Web-based medical diagnostic and training system6991464Abstract An interactive computer system for use in educating and training medical personnel in point of entry triage utilizing multiple visual and audio displays as well as providing access to various other sources of information. The system includes visual, audio and textual interactive display screens that are responsive to input from the user and guides the user through a scenario based upon different conditions presented by the medical patient. The system may be stored on magnetic media or be web-based. Claims What is claimed: Description BACKGROUND OF THE INVENTION
By way of illustration, if the user has accessed the expert help feature of an infectious disease expert, the user may selectively hyperlink to
The user is given a predetermined amount of time to select a hyperlink after the expert help lecture, after which the help feature preferably prompts the user to select further relevant clinical pathways that must be ruled out to prevent comorbid exacerbation of the patient. The user is given a predetermined length of time to respond by choosing to remain in the ICU virtual reality setting, terminate triage, or select additional "tracks". Should the user elect to remain in the ICU setting, an interactive workup of the hypothetical patient is presented. To begin the workup, the user must select the patient's clinical state of awareness. During this selection, the user should not select the green or blue zones, since this indicates that the user judges the patient to be chronically ill and able to wait two or more hours for clinical intervention. As the user moves back and forth among red, orange and yellow zones, treatment protocols or interactive questions and answers are provided. If for example, the user views "eye problems" in the yellow zone, along with all protocols, the user will also view bundled necessary information regarding ophthalmology for a one hour encounter with an unknown patient having an eye problem. The user may select from among many time-determined bundles of information. The bundles may be selected from a predetermined medical specialty, physiological system, or disease. Alternatively, if the user chooses to close triage for the hypothetical case, the screen will flash red and a banner scrolls across the screen advising the user to select another "line", such as the aqua line, leading to another station. The user inputs a choice, such as "traumatic stress" and the train car moves on aqua line to the station labeled "Critical Incident Stress Debriefing". The car may be coupled with additional cars, such as, for example, "Post/Traumatic Syndrome". The screen may display an interview session illustrating an interviewer in an interview situation. The interviewer prompts the user to select from a menu of interactive choices such as: After exit of the counseling room, the station is displayed on the screen. The train displayed may include a plurality of cars bearing associated syndromes, or comorbidity. The user is given a predetermined amount of time to select an option. Unless the user selects to proceed with diagnosis and treatment, the screen goes red. The student is given visual and verbal feedback as to the appropriateness of selections made. For example, in some circumstances, selecting green or blue tabs will invoke a fading red screen having a text banner message indicating that medical surgical care has been dangerously neglected. If the user selects the blue or green tab while in the station labeled "Critical Incident Stress Debriefing", the help feature is invoked. The help feature preferably instructs the user on how to handle the presented clinical situation, such as instruction to reduce psychiatric complication for patient family and relevant others. Should the user select any other colored lines, the lines go dark. The user may choose to terminate triage after the Critical Incident Stress Debriefing lecture. If triage is terminated, the user is prompted by the system to either select to triage another case or take a final examination as administered by an expert on the case. If the user selects another case, the screen will display the lighted clinical track map, with timer and cost tabulator displayed, followed by a hypothetical clinical presentation. The present device is open ended, allowing for use in conjunction with other navigational systems and emerging clinical advances. Additional tabular displays may be conceivable and those presently used by be modified and not depart from the spirit and scope of the invention. Further, the diagnostic and clinical management information included in the present invention is preferably bundled into time-determined bundles or packets, as seen in The Digital Clinician 2, for example. The comprehensive clinical tracking system for The Triage Algorithm is preferably embedded into The Digital Clinician 2. The help, or auto-tutoring feature may include "talking heads" delivering salient lectured material, videotaped presentations, or virtual reality interactive sessions, by way of example. Other useful help features may also be envisioned. The Triage Algorithm seen in FIG. 2 is a visual representation of the clinical pathways and stations or nodes located along them. Each "station" opens to a realistic clinical setting and couples comorbidity "cars" to the navigating train. The system of the present invention is preferably linked to hyperlinks available in relevant medical informatics technology. This feature is a novel innovation for distant education in clinical decision-making for health professionals. The following examples