5P41-RR00785-12 MOLGEN Project

B. Justification and Requirements for Continued SUMEX Use

The MOLGEN project depends heavily on the SUMEX facility. We have already
developed several useful tools on the facility and are continuing research toward
applying the methods of artificial intelligence to the field of molecular biology. The
community of potential users is growing nearly exponentially as researchers from most
of the biomedical-medical fields become interested in the technology of recombinant
DNA. We believe the MOLGEN work is already important to this growing community
and will continue to be important. The evidence for this is an already large list of
pilot exo-MOLGEN users on SUMEX.

We support with great enthusiasm the acquisition of satellite computers for technology
transfer and hope that the SUMEX staff continues to develop and support these
systems. One of the oft-mentioned problems of artificial intelligence research is
exactly the problem of taking prototypical systems and applying them to real problems.
SUMEX gives the MOLGEN project a chance to conquer that problem and potentially
supply scientific computing resources to a national audience of biomedical-medical
research scientists.

Responses to Questions Regarding Resource Future

1. role of SUMEX after 7/86--I strongly believe that the 2060 should have
continuing support for the forseeable future. The maturity of software for
communications, document preparation, and general support of scientific
literacy is unsurpassed. One has only to note the heavy continued load on
SUMEX, despite the proliferation of workstations, VAXes, etc. around the
KSL to see that it is still being used productively. In addition, the ability to
easily work from home at all hours contributes greatly to overall
productivity within the SUMEX community.

2. will my group require continued access--Yes, very much so for all of the
Teasons outlined above.

3. impact of user fees--Modest user fees would not have an enormous impact,
but would prevent the kind of easy, productive use for general purposes that
SUMEX now serves. I think the greater impact would be on not fully
established or new research groups during start-up mode.

4. workstation plans--my group, MOLGEN, already makes extensive use of
workstations for mainline computing purposes. Despite this use, we still
find the SUMEX 2060 invaluable.

I would add to #1, that continuing research on melding together a distributed

environment, of which both single-user workstations and the 2060 are parts should be a
major continuing goal of SUMEX research.

101 E. H. Shortliffe
ONCOCIN Project $P41-RRO0785-12

IV.A.3. ONCOCIN Project

ONCOCIN Project

Edward H. Shortliffe, M.D., Ph.D.
Departments of Medicine and Computer Science
Stanford University

I. SUMMARY OF RESEARCH PROGRAM

A, Project Rationale

The ONCOCIN Project is one of many Stanford research programs devoted to the
development of knowledge-based expert systems for application to medicine and the
allied sciences. The central issue in this work has been to develop a program that can
provide advice similar in quality to that given by human experts, and to insure that the
system is easy to use and acceptable to physicians. The work seeks to improve the
interactive process, both for the developer of a knowledge-based system, and for the
intended end user. In addition, we have emphasized clinical implementation of the
developing tool so that we can ascertain the effectiveness of the program's interactive
capabilities when it is used by physicians who are caring for patients and are
uninvolved in the computer-based research activity.

B. Medical Relevance and Collaboration

The lessons learned in building prior production rule systems have allowed us to create
a large oncology protocol management system much more rapidly than was the case
when we started to build MYCIN. We introduced ONCOCIN for use by Stanford
oncologists in May 1981. This would not have been possible without the active
collaboration of Stanford oncologists who helped with the construction of the
knowledge base and also kept project computer scientists aware of the psychological and
logistical issues related to the operation of a busy outpatient clinic.

C. Highlights of Research Progress
C.l Background and Overview of Accomplishments

The ONCOCIN Project is a large interdisciplinary effort that has involved over 35
individuals since the project's inception in July 1979. With the work currently in its
sixth year, we summarize here the milestones that have occurred in the research to date:

e Year 1: The project began with two programmers (Carli Scott and Miriam
Bischoff), a Clinical Specialist (Dr. Bruce Campbell) and students under the
direction of Dr. Shortliffe and Dr. Charlotte Jacobs from the Division of
Oncology. During the first year of this research (1979-1980), we developed
a prototype of the ONCOCIN consultation system, drawing from programs
and capabilities developed for the EMYCIN system-building project. During
that year, we also undertook a detailed analysis of the day-to-day activities
of the Stanford Oncology Clinic in order to determine how to introduce
ONCOCIN with minimal disruption of an operation which is already
running smoothly. We also spent much of our time in the first year giving
careful consideration to the most appropriate mode of interaction with
physicians in order to optimize the chances for ONCOCIN to become a
useful and accepted tool in this specialized clinical environment.

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5P41-RR00785-12 ONCOCIN Project

« Year 2: The following year (1980-1981) we completed the development of a
special interface program that responds to commands from a customized
keypad. We also encoded the rules for one more chemotherapy protocol (oat
cell carcinoma of the lung) and updated the Hodgkin's Disease protocols
when new versions were released late in 1980; these exercises demonstrated
the generality and flexibility of the representation scheme we had devised.
Software protocols were developed for achieving communication between the
interface program and the reasoning program, and we coordinated the
printing routines needed to produce hard copy flow sheets, patient
summaries, and encounter sheets. Finally, lines were installed in the
Stanford Oncology Day Care Center, and, beginning in May 1981, eight
fellows in oncology began using the system three mornings per week for
Management of their patients enrolied in lymphoma chemotherapy protocols.

e Year 3: During our third year (1981 - 1982) the results of our early
experience with physician users guided both our basic and applied work. We
designed and began to collect data for three formal studies to evaluate the
impact of ONCOCIN in the clinic. This latter task required special software
development to generate special flow sheets and to maintain the records
needed for the data analysis. Towards the end of 1982 we also began new
research into a critiquing model for ONCOCIN that involves “hypothesis
assessment" rather than formal advice giving. Finally, in 1982 we began to
develop a query system to allow system builders as well as end users to
examine the growing complex knowledge base of the program.

¢ Year 4: Our fourth year (1982-1983) saw the departure of Carli Scott, a key
figure in the initial design and implementation of ONCOCIN, the
promotion of Miriam Bischoff to Chief Programmer, and the arrival of
Christopher Lane as our second scientific programmer. At this time we
began exploring the possibility of running ONCOCIN on a single-user
professional workstation and experimented with different options for data-
entry using a “mouse” pointing device. Christopher Lane became an expert
on the Xerox workstations that we are using. In addition, since ONCOCIN
had grown to such a large program with many different facets, we spent
much of our fourth year documenting the system. During that year we also
modified the clinic system based upon feedback from the physician-users,
made some modifications to the rules for Hodgkin's disease based upon
changes to the protocols, and completed several evaluation studies.

Year 5: The project's fifth year (1983-1984) was characterized by growth in
the size of our staff (three new full-time staff members and a new
oncologist joined the group). The increased size resulted from a DRR grant
that permitted us to begin a major effort to rewrite ONCOCIN to run on
professional workstations. Dr. Robert Carlson, who had been our Clinical
Specialist for the previous two years, was replaced by Dr. Joel Bernstein,
while Dr. Carlson assumed a position with the nearby Northern California
Oncology Group; this appointment permitted him to continue his affiliation
both with Stanford and with our research group. In August of 1983, Larry
Fagan joined the project to take over the duties of the ONCOCIN Project
Director while also becoming the Co-Director of the newly formed Medical
Information Sciences Program. Dr. Fagan continues to be in charge of the
day-to-day efforts of our research. An_ additional programmer, Jay
Ferguson, joined the group in the fall to assist with the effort Tequired to
transfer ONCOCIN from SUMEX to the 1108 workstation. A fourth
programmer, Joan Differding, joined the staff to work on our protocol
acquisition effort (OPAL).

