CAMEOS HANDBOOK

1. TABLE OF CONTENTS

1. INTRODUCTION

2. HOW TO USE CAMEOS - P

3. DATA ENTRY INTO CAMEOS SYSTEM

4. INTERPRETATION OF CAMEOS OUTPUT

5. CAMEOS PRODUCT FUTURE

2. HOW TO USE CAMEOS-P

HOW TO USE CAMEOS PROGRAMS IN CLINICAL PRACTICE

The following notes are applicable to CAMEOS adult and pediatric versions ONLY
1. Programs are available as web applications
2. Programs are available as integrated modules for EMRs
3. Programs can be used live during an average primary care consultation
4. Although the system has nearly 3000 to 4000 symptoms not all of these need probing in a given consultation
5. At a given consultation as in a usual consultation first identify the body system at fault
6. Then collect the relevant presenting symptoms and signs
7. Then run the CAMEOS and first go to the relevant body system in the program symptom panel
8. Then locate a few of the symptoms in the area where the body system located in the system
9. Then probe for the 5 or 6 symptoms up or down that location
10. Then click for the advice
11. Advice can be saved in your phone or if you so wish can be saved in the system also giving password
12. You may then retrieve the data at a later time for follow up

ASSUMPTIONS ABOUT THE USERS AND THE USAGES OF THE CAMEOS
1. CAMEOS is Computer Assisted Medical Evaluation of Symptoms - for PRIMARY CARE and for PRIMARY CARE PHYSICIANS
2. The physician is expected to convert the patients symptom experience into a searchable and specific indicant
3. The users are not expected to be diagnostic experts nor poor diagnosticians - because you need a basic ampunt of medical knowledge and clinical experience in primary care to get the maximum power of the system
4. The system can be used as a diagnostician, documentation expert, reasoning wizard.
5. CAMEOS has 4 major lines of developments - CAMEOS - A for adults, CAMEOS - P for paediatrics, CAMEOS - S for Symptom Checkers, CAMEOS - M for minor usages like diet consultations, developmental screen, vaccines expert and surgery modules etc etc.

USES OF CAMEOS - P FOR PRIMARY CARE PHYSICIANS
(BENEFITS OF CAMEOS - P FOR PRIMARY CARE PHYSICIANS)

1. Generation of most probable diagnosis

2. Generation of a list of differential diagnosis

3. Generation of all the steps taken in making a diagnosis in a given case

4. Reasoning steps for generating the list of differential diagnosis list

5. Mapping of the input symptoms, disease and the management triad of the clinical encounter

6. Autodocumentation of the primary care clinical encounter - the physician has to enter the input symptoms elicited from the patient. The rest is generated by the CAMEOS - P

7. Autocorrection feature for readjustment of the probabilities based on the repeated re-evaluation of the patient for more and refined history taking

8. Autoindexing based on ICD11 of all the common diagnoses made by the system

9. Segregation of the diagnosis from the management. CAMEOS - P does the job of making of the diangosis based on your input. Physician does the managment based on other information gathered during the consultation\

10. Practice of evidence based medicine ensured

11. Availability of the current guidelines on diagnosis of the primary care diseases at the point of care

12. Providing a foundation for continuous professional development

13. Providing a evidence based template for the structured data entry for a clinical encounter

14. Availability of the CAMEOS - P at the point of care where the clinical encounter is taking place

15. Providing a foundation for medical research and audit by way of big data analysis in the future

16. Use of a validated and reliable tool for the differential diagnosis in primary care

17. A unique diagnostic strategy attempting to reduce diagnostic errors - eg dyspepsia
Dyspepsia => functional dyspepsia -> treatment resistent or progressive dyspepsis => UGIE negative dyspepsia
=> Gluten sensitivity, Celiac disease, Wheat allergy
Any symptoms => treatment reractory => progressive => severity high => identification of the boundaries of primary care morbidity
Multiple symptoms => unexplained within the boundaries of primary care morbdidity => Early referral to other specialists so that diangosis is not delayed

18. Moving towards new developments in the health care industry : after visit summary generation, medication reconcilliation, helath care safety issues, digitalization of healthcare, adoption of ICD 11,

19. Moving towards new Healthcare Information Technology (HIT) initiatives - electronic pescribing, Computerized Physician Order Entr (CPOEs)

