Explorer-2: A Multi-Modal Knowledge Management

Framework for Medical Education and Decision Support

Robert A. Greenes, MD, PhD, David Tarabar, MS, Eric Slosser

Decision Systems Group, Brigham and Women's Hospital

Harvard Medical School
Boston, Massachusetts, USA

1.

Introduction

Physicians today are faced with "data overload", and paradoxically, "information underload" - inability to locate pertinent,
needed knowledge in a sea of data in which they are inundated.
In the Decision Systems Group we have focused on the development of a prototype desktop knowledge management environment known as Explorer-2[ 1], with the objective of providing a
consistent interface for access to a wide variety of knowledge.
We define the term knowledge quite broadly as any organization, analysis, or interpretation of observations or data that
conveys a higher level of understanding. We differentiate (1)
passive knowledge, contained in books, articles, pictures, data
bases, or other repositories of knowledge content; from (2)
dynamic knowledge, the result of an active process of organization and analysis of data according to principles or defined
methods or heuristics (e.g., inference or simulation).
Physicians and students have need for three major kinds of
capabilities which we broadly classify as "knowledge management" [2]: (1) direct access to knowledge for problem solving;
(2) support for browsing and the pursuit of curiosity; and (3)
the ability to personalize knowledge, by creating and saving
annotated, tailored pathways through available knowledge
resources. Hypertext-oriented systems [3,4] provide useful and
previously unavailable capabilities for enhanced browsing and
navigation. However, a broader range of knowledge types must
be supported, and a larger repertoire of knowledge management
and knowledge access capabilities are required.
2. Explorer-2 Features

Initial applications of Explorer-1 were chosen based on availability to us of static knowledge bases and expert systems modules which could be adapted to Explorer-i use. Each knowledge
domain
certain

presented
unique problems of organization, presentation, user interface, and implementation, which could serve
to uncover needed design features of Explorer-1. In addition,
the prospect of providing a knowledge interface tool capable of
providing access to knowledge in all three domains was intended
to approach the provision of a critical mass of capability we
believe is essential for continued use of, and reliance on, knowledge management systems by the health care professional.
Explorer-2 provides access to the knowledge resources available
in Explorer-i plus certain new ones.
Current knowledge resources in Explorer-2:

CASPER (Computer-Aided Sekection of Procedures and Evalu

ation of Results) - This resource is intended to aid in
determination of optimal diagnostic workup strategy for a
clinical problems involving imaging procedures [5]. Its
knowledge is based in part on a monograph assembled by
our Department of Radiology [6]. It includes problemspecific expert opinion, suggested algorithms for patient
workup, data characterizing specific imaging tests, and
dynamic procedures for relating contemplated tests to
patient-specific factors [7,8].

In pursuit of the above objectives, our system development

efforts initially focused on a prototype knowledge management
shell known as Explorer- 1[4], and are now concentrated on
completion of its successor, Explorer-2 [1]. Our approach
involves concurrently developing system features and utilizing
the system in a variety of application areas, in order to help
uncover the principles of design that appear to be optimal. The
implementation of Explorer-i was done for the Macintosh
computer (Apple Computer, Inc.), and was written largely in
Pascal. Explorer-2 is an object-oriented reimplementation of
Explorer-i that provides access to more diverse types of
knowledge, does so in a more modular fashion, enhances
browsing and search capabilities, and facilitates extensibility.
The demonstration will focus on the design and features of use
of Explorer-2. These features include capabilities for access to
knowledge of a multiple types, in a wide variety of knowledge
domains, via a number of possible modes:

0195-4210/89/0000/1024$01.00 1989 SCAMC, Inc.

keyword or index-term access to knowledge units

hypertext or menu-based access to other knowledge units
hierarchical access to knowledge units that have structural
(e.g., outline-based) relation to one another
dynamic knowledge invocation, for invoking procedural
units which are available to Explorer-2
overview/browsing capabilities, for viewing pathways
through the knowledge base and potential links from each
knowledge unit
tailoring ofpersonal access paths for subsequent use

QMRTm

With the cooperation of the University of Pittsburgh

(R. Miller et al) we have incorporated both the knowledge
base and inference procedures of this microcomputer-based
version of

INTERNIST-1[9].

Medical pathophysiology and therapeutics - Portions of two

well-known textbooks of medicine were adapted for use
with Explorer-2, on an exploratory basis with the publishers. The aim was to gain experience with the problems of
converting existing material created for print publication into
a format suitable for hypertext access.

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References

Clinical algorithms as guidelinesfor medical care - We have

been collaborating with the Harvard Community Health Plan
to provide a representation method for dynamic access to a
set of clinical algorithms [10], permitting portions of them to
be viewed selectively, to adapt to patient data that are known
or provided, and to provide explanatory information and
links to other information via hypertext links.

