for pheochromocytoma)C0798 (mitral stenosis on cardiac magnetic resonance imaging)C0682 (multislice spiral chest CT or MRI for pulmonary embolism)C0612 (spiral CT scanning for pancreatic head carcinoma)C0785 (spiral CT scanning for pancreatic body or tail carcinoma)C0045 (aortic dissection on MRI)

G0009 SCANNINGC0833 (nuclear medicine scintigraphy with MIBG for pheochromocytoma)C0233 (thyroid radionuclide scan)C0665 (radionuclide imaging: viable myocardium, ventricular eject.)

G0010 ENDOSCOPYC0153 (colonoscopy and biopsy for Crohn's disease)C0186 (colonoscopy and biopsy for ulcerative colitis)

G0011 BIOPSYC0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion)C0399 (biopsy of small intestine for Giardia lamblia)

Great Cost best cost-benefit clinical data: 7

G0011 BIOPSYC0611 (biopsy for pancreatic head carcinoma)C0786 (biopsy for pancreatic body or tail carcinoma)

G0013 ANGIOGRAPHYC0047 (aortography)C0071 (aortic valve stenosis on catheterization)C0090 (atrial septal defect on arteriography)C0103 (mitral stenosis on catheterization)C0160 (pulmonary angiogram)

Total: 85

Abridged Data Cost Procedure QuantityNo Cost best cost-benefit clinical data: 35

G0001 MEDICAL HISTORYC0353 (abdominal pain, right lower quadrant)C0800 (abdominal pain, left lower quadrant)C0781 (abdominal pain, left upper quadrant)C0780 (strong analgesics)C0673 (pregnancy)C0401 (urinary tract symptoms, female)C0333 (malabsorption)C0296 (gross blood in stool)C0262 (acholic, pale, clay-colored stool)C0215 (hypersensitivity to heat)C0163 (anorexia, loss of appetite)C0127 (arthralgia)C0004 (chest pain)C0052 (history of angina pectoris)C0107 (diabetes)

G0002 PHYSICAL EXAMINATIONC0794 (systolic thrill)C0678 (paradoxical bradycardia)C0562 (Horner's syndrome)C0475 (chest dullness at percussion)C0379 (new/worsened regurgitant murmur)C0375 (meningism)C0365 (skin lesions)C0337 (mouth lesions)C0332 (intestinal fistulas)C0248 (jaundice, icterus)C0238 (funduscopic abnormalities for pheochromocytoma)C0147 (tachypnea)C0015 (abdominal tenderness)C0018 (fever)C0019 (hypertension)C0022 (heart murmur)C0054 (clinical data of advanced age)C0055 (delayed second heart sound)C0074 (right ventricular abnormal maximal impulse)C0094 (mitral opening snap)

Small Cost best cost-benefit clinical data: 27

G0004 LABORATORY TESTSC0867 (nucleic acid urogenital probe tests for gonococcus)C0788 (CA 19-9)C0789 (CA 19-9)C0705 (plasma ketones ++++)

C0819 (increased troponins with masked chest pain)C0829 (increased troponins without masked chest pain)C0679 (plasma D-dimer ELISA)C0535 (ANA, antinuclear antibodies)C0496 (latex agglutination test for rocky mountain spotted fever)C0495 (indirect immunofluorescence assay for rocky mountain spotted fever)C0884 (sputum culture for pneumococcus)C0395 (antigen detection in stool)C0384 (multiple blood cultures for acute endocardits)C0345 (serologic markers for Crohn's disease: ASCA)C0852 (serologic markers for ulcerative colitis: pANCA)C0244 (elevated plasma and urine catecholamines and metanephrines)C0229 (suppressed TSH)C0228 (increased free, uncombined thyroxin, T four or T three)C0151 (increased bilirubin)C0131 (increased ESR)C0033 (leukocytosis)

G0005 RADIOLOGYC0042 (abnormal aortic contour on chest x-ray; widening of mediastinum)C0085 (cardiac enlargement on imaging; usually due to right ventric. enlarg.)C0086 (increased pulmonary artery and/or vascular engorgement on imaging)