103 E. H. Shortliffe
ONCOCIN Project 3P41-RR00785-12

e Year 6: During our sixth year (1984-1985) we have further increased the
size of our programming staff to help in the major workstation conversion
effort. The ONCOCIN and OPAL efforts were greatly facilitated by a
successful application for an equipment grant from Xerox Corporation.
With a total of 15 Xerox LISP machines now available for our group's
research, all full time programmers have dedicated machines, as do several of
the senior graduate students working on the project. Christopher Lane took
on full-time responsibility for the integration and maintenance of the
group's equipment and associated software. Two of our programming staff
moved on to jobs in industry (Bischoff and Ferguson) and three new
programmers (David Combs, Cliff Wulfman, and Samson Tu) were hired to
fill the void created by their departure and by the reassignment of
Christopher Lane.

With daily coordination by the project's data manager, Janice Rohn, the DEC-20
version of ONCOCIN continues to be used on a limited basis in the Stanford Oncology
Clinic. The continued dependence on this time-shared computer, however, has
prevented us from using ONCOCIN in in many clinical problem areas (other than the
lymphomas where clinics are held three mornings per week, and breast cancer where
clinic is held one day per week) because of our inability to assure the system's
availability with reasonable response time. It is this latter point that has accounted for
our decision not to spend a great deal of time developing new protocols to run on the
DEC-20 ONCOCIN prototype. Instead we have pressed our effort to adapt ONCOCIN
to run on professional workstations which can eventually be dedicated to full time
clinic use. We envision these workstations as the model for eventual dissemination of
this kind of technology.

In addition to funding from DRR for the workstation conversion effort, we have
support from the National Library of Medicine that supports our more basic research
activities regarding biomedical knowledge representation, knowledge acquisition, therapy
planning, and explanation as it relates to the ONCOCIN task domain. A grant from
the NLM to study the therapy planning process was received, and this work (led by Dr.
Fagan) is in its second year. This research is investigating how to represent the therapy
planning strategies used to decide treatment for patients on the oat cell carcinoma
protocol who run into serious problems requiring consultation with the protocol study
chairman. Dr. Branimar Sikic, a faculty member from the Stanford University
Department of Medicine, and the Study Chairman for the oat cell protocol, is
collaborating on this project.

C.2 Research in Progress

The major efforts of the ONCOCIN project over the last year have fallen into three
major categories: (1) conversion of ONCOCIN to run on workstations, (2) development
of a knowledge acquisition interface (OPAL) for entering new protocols, and (3)
research on modeling the strategic therapy selection process (ONYX). Efforts are also
in progress to evaluate the system, to document the results of the research, and to
disseminate the technology to sites beyond Stanford. We summarize these ongoing
research efforts below.

C.2.1 Transfer of the ONCOCIN system from the DEC-20 to the Xerox 1108

In an effort to improve the efficiency of the reimplemented system (and thereby to
improve its response time and make it more acceptable to physicians), we have
undertaken a substantial system redesign while transferring it to the new machines. An
additional commitment in time and programming effort has resulted, but we are
confident that the resulting system will be a substantial improvement over the
prototype. There have been several aspects to the system's reimplementation during the
current year:

E. H. Shortliffe 104
5P41-RRO00785~12 ONCOCIN Project

e Reorganization and recoding of existing programs for improved efficiency.
In last year's report, we discussed our first steps in reorganizing the program.
A further analysis during the year suggested that we should consider a
redesign of the program to take advantage of our experience with the
existing program and to respond to advances in artificial intelligence
representation methods since ONCOCIN was first designed. In addition, our
work during the year on new methods for entering knowledge into the
System suggested corresponding improvements in the ways to represent
oncologic knowledge in the system (see paper by Musen, et al. for more
details on the redesign of the ONCOCIN system).

« Redesign of the reasoning component. As a major part of the redesign of
the system, we decided to concentrate on methods that would allow for a
more efficient search of the knowledge base during the running of a case.
We have implemented and are currently debugging a reasoning program that
uses a discrimination network to process the cancer protocols. This network
allows for a compact representation of information that overlaps elements
of multiple protocols, but does not require the program to consider and then
disregard information related to protocols that are irrelevant to a particular
patient.

e Development of a temporal network. The ability to represent temporal
information is a key element of programs that must reason about treatment
protocols. The earlier version of the ONCOCIN system did not have an
explicit structure for reasoning about time oriented events (see the paper by
Kahn, et al. for a more detailed description of the temporal network).

e Extensions to the user interface. The user interface has been extended so
that it can read patient data files of the type that are created by the original
ONCOCIN system. This will allow us to transfer currently active patients to
the new version of the ONCOCIN system. A detailed description of the
user interface is available in the paper by Lane, et al.

e Connecting the components of the ONCOCIN system. The reasoning
component, user interface, and knowledge acquisition program (described
below) have been developed as separate programs. In the final version of the
system, the knowledge acquisition program must be able to automatically
translate from the graphical input forms into the knowledge base. The
Teasoner and user interface components are independent programs that run
in parallel while communicating with each other. Each of these connections
between components has been tested on a limited basis and will continue to
be exercised during the next several months.

Knowledge engineering tools. The challenge of coordinating a large software
development project, with multiple programmers working in parallel, has
necessitated the development of specialized tools to facilitate the process of
system construction and maintenance. One area of particular concern has
been the need for tools to assist with knowledge base maintenance (see paper
by Tsuji and Shortliffe for a discussion of our initial work in this area).

e System support for the reorganization. The LISP language that we used to
build the first version of ONCOCIN does not explicitly support basic
knowledge manipulation techniques (viz. message passing, inheritance
techniques, or other object oriented programming structures). These
facilities are available in some commercial products, but none of the
existing commercial implementations provides the reliability, Speed, size, or
special memory-manipulation techniques that are needed for our project.

105 E. H. Shortliffe
ONCOCIN Project 53P41-RR00785-12

We have accordingly developed a “minimal” object-oriented system to meet
these specifications. The object system is currently in use by each
component of the new version of ONCOCIN and in the software used to
connect the components. In addition, several student projects are now able
to use this programming environment.

C.2.2 Interactive Entry of Chemotherapy Protocols by Oncologists (OPAL)

A_major effort in this grant year has been the development of software (termed the
OPAL system) that will permit physicians who are not computer programmers to enter
protocol information into a structured set of forms on a graphical display. Most early
expert systems required tedious (and occasionally erroneous) entry of the system's
medical knowledge. Each segment of knowledge was transferred from physician to
programmer and then entered into the program by the computer expert. Although
many programs allowed for specification of a structure within which to organize the
information, only minimal attempts were made to define a description that would be
generic enough to provide a basis for a series of related knowledge bases in one medical
area,

We have taken advantage of the generally well-structured nature of cancer treatment
plans to design a knowledge entry program that can be used directly by clinicians. The
structure of cancer treatment plans includes: multiple protocols (that may be related to
each other), experimental research arms in each protocol, drug combinations, individual
drugs, and drug modifications. Using the graphically-oriented workstations, this
information is presented to the user as computer-generated forms that appear on the
screen. As the protocol is described, new forms are added to the computer display to
allow for the specification of the special cases that make the protocols so complicated.

Although this design appears to be organized specifically for cancer treatment plans, we
believe that the technique can be extended to other clinical trials, and eventually to
other structured decision tasks. The key factor is to exploit the regularities in the
Structure of the task (eg., this interface has an extensive notion of how chemotherapy
regimens are constructed) rather than to try to build a knowledge entry system that
could accept any possible problem specification.

