Twenty Questions

I while ago, I had a friend show me this little electronic ball called "20 Questions" that promised to guess what I was thinking with only twenty questions. I thought a bit, decided on an inanimate object for the gizmo to guess, and then answered the questions one by one that the device posed to me. For each question I pushed the buttons corresponding to "Yes,"No," "Sometimes," and "Unknown" in response. I was astonished at the depth of answers the device could conceive based on my answers, but soon realized I could "beat" it by thinking about something fairly obscure or unusual.

Now it seems "20 questions" has come to diagnostic medicine.

iVillage.com has introduced a beta version of its "Symptom Solver" in conjunction with GE Healthcare that helps patients determine possible causes for the symptoms they are experiencing. It seems that medicine can really be reduced to 20 questions!

So I decided to take the system for a test drive.

My case?

I pretended to be a 24 year-old 34-week pregnant woman who has had two hours of chest pain associated with abdominal cramping from a dissection of a coronary artery with an associated heart attack that also induced labor (I had a case like this). This was on the Women's Wellness section of their website after all... Let's see how it does....

First question: My age? 18-29. Check.

Second question: Which symptoms (about 20 were shown)? I clicked on "Abdominal pain or discomfort" and "Chest Pain." Check.

Third question: "Tell us more about your abdominal pain?" I clicked "Abdominal Pain extends to the back and other areas." Check.

Fourth question: "Tell us more about your chest pain?" I clicked "Chest pain extends to arms, shoulders, neck, back or jaw" and "Chest pain for longer than 20 minutes." Check.

With the next screen, I received an "Emergency Notification" in small red letters at the top of the question box suggesting I seek immediate medical attention for my chest pain extending to my arms, shoulders, neck and jaw and chest pain for over 20 minutes. But I ignored this and continued... after all I'm only 24 years old!

Fifth question: "Additional symptoms?" I checked "Chest tightness," "Abdominal tenderness," "Sudden sharp chest pain," and "Heartburn." Check.

The next screen gave be my most likely diagnoses so far in the following order: (1) collapsed lung, (2) gastroesophageal reflux (What's that, I wonder as a non-medical person?), (3) pancreatitis (huh?), (4) cardiac ischemia (sounds interesting...but they expect me to know what this is?, and (5) heart attack (I know what that is, only old people have one of those...). Oh, and this little disclaimer appears:

The Symptom Solver service is designed for educational purposes only. You should not rely on this information as a substitute for personal medical attention, diagnosis or hands-on treatment. If you are concerned about your health, please consult your family’s health provider or go to the emergency room.

So I answer the next question:

Sixth question: "Tell us more about your heartburn?" I click "Frequent heartburn." Check. (Hey, things must be better! That little red warning box went away...)

With the next screen, GE reflux springs to the top of the likely diagnoses! Whew! I'm feeling reassured already! Glad it's not my lung! So I continue...

Seventh question: "Select additional symptoms:" I checked "indigestion." Check.

Eighth question: "Select additional symptoms:" I checked "Cramps" here. Check.

Of course, it wants to know more about the cramps. I noticed now the diagnosis of Irritable Bowel Syndrome is now in the mix of possibilities. (Hello, would anyone think about pregnancy??? But maybe the "Symptom Solver" needs more information...)

Ninth question: "Tell us more about the cramps:" I checked "Abdominal cramps" and "Sudden, severe abdominal cramps." Check.

Tenth question: "Additional symptoms?" This time I didn't see anything that correlated, so I said "None of these. Show me more." (Ugh... Hmmm, I'm feeling this sudden incredible sense I need to have a bowel movement...)

Eleventh question: "Select additional symptoms:" Hmmmm. My eyes don't look yellow, I'm not dehydrated (am I?), my heart is not pounding... I just have to have a bowel movement. So once again I click "None of these. Show me more."

The next screen got closer when it again asked for additional symptoms:

Twelveth question: "Select additional symptoms:" Oh my goodness! Although I feel like I needed to have a "bulky or foul-smelling stool" but I hadn't had this yet, so I again checked "None of these. Show me more." By now, I'm becoming weary...but I persist!

This time some interesting things popped up to select:

Thirteenth question: "Select additonal symptoms:" I checked "Loss of interest in sex" and "bloating." Check. (By the way, I have been at this for an hour now. It seems the website loads its ads too slowly...) Wow, that chest pain sure is burning... The order of diagnoses right now? #1: Gastroesophageal Reflux, #2 Collapsed Lung, #3 Heart Attack, #4 Irritable Bowel Syndrome, #5 Pancreatitis.

Fourteenth question: "Select additional symptoms:" Hey look, there's "Pregnancy!" So I click it!

Sadly. I'm asked again to select an "Additional Symptoms:" So for Question Fifteen, I answer "Pain all over."

Question sixteen appears: "More symptoms!" So I pick "Lump or mass in the pelvis or abdominal area."

Again, adding more symptoms is what is needed it seems: But for question seventeen's questions, I pick "None of these. Show me more." (I'm feel a bit masochistic now...) And now, my top five diagnoses do not include heart disease: #1 Gastroesophageal reflux, #2 Irritable Bowel syndrome, #3 Esophagitis, #4 Ovarian Cancer, #5 Collapsed Lung. And yes, it wants more symptoms for question seventeen.