[1] Tarabar DB, Greenes RA, Slosser ET: An object-oriented

software architecture for the Explorer-2 knowledge management environment. Proc. 13th Annual Symposium on
Computer Applications in Medical Care (SCAMC); 1989,
New York: IEEE Computer Society Press; in press.
[2] Greenes RA: Knowledge management as an aid to medical
decision making and education: The Explorer-I system.
Proc MEDINFO 86, North-Holland: Elsevier Science
Publishers B.V., 1986: 895-899.
[3] Conklin EJ: Hypertext: An introduction and survey. IEEE
Computer 1987; 2 (9): 17-41.
[4] Smith JB, Weiss SF, eds: Special Issue: Hypertext.
Commun of ACM 1988; 31 (7).
[5] Greenes RA, Tarabar DB, Krauss M, Anderson G, Wolnik
WJ, Cope L, Slosser E, Hersh W: Knowledge management as a decision support method: A diagnostic workup
strategy application. Computers and Biomed. Res., 1989;
22: 113-135.
[6] McNeil BJ, Abrams HL, eds.: Brigham and Women's
Hospital Handbook of Diagnostic Imaging, Little, Brown,
and Co., 1986.
[7] Greenes RA: Computer aided diagnostic strategy selection.
Rad Clinics of North America, Philadelphia: WB Saunders Co, 1986; 24(1): 105-120.
[8] Pollack MA, Greenes RA: A pictorial simulation construction kit for enhancing knowledge-based learning. Proc
MEDINFO 86; 1986. Amsterdam: Elsevier Science Pub'lishers; 887-890.
[9] Miller RA, McNeil MA, Challinor SM, Masarie FE, Myers
JD: The INTERNIST-l/ QUICK MEDICAL REFERENCE project - Status Report. Western J Med 1986;
145: 816-822.
[10] Abendroth TW, Greenes RA, Joyce EA: Investigations in
the use of clinical algorithms to organize medical knowledge. Proc. 12th Annual Symposium on Computer
Applications in Medical Care (SCAMC); 1988, New York:
WEE Computer Society Press; 90-93.
[11] Komorowski HJ, Greenes RA, Barr C, Pattison-Gordon
E: Browsing and authoring tools for a Unified Medical
Language System. Proc. RIAO 88 Conference: UserOriented Content-Based Text and Image Handling,
Massachusetts Institute of Technology, Boston, MA,
March 1988; 624-641.
[12] MEDLINE Knowledge Finderm, Aries Systems Corporation, North Andover, MA.

Other existing knowledge resources. currently being incorporated into Explorer-2:

A Prototype Semantic-Net Representation of Medical Taxonomy
- As part of our collaboration on the Unified Medical Language System (UMLS) project sponsored by the National
Library of Medicine, we have built a semantic net browser
for exploring structured medical taxonomies[1 1], both as a

tool for directly identifying pertinent taxonomic relationships

and as a query interface. We have incorporated the MeSH
taxonomy into this browser, and have enhanced it with
additional semantic relationships and other concepts.

MEDLINE Server - In collaboration with a vendor of a

CDROM-based MEDLINE search product [12], a
background search engine is now operational that provides
MEDLINE searches on demand from other applications.
This can be invoked from the context of any of the above
knowledge resources.
Medical Image Library - We are currently engaged in two
projects that require use of an optical disc library of medical
images, particularly radiologic. As part of this effort, we
have developed an indexing and storage scheme using our
semantic net taxonomy to permit these images to be accessed
by any of the above applications.
We assessed the use of Explorer-i with respect to queries of the
CASPER knowledge base, by radiologists. The subjects were
unequivocal in their evaluation of the system as being extremely
easy to use and desirable. The main deficiencies they noted
were lack of knowledge in topic areas they wished to explore,
arguing for extension of the knowledge base in those directions.
These results support the view that use of the computer as a
knowledge resource is limited primarily by lack of "critical
mass" of content, and not by fundamental technological barriers.

3. Future Directions
A number of issues are involved in considering how to achieve
widespread use of the model represented by Explorer-2. Further
progress in developing computer-based knowledge resources
depends on the addressing of such issues as support for authoring and content development, means for integration of increasingly diverse knowledge resources, need for enhanced scripting
for linkage among knowledge units, and importance of im-

proved taxonomies and indexing methods for user-directed

query. We also wish to gain increased experience with the use
and adaptation of our knowledge management capabiities in both
curriculum settings and clnical environments. Our current and
future efforts are aimed in these directions.
ACKNOWLEDGMENT. This work was supported in part by
grants LM03401 and LM07037 from the National Library of
Medicine, and by a grant from the CAMDAT Foundation, Farmington, CT. Explorer-2 development reflects contributions of
a number of individuals in the Decision Systems Group, among
them Thomas Abendroth, M.D., Lawrence Cope, Stephan
Deibel, William Hersh, M.D., Edward Pattison-Gordon, M.S.,
and Jan Snydr-Michal.

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