20. CAMEOS - P solves the problem of missed diagnosis, overdiagnosis and underdiagnosis in primary care (SHOW HOW ?)

21. ECODE (Error Correction Of Diagnostic Evalutions) mechanim built into the CAMEOS-P is the reason for benefit number 20. But ECODE has other benefits as well. Someof these are :
a. Record of detailed diagnostic evaluations carried out by the attending physician
b. Record of diagnostic reasoning behind the attending physician's diagnosis
c. Providing a baseline documentation for the further self audit of diangosis in primary care
d. Providing a baseline prevalence and or incidence of dianognostic problems
e. Providing comparative evidence for the efficiency of clinical practice guidelines - particularly those developed outside of the primary care
f. Providing data for an epidemiology of diagnostic problems in primary care
SEE BELOW FOR EXAMPLES OF
ECODE (Error Correction Of Diagnostic Evalutions)

22. Reduction of unncessary lab investigations based soley on the suggested investigations by the systems :
See the following examples :

Gononcoccal Conjunctivitis
$conjnn = array("D1 - D10 neonate",","days 2-7 after birth usually","In first month of life","eyes red","eyes red bilateral","eye papillae","eye discharge purulent","eye discharge copious","severe injection","chemosis","ph recent maternal gonorrhoea","Discharge Gram stain gramp positive cocci in clsuters","GC culture positive");
"Tx - Ceftriaxone 50mg/kg IM single dose should not exceed 125mg, topical antimicrobials are not recommended. Treat mother and her sexual partner. Insert from guidelines. Dx Ref - https://emedicine.medscape.com/article/1191730-overview, https://emedicine.medscape.com/article/797874-overview",

23. So much of knowledge base required for optimal practice of primary care medicine in integrated into the system - for instance with your good history taking skills some of the most complex clinical evaluations which are possible with the CAMEOS are :

a. Evaluation of a neonate
b. Evaluation of developmental milestones
e. Evaluation of comorbidity by using the statistic of rule out comorbidity
f. Evaluation of complex chronic diseases NCD as well as any other ongoing and recurrent medical problems

THERE ARE MANY WAYS TO USE THE CAMEOS - P

1. You can evaluate the patient using the symptom panel as a Pro Forma. For instance within few
seconds of a medical consultation the system at fault is discerned. Then use the relevant module
in the symptom panel. This is advised when the system is used for educational purposes. This method
may also be used by physicians just entering the speciality of the primary care.

2. You can also evaluate the patient using the principle of neighbouring item approach. Here you will
evaluate the patient and get the key symptom of the presentation. Then go to the symptom panel and select
the key item in the panel. Then probe for the 5 items above and 5 item below. Then either you will get a diagnosis
or you may not. In the latter probe for more key symptoms in the patient's history. Then do the same
as above until you get a dignosis or exclude the common problems

3. An expert in the primary care diagnosis may focus on the symptoms in the symptom panel based on the
principle of descending prevalance ordering. The items in the symptom panel are not in the alphabetical
order. There is a reason for this. If this is the case then selecting fever and then wheeze may need
many clicks or scrolls which is time consuming. Prevalence ordering means that the symptoms which
occur together commonly based on the prevalance of diseases in the primary care are kept close together.
In fact an expert may see the dignostic patterns by visually scanning the symptom panel.

4. There is also an approach referred to as progressive diagnostic refinement by probabilities. Here
the physician runs the program once. Then the output of the program is evaluated for the diagnostic
probabilities. The probabilities given in the output are modifiable as the symptoms reported and symptoms
unreported are given in the output. Then focus on the synmptoms unreported by the patient and focus
and probe deeply for these from the patient. If any found positive and then re-entered the diagnostic
probabilities of the output can be increased and the final diagnosis may change.

5. The knowledge base for the system is based on identifying the common problems in the primary care
first. If there is no diagnosis or elese the diagnostic probabilities reported are very low say below
40% then one may analyse the output for progressive diagnostic refinement by probabilities. If this
also fails the chances are that either index case is a rare disease, uncommon in primary care but common
in other settings like gastroenterology or cardiology or the patient may be normal. To complete the
clinical evaluation then go to the red flag module of the system.

