In one of his usual insightful pieces on lab software, Bruce Friedman writes about the oops button present in some major anatomic pathology (AP) systems. The feature provides a grace period after a pathology report is signed out before it is released for consumption by the referring physician. Friedman notes how this is not appropriate for clinical lab systems, which deal mainly in numbers, as opposed to AP systems, which deal mainly with narrative text:

Most clinical pathology results are numerical and various rules can be deployed such as autoverification or interval checking to catch errors… By way of contrast, the surgical pathologist frequently works alone, creating narrative reports not amenable to rule-checking or real-time quality control.

I would like to add that the shift toward structured, synoptic AP reports changes this. Unfortunately, most synoptic reporting modules inside traditional AP systems do little more than produce bullet-like text. A very few systems, including mTuitive’s xPert for Pathology, provide true structured, synoptic reporting. What’s the difference? A synoptic report presents discrete data points to the human eye, while a structured report is stored as discrete data and enables all the benefits of granular data — querying, analysis, quality control using database technologies, expert systems, and so forth.

Pathologists are some of the most patient, meticulous, and knowledgable people in the world. The density of information in a typical pathology report on a malignant tumor far outweighs most written communication in medicine or elsewhere. It is time for AP data to become first-class citizens in the modern world of data management. The way to do this is not to turn pathologists into data entry clerks, but to give them tools that enhance their already instant recall of voluminous knowledge, that give them a consistent method of communicating life-and-death factors to surgeons and oncologists, that help keep the generalists up to date with the specialists, that do allow rule-checking and sophisticated algorithms to prevent errors and find rare diagnoses, that via aggregation of structured data enable real-time epidemiology. The people and the job remain the same, but oh what you can do with the results! Synoptic reporting changes everything.

Dave Winer and Scott Rosenberg disagree that an outlining metaphor forces you into hierarchical thinking. This discussion is entirely coincident, but relevant, to yesterday’s discussion between Jon Udell and Don Thomas about how the tree metaphor works great for users who think a certain way (which turns out to be a lot of people).

In many cases, structured hierarchies are hard to understand and navigate, like a massive file system or a deeply nested taxonomy. But in the case of lightweight tools like outliners that let you do the nesting and grouping, it is a structure you have created yourself. In my own experience with this metaphor (mTuitive Authoring Environment), I’ve found that it is best to resist nesting greater than three levels deep, unless absolutely necessary. Similar to the “three-tap rule” in Palm’s early days (nothing is more than three taps away from the home screen), I’ve used this as a guideline in working with subject matter experts who use our tool, and it keeps the tree under control.

The Health Tech Blog nicely picked up and elaborated on Jon Udell’s screencast. More insight from someone with healthcare and expert systems experience.

Experts abound in healthcare. By definition, physicians themselves are all experts in their chosen field. And from these experts, super-experts and super-specialists emerge who become the authorities on very narrow yet important subjects. At mTuitive, it is our goal to make it easy for any subject matter expert to translate their knowledge into a working application that guides users through processes like data collection and decision-making.

Jon Udell produced an excellent screencast where he interviews Dr. Donald Thomas (Mentat Systems), an expert in running hospital emergency departments, on his use of the mTuitive Authoring Environment to create an xPert Application for ER Triage. This is a lengthy, thoughtful discussion on the use of lightweight tools to encode expert medical knowledge, and we all enjoyed it and appreciate Mr. Udell’s and Dr. Thomas’s take.

Jon and Don talk about how a tool needs to accomodate the way the user-author-developer thinks… In the case of our tool, folks who generally like outlining tools ease right into the tree metaphor. They talk about how a programming background is very helpful when getting started, but in our experience at mTuitive non-technical people have been quite successful creating applications as well. The simple, declarative method of creating dynamic logic and rules makes sense to a lot of people, maybe moreso to non-techies who aren’t thinking constantly about what’s happening under the hood. At the end of the day, though, there must be many different congnitive styles of presentation and interaction that would help different experts in different fields encode their hard-won knowledge as useful applications. As we move ahead in healthcare, we’ll be constantly layering and adjusting our tools to make the transition from the expert’s brain to the computer as smooth and pleasurable as possible.

Again, the screencast is worth the time.