A patient who arrives at a hospital or doctor's office in the Northeastern United States complaining of flu-like symptoms and presenting a red, slowly expanding bull's-eye marking on his or her skin will quickly be diagnosed with Lyme disease. Healthcare workers in the Northeast are all too familiar with the distinctive rash that is the disease's telltale sign.

But many other skin inflammations that indicate equally serious conditions aren't as unique as the rash caused by Lyme disease. That's what frustrates medical professionals: The red, itchy bumps driving a patient to distraction might be an annoying but harmless heat rash, the measles, an allergic reaction to medication, or an indicator of exposure to anthrax spores. Determining the likely cause using traditional diagnostic tools can be tricky.

Java Platform Offers Crucial Interoperability Logical Images founder Dr. Art Papier says the Sun Java platform was the natural choice for programming VisualDx since he wanted to build an open-ended solution. "We knew that the underlying search technology that powers VisualDx could be used for any sort of visually based search tool, from gardening information—for example, 'What is that fungus on my plants?'—to a complete encyclopedia," Papier says. "We don't see any limits for VisualDx, and Java technology adds to the options by not restricting any further development to one software platform." Java is also the programming language of choice for providing interactive content that must be refreshed in real time. Logical Images must ensure that the information in its medical applications is rigorously updated, and Java technology's advanced network capabilities enable new information to be seamlessly added to each module's word and image databases. "Java is a full-featured, object-oriented language that supports Web-deployed as well as standalone installations," says Bill Haake, Logical Images manager of engineering. "It is also more platform independent than other languages."

"The text references used to identify visually diagnosable conditions are really difficult to work with," says Dr. Art Papier, M.D., assistant professor of dermatology and medical informatics at the University of Rochester Medical Center and founder and chief scientific officer at Logical Images, which develops interactive point-of-care diagnostic and training software to help healthcare workers respond to and accurately diagnose and treat disease.

"Often the clinician must know the name of a diagnosis to find information on it or has to flip through a book to try to match its photographs with a patient's presentation," Papier says. "Obviously, neither of these procedures is ideal. It takes too long to find the information, and since rashes in themselves aren't always distinct indicators of disease, there is a margin for error."

In addition, 10 to 20 percent of patient visits to general practitioners include skin complaints. However, there is evidence that in many of these instances the physicians order the wrong tests and misdiagnose dermatologic and other visually diagnosable problems, according to numerous studies published in the Journal of the American Academy of Dermatology and the Archives of Dermatology over the past decade.

To address these issues, Papier conceived a solution that has since become VisualDx, Logical Images' flagship product. By integrating photos of skin conditions and diagnostic information with a powerful, easy-to-use search tool, VisualDx enables healthcare workers to quickly assess and treat hundreds of rare and common conditions.

A university study (PDF) assessed 50 doctors' ability to diagnosis difficult cases by using VisualDx compared to the doctors' reference textbooks containing pictures. Results showed that diagnostic accuracy doubled using the VisualDx technology.

Visual Diagnosis

When making a diagnosis with the help of VisualDx, a physician starts by selecting icons that match the visual symptoms the patient presents. The physician then narrows the field by selecting from pull-down menus or typing other physical symptoms—for example, fever, pain, or lethargy—and other possible diagnostic cues, such as a patient's occupation, recent travel, family history, prescribed medications, and so on.

Since the program was built using the Sun Microsystems Java platform (see sidebar), users can take advantage of the "type ahead" feature, which lets them type just the first few characters of a file name to select a desired document from VisualDx's database. Type ahead speeds up data entry, an obvious plus in a fast-paced medical environment.

As the system collects details, the possibilities narrow. A physician may end a search with a definitive diagnosis or with two or three possibilities, and can then easily compare and contrast his or her patient's symptoms to the detailed, high-resolution photos displayed onscreen. These images show skin conditions in various stages and on skin of various colors—not just the most severe stage of a disease as it appears on Caucasian skin, which is what physicians are often stuck with in dermatology reference books.