Using this program we have entered several versions of a small cell lung cancer
protocol, and a complicated lymphoma protocol with several different therapies. We
are currently implementing the changes suggested by entering these protocols.

C.2.3 Strategic Therapy Planning (ONYX)

As mentioned above, we have begun a new research project to study the therapy
planning process, and how strategies which are used to plan therapy in difficult cases
might be represented on a computer. This project, which we call the ONYX project,
has as its goals: to conduct basic research into the possible representations of the
therapy planning process; to develop a computer program to represent this process; and
eventually to interface the planning program with ONCOCIN. The project members
(Fagan, Tu, Langlotz, and Williams) have spent many hours meeting with Dr. Sikic
trying to understand how he plans therapy for patients whose special clinical situation
precludes following the standard therapeutic plan described in the protocol document.
In March of last year, the group spent two days at Xerox Palo Alto Research Center
(PARC), working with Mark Stefik, Daniel Bobrow and Sanjay Mittal of PARC on
possible representations for the knowledge structures and how such a program might run
using the LOOPS knowledge programming system. A prototype version of this program
is currently being tested. The prototype program has been designed as two components:
the strategic planning program and the qualitative simulation builder. The strategic
planning program is capable of turning the patient's medical data and knowledge of the

E. H. Shortliffe 106
3P41-RR00785-12 ONCOCIN Project

intent of the protocol into a small number of plausible protocol modifications for the
current point in time, and conditional modifications for the near future. Another
component of the system is capable of building simulation models using the graphical
abilities of the 1108 workstation. The first test of this component is the construction
of a model of the effects of chemotherapy drugs on the bone marrow of the patient.
During the next year of research this type of qualitative simulation model will be
integrated into the strategic planning program.

C.2.4 Evaluations of ONCOCIN’s performance

We have completed our first three formal studies of ONCOCIN's DEC-20 version (see
papers by Kent et al. and Hickam et al. for results of two of these: written reports on
the third is in preparation). Lessons learned in these initial studies have led to revisions
both in the design of ONCOCIN and in our plans for evaluation studies of the 1108
version of the system when it is implemented at non-Stanford sites in later years.

C.2.5 Documentation

We have developed a videotape that discusses and demonstrates our research on the
workstation version of our system. This tape has been shown at national meetings and
has been extensively distributed to researchers internationally who have shown an
interest in our work. The publication list that accompanies this report further
documents the design decisions we have made in developing the new version of
ONCOCIN.

C.2.6 Dissemination

In anticipation of completion of the workstation version of ONCOCIN, we are
beginning to plan for an experiment in which we will install ONCOCIN workstations
in private oncology offices in San Jose and Fresno. An application proposing this
work is current under review.

D. Publications Since January 1984

1. (*) Buchanan, B.G. and Shortliffe, EH: Rule-Based Expert Systems: The
MYCIN Experiments of the Stanford Heuristic Programming Project.
Addison-Wesley, Reading, MA., 1984. [book]

2. (*) Clancey, WJ. and Shortliffe, E.H.: Readings in Medical Artificial
thoowyene The First Decade. Addison-Wesley, Reading, MA., 1984.
k

3. Clancey, WJ. and Shortliffe, EH: Strategies for medical knowledge
engineering: Lessons from the first decade. To appear in the Proceedings of
the AAMSI Congress 85, San Francisco, CA., May 1985.

4. Differding, J.C: The OPAL interface: General Overview. Working paper.
August 1984.

5. (*) Fagan, L: New Directions for Expert Systems: Examples from the
ONCOCIN Project. To appear in the Proceedings of AAMSI Congress 85,
San Francisco, CA., May 1985.

6. (*) Hickam, D.H., Shortliffe, E.H., Bischoff, M.B., Scott, A.C., Jacobs, C.D.: A
study of the treatment advice of a computer-based cancer chemotherapy
protocol advisor. Submitted for publication, May 1985.

7. (*) Kahn, M.G., Ferguson, J., Shortliffe, E.H., Fagan, L.: An approach for
structuring temporal information in the ONCOCIN system. To appear in the

107 E. H. Shortliffe
ONCOCIN Project 3P41-RR00785-12

Proceedings of the Symposium on Computer Applications in Medical Care,
Baltimore, MD., November 1985.

8. (*) Kent, D.L. Shortliffe, EH. Carlson, R.W., Bischoff, M.B., Jacobs,
C.D.: Improvements in data collection through physician use of a computer-

based chemotherapy treatment consultant. Submitted for publication, March
1985.

9.(*) Lane, C.D. Differding, J.C, Shortliffe, E.H: Design of a graphic
interface for a medical expert system. (Memo KSL-85-15). Working paper.

10. (*) Langlotz, C, Fagan, L., Tu, S., Williams, J.. Sikic, B: ONYX: An
architecture for planning in uncertain environments. To appear in the
Proceedings of International Joint Conference on Artificial Intelligence, Los
Angeles, CA., August 1985.

11. (*) Langlotz, C.P. and Shortliffe, EH: Adapting a consultation system to
critique user plans. In Developments in Expert Systems, (M. Coombs, ed.),
pp. 77-94, London: Academic Press, 1984.

12. (*) Musen, M., Langlotz, C., Fagan, L., Shortliffe, EH: Rationale for
knowledge base redesign in a medical advice system. To appear in the
Proceedings of AAMSI Congress 85, San Francisco, CA., May 1985.

13. Shortliffe, EH: The science of biomedical computing.Medical Informatics,
Vol.9, Nos. 3/4, 185-193 (1984).

14. (*) Shortliffe, E.H:Reasoning methods in medical consultation systems:
artificial intelligence approaches (tutorial). Computer Programs in
Biomedicine 18:5-14 (1984). .

15. Shortliffe, E. H.: Explanation capabilities for medical consultation systems
(tutorial). Proceedings of AAMSI Congress 84 (D. Lindberg and M. Collen,
Eds.), pp. 193-197, San Francisco, May 1984,

16. Shortliffe, ELH. and Fagan, L.M.: Artificial intelligence: the expert systems
approach to medical consultation. Proceedings of the 6th Annual
International Symposium on Computers in Critical Care and Pulmonary
Medicine, Heidelberg, Germany, June 1984.

17. (*) Shortliffe, E.H.: Update on ONCOCIN: A chemotherapy advisor for
clinical oncology. Proceedings of the Symposium on Computer Applications
in Medical Care, November 1984,

18. (*) Tsuji, S. and Shortliffe, EH: Graphics for knowledge engineers: a

window on knowledge base management (Memo KSL~-85-11). Submitted for
publication, April 1985.

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5P41-RR00785-12 ONCOCIN Project

Il. INTERACTIONS WITH THE SUMEX-AIM RESOURCE

A, Medical Collaborations and Program Dissemination via SUMEX

A great deal of interest in ONCOCIN has been shown by the medical, computer science,
and lay communities. We are frequently asked to demonstrate the program to Stanford
visitors (both the prototype system funning in the clinic and the newer work
transferring the system to professional workstations). We also demonstrated our
developing workstation code in the Xerox exhibit in the trade show associated with
AAAI-84 in Austin, Texas. Physicians have generally been enthusiastic about
ONCOCIN's potential. The interest of the lay community is reflected in the frequent
requests for magazine interviews and television coverage of the work. Articles about
MYCIN and ONCOCIN have appeared in such diverse publications as Time and
Fortune, whereas ONCOCIN has been featured on the "NBC Nightly News", the PBS

109 E. H. Shortliffe
ONCOCIN Project 5P41-RR00785-12

“Health Notes" series, and "The MacNeil-Lehrer Report.” Due to the frequent requests
for ONCOCIN demonstrations, we have produced a videotape about the ONCOCIN
research which includes demonstrations of our the professional workstation research
projects and the 2020-based clinic system. The tape has been shown at several national
meetings, including the 1984 Workshop on Artificial Intelligence in Medicine, the 1984
meeting of the Society for Medical Decision Making, and the 1985 meeting of the
Society for Research and Education in Primary Care Internal Medicine. The tape has
also been shown to both national and international researchers in biomedical
computing.