will further exemplify the current invention. EXAMPLE 1 Emergency Emergency conditions are preferably represented by a red line and red screen. The system is designed to ensure that by grouping specific related symptoms at different intervals, the most life threatening injuries and conditions are treated first. As may be seen, the system uses mnemonics to assist user recall under the real life pressured circumstances of emergency presentations. For instance, an example patient to be treated may be a young child covering her eye. The user determines that the child is in severe pain and selects, as shown in FIG. 3, the Immediate Emergency tab for diagnosis, which is represented by a red screen and red line. Once selected, the simulated subway car proceeds to the next station where a user is presented with what is considered the five most critical "ABCs" of triage. The five categories presented as the "ABCs" are: Airway Compromised Breathing Inadequate Circulation Inadequate Disability Severe Exposing Body Shows Severe: When the system is used for training purposes, the user must contemplate all of the five categories before the user is allowed to proceed to the next station. In the present example, the user should choose "Exposing Body Shows Severe:", which allows the subway car to proceed to another station that lists specific body injuries, which can be seen in FIG. 4. At this station the user selects "Eye Problem". This choice prompts the car to move to another station showing possible acute eye problems. By selecting one of the presented eye problems, the user prompts the screen to present the differential diagnosis of acute eye problems requiring immediate treatment intervention. Of all the possible eye injuries, only chemical injury, the user will see, requires as immediate a treatment as the other "ABCs" of the first station to thereby prevent the permanent morbidity of blindness. If a chemical injury is deemed to be the correct diagnosis, the screen will give instructions for immediate care, as shown in FIG. 5. For educational purposes, optional links lead to useful websites, such as The Dictionary of The Digital Clinician, ophthalmological virtual reality sites elsewhere which provide the user with the actual experience of, for example, using eye wash equipment on a virtual patient, or still and moving images of instruments and technique, accompanied by autotutorial lectures on diagnosis and treatment of chemical eye injuries. Also, an optional chat room allows users to communicate with one another about the management of a particular injury, and e-mail functions allow users to communicate with the ophthalmological authority represented by the autotutor talking head. As for all diagnoses, any one or all of these features may be available, but the system is designed as an open platform to access all other platforms rapidly becoming available, thus compelling the web master to maintain timeliness for currently authoritative information. Optionally, banners on the chat room site may allow medical instrument vendors and pharmaceutical companies to present testimonials, perhaps in response to autotutorial authority or emails from users. This feature is the equivalent of a real-time medical letter containing input from pharmaceutical companies, for example to support or refute statements from an "objective source". In the example, if the presented injury is not a chemical injury, but another eye injury that is not life threatening or an imminent loss of sight, the system directs the user back to the main red line, and allows the user to proceed to the next station. The next station, and as seen in FIG. 6, uses another mnemonic, WHHHIMPES, to determine eight emergency situations regarding altered states: Withdrawal, Wenrickes, Hypoglycemia, Hypoxia, Hypertensive Encephalopathy, Intra Cerebral Bleed, Meningitis, Poisoning, Encephalitis, and Status Epilepticus. It should be noted that the WHHHIMPES station is an example of organizing differential diagnosis into time-determined bundles of information. The present system includes hundreds of causes for altered states of consciousness, but only knowledge of the eight represented in the mnemonic is needed to prevent death or morbidity from failure to intervene immediately upon presentation. Other causes that may be equally dramatic in presentation, therefore, can safely wait until after higher priority presentations are attended to. After the WHHHIMPES station is properly exited, the subway line is directed to a station that deals with assessing a dangerous situation. The "GUNS" station assists the user in an interactive learning situation. The user is dramatically informed of skipping these steps by a visual aid, such as the screen flashing similar to an emergency vehicle light bar, thereby dramatizing that violence has occurred at point of entry due to failure to observe for evidence of weapons (G) and proper disarming of patient; drug Usage (U) i.e. needle marks on forearms, Need to protect (N), as evidenced by fear patient has for immediate safety from a real threat to his or her life and (S) Situation of violence, as evidenced by a sullen, or even an arrogant, attitude. This requires checking the facility grounds for other persons potentially threatening to patient or site itself—i.e. terrorists or gangs. Selecting any of the four letters of the GUNS station directs the user to a related link, which displays useful information for the specific situation. For instance, if the user is not sure whether the presented patient uses drugs, selecting the "U" link, provides access to images of skin lesions caused by