G0006 ULTRASOUNDC0044 (transthoracic aorta ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAMC0070 (aortic valve stenosis on echocardiogram)C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 16

G0005 RADIOLOGYC0856 (upper GI series with small bowel follow-through for Crohn's disease)

G0006 ULTRASOUNDC0792 (transesophageal ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAMC0797 (echocardiogram of atrial septal defect secundum)

G0008 IMAGING: CT AND/OR MRIC0834 (positron-emission tomography (PET) for pheochromocytoma)C0798 (mitral stenosis on cardiac magnetic resonance imaging)C0682 (multislice spiral chest CT or MRI for pulmonary embolism)C0612 (spiral CT scanning for pancreatic head carcinoma)C0785 (spiral CT scanning for pancreatic body or tail carcinoma)C0045 (aortic dissection on MRI)

G0009 SCANNINGC0833 (nuclear medicine scintigraphy with MIBG for pheochromocytoma)C0233 (thyroid radionuclide scan)C0665 (radionuclide imaging: viable myocardium, ventricular eject.)

G0010 ENDOSCOPYC0153 (colonoscopy and biopsy for Crohn's disease)C0186 (colonoscopy and biopsy for ulcerative colitis)

G0011 BIOPSYC0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion)C0399 (biopsy of small intestine for Giardia lamblia)

Great Cost best cost-benefit clinical data: 7

G0011 BIOPSYC0611 (biopsy for pancreatic head carcinoma)C0786 (biopsy for pancreatic body or tail carcinoma)

G0013 ANGIOGRAPHYC0047 (aortography)C0071 (aortic valve stenosis on catheterization)C0090 (atrial septal defect on arteriography)C0103 (mitral stenosis on catheterization)C0160 (pulmonary angiogram)

Total: 85

CLINCAL DATA PRESENT

No Cost clinical dataMedical History (symptoms)C0072 (palpitations)C0216 (nervousness/anxiety)C0606 (depression)C0050 (fatigue, asthenia)C0109 (sweating, diaphoresis, perspiration)C0161 (weight loss)C0165 (diarrhea)C0010 (dyspnea, breathlessness, shortness of breath)C0215 (hypersensitivity to heat)Physical Examination (physical signs)C0078 (tachycardia)C0219 (fine texture of skin/hair)C0224 (exophthalmos)C0490 (conjunctival redness)C0222 (lid lag)C0220 (goiter, enlarged thyroid gland)C0095 (loud first heart sound)C0053 (systolic murmur)C0111 (weakness)C0223 (tremor)

CLINCAL DATA ABSENT

No Cost clinical dataMedical History (symptoms)C0498 (male)C0353 (abdominal pain, right lower quadrant)C0800 (abdominal pain, left lower quadrant)C0781 (abdominal pain, left upper quadrant)C0780 (strong analgesics)C0673 (pregnancy)C0401 (urinary tract symptoms, female)C0333 (malabsorption)C0296 (gross blood in stool)C0262 (acholic, pale, clay-colored stool)C0163 (anorexia, loss of appetite)C0127 (arthralgia)C0004 (chest pain)C0052 (history of angina pectoris)C0107 (diabetes)Physical Examination (physical signs)C0794 (systolic thrill)C0678 (paradoxical bradycardia)C0562 (Horner's syndrome)C0475 (chest dullness at percussion)C0379 (new/worsened regurgitant murmur)C0375 (meningism)C0365 (skin lesions)C0337 (mouth lesions)C0332 (intestinal fistulas)C0248 (jaundice, icterus)

C0238 (funduscopic abnormalities for pheochromocytoma)C0147 (tachypnea)C0015 (abdominal tenderness)C0018 (fever)C0019 (hypertension)C0022 (heart murmur)C0054 (clinical data of advanced age)C0055 (delayed second heart sound)C0074 (right ventricular abnormal maximal impulse)C0094 (mitral opening snap)

DIFFERENTIAL DIAGNOSIS LIST

D0011 (HYPERTHYROIDISM, GRAVES' DISEASE)total P: 671----------D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE)total P: 103----------