DATA ENTRY RULES
1. Organize your symptoms experience in your mind
2. If you have many symptoms determine the duration of each symptoms. All the symptoms with similar durations comprise 1 illness experience
3. CAMEOS ASC is designed to accommodate single illness experience in 1 run. Each set of multiple symptom sets require a separate run of the program
4. Once you start the progam and is in the home page http://pcdg.info/cameos.php
click the start button. This will bring the symptom panel
5. In the symptom panel symptoms are arranged in major categories - namely
PHELGM SYMPTOMS, BOWEL SYMPTOMS, SINGLE SYMPTOM SYNDROME, GENITAL SYMPTOMS, GYN SYMPTOMS,
JOINT AND MUSCLE SYMPTOMS, EMOTIONAL SYMPTOMS. There are many more catogories of symptom collections
6. You have to select the category of symptoms for which your symptoms belong
7. Then you can focus your attention only to the items in that category
8. If you have many symptoms for which most of the consultants have expressed the opinion that nothing wrong can be found then you can focus on the emotional symptom section
9. SINGLE SYMPTOM SYNDROME is for evaluation of chest pain, backache and abdominal pain when they are not accompanied by any other symptom referrable to the system concerned
10. To select a symptom click on the symptom
11. To select many symptoms press 'ctrl' button in your key pad and click with mouse each symptom
12. To deselect press 'ctrl' and click a selected symptom then it is deselected
13. Once you are stisfied you have correctly entered the symptoms of you illness experience then click advice button
14. The program will run without any other data
15. But if you want to have a copy of your consultation then enter the data in the text fields and run the
program as usual. Click 'advice' to get the output. Them click 'record button to 'save' data

3. DATA ENTRY INTO CAMEOS - P

HOW TO ENTER DATA FOR A CASE OF URTI

1. Focus on the Respiratory Module
2. Click and Select fever few day, cold few days, cough few days, sore throat few days, swallowing difficulty few days, hoarseness few days,
3. Click and Select the from the ILLNESS DATA PANEL - First episode, current episode < day, Total duration < 1 month, illness onset sudden, Continues in the same severity, consultation number, degrees of functional status in impairment, disability and handicap, Select the applicable FAMILY MEDICINE VITAL SIGNS
4. Click the diagnose button and you will get the CAMEOS-P output

HOW TO ENTER DATA FOR A CASE OF URTI NOT RESPONDING TO THE FIRST CONSULTATION
1. Focus on the Respiratory Module
2. Click and Select fever few day, cold few days, cough few days, sore throat few days, swallowing difficulty few days, hoarseness few days,
3. Click and Select the from the ILLNESS DATA PANEL - First episode, current episode < few weeks, Total duration < 1 month, illness onset sudden, Progressive severity, consultation number, degrees of functional status in impairment, disability and handicap, Select the applicable FAMILY MEDICINE VITAL SIGNS - may be smoking, obesity, alcohol etc
4. Click the diagnose button and you will get the CAMEOS-P output

HOW TO ENTER DATA FOR A CASE OF MIGRAINE
1. Focus on the headache module
2. Click and select headache, headache attack lasts 4-72 hrs, headache unilateral, headache throbbing, severe headache, headache worsen with physical exertion, headache and vomiting
3. Now focus on the ILLNESS DATA PANEL - select Recurrent episode (migraine by definition is recurrent), current episode few days, total duration < 1 yr, illness onset sudden, illness in discrete attacks, continues in the same severity, consultation number, functional status according to the definitions given in the glossary
4. Click on the relevant Family Medicine Vital Signs
5. Click the diagnose button and you will get the CAMEOS-P output

HOW TO ENTER DATA FOR A CASE OF MIGRAINE and TENSION HEADACHE or A MIXED HEADACHE DSIORDER
1. Focus on the headache module
2. Click and select headache, headache attack lasts 4-72 hrs, headache unilateral, headache throbbing, severe headache, headache worsen with physical exertion, headache and vomiting
3. You will have a another set of symptoms suggestive tension headache - may be the same or different duration - enter them also
3. Now focus on the ILLNESS DATA PANEL - select Recurrent episode (migraine by definition is recurrent), current episode few days, total duration < 1 yr, illness onset sudden, illness in discrete attacks, continues in the same severity, consultation number, functional status according to the definitions given in the glossary
4. Click on the relevant Family Medicine Vital Signs
5. Click the diagnose button and you will get the CAMEOS-P output