Our group also continues to oversee the MYCIN program (not an active research project
since 1978) and the EMYCIN program. Both systems continue to be in demand as
demonstrations of expert systems technology. MYCIN been demonstrated via networks
at both national and international meetings in the past, and several medical school and
computer science teachers continue to use the program in their computer science or
medical computing courses. Researchers who visit our laboratory, often start out by
experimenting with the MYCIN/EMYCIN systems. We also have made the MYCIN
program available to researchers around the world who access SUMEX using the
GUEST account. EMYCIN has been made available to interested researchers developing
expert systems who access SUMEX via the CONSULT account. One such consultation
system for psychopharmacological treatment of depression, called Blue-Box, developed
by two French medical students, Benoit Mulsant and David Servan-Schreiber, was
reported on in July of 1983 in Computers and Biomedical Research.

B. Sharing and Interaction with Other SUMEX-AIM Projects

The community created on the SUMEX resource has other benefits that go beyond
actual shared computing. Because we are able to experiment with other developing
systems, such as INTERNIST/CADUCEUS, and because we frequently interact with
other workers (at AIM Workshops or at other meetings), many of us have found the
scientific exchange and stimulation to be heightened. Several of us have visited workers
at other sites, sometimes for extended periods, in order to pursue further issues which
have arisen through SUMEX- or Workshop-based interactions. In this tegard, the
ability to exchange messages with other workers, both on SUMEX and at other Sites, has
been crucial to rapid and efficient exchange of ideas. Certainly it is unusual for a
small community of researchers with similar scholarly interests to have at their disposal
such powerful and efficient communication mechanisms, even among those on opposite
coasts of the country.

C. Critique of Resource Management

Our community of researchers has been extremely fortunate to work on a facility that
has continued to maintain the high standards that we have praised in the past. The
staff members are always helpful and friendly, and work as hard to please the SUMEX
community as to please themselves. As a result, the computer is as accessible and easy
to use as they can make it. More importantly, it is a reliable and convenient research
tool. We extend special thanks to Tom Rindfleisch for Maintaining such high
professional standards. As our computing needs grow, we have increased our dependence
on special SUMEX skills such as networking and communication protocols.

III. RESEARCH PLANS
A, Project Goals and Plans

In the coming year, there are several areas in which we expect to expend our efforts on
the ONCOCIN System:

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3P41-RR00785-12 ONCOCIN Project

1. To transfer the oncology prototype from its current research computer to a
professional workstation that provides a_ model for cost-effective
dissemination of clinical consultation systems. To meet this specific aim
we will we will continue the basic and applied programming efforts
(ONCOCIN, OPAL, and ONYX) described earlier in this report.

2.T0 encode and implement for use by ONCOCIN the commonly used
chemotherapy protocols from our oncology clinic. In the coming year, we
will:

e Complete our OPAL protocol entry system

e Continue entry of additional protocols, hopefully at the rate of one
protocol/month (including testing)

e Place a version of the OPAL protocol entry system into the clinic for
use by physicians as a graphical reference guide to the protocols.

3. To introduce ONCOCIN gradually for ongoing use so that by mid-1986 two
professional workstations will be available in the oncology clinic to assist
in the management of cancer patients. During the next year, we will:

e Implement the first workstation-based ONCOCIN system for use by
physicians in the oncology clinic by the end of the calendar year 1985,
adding a second workstation within a few months thereafter

« Continue to operate the DEC-2020 version to maintain continuity of
support in the clinic setting until the workstation version is fully
operational.

B. Justification and Requirements for Continued SUMEX Use

All the work we are doing (ONCOCIN plus continued use of the original MYCIN
program) continues to be dependent on daily use of the SUMEX resource. Although
much of the ONCOCIN work is shifting to Xerox workstations, the SUMEX 2060 and
the 2020 continue to be key elements in our research plan. The programs all make
assumptions regarding the computing environment in which they operate, and the
ONCOCIN prototype currently used in the clinic depends upon proximity to the DEC
2020 which enables us to use a 9600 baud interface.

In addition, we have long appreciated the benefits of GUEST and network access to the
programs we are developing. SUMEX greatly enhances our ability to obtain feedback
from interested physicians and computer scientists around the country. Network access
has also permitted high quality formal demonstrations of our work both from around
the United States and from sites abroad (e.g., Finland, Japan, Sweden, Switzerland).

The main development of our project will continue to take place on Dandelion lisp
machines that we have purchased or have been donated by XEROX corporation. We
also have special needs for more computing power for our ONYX therapy planning
sige and have been able to share an upgraded Dandelion loaned by SUMEX for
this wor

C. Requirements for Additional Computing Resources

The acquisition of the DEC 2020 by SUMEX was crucial to the growth of our research
work. It has insured high quality demonstrations and has enabled us to develop a
system (ONCOCIN) for real-world use in a clinical setting. As we have begun to
develop systems that are potentially useful as stand-alone packages (i.e, an exportable

111 E. H. Shortliffe
ONCOCIN Project 5P41-RRO00785-12

ONCOCIN), the addition of personal workstations has provided particularly valuable
new resources. We have made a commitment to the smaller Interlisp-D machines
(Dandelions) produced by Xerox, and our work will increasingly transfer to them over
the next several years. Our current funding supports our effort to implement
ONCOCIN on workstations in the Stanford oncology clinic (and eventually to move the
program to non-Stanford environments) but we will simultaneously continue to require
access to Interlisp on upgraded workstations for extremely CPU intensive tasks.
Although our dependence on SUMEX for workstations has decreased due to a recent
gift from XEROX, our requirements for network support of the machines has
drastically increased. Individual machines do not provide sufficient space to store all
of the software used in our project, nor to provide backup or long term storage of work
in progress. It is the networks, file storage devices, protocol converters, and other parts
of the SUMEX network that hold our project together. In addition, with a research
group of about 20 people, we are taking advantage of file sharing, electronic mail, and
other information coordinating activities provided by the DEC 2060. We hope that
with systems support and research by SUMEX staff, we will be able to gradually move
away from a need for the central coordinating machine over the next five years,

The acquisition of the DEC 2060, coupled with our increasing use of workstations, has
greatly helped with the problems in SUMEX response time that we had described in
previous annual reports. We are extremely grateful for access both to the central
machine and to the research workstations on which we are currently building the new
ONCOCIN prototype. The D-machine’s address space is permitting development of the
large knowledge base that ONCOCIN requires. The graphics capability of the
workstations has also enabled us to develop new methods for presenting material to
naive users. In addition, the D-machines have provided a reliable, constant “load-
average" machine for running experiments with physicians and doing development work.
The development of ONCOCIN on the Dandelion will demonstrate the feasibility of
running intelligent consultation systems on small, affordable machines in physicians’
offices and other remote sites.