IV drug usage. This added information allows the user to either confirm or rule out drug use in the presented patient. After the "GUNS" station has been successfully passed, the subway line passes to another station, the "ACT MYSELF" station, as shown in FIG. 7. This station further assesses the presented patient's state of mind. As may be seen in FIG. 7, the assessment may be analyzed as follows: Agitation severe Combativeness Threatening Male, Young, and Sociopathic Empathy Lacking Lacks Disregard Fighting Wounds. As with the other stations, each letter links to another page that lists rules and instructions for how to deal with the indicated element. For instance selecting "agitation, severe" provides the user with possible medical restraint protocol, including possible drugs for soothing the situation. As mentioned previously, the system may further provide links to various updates, including for this example, currently prescribed drugs. As known in the art, the currently used drug for combating such a situation, IM Haldol, may be replaced soon with a safer compound, Geodon; the system can be linked to update such information. At any of these stations, if an emergency is detected proper actions may be input. However, if all of the preceding stations are passed with negative results (no problems encountered), the system directs the user to another station, which allows the user to enter what is coded as the orange line. The orange line directs the user in situations considered very urgent but not as urgent as those encountered in the red line. For instance, if the child with the injured eye presented in the red line did not have any other problems, and the eye injury was not chemically induced, the diagnosis would lead the subway car to the end of the line, which would give assessment criteria for the very urgent, or orange line. As a training tool, the system allows the user to progressively navigate the screens from highest to lowest levels of lethality or danger. EXAMPLE 2 Conditions that are considered very urgent but not life threatening are shown as an orange subway line. For example, the child from example 1 enters with an eye injury. The injury looks severe, but is not determined to be cause by a chemical burn. As seen in FIG. 8, the user selects the very urgent, or orange line to proceed with a diagnosis. As seen in FIG. 8, the first station on the orange line preferably includes prompts to aid the user in verification that the user has cleared all emergency situations, such as that airway, breathing, and circulation is adequate, the patient is not violent, the patient is responsive and not convulsing, and the patient has not suffered a chemical eye injury. If any of the above criteria are not met, the system will redirect the user to the emergency red line of the system. If the above criteria are met, the system allows the user to proceed along the orange line. The next station on the orange Very Urgent line is the same WHHHIMPES station seen previously in FIG. 6 with reference to the red Emergency line. This station prompts the user to determine eight emergency situations regarding altered states: Withdrawal, Wenrickes, Hypoglycemia, Hypoxia, Hypertensive Encephalopathy, Intra Cerebral Bleed, Meningitis, Poisoning, Encephalitis, and Status Epilepticus. The WHHHIMPES station, it should be noted, is an example of organizing differential diagnosis into time-determined bundles of information. This station is preferably built into both the red Emergency and orange Very Urgent lines to ensure that the user does not overlook potentially life-threatening situations. Once the station is passed, the user may proceed to the next station along the line. The next station prompts the user to analyze the vital signs of the presented patient. As shown in FIG. 9, the user is presented with an acronym, SOAP, to facilitate the user's ability to properly diagnose the presented patient's symptoms. If for example, the user selects S, for Sensorium and Cognition, the system links the user to another station in which the user is prompted to query the patient with general information seeking questions, such as name and date. If the patient has difficulty answering any of these questions, or appears disoriented, the user is rerouted to the red emergency line for reevaluation. If the patient appears lucid, the user will be directed back to the SOAP station. As seen in FIG. 9, if the user selects O, for Output, the system links the user to aids in assessing the presented patient's exhibited characteristics. For instance, if the child presented in the example is unresponsive and that characteristic is entered in the system, the user is linked to a tutorial, seen in FIG. 10, showing steps in restoration of breathing. The tutorial gives directions how to revive the child, including links to photographs of relevant situations. If the patient's output appears normal, the patient can continue at the SOAP station. If the user selects A, for apperception, the system links to aids to help the user determine whether the presented patient may be overtly paranoid or hallucinating. If either of these situations is present, the user follows the A link further to determine whether the patient is a high risk to herself or others. In this instance, the user would once again be rerouted to the emergency line. If not, the user may proceed further at the SOAP station. The final link at the SOAP station, P, allows the user to determine whether the patient exhibits any psychotic symptoms. If the presented patient exhibits psychosis and potential harm to others, and this information is input into