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C. Medical Expert Systems Certain artificial intelligence software packages termed "expert systems," rep- resent an attempt to use a computer to store and apply the knowledge of an expert. They have been tried extensively in medicine, especially for diagnosis and prognosis. Expert systems can be divided into three groups: 1. Medical Diagnostic Programs. Diag- nostic programs have been around since the 1950s. From hardware to software these programs are used by physicians to diagnose diseases. The physician enters the symptoms, test results, and medical history into the program, which then sug- gests a list of possible diagnoses. 2. Protocol Programs. The automation of care, using statistically generated pa- tient protocols or routines have been around since the mid-1970s. Clinical path- ways are also called critical paths, care maps, collaborative plans of care, multi disciplinary action plans (MAPS), and anticipated recovery paths are interdisci- plinary patient care plans. They delineate assessments, interventions, treatments and outcomes for specific health-related conditions across a designated time line. 3. Prognostic Programs. These pro- grams are used to calculate the chances of a critically ill patient survival for a given disorder or predicting patient outcomes based upon patient physiology. The pro- gram recommends withholding of any treatment if the chances of survival fall below the percentage calculated by the program. Several scoring systems exist for triage, predicting prognosis and the with- drawal of therapy. a. Therapeutic Intervention Scoring Systems (TISS); used to indicate suitabil- ity for transfer from the ICU to a high dependency unit or a general unit. b. Injury Severity Score (ISS); an ana- tomic trauma scoring scale used for ret- rospective comparisons of outcomes in trauma centers c. Acute Physiology and Chronic Health Evaluations (APACHE); A conceptual model for the APACHE prognostic systems was formulated in 1979, identifying factors that influenced outcome from an acute illness. Since then APACHE II and III were developed. APACHE II is used for control for case mix, quality assurance in ICUs, predicting death in non-ICU patients, and resource allocations. APACHE III is used to predict the sta- tistical power of the APACHE score, and to identify and quantify the factors in ICU care that contribute to the variation in ICU outcomes. The principal danger with such pro- grams is that they tend to generate clini- cal self-fulfilling prophecies. Once the care is withdrawn, the chances of patient sur- vival tend to be zero. The patient death may then be entered into the master data set. The next time the program is "asked" about a similar patient case, the recom- mendation to withdraw care is even more likely to be forthcoming. Patient Advocacy and Decision—Support Technology The RN advocacy role is delineated in the Standards of Competent Performance, which clearly require that all RNs regard- less of education preparation or creden- tialing including providers of direct and indirect patient care, must act as patient advocate, as circumstances require, by initiating actions to improve health or to change decisions or activities which are against the interest and whishes of the patient, including providing the patient with all necessary information so the patient can make an informed decision before care is rendered. Technology-driven care depersonal- izes the RN relationship with her/his patients. Unfettered use of technology will have a chilling effect on the RN's ability to advocate for her/his patient. Undue reliance on technology can jeopardize the accuracy of diagnosis and treatment and can harm the patients. Such reliance will also create erosion of skill for the next gen- eration of registered nurses who (unless stopped) will be trained in tasks in stead of educated in skills. As patient advocates RNs and the profession must avoid at all cost the repeat and/or the perpetuation of the health care environment which existed after World War I, where working conditions were not conducive to safe, therapeutic and effec- tive patient care nor for the professional development of registered nurses, Nursing became focused on tasks in order to take care of a large number of patients. As a result, the patient's 'human- ism was mechanized; his organic whole was fractured in parts, his basic physio- logical and technical needs were reduced to a checklist on paper. Thus he became an automated patient." Human cognition is still superior to machine intelligence. Included in the skills RNs must exercise on behalf of their patients is critical thinking... At the core of critical thinking are these six cognitive skills; interpretation, analysis, evaluation, inference, explanation and self-regulation. One fact is certain; computers and machines cannot think, analyze or reason as registered nurses do, nor are they edu- cated or capable of critical thinking in cri- sis intervention situations. Computers and machines are capable of quantifying data but it will take a qualified RN to syn- thesize and interpret the data - otherwise it is meaningless. In 1998 the California Nurses Asso- ciation took the following positions; 1. Oppose any and all technologies which are developed to maintain a health care system driven by private interest rather than the individual health care needs of an entire popula- tion; information systems which do not provide for competent hu- man interventions; computers/ software or medical equipment which is used to supplant instead of supplement health care pro- viders/givers skilled judgment. 2. Oppose any and all forms of auto- mation which inappropriately replace health care professional with technology or force them to keep pace with machines or interfere with the face-to-face' hands on "therapeutic touch" by health care pro- fessionals. Conclusion: RNs have the right and the duty to act as patient advocates, and therefore must have the ability to override any decision, solution, recommendation made by any computer software, system, tool which in the RNs' professional judg- ment is against the interest and wishes of the patient. Source: Telenursing, California Nurses Association Position Statement, May 1998. Hedy Dumpel, RN, JD, is Chief Director of Nursing Practice and Patient Advocacy for the California Nurses Association. 20 M A Y 2 0 0 5 C A L I F O R N I A N U R S E Unfettered use of technology will have a chilling effect on the RN's ability to advocate for her or his patient.