D. Recommendations for Future Community and Resource Development

SUMEX is providing an excellent research environment and we are delighted with the
help that SUMEX staff have provided implementing enhanced system features on the
2060 and on the workstations. We feel that we have a highly acceptable research
environment in which to undertake our work. Workstation availability is becoming
increasingly crucial to our research, and we have found over the past year that
workstation access is at a premium. The SUMEX staff has been very helpful and
understanding about our needs for workstation access, allowing us Dandelion use
wherever possible, and providing us with systems-level support when needed. We look
forward to the arrival of additional advanced workstations and the development of a
more distributed computing environment through SUMEX-AIM.

Responses to Questions Regarding Resource Future

“What do you think the role of the SUMEX-AIM resource should be for the period
after 7/86, e.g., continue like it is, discontinue support of the central machine, act as a
communications crossroads, develop software for user community workstations, etc?"

We believe that the trend towards distributed computing that characterized the early
1980's will continue during the second half of the decade. Although we have begun this
process by moving much of our research activity to LISP machines, the SUMEX
DEC-20 continues to be a major source of support for all communication,
collaboration, and administrative functions. It also continues to provide a quality LISP
environment for rapid prototyping, student projects in the early stages before
workstations are made available, and for demonstrating system features to people at a

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distance. These latter functions are still not well handled by distributed machines, and
we believe that a logical role for the resource in the future is to develop software and
communications techniques that will allow us to further decrease our dependence on the
large central machine.

"Will you require continued access to the SUMEX-AIM 2060 and if so, for how long?”

As indicated above, our needs could still be met with a gradual phaseout of the 2060
over the next 3-5 years, provided that current services such as file handling and backup,
mail, document preparation and advanced network support are available from other
machines (e.g., SAFE plus the Medical Computer Science file server). This implies
Maintenance of an ARPANET connection, connections to other campus machines, and
facilities for linking together the heterogeneous collection of computing equipment
upon which our research group depends. SUMEX would need to concentrate on
providing software support for networks and systems software for workstations if it
were to provide the same level of service we now experience while moving to a fully
distributed environment.

"What would be the effect of imposing fees for using SUMEX resources (computing
and communications) if NIH were to require this?”

Since all our research is NIH-supported, we see nothing but administrative headaches
without benefits if there were to be a move to require fee-for-service billing for access
to shared SUMEX resources. The net effect would simply be a transfer of funds from
one arm of NIH to another (assuming that the agencies that currently fund our work
could supplement our grants to cover SUMEX charges), and there would be a
simultaneous restraining effect on the research environment. The current scheme
permits experimentation and flexibility in use that would be severely inhibited if all
access incurred an incremental charge.

"Do you have plans to move your work to another machine workstation and if so, when
and to what kind of system?”

As mentioned above, and described in greater detail in our annual Teport, we are
making a major effort to move much of research activity to LISP machines (currently
Xerox 1108's and HP-9836's). Our familiarity with this technology, and our
commitment to it, have resulted solely from the foresight of the SUMEX resource in
anticipating the technology and providing for it at the time of their last renewal.
However, for the reasons mentioned above, we continue to depend upon the central
communication node for many aspects of our activities and could effectively adapt to
its demise only if the phaseout were gradual and accompanied by improved support for
a totally distributed computing environment.

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IV.A.4. PROTEAN Project

PROTEAN Project

Oleg Jardetzky
Nuclear Magnetic Resonance Lab, School of Medicine
Stanford University

Bruce Buchanan, Ph.D.
Computer Science Department
Stanford University

I. SUMMARY OF RESEARCH PROGRAM

A. Project Rationale

The goals of this project are related both to biochemistry and artificial intelligence: (a)
use existing AI methods to aid in the determination of the 3-dimensional structure of
proteins in solution (not from x-ray crystallography proteins), and (b) use protein
structure determination as a test problem for experiments with the AI problem solving
structure known as the Blackboard Model. Empirical data from nuclear magnetic
resonance (NMR) and other sources may provide enough constraints on structural
descriptions to allow protein chemists to bypass the laborious methods of crystallizing a
protein and using X-ray crystallography to determine its structure. This problem
exhibits considerable complexity. Yet there is reason to believe that AI programs can
be written that reason much as experts do to resolve these difficulties [16].

B. Medical Relevance

The molecular structure of proteins is essential for understanding many problems of
medicine at the molecular level, such as the mechanisms of drug action. Using NMR
data from proteins in solution will speed up the determination.

C. Highlights of Progress

We have constructed a prototype of such a program, called PROTEAN, designed on the
blackboard model [7], [12]. It is implemented in BB1 [13], a framework system for
building blackboard systems that control their own problem-solving behavior [14](see
discussion of BBl above). We have coupled the reasoning program with an IRIS
graphics terminal (shared with SUMEX) which displays protein structures at different
levels of detail. This provides a visual understanding of how the program is behaving,
which is essential for this problem.

PROTEAN embodies the following experimental techniques for coping with the
complexities of constraint satisfaction:

1. The problem-solver partitions each problem into a network of loosely-
coupled sub-problems. PROTEAN partitions the problem of positioning all
of a protein's constituent structures within a global coordinate system into
sub-problems of positioning individual pieces of structures and their
immediate neighbors within local coordinate systems. It subsequently
composes the most constrained partial solutions developed for these sub-
problems in a complete solution for the entire protein. This partitioning
and composition technique reduces the combinatorics of search. It also

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introduces additional constraints in the global characteristics of internally
constrained partial solutions. For example, the conformations of partial
protein solutions constrain their composability with other partial solutions.

2. The problem-solver attempts to solve sub-problems and coordinate solutions
at multiple levels of abstraction, where lower levels of abstraction partition
solution elements with finer granularity. For example, PROTEAN Operates at
three levels of abstraction. At the "Solid" level, it positions elements of the
protein's secondary structure: alpha-helices, beta-sheets, and random coils. At
the “Blob” level, it positions elements of the protein's primary structure of
amino acids: peptide units and side-chains. At the "Atom" level, it positions
the protein's individual atoms. Partial solutions at higher levels of
abstraction reduce the combinatorics of search at lower levels. Conversely,
tightly constrained partial solutions at lower levels introduce new constraints
on higher-level solutions.

3. The problem-solver forbears hypothesizing specific partial solutions for a
sub-problem in favor of preserving the “family” of solutions consistent with
all constraints applied thus far. For example, in positioning a helix within a
partial solution, PROTEAN does not attempt to identify a unique spatial
position for the helix. Instead, it identifies the entire spatial volume within
which the helix might lie, given the constraints applied thus far. Preserving
the family of legal solutions accommodates problems with incomplete
constraints; the solution is only as constrained as the data are constraining.
It also accommodates incompatible constraints by permitting disjunctive sub-
families. For PROTEAN, disjunctive sub-volumes imply that the associated:
Structure lies within any one of the sub-volumes or, if the structure is
mobile, that it may move from one sub-volume to another.

4. The problem-soiver applies constraints one at a time, successively restricting
the family of solutions hypothesized for different sub-problems. PROTEAN
successively applies constraints on the positions of protein structures,
successively restricting the spatial volumes within which they may lie.
Independent application of different constraints finesses the problem of
integrating qualitatively different kinds of constraints by simply integrating
their results. In addition, successive restriction of the family of solutions
obviates guessing which specific solutions within a family are likely to be
consistent with subsequently applied constraints and the otherwise inevitable
back-tracking.