the system, the system directs the user to the red Emergency line. If no such information is entered, the user is directed to proceed to the next station on the line. The next station presents bundled information to assist the user in further determining the extent of the presented patient's injury. In the present example, the user can select eye injury from the Medical link, causing the system to link to possible eye injuries. Once linked to possible eye injuries, the user is presented with choices to link to specific problems, such as globe rupture or recent loss of vision. Once the user selects a specific problem, the system presents a tutorial showing proper treatment for the selected injury. After assessing the injury, this system further prompts the user to determine whether the patient is a threat to other patients or is, a possible suicide risk. If either of these options is selected and input into the system, the system redirects the user to the red emergency line. Alternatively, if the user passes through this station without prescribing any treatment for the patient, the system presents a next station, linking to the yellow Urgent line. EXAMPLE 3 A user selects the yellow Urgent line in situations in which the presented patient shows symptoms not overly severe. For example, the hypothetical child may be presented with a hand over one eye, appearing lucid and relatively calm, in pain, but appearing to handle the pain. In this instance the user selects the yellow Urgent line. The first station of the yellow Urgent line is shown in FIG. 11. As seen, selections regarding the how and why of patient arrival are also presented, in addition to assessment options. The first station on the yellow line prompts the user to analyze the patient for any contagious diseases, such as herpes, chicken pox or the mumps. The station supplies links to each of the diseases. The links contain information about each disease, including for example, pictures, disease transmittal, and precautions. If a disease is selected, the user will be directed to reassess the situation. If not, the user is prompted to proceed to the next station. As shown in FIG. 12, the next station, coined TACO SALAD, assists the user in determining more extensively the nature of the presented patient's symptoms. The TACO SALAD mnemonic stands for: Triad Affect Culture of Violence Organization Separation Alone Loss Alcohol Drugs. The TACO SALAD station functions as a gateway station for further diagnosis on the yellow Urgent line. If the user selects Triad, the system links to a station that prompts the user in determining the impulse control of the patient. If the patient has difficulty with impulse control or has a history of violence, for example, the user is prompted to reassess the situation. If none of the questions asked prompts a positive (yes) response by the user, the user is prompted to return to and continue at the TACO SALAD station. The next two links at the TACO SALAD station, Affect and Culture of Violence, also direct the user through a battery of questions to assist the user in determining whether the presented patient is considered harmful or dangerous. As with the Triad link, negative responses prompt the user to continue at the TACO SALAD station. At the Organization link, the user is prompted to determine the extent of the patient's mental organization. The Organization link also prompts the user to assess whether the patient has more severe problems, such as liver failure, which require urgent attention. If such a symptom is entered, the system directs the user to a relevant tutorial. If no such problems are entered, the user is prompted to determine whether the presented patient is disorganized, such as if the patient appeared drunk. If the patient's disposition is entered as normal, the system prompts the user continue the assessment. The next three links at the TACO SALAD station, Separation, Alone, and Loss, assist the user when the presented patient displays serious psychological problems. The user works through the three links as the system prompts the-user to answer questions to indicate whether the patient has more serious problems that may not be visible. The questions present to the user reinforce the concept that potentially harmful situations should not be overlooked in any stage of patient evaluation. In the present example, for instance, if it is determined that the child does not have a chemical injury to the eye and appears to a have non-serious eye injury, but the child isolates herself and is in an agitated state, the system assists the user in determining whether there is more serious problem needing immediate attention. In this way the system assists the user in performing a thorough patient analysis. The final two links at the TACO SALAD station, Alcohol and Drugs, aid the user in assessing whether the presented patient is in an altered state due to use of alcohol or drugs. As with other TACO SALAD links, any input by the user indicating that the patient may need more serious attention causes the system to prompt the user to reassess the situation or to lead the user to another treatment line. If the Alcohol and Drug links return negative responses, the user is directed to proceed to the green Standard Treatment line since no urgent clinical problems are indicated. EXAMPLE 4 A user selects the green Standard line if the user determines that the presented situation is not life threatening or does not require urgent care. For example, if the child's eye injury appears to be a mild scratch and the child is calm. The user then properly selects the green Standard