Abridged Data Cost Procedure Quantity

No Cost best cost-benefit clinical data: 2G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three)G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 2G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging)G0009 SCANNING C0233 (thyroid radionuclide scan)

Great Cost best cost-benefit clinical data: 1G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization)

Total: 8

Abridged Data Cost Procedure Quantity

No Cost best cost-benefit clinical data: 2G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three)G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 2G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging)G0009 SCANNING C0233 (thyroid radionuclide scan)

Great Cost best cost-benefit clinical data: 1G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization)

Total: 8

Abridged Data Cost Procedure Quantity

No Cost best cost-benefit clinical data: 2G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three)G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 2G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging)G0009 SCANNING C0233 (thyroid radionuclide scan)

Great Cost best cost-benefit clinical data: 1G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization)

Total: 8

CLINCAL DATA PRESENT

No Cost clinical dataMedical History (symptoms)C0072 (palpitations)C0216 (nervousness/anxiety)C0606 (depression)C0050 (fatigue, asthenia)C0109 (sweating, diaphoresis, perspiration)C0161 (weight loss)C0165 (diarrhea)C0010 (dyspnea, breathlessness, shortness of breath)C0215 (hypersensitivity to heat)Physical Examination (physical signs)C0078 (tachycardia)C0219 (fine texture of skin/hair)C0224 (exophthalmos)C0490 (conjunctival redness)C0222 (lid lag)C0220 (goiter, enlarged thyroid gland)C0095 (loud first heart sound)C0053 (systolic murmur)C0111 (weakness)C0223 (tremor)

Small Cost clinical dataLaboratory TestsC0229 (suppressed TSH)C0228 (increased free, uncombined thyroxin, T four or T three)

CLINCAL DATA ABSENT

No Cost clinical dataMedical History (symptoms)C0498 (male)C0353 (abdominal pain, right lower quadrant)C0800 (abdominal pain, left lower quadrant)C0781 (abdominal pain, left upper quadrant)C0780 (strong analgesics)C0673 (pregnancy)C0401 (urinary tract symptoms, female)C0333 (malabsorption)C0296 (gross blood in stool)C0262 (acholic, pale, clay-colored stool)C0163 (anorexia, loss of appetite)C0127 (arthralgia)C0004 (chest pain)C0052 (history of angina pectoris)C0107 (diabetes)Physical Examination (physical signs)C0794 (systolic thrill)C0678 (paradoxical bradycardia)C0562 (Horner's syndrome)C0475 (chest dullness at percussion)C0379 (new/worsened regurgitant murmur)C0375 (meningism)C0365 (skin lesions)C0337 (mouth lesions)C0332 (intestinal fistulas)C0248 (jaundice, icterus)

C0238 (funduscopic abnormalities for pheochromocytoma)C0147 (tachypnea)C0015 (abdominal tenderness)C0018 (fever)C0019 (hypertension)C0022 (heart murmur)C0054 (clinical data of advanced age)C0055 (delayed second heart sound)C0074 (right ventricular abnormal maximal impulse)C0094 (mitral opening snap)

C0221 (thyroid bruit or thrill)C0096 (rumbling diastolic murmur)

Small Cost clinical dataEchocardiogramC0102 (mitral stenosis on echocardiogram)

DIFFERENTIAL DIAGNOSIS LIST

D0011 (HYPERTHYROIDISM, GRAVES' DISEASE)total P: 1000

Abridged Data Cost Procedure Quantity

No Cost best cost-benefit clinical data: 0

Small Cost best cost-benefit clinical data: 0

Intermediate Cost best cost-benefit clinical data: 0

Great Cost best cost-benefit clinical data: 0

Total: 0

Abridged Data Cost Procedure QuantityNo Cost best cost-benefit clinical data: 35

G0001 MEDICAL HISTORYC0353 (abdominal pain, right lower quadrant)C0800 (abdominal pain, left lower quadrant)C0781 (abdominal pain, left upper quadrant)C0780 (strong analgesics)C0673 (pregnancy)C0401 (urinary tract symptoms, female)C0333 (malabsorption)C0296 (gross blood in stool)C0262 (acholic, pale, clay-colored stool)C0215 (hypersensitivity to heat)C0163 (anorexia, loss of appetite)C0127 (arthralgia)C0004 (chest pain)C0052 (history of angina pectoris)C0107 (diabetes)