5. The problem-solver tolerates overlapping solutions for different sub-
problems. For example, in identifying the volume within which structure-a
might lie in partial solution 1, PROTEAN may include part of the volume
identified for structure-b. Toleration of overlapping partial solutions is
another accommodation of incomplete or incompatible constraints and
potentially dynamic solutions. For PROTEAN, overlapping volumes for two
protein structures indicate either: (a) that the two structures actually occupy
disjoint sub-volumes that cannot be distinguished within the larger,
overlapping volumes identified for them because the constraints are
incomplete; or (b) that the two structures are mobile and alternately occupy
the shared volume.

6. The problem-solver reasons explicitly about control of its own problem-
solving actions: which sub-problems it will attack, which partial solutions it
will expand, and which constraints it will apply. Control reasoning guides
the problem-solver to perform actions that minimize computation, while
maximizing progress toward a complete solution (see section 3.2.1). It also

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provides a foundation for the problem-solver’s explanation of problem-
solving activities and intermediate partial solutions (see section 3.2.2) and
for its learning of new control heuristics (see section 5.5).

The current version of PROTEAN has six knowledge sources that demonstrate the
reasoning techniques described above. These knowledge sources develop partial solutions
that position multiple helices at the Solid level and refine those helices at the Blob
level. Proposed work will introduce knowledge sources that operate on other protein
structures at the Solid level, as well as knowledge sources that apply the reasoning
techniques at the Blob and Atom levels. We also will investigate emergent constraints
entailed in reliable partial solutions, composition of partial solutions into complete
solutions, and intelligent control.

D. Relevant Publications

1, Erman, L.D., Hayes-Roth, B. Lesser, V.R., Reddy, D.R:The HEARSAY-II
Speech Understanding System: Integrating Knowledge to Resolve
Uncertainty. ACM Computing Surveys 12(2):213-254, June, 1980.

2. Hayes-Roth, B: The Blackboard Architecture: A General Framework for
Problem Solving? Report HPP-83-30, Department of Computer Science,
Stanford University, 1983.

3. Hayes-Roth, B: BBI: An Environment for Building Blackboard Systems
that Control, Explain, and Learn about their own Behavior. Report
HPP-84-16, Department of Computer Science, Stanford University, 1984.

4. Hayes-Roth, B.:A Blackboard Architecture for Control. Artificial Intelligence
In Press, 1985.

5. Hayes-Roth, B. and Hewett, M.: Learning Control Heuristics in BB1. Report
HPP-85-2, Department of Computer Science, 1985.

6. Jardetzky, O. A Method for the Definition of the Solution Structure of
Proteins from NMR and Other Physical Measurements: The LAC-Repressor
Headpiece. Proceedings of the International Conference on the Frontiers of
Biochemistry and Molecular Biology, Alma Alta, June 17-24, 1984, October,

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5P41-RR00785-12 PROTEAN Project

Il. INTERACTIONS WITH THE SUMEX-AIM: RESOURCE
A. Medical Collaborations

Several members of Prof. Jardetzky's research group are involved in this research.
B. Interactions with other SUMEX-AIM projects

Robert Langridge was visiting at Stanford last year, and informal discussions with him
and his group have continued in this year.

C. Critique of Resource Management

The SUMEX staff has continued to be most cooperative in getting this project started.
Without their persistence, we would not have been able to obtain Ethernet software for
the IRIS graphics terminal from Xerox.

III. RESEARCH PLANS
A, Goals & Plans

Our long-range goal is to build an automatic interpretation system similar to
CRYSALIS (which worked with x-ray crystallography data). In the shorter term, we are
building interactive programs that aid in the interpretation of NMR data on small
proteins. The current version of PROTEAN has six knowledge sources that demonstrate
the reasoning techniques described above. These knowledge sources develop partial
solutions that position multiple helices at the Solid level and refine those helices at the
Blob level. The proposed research would expand PROTEAN to include knowledge
sources that:

1. construct partial solutions combining helices, beta sheets, and random coils
at the Solid level;

2. merge highly constrained partial solutions at the Solid level;

3. refine Solid level solutions in terms of the relative positions of constituent
peptide units and side chains at the Blob level:

4. further restrict the relative locations of peptide units and side chains relative
to one another at the Blob level:

5. propagate emergent constraints at the Blob level back up to the Solid level
to further restrict the relative positions of superordinate helices, beta sheets,
and random coils;

6. refine Blob level solutions at the Atom level;
7. further restrict the relative locations of atoms relative to one another;
8. propagate emergent constraints at the Atom level back up to the Blob level

to further restrict the relative positions of superordinate peptide units and
side chains.

The research will also develop a set of control knowledge sources to guide PROTEAN's
application of constraints to identify the family of legal protein conformations as
efficiently as possible. And we expect to improve the graphics interface to provide
more functionality and options for viewing partial structures.

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PROTEAN Project 5P41-RRO00785-12

B. Justification for continued SUMEX use

We will continue to use SUMEX for developing parts of the program before integrating
them with the whole system. We are using Interlisp to implement the Blackboard
model and knowledge structures most flexibly and quickly.

C. Need for other computing resources

In this stage of development we need more computer cycles and hope to have access to
additional D-machines. We expect to upgrade the Silicon Graphics IRIS terminal to a
workstation for more efficiency in the subprograms doing computational geometry.

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5P41-RR00785-12 RADIX Project

IV.A.5. RADIX Project

The RADIX Project: Deriving Medical Knowledge from
Time-Oriented Clinical Databases

Robert L. Blum, M.D., Ph.D.
Department of Computer Science
Stanford University

Gio C. M. Wiederhold, Ph.D.
Departments of Computer Science and Medicine
Stanford University

I, SUMMARY OF RESEARCH PROGRAM

A, Technical Goals - Introduction

Medical and Computer Science Goals -- The long-range objectives of our project, called
RADIX (formerly RX), are 1) to increase the validity of medical knowledge derived
from large time-oriented databases containing routine, non-randomized clinical data, 2)
to provide knowledgeable assistance to a research investigator in studying medical
hypotheses on large databases, 3) to fully automate the process of hypothesis generation
and exploratory confirmation. For system development we have used a subset of the
ARAMIS database.

Computerized clinical databases and automated medical records systems have been under
development throughout the world for at least a decade. Among the earliest of these
endeavors was the ARAMIS Project, (American Rheumatism Association Medical
Information System) under development since 1969 in the Stanford Department of
Medicine. ARAMIS contains records of over 17,000 patients with a variety of
theumatologic diagnoses. Over 62,000 patient visits have been recorded, accounting for
50,000 patient-years of observation. The ARAMIS Project has now been generalized to
include databases for many chronic diseases other than arthritis.

The fundamental objective of the ARAMIS Project and many other clinical database
projects is to use the data that have been gathered by clinical observation in order to
study the evolution and medical management of chronic diseases. Unfortunately, the
process of reliably deriving knowledge has proven to be exceedingly difficult.
Numerous problems arise stemming from the complexity of disease, therapy, and
outcome definitions, from the complexity of causal relationships, from errors
introduced by bias, and from frequently missing and outlying data. A major objective
of the RADIX Project is to explore the utility of symbolic computational methods and
knowledge-based techniques at solving some of these problems.

The RADIX computer program is designed to examine a time-oriented clinical database
such as ARAMIS and to produce a set of (possibly) causal relationships. The algorithm
exploits three properties of causal relationships: time precedence, correlation, and
nonspuriousness. First, a Discovery Module uses lagged, nonparametric correlations to
generate an ordered list of tentative relationships. Second, a Study Module uses a
knowledge base (KB) of medicine and statistics to try to establish nonspuriousness by
controlling for known confounders.