Once the diagnosis has been made, healthcare workers can consult VisualDx's built-in knowledge base for a concise synopsis of the disease, recommended tests and therapy, issues to be aware of, and other important information provided by doctors who are recognized experts in their field.

The program also updates itself automatically with the latest medical information and images. On the server side, VisualDx supports the Sun Solaris UltraSPARC and Solaris x86 platforms; it also runs on the Solaris Operating System for x86 on the client side.

VisualDx is sold in modules that can be deployed according to the individual needs of a medical facility or practice. Modules available now cover infectious disease (including bioterrorism), adult dermatology, dark skin dermatology, gynecological conditions, drug eruptions, smallpox vaccination, and terrorism recognition (visual diagnosis of diseases and conditions caused by weapons of mass destruction).

Two modules covering pediatric disease, another focused on sexually transmitted disease, and a fourth covering travel and internationally acquired disease will be available in September 2004. The travel module allows a doctor to request data for any country in the world and view the rashes and infectious diseases that might affect a patient who lives in or has visited a particular region.

One Solution, Many Applications

Papier says many healthcare organizations are especially interested in VisualDx's ability to aid physicians in the early detection of infectious diseases caused by potential bioterrorism agents, chemical warfare, and radiation.

"When VisualDx was first released in March of 2001 the doctors who saw the technology thought it was a great improvement on any of the existing resources, but many complained there was too much attention on the bioterrorism diagnoses such as smallpox," says Papier.

"In particular I remember one emergency room doctor telling me that smallpox had been eliminated and that it was not really a concern. Before 9/11 and the events of the fall of 2001 involving anthrax there were just a handful of people talking about bioterrorism. And, truthfully, we only included the bioterrorism information to be complete and thorough," he says.

But the world has changed, and health professionals now want to ensure their ability to respond to diseases that they never expected to see.

"While we've improved our readiness, I doubt that there are many healthcare workers outside major urban areas who have the skills to recognize the symptoms of diseases that are likely to be an issue should this country ever experience a bioterrorism attack," says Samuel Finkle, a retired dermatologist who has independently studied the history of epidemics for the last 34 years.

"Ask yourself how quickly the diagnosis of septicemic plague would pop into your head if you were examining a patient who had a rash, fever, and stomachache," says Finkle. "But, left untreated, septicemic plague—which is classified by the Centers for Disease Control and Prevention as a Category A bioterrorism agent—will absolutely kill a patient within 24 hours."

Papier adds that nervousness about bioterrorism can lead to false alarms, which VisualDx can help combat.

"There have been no cases of intentionally spread anthrax in about two years, or any other bioterrorism-related diagnosis for that matter," he says. "So how do you keep these diagnoses in the minds of busy health professionals without flooding the system with mistaken diagnoses?

"Public health officials and emergency physicians are just as concerned about the issues around false alarms and false-positive diagnoses of smallpox as they are missed diagnoses of bioterrorism. In fact there have been dozens of cases around the United States of false alarms closing emergency rooms. Rashes are common, and severe blistering rashes have been mistaken for smallpox. The strength of VisualDx is that it helps doctors diagnose all rashes more accurately, thereby avoiding the false alarms."

Finkle says he believes physicians are more likely to arrive at a correct diagnosis if they are using an electronic diagnostic tool with a broad base of options, as opposed to a reference book that separates information into discrete, linear sections.

"Visual references are the biggest key to diagnosing skin diseases and conditions with primary symptoms that manifest in the skin," says Finkle. "I wish this product had been available when I was in practice."

The VisualDx platform is currently being expanded to other areas within healthcare, including oral care and dentistry, but the patent-pending technology that powers the application can be applied in any situation where a user knows what something looks like but doesn't know what words to enter in a search query.

"Purposefully designed tools to aid recognition is what we are about, as well as the organization of digital images and knowledge," says Papier of Logical Images. "The opportunities for advancing healthcare research, epidemiology, and patient care are enormous. As medicine finally embraces computerized records, we are just now beginning to see the tools that will enhance care and reduce costs."