G0002 PHYSICAL EXAMINATIONC0794 (systolic thrill)C0678 (paradoxical bradycardia)C0562 (Horner's syndrome)C0475 (chest dullness at percussion)C0379 (new/worsened regurgitant murmur)C0375 (meningism)C0365 (skin lesions)C0337 (mouth lesions)C0332 (intestinal fistulas)C0248 (jaundice, icterus)C0238 (funduscopic abnormalities for pheochromocytoma)C0147 (tachypnea)C0015 (abdominal tenderness)C0018 (fever)C0019 (hypertension)C0022 (heart murmur)C0054 (clinical data of advanced age)C0055 (delayed second heart sound)C0074 (right ventricular abnormal maximal impulse)C0094 (mitral opening snap)

Small Cost best cost-benefit clinical data: 27

G0004 LABORATORY TESTSC0867 (nucleic acid urogenital probe tests for gonococcus)C0788 (CA 19-9)C0789 (CA 19-9)C0705 (plasma ketones ++++)

C0819 (increased troponins with masked chest pain)C0829 (increased troponins without masked chest pain)C0679 (plasma D-dimer ELISA)C0535 (ANA, antinuclear antibodies)C0496 (latex agglutination test for rocky mountain spotted fever)C0495 (indirect immunofluorescence assay for rocky mountain spotted fever)C0884 (sputum culture for pneumococcus)C0395 (antigen detection in stool)C0384 (multiple blood cultures for acute endocardits)C0345 (serologic markers for Crohn's disease: ASCA)C0852 (serologic markers for ulcerative colitis: pANCA)C0244 (elevated plasma and urine catecholamines and metanephrines)C0229 (suppressed TSH)C0228 (increased free, uncombined thyroxin, T four or T three)C0151 (increased bilirubin)C0131 (increased ESR)C0033 (leukocytosis)

G0005 RADIOLOGYC0042 (abnormal aortic contour on chest x-ray; widening of mediastinum)C0085 (cardiac enlargement on imaging; usually due to right ventric. enlarg.)C0086 (increased pulmonary artery and/or vascular engorgement on imaging)

G0006 ULTRASOUNDC0044 (transthoracic aorta ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAMC0070 (aortic valve stenosis on echocardiogram)C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 16

G0005 RADIOLOGYC0856 (upper GI series with small bowel follow-through for Crohn's disease)

G0006 ULTRASOUNDC0792 (transesophageal ultrasound for aortic dissection)

G0007 ECHOCARDIOGRAMC0797 (echocardiogram of atrial septal defect secundum)

G0008 IMAGING: CT AND/OR MRIC0834 (positron-emission tomography (PET) for pheochromocytoma)C0798 (mitral stenosis on cardiac magnetic resonance imaging)C0682 (multislice spiral chest CT or MRI for pulmonary embolism)C0612 (spiral CT scanning for pancreatic head carcinoma)C0785 (spiral CT scanning for pancreatic body or tail carcinoma)C0045 (aortic dissection on MRI)

G0009 SCANNINGC0833 (nuclear medicine scintigraphy with MIBG for pheochromocytoma)C0233 (thyroid radionuclide scan)C0665 (radionuclide imaging: viable myocardium, ventricular eject.)