The principal innovations of RADIX are the Study Module and the KB. The Study

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RADIX Project 5P41-RR00785-12

Module takes a causal hypothesis obtained from the Discovery Module and produces a
comprehensive study design, using knowledge from the KB. The study design is then
executed by an on-line statistical package, and the results are automatically incorporated
into the KB. Each new causal relationship is incorporated as a machine-readable record
specifying its intensity, distribution across patients, functional form, clinical setting,
validity, and evidence. In determining the confounders of a new hypothesis the Study
Module uses previously “learned” causal relationships.

In creating a study design the Study Module follows accepted principles of
epidemiological research. It determines study feasibility and study design: cross-
sectional versus longitudinal. It uses the KB to determine the confounders of a given
hypothesis, and it selects methods for controlling their influence: elimination of
patient records, elimination of confounding time intervals, or statistical control. The
Study Module then determines an appropriate statistical method, using knowledge stored
as production rules. Most studies have used a longitudinal design involving a multiple
regression model applied to individual patient records. Results across patients are
combined using weights based on the precision of the estimated regression coefficient
for each patient.

B. Medical Relevance and Collaboration

As a test bed for system development our focus of attention has been on the records of
patients with systemic lupus erythematosus (SLE) contained in the Stanford portion of
the ARAMIS Data Bank. SLE is a chronic rheumatologic disease with a broad spectrum
of manifestations. Occasionally the disease can cause profound renal failure and lead
to an early death. With many perplexing diagnostic and therapeutic dilemmas, it is a
disease of considerable medical interest.

In the future we anticipate possible collaborations with other project users of the TOD
System such as the National Stroke Data Bank, the Northern California Oncology
Group, and the Stanford Divisions of Oncology and of Radiation Therapy.

We believe that this research project is broadly applicable to the entire gamut of
chronic diseases that constitute the bulk of morbidity and mortality in the United
States. Consider five major diagnostic categories responsible for approximately two
thirds of the two million deaths per year in the United States: myocardial infarction,
stroke, cancer, hypertension, and diabetes. Therapy for each of these diagnoses is
fraught with controversy concerning the balance of benefits versus costs.

1. Myocardial Infarction: Indications for and efficacy of coronary artery bypass
graft vs. medical management alone. Indications for long-term
antiarrhythmics .. long-term anticoagulants. Benefits of cholesterol-lowering
diets, exercise, etc.

2. Stroke: Efficacy of long-term anti-platelet agents, long-term anticoagulation.
Indications for revascularization.

3. Cancer: Relative efficacy of radiation therapy, chemotherapy, surgical
excision - singly or in combination. Optimal frequency of screening
procedures. Prophylactic therapy.

4. Hypertension: Indications for therapy. Efficacy versus adverse effects of
chronic antihypertensive drugs. Role of various diagnostic tests such as renal
arteriography in work-up.

5. Diabetes: Influence of insulin administration on microvascular
complications. Role of oral hypoglycemics.

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5P41-RR00785-12 RADIX Project

Despite the expenditure of billions of dollars over recent years for randomized
controlled trials (RCT's) designed to answer these and other questions, answers have
been slow in coming. RCT’s are expensive in terms of funds and personnel. The
therapeutic questions in clinical medicine are too numerous for each to be addressed by
its own series of RCT's.

On the other hand, the data regularly gathered in patient records in the course of the
normal performance of health care delivery are a rich and largely underutilized
resource. The ease of accessibility and manipulation of these data afforded by
computerized clinical databases holds out the possibility of a major new resource for
acquiring knowledge on the evolution and therapy of chronic diseases.

The goal of the research that we are pursuing on SUMEX is to increase the reliability
of knowledge derived from clinical data banks with the hope of providing a new tool
for augmenting knowledge of diseases and therapies as a supplement to knowledge
derived from formal prospective clinical trials. Furthermore, the incorporation of
knowledge from both clinical data banks and other sources into a uniform knowledge
base should increase the ease of access by individual clinicians to this knowledge and
thereby facilitate both the practice of medicine as well as the investigation of human
disease processes.

C. Highlights of Research Progress
C.1 April 1984 to April 1985
Our primary accomplishments in this period have been the following:

1) completion of modifications to RADIX to accommodate the one hundred-fold
increase in the size of our database to 1700 patients,

2) carrying out and publishing the study of the effect of prednisone on serum
cholesterol on this expanded database,

3) publishing a description of the two-stage regression method adapted by us to this
study,

4) completion of a System Programmer's Manuals and User's Manual
5) initiation of transfer of RADIX to Xerox 1108 personal work stations.
C.1.1 Modifications to RADIX for the enlarged database

Extensive modifications to RADIX were required to deal with the 100-fold increase in
the size of the database. The modifications necessary to run the study module
automatically on the prednisone/cholesterol study were completed this year.

C.1.2 Prednisone/chlosterol study on enlarged database

We have carried out the automated study of the effect of prednisone on serum
cholesterol using the new 1700 patient database. It has strongly confirmed the effect
previously observed in the 50-patient SLE database. In addition, we are examining the
effect in non-SLE patients and in other patient subsets. We are also examining
alternative pharmacokinetic models for the prednione effect using the newly available
ata.

An extensive paper describing the RADIX System and reporting the results of the
prednisone/cholesterol study has been submitted to a major medical journal for
publication.

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RADIX Project 5P41-RR00785-12

C.1.3 Publish description of 2-stage regression method

A detailed description of the 2-stage regression method used by us for the above study
has been sent to a major statistical journal for publication.

C.1.4 Documentation

A two-volume System Programmer's Manual and a User's Manual describing
implementation, maintenance and use of the system at Stanford has been completed. In
addition, a complete set of the files needed for on-line demonstrations has been
created, separating them from the working versions.

C.1.5 Transer of RADIX to D-Machines

Preliminary work on implementing RADIX on D-Machines has begun. This will
continue in coming years.

C.1.6 Other accomplishments

We have presented the results of our research at several conferences during the year.
Additional publications for the year are noted in the section on publications.

In addition, new work on the theory of medical knowledge representation is described
below.

C.2 Research in Progress

Our current work is focusing on problems involved in the representation of medical
knowledge. Specifically, we are developing new methods for representing medical causal
relationships. These have been represented in most other systems as simply binary
relationships with conditional probabilities or certainty factors. In our project we are
exploring the representation of causal relationships using categorical, rank, and real-
valued relationships, as well as binary ones. We anticipate that these relationships will
a) lend greater accuracy to predictions and diagnoses made by medical consultation
systems, and b) will enable medical knowledge bases to be more compact and
perspicuous.

In addition to this theoretical work, we are also pursuing two applications. First, we
are developing a system for using a medical knowledge base to summarize a patient's
time-oriented record. That is, our intended system will take as input a table of signs,
symptoms, and lab values of the patient over time and will transform this into a time-
oriented summary of arbitrary detail. This application draws upon our existing work in
Tepresentation of causal relationships and in labeling time-oriented records.

Our second application involves the development of methods for automating the
discovery of new relationships from time-oriented patient records. Here, we have
elaborated a number of methods that we intend to exploit in a newly designed version
of our discovery module. These methods take advantage of pre-existing medical
knowledge by using analogical reasoning. We expect that this work will be facilitated
by our recent acquisition of the KEE knowledge representation system, courtesy of
Intellicorp, for use on our Xerox 1108's.

D. Publications
1. Blum, R.L.: Two Stage Regression: Application to a Time-Oriented Clinical
Database. (Submitted for publication to the Journal of Statistics in

Medicine.)

2. Blum, R.L.: Prednisone Elevates Cholesterol: An Automated Study of
Longitudinal Clinical Data. (Submitted to the Annals of Internal Medicine.)