Question seventeen: More symptoms: I pick "Severe lower abdominal pain or pelvic pain."

And again: It wants more symptoms but I've run out. 10 more answers to the additional symptoms questions with "None of these. Show me more." makes clear that the program will continue to ask symptoms until the person clicks "Skip to Results." At which time I see an explantation of Gastroesophageal reflux disease, Esophagitis, Irritable bowel syndrome, Collapsed Lung, Ovarian Cancer, Misscarriage, Stomach Cancer, an then finally, Heart Attack (#8).

I think I beat the game, but probably sacrificed my fictional heart and baby...

What is clear is that more and more of these tools will soon surface on the internet, especially with similar efforts underway by Steve Case, former co-founder of AOL (RevolutionHealth), or by other corporate efforts like the Continua Health Alliance. It is clear that patients are turning to the internet more frequently to identify a cause of ailments before seeking the advice of a health care professional. While there is great information out there, there is a moral to today's post:

Take these symptom-related questionnaires with a grain of salt... you might just beat them at your expense.

-Wes

Patient Blogs Make HIPAA Unenforceable

HIPAA, the Health Insurance Portability and Accountability Act of 1996, contains privacy provisions that provide "protection" of patient's health care information to assure that health care providers, health plans, and health care clearinghouses don't leak such sensitive information in a public forum. You see, our legislature felt that doctors and health care providers might use such information to the detriment of our patients, so they made this law to allow government to reassure others that Big Brother could do a better job at protecting your privacy.

But now comes another realization: patient's family members might leak the informaton instead.

Patient blogs are now the rage at local hospitals here in Chicago, detailing play-by-play accounts of health care delivery and histories on patients themselves. You see, patients aren't covered by HIPAA. They can say what ever they want about themselves. But sometimes the patient isn't the one posting on the patient's blog, family members were, dutifully updating the daily progress of their loved one to the world.

"Many people have been inquiring about him so I would like to share some information with everyone," said the first in a series of near-daily updates posted by Nequin's wife, Dawn.

She described in detail how her husband had slipped on ice March 6 while walking the family dog, hit his head on the sidewalk and, nearly three hours later, asked to be taken to the hospital, complaining of a headache and weakness in his leg.

"Within minutes he was having a CAT scan, and in a few more minutes we knew he had a brain bleed," she wrote.

And companies providing these patient weblogs and message boards are springing up like 17-year cicadas:

TLContact Inc., the Northwest Side company that oversees CarePages, has created more than 50,000 such pages, according to a spokeswoman. CaringBridge, a competing service based near Minneapolis, and theStatus.com, a third major competitor based in Anchorage, claim roughly the same numbers of pages, most of them generated in the last few years as word has spread about their availability.

"Most people don't find out about them until a friend goes into the hospital and starts one," said theStatus founder Mark Pierson.

Such sites have been around nearly 10 years, are free, easy to use and fairly secure -- families can control access to them via passwords and invitation lists. Though the companies contract with hospitals for branding and promotional purposes, any patient anywhere can sign up and use any of the services.

They relieve family members and patients of the tedious job of telling the same story over and over, while the accompanying message areas become a forum for encouragement and prayers.

They offer an advantage for health-care professionals as well. Having the family post updates online allows them to skirt the awkwardness and even legal peril that newly stringent medical privacy regulations have added to such simple questions as "How's he doing?"

So in the future, if doctors or insurers get accused of violating the HIPAA provisions, they'll just look stupid and say, "Hey, I just read what I know about him on his patient blog!"

-Wes

64-Slice CT Predicts ER Outcome in Patients with Chest Pain

Today a single-center, prospective study from Israel was published that evaluated higher-resolution 64-slice multi-detector computed tomography (CT) scanning (MDCT) in patients with chest pain presenting to the Emergency Department. The study, published on-line in the journal Circulation, prospectively studied 58 patients with chest pain and no EKG or chemical evidence of cardiac injury that received MDCT scans to evaluate their coronary anatomy. 15 patients were classified as normal, 20 had mild, non-specific disease and 23 had significant coronary blockage (defined as greater than 50% occlusion) in at least one artery. The study demonstrated that MDCT had a 100% negative predictive value and 100% sensitivity (20/20) with a 92% specificity (32/38 patients) for a positive predictive value of 87% (20/23). Importantly, the study followed patients for 15 months after their ER discharge, and no deaths or heart attacks (myocardial infarctions) occurred in any of the 35 patients discharged from the Emergency Department after initial triage and MDCT. One patient had a late coronary intervention at 13 months after discharge of a distal circumflex coronary artery.

The study was limited by its relatively small size and its single-center experience. Additionally, patients with irregular heart rhythms (atrial fibrillation or frequent premature ventricular contractions) or rapid heart rate (>90 beats/min) were excluded.

Nonetheless, the potential for these scans to have a major impact on ER decision making, especially in patients with other equivocal risk factors and testing, is significant. Cost-effectiveness data are still needed, but the potential for limiting expensive cardiac admissions might be found to be cost-effective in the long run. It likely won’t be long before these scanners become standard equipment in Emergency Departments across the country – patients will demand it.

But there’s still one big barrier to implementation: we still have to secure insurance reimbursement for them… You can bet the Big Boys (like GE and Phillips) will be working on this...

-Wes