G0010 ENDOSCOPYC0153 (colonoscopy and biopsy for Crohn's disease)C0186 (colonoscopy and biopsy for ulcerative colitis)

G0011 BIOPSYC0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion)C0399 (biopsy of small intestine for Giardia lamblia)

Great Cost best cost-benefit clinical data: 7

G0011 BIOPSYC0611 (biopsy for pancreatic head carcinoma)C0786 (biopsy for pancreatic body or tail carcinoma)

G0013 ANGIOGRAPHYC0047 (aortography)C0071 (aortic valve stenosis on catheterization)C0090 (atrial septal defect on arteriography)C0103 (mitral stenosis on catheterization)C0160 (pulmonary angiogram)

Total: 85

Abridged Global OverviewNo Cost best cost-benefit clinical data: 35G0001 MEDICAL HISTORY C0353 (abdominal pain, right lower quadrant) D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) total P: 107 absent total P: 35C0781 (abdominal pain, left upper quadrant) D0069 (PANCREATIC BODY-TAIL CARCINOMA) total P: 176 present total P: 800 D0069 (PANCREATIC BODY-TAIL CARCINOMA) total P: 176 absent total P: 26G0002 PHYSICAL EXAMINATION C0794 (systolic thrill) D0002 (AORTIC VALVE STENOSIS) total P: 332 present total P: 651 C0678 (paradoxical bradycardia) D0007 (PULMONARY EMBOLISM) total P: 157 present total P: 500 D0034 (PNEUMOCOCCAL PNEUMONIA) total P: 100 present total P: 649 Continues…Small Cost best cost-benefit clinical data: 27G0004 LABORATORY TESTS C0867 (nucleic acid urogenital probe tests for gonococcus) D0027 (DISSEMINATED GONOCOCCAL INFECTION) total P: 181 present total P: 1000 C0229 (suppressed TSH) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 818 present total P: 1000 C0228 (increased free, uncombined thyroxin, T four or T three) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 818 absent total P: 0G0005 RADIOLOGY C0042 (abnormal aortic contour on chest x-ray; widening of mediastinum) D0001 (AORTIC DISSECTION) total P: 169 absent total P: 54 C0085 (cardiac enlargement on imaging; usually due to right ventric. enlarg.) D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) total P: 338 absent total P: 101

G0006 ULTRASOUND C0044 (transthoracic aorta ultrasound for aortic dissection)

D0001 (AORTIC DISSECTION) total P: 169 present total P: 1000G0007 ECHOCARDIOGRAM C0070 (aortic valve stenosis on echocardiogram) D0002 (AORTIC VALVE STENOSIS) total P: 332 present total P: 1000 D0002 (AORTIC VALVE STENOSIS) total P: 332 absent total P: 0 Continues…Intermediate Cost best cost-benefit clinical data: 16G0005 RADIOLOGY C0856 (upper GI series with small bowel follow-through for Crohn's disease) D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) total P: 107 present total P: 1000G0006 ULTRASOUND C0792 (transesophageal ultrasound for aortic dissection) D0001 (AORTIC DISSECTION) total P: 169 present total P: 1000G0007 ECHOCARDIOGRAM C0797 (echocardiogram of atrial septal defect secundum) D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) total P: 338 present total P: 1000 D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) total P: 338 absent total P: 0G0008 IMAGING: CT AND/OR MRI C0834 (positron-emission tomography (PET) for pheochromocytoma) D0012 (PHEOCHROMOCYTOMA) total P: 364 present total P: 1000 C0798 (mitral stenosis on cardiac magnetic resonance imaging) D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE) total P: 780 present total P: 1000 D0004 (MITRAL STENOSIS/RHEUMATIC HEART DISEASE) total P: 780 absent total P: 0G0009 SCANNING C0833 (nuclear medicine scintigraphy with MIBG for pheochromocytoma) D0012 (PHEOCHROMOCYTOMA) total P: 364 absent total P: 27