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5P41-RR00785-12 RADIX Project

3. Blum, R.L., and Walker, M.G.: Minimycin: A Miniature Rule-Based System
(Accepted for publication by M.D.Computing)

4, Blum, R.L.: Modeling and encoding clinical causal relationships.
Proceedings of SCAMC, Baltimore, MD, October, 1983.

5. Blum, R.L.: Representation of empirically derived causal relationships.
IJCAI, Karlsruhe, West Germany, August, 1983 .

6. Blum, R.L: Machine representation of clinical causal relationships.
MEDINFO 83, Amsterdam, August, 1983.

7, Blum, R.L: Clinical decision making aboard the Starship Enterprise.
Chairman's paper, Session on Artificial Intelligence and Clinical Decision
Making, AAMSI, San Francisco, May, 1983.

8. Blum, R.L. and Wiederhold, G.: Studying hypotheses on a time-oriented
database: An overview of the RX project. Proc. Sixth SCAMC, IEEE,
Washington D.C., October, 1982.

9. Blum, R.L.: Induction of causal relationships from a time-oriented clinical
database: An overview of the RX project. Proc. AAAI, Pittsburgh, August,
1982.

10. Blum, R.L.: Automated induction of causal relationships from a time-
oo clinical database: The RX project. Proc. AMIA San Francisco,
982.

11. Blum, R.L: Discovery and Representation of Causal Relationships from a
Large Time-oriented Clinical Database: The RX Project. IN D.A.B.
Lindberg and P.L. Reichertz (Eds.), LECTURE NOTES IN MEDICAL
INFORMATICS, Springer-Verlag, 1982.

12. Blum, R.L.: Discovery, confirmation, and incorporation of causal
relationships from a large time-oriented clinical database: The RX project.
Computers and Biomed. Res. 15(2):164-187, April, 1982.

13. Blum, R.L.: Discovery and representation of causal relationships from a
large time-oriented clinical database: The RX project (Ph.D. thesis).
Computer Science and Biostatistics, Stanford University, 1982.

14. Blum, R.L.: Displaying clinical data from a time-oriented database.
Computers in Biol. and Med. 11(4):197-210, 1981.

15. Blum, R.L.: Automating the study of clinical hypotheses on a time-oriented
database: The RX project. Proc. MEDINFO 80, Tokyo, October, 1980, pp.
456-460. (Also STAN-CS-79-816)

16. Blum, R.L. and Wiederhold, G.: Inferring knowledge from clinical data
banks utilizing techniques from artificial intelligence. Proc. Second
SCAMC, IEEE, Washington, D.C., November, 1978.

17. Blum, R.L.: The RX project: A medical consultation system integrating
clinical data banking and artificial intelligence methodologies, Stanford
University Ph.D. thesis proposal, August, 1978.

18. Kuhn, I., Wiederhold, G., Rodnick, J.E., Ramsey-Klee, D.M., Benett, S., Beck,
D.D.: Automated Ambulatory Medical Record Systems in the U.S., to be

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RADIX Project 5P41-RR00785-12

published by Springer-Verlag, 1983, in Information Systems for Patient Care,
B. Blum (ed.), Section III, Chapter 14.

19. Walker, M.G., and Blum, R.L:: 4 Lisp Tutorial. (Submitted for publication to
M.D.Computing.)

20. Wiederhold, G.: Knowledge and Database Management, IEEE Software
Premier Issue, Jan.1984, pp.63--73.

21. Wiederhold, G.: Networking of Data Information, National Cancer Institute
Workshop on the Role of Computers in Cancer Clinical Trials, National
Institutes of Health, June 1983, pp.113-119.

22. Wiederhold, G.: Database Design (in the Computer Science Series)
McGraw-Hill Book Company, New York, NY, May 1977, 678 pp. Second
edition, Jan. 1983, 768 pp.

23. Wiederhold, G.: IN D.A.B. Lindberg and P.L. Reichertz (Eds.), Databases for
Health Care, Lecture Notes in Medical Informatics, Springer-Veriag, 1981.

24. Wiederhold, G: Database technology in health care. J. Medical Systems
5(3):175-196, 1981.

II. INTERACTIONS WITH THE SUMEX-AIM RESOURCE

A, Collaborations

During the past year we completed System Programmer's Manuals and a User's Manual
as steps towards making the system available to outside collaborators. Once the RADIX
program is developed, we would anticipate collaboration with some of the ARAMIS
project sites in the further development of a knowledge base pertaining to the chronic
arthritides. The ARAMIS Project at the Stanford Center for Information Technology is
used by a number of institutions around the country via commercial leased lines to
store and process their data. These institutions include the University of California
School of Medicine, San Francisco and Los Angeles; The Phoenix Arthritis Center,
Phoenix; The University of Cincinnati School of Medicine; The University of
Pittsburgh School of Medicine; Kansas University; and The University of Saskatchewan.
All of the rheumatologists at these sites have closely collaborated with the development
of ARAMIS, and their interest in and use of the RADIX project is anticipated. We
hasten to mention that we do not expect SUMEX to Support the active use of RADIX

E. H. Shortliffe 124
5P41-RRO00785-12 RADIX Project

as an on-going service to this extensive network of arthritis centers, but we would like
to be able to allow the national centers to participate in the development of the
arthritis knowledge base and to test that knowledge base on their own clinical data
banks,

B. Interactions with Other SUMEX-AIM Projects

This past year, in moving our work to the Xerox 1108's, we have had frequent
consultations with members of the Oncocin staff and have made use of several utility
programs developed by them including hash file facilities and programs facilitating the
tabular display of data.

Regular communication on programming details is facilitated by the on-line mail
system.

C. Critique of Resource Management

The DEC System 20 continues to provide acceptable performance, but it is frequently
heavily loaded at peek hours.

The SUMEX resource management continues to be accessible and and quite helpful.

III, RESEARCH PLANS

A. Project Goals and Plans

The overall goal of the RADIX Project is to develop a computerized medical
information system capable of accurately extracting medical knowledge pertaining to the
therapy and evolution of chronic diseases from a database consisting of a collection of
stored patient records.

SHORT-TERM GOALS --

For the past two years we have concentrated principally on publishing and presenting
our earlier AI results, on acquisition of a 1700 patient database, on medical studies
based on the enlarged database, and on Teporting the medical results and statistical
techniques arising from our research. This is in concert with the long-term goal of
ensuring that the work of the SUMEX / Artificial Intelligence in Medicine community
be disseminated and applied in the general medical community.

During the coming two years we will concentrate much more on the artificial
intelligence aspects of RADIX. We were successful last year in obtaining funding from
the National Library of Medicine and the National Science Foundation to pursue this
work. In particular, we will be deeply concerned with the Tepresentation of causal,
temporal, and quantitative medical knowledge. It has become clear that these types of
knowledge are crucial for the RADIX tasks of automated discovery of medical
knowledge and the provision of intelligent automated assistance to clinical Tesearchers,
in addition to their generally perceived value in other medical expert systems
applications.

LONG-RANGE GOALS -- There are two inter-related long-range goals of the RADIX
Project: 1) automatic discovery of knowledge in a large time-oriented database and 2)
provision of assistance to a clinician who is interested in testing a specific hypothesis.
These tasks overlap to the extent that some of the algorithms used for discovery are
also used in the process of testing an hypothesis.

We hope to make these algorithms sufficiently robust that they will work over a broad
range of hypotheses and over a broad spectrum of data distributions in the patient
records.

125 E. H. Shortliffe