line to assess the presented situation. If the green Standard line is selected, the system presents the user with questions regarding the patient to aid the user in determining if any problems require redirection to the red Emergency, orange Very Urgent, or yellow Urgent lines. If no such indication is detected, the user is prompted to proceed along the green Standard line. Since the presented situation is determined not to be as urgent as in previous examples, the system allows the user more time to enter patient information. An example of a screen for entering this data is shown in FIG. 13. When entering patient information, the user is prompted to determine whether the presented patient has a high level of perception, or if the patient has a chronic underlying problem that caused the patient's arrival. If the patient is perceptive or if the patient's chronic problem has been exacerbated, the user is prompted to continue on the green Standard line. If the patient has a chronic problem that is not exacerbated, the system redirects the user to the low acuity blue line. When the user stays on the green Standard line, the system directs the user to the Green Zone Evaluation station, shown in FIG. 14. The Evaluation Station prompts the user to enter general patient information, such as date of birth, address, and marital status. Once the information is entered, the system prompts the user to proceed to the next station on the line. The next station, shown in FIG. 15, prompts the user to more thoroughly address the mental and physical characteristics of the patient. If the user inputs information that indicates an abnormal patient characteristic, such as agitation, the system directs the user to reassess the presented situation. If the characteristics entered by the user are normal, the user is prompted to print out assessment sheets showing the entered information. Since the system forces the user to look at each symptom one at a time, the chance of underdiagnosing a patient is reduced. The user must properly pass through each station to progress to the next station on a selected line. Even though, the green Standard line is selected when the user is presented with less urgent conditions than the red, orange and yellow lines, the system requires the user to thoroughly travel the line. If the user does not complete the system requirements of the green line, the system prompts the user to reassess the presented situation, thereby assisting the user to become careful and cautious in diagnosis. EXAMPLE 5 Since not every presented patient elicits an emergency response, the present invention also allows analysis of minor injuries, minor recurrent problems, or dormant problems. For instance, the example child with the eye injury may only have what appears to be pink eye. Also, if the presented patient appears normal and is not concerned with the eye, the user of the system selects the blue, Low Acuity line. When the user is presented with a patient having a non-urgent, non-life threatening problem, the user selects the first station of the blue Low Acuity line, shown in FIG. 16. At the first station, the system prompts the user to enter more extensive personal information than required by the assessment features of previously mentioned, more urgent lines. However, it should be noted that the system preferably includes prompt questions such as: "Do you have any medical condition that may take your life right now?" to thereby assist the user in diagnosing any non-evident problems. In this way the system emphasizes user thoroughness. After the user has entered initial patient information, the system directs the user to the next station, shown in FIG. 17. At this station, the user is directed to assess the presented patient's general state of being. The system prompts the user to answer questions regarding the presented patient's appearance. If the user enters a choice that indicates an abnormal condition, such as the patient having abnormal cognitive output, the system directs the user to reassess the situation. If no abnormal choices are entered, the user is directed to a station in which in-depth information regarding the presented patient is documented. As the user continues, the system prompts the user to answer additional questions regarding the presented patient. If at any time information is entered in the system that indicates that more urgent care is required, the system routes the user to the proper line. If no such information is entered, the system prompts the user to print the patient's assessment. Although each of the assessment lines of the present system has been described separately, it should be noted that the each of the lines is integrated with the other lines. As FIG. 2 shows, the lines are intertwined. Since the present training system instructs a user to consider every step in diagnosing a presented patient, the user is taught proper assessment tools. It should also be noted that the color scheme and groupings of information could be rearranged for different purposes. The present arrangement has been evaluated as being the most efficient system for teaching and reinforcing proper triaging skills. The foregoing is considered as illustrative only of the principles of the invention. Furthermore, since numerous modifications and changes will readily occur to those skilled in the art, it is not desired to limit the invention to the exact construction and operation shown and described. While the preferred embodiment has been described, the details may be changed without departing from the invention.
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