C0233 (thyroid radionuclide scan) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 818 present total P: 1000 D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 818

absent total P: 0G0010 ENDOSCOPY C0153 (colonoscopy and biopsy for Crohn's disease) D0021 (CROHN'S DISEASE, REGIONAL ENTERITIS) total P: 107 absent total P: 0 C0186 (colonoscopy and biopsy for ulcerative colitis) D0022 (ULCERATIVE COLITIS) total P: 145 present total P: 1000 D0022 (ULCERATIVE COLITIS) total P: 145 absent total P: 0G0011 BIOPSY C0497 (biopsy and immunologic exam for R. rickettsii of a rash lesion) D0035 (ROCKY MOUNTAIN SPOTTED FEVER) total P: 272 present total P: 1000 D0035 (ROCKY MOUNTAIN SPOTTED FEVER) total P: 272 absent total P: 64 C0399 (biopsy of small intestine for Giardia lamblia) D0026 (INTESTINAL GIARDIASIS) total P: 145 present total P: 1000 D0026 (INTESTINAL GIARDIASIS) total P: 145 absent total P: 8 Continues…Great Cost best cost-benefit clinical data: 7G0013 ANGIOGRAPHY C0047 (aortography) D0001 (AORTIC DISSECTION) total P: 169 present total P: 1000 D0001 (AORTIC DISSECTION) total P: 169 absent total P: 6 C0090 (atrial septal defect on arteriography) D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) total P: 338 present total P: 1000 D0003 (ATRIAL SEPTAL DEFECT SECUNDUM) total P: 338 absent total P: 0 Continues…Total: 85

Abridged Data Cost Procedure Quantity

No Cost best cost-benefit clinical data: 2G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) C0096 (rumbling diastolic murmur) Small Cost best cost-benefit clinical data: 3G0004 LABORATORY TESTS C0229 (suppressed TSH) C0228 (increased free, uncombined thyroxin, T four or T three)G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram)

Intermediate Cost best cost-benefit clinical data: 2G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging)G0009 SCANNING C0233 (thyroid radionuclide scan)

Great Cost best cost-benefit clinical data: 1G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization)

Total: 8

Abridged Global OverviewNo Cost best cost-benefit clinical data: 2G0002 PHYSICAL EXAMINATION C0221 (thyroid bruit or thrill) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 absent total P: 408 C0096 (rumbling diastolic murmur) D0004 (MITRAL STENOSIS) total P: 103 present total P: 176

Small Cost best cost-benefit clinical data: 3G0004 LABORATORY TESTS C0229 (suppressed TSH)

D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 present total P: 1000

D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 absent total P: 0 C0228 (increased free, uncombined thyroxin, T four or T three) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 absent total P: 0G0007 ECHOCARDIOGRAM C0102 (mitral stenosis on echocardiogram) D0004 (MITRAL STENOSIS) total P: 103 present total P: 1000 D0004 (MITRAL STENOSIS) total P: 103 absent total P: 0

Intermediate Cost best cost-benefit clinical data: 2G0008 IMAGING: CT AND/OR MRI C0798 (mitral stenosis on cardiac magnetic resonance imaging) D0004 (MITRAL STENOSIS) total P: 103 present total P: 1000 D0004 (MITRAL STENOSIS) total P: 103 absent total P: 0G0009 SCANNING C0233 (thyroid radionuclide scan) D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 present total P: 1000 D0011 (HYPERTHYROIDISM, GRAVES' DISEASE) total P: 671 absent total P: 0

Great Cost best cost-benefit clinical data: 1G0013 ANGIOGRAPHY C0103 (mitral stenosis on catheterization) D0004 (MITRAL STENOSIS) total P: 103 present total P: 1000 D0004 (MITRAL STENOSIS) total P: 103 absent total P: 0

Total: 8

WHAT HAPPENED SO FAR ?

The theory behind our diagnostic system, its terminology, principles, and operation were first published in 2006

COMPUTERIZED MEDICAL DIAGNOSIS:

A NOVEL SOLUTION TO AN OLD PROBLEM

Carlos Feder 2006

INITIAL CLINICAL DATA COLLECTION AND SYNONYM HANDLING

CLINICAL DATA MATCHING

CREATION OF CLINICAL DATUM LISTS

CREATION OF DIFFERENTIAL DIAGNOSIS LIST

CALCULATION OF PROBABILITY OF DIAGNOSES. MINI-MAX PROCEDURE

Step 1. Process

clinical data present

Step 2. Process clinical data absent

Step 3. Create clinical data pairs

Step 4. Create clinical data pair tables

Step 5. Calculate partial P that

each clinical data pair confers to each diagnosis

Step 6. Create mini-max tables

Step 7. Determine total P

of the diagnosis

Step 8. Update differential diagnosis list

CONCLUSION OF DIAGNOSTIC QUEST?

BEST COST-BENEFIT CLINICAL DATUM NEXT TO INVESTIGATE

Step 1. Select clinical data not yet

investigated in the patient

Step 2. Organize clinical data not yet investigated according to cost category, diagnosis, PP value, and S

Step 3. Recommend a new clinical

datum as best clinical datum assuming it present

Step 4. Recommend a new clinical

datum as best clinical datum assuming it absent

SIMULTANEOUS RECOMMENDATION OF SEVERAL BEST COST-BENEFIT

CLINICAL DATA

SAFETY CHECK FOR RISK FLAGGED DIAGNOSES AND CLINICAL DATA

SAFETY CHECK FOR RELATED CLINICAL ENTITIES

CLINICAL PRESENTATION

MASKING

CONCURRENT DIAGNOSES

WHAT HAPPENED SO FAR ?

The theory behind our diagnostic system, its terminology, principles, and operation were first published in 2006

A patent is pending

The computer program that runs our algorithm was written by Tomás Feder in 2007

This computer program provided a prototype, instrumental in confirming essentially all our novel ideas, enabling to challenge real clinical cases of individual patients and the theories behind, with excellent diagnostic results; it broadened our understanding of the medical diagnostic process, dissipating earlier uncertainties, enabling the discovery of new functions and eliciting ideas that opened an entire new realm in this field. So many are the simplifications, additions, and codes that execute new functions, that they justified writing a new book that we published in 2008

A PRACTICAL COMPUTER PROGRAM

THAT DIAGNOSES DISEASES IN ACTUAL PATIENTS

Carlos Feder & Tomás Feder

WHAT HAPPENED SO FAR ?

The theory behind our diagnostic system, its terminology, principles, and operation were first published in 2006

A patent is pending

The computer program that runs our algorithm was written by Tomás Feder in 2007

This computer program provided a prototype, instrumental in confirming essentially all our novel ideas, enabling to challenge real clinical cases of individual patients and the theories behind, with excellent diagnostic results; it broadened our understanding of the medical diagnostic process, dissipating earlier uncertainties, enabling the discovery of new functions and eliciting ideas that opened an entire new realm in this field. So many are the simplifications, additions, and codes that execute new functions, that they justified writing a new book that we published in 2008

Our prototype includes so far 60 diseases in its database, and diagnoses beautifully real patients afflicted by any of such diseases

WHAT NEXT?

Our diagnostic system, in order to accomplish all the envisioned benefits, must have its database integrated with all currently known diseases, all their clinical data and corresponding sensitivities. All complex clinical presentation models, which lists related diagnoses must be created and also included in the database. This task requires the cooperation of a team of medical specialists.

Our computer program is not a fancy program that opens colorful windows clicking on menus or icons, but it satisfies all requisite functions of the algorithm and works efficiently and accurately. This program would benefit from some cosmetic improvement by an experienced professional programmer, able to make it more glamorous and attractive.

We hope that Google or somebody else may help and support us with this project.

WHAT NEXT?

Our diagnostic system, in order to accomplish all the envisioned benefits, must have its database integrated with all currently known diseases, all their clinical data and corresponding sensitivities. All complex clinical presentation models, which lists related diagnoses must be created and also included in the database. This task requires the cooperation of a team of medical specialists.

Our computer program is not a fancy program that opens colorful windows clicking on menus or icons, but it satisfies all requisite functions of the algorithm and works efficiently and accurately. This program would benefit from some cosmetic improvement by an experienced professional programmer, able to make it more glamorous and attractive.

We hope that Google or somebody else may help and support us with this project.

WHAT NEXT?

Our diagnostic system, once implemented with all known diseases and clinical data, is expected to provide invaluable diagnostic benefits to patients, physicians, nurses, health insurance companies, malpractice lawyers, and the entire medical establishment

Thank you for your attention