HOW TO ENTER DATA FOR A CASE OF DIABETES CONSULTATION
1. Focus on the Chronic Disease Manager Module of CDMM
2. Select Diabetes
3. Focus on CDMM Overall Management - Parameter is the blood sugar or Hba1c, impairment, disability, handicap, emotions as relevant, Quality of Life,
4. Focus on the CDMM - Knowledge - patient's knowledge about the disease
5. Focus on the CDMM - Empowerment - how the patient copes up with the illness experience
6. Focus on the CDMM - Adherence - the degree of adherence to the prescribed regimen
7. Focus on the CDMM - Patient Engagement - steps taken to empower patient
8. Focus on the CDMM - Disease related Quality of Life - patient's perception of physical and mental health as experiencing the illness experience of the known disease
9. Focus on the CDMM - Selfcare

HOW TO ENTER DATA FOR A CASE OF multi-morbidity (URTI and Migraine)
1. Focus on the patients history - particularly the symptoms and their duration
2. You will observe 1 set of symptoms are merely of day duration
3. You will observe 2nd set of symptoms for years or months and recurrent
4. Obviously you run the program twice - once for each set of symptoms
5. If you happen to enter all the symptoms together this will be caught as the rule out probability and comorbidity probability

4. INTERPRETATION OF CAMEOS-P OUTPUT

INTERPRETATION OF THE OUTPUT

Explanatory probability = number of symptoms common to both the patient and the disease / number of symptoms elicited from the patient
Contributory probability = number of symptoms common to both the patient and the disease / number of symptoms in the disease set
Rule out probability = number of symptoms not seen in the disease symptom collection / number of symptoms in the disease set
Alternate disease probability = number of symptoms not seen in the patients' symptom collection / number of symptoms in the patient's symptom collection

Explanatory probability is directly proportional to the probability of having a given disease
Contributory probability is directly proportional to the degree of confidence in making the given diagnosis with a given explanatory probability
Rule out probability is directly proportional to the degree of confidence in ruling out a given diagnosis.
Alternate disease probability is directly proportional to the degree of confidence in having another disease as an explanation for the patients diagnosis.

CAMEOS - P OUTPUT DETAILED
Major Sections of the Output include :
Symptoms Reported - Symptoms you have collected from the patient during history taking
Illness Data Reported - duration, severity, disability, impairment and handicap associated with each illness experience
Calculating the Diagnostic Statistics for each Diagnosis in the Differential Diagnosis - For each disease considered by the inference engine the following information is given : number of the symptoms complained of, number of symptoms not complained of, input symptoms unexplained by the diagnosis, explanatory probability, contributory probability, rule out probability, comorbidity probability with the respective probabilities
Differential Diagnosis by Explanatory Probability
Differential Diagnosis by Contributory Probability
Rank Ordering of the Diagnoses by Descending Order of the Explanatory Probability
Rank Ordering of the Diagnoses by Descending Order of the Contributory Probability
Final Diagnosis and the Required Treatment
See the explanation for details and interpretation of the above probabilities

INTERPRETATION OF THE CAMEOS - P OUTPUT
Explanatory probability = number of symptoms common to both the input and the disease / number of symptoms in the input set
Contributory probability = number of symptoms common to both the input and the disease / number of symptoms in the disease set
Rule out probability = number of symptoms not seen in the disease symptom collection / number of symptoms in the disease set
Alternate disease probability = number of symptoms not seen in the disease symptom collection / number of symptoms in the input set
Explanatory probability is directly proportional to the probability of having a given disease. Contributory probability is directly proportional to the degree of confidence in making the given diagnosis with a given explanatory probability. A disease may have a very high explanatory probability but with a very low contributory probability. This may happen when the user input set has few symptoms all of which are seen in the disease array but diagnosis set has so many other indicants not endorsed by the user. The converse too may happen. A given disease may have a low explanatory power with a very high contributory probability. The formula given above clearly shows that this can happen when there are many unrelated symptoms in the input set but all the indicants required to make a diagnosis of the given disease are seen. So then obviously there are many unexplained indicants by the selected diagnosis.
Rule out probability is directly proportional to the degree of confidence in ruling out a given diagnosis. This is because the number of indicants in the complement set is high in comparison to the number of indicants in the disease indicant set. To put it another way as the complement set contains elements not seen in the disease set higher the number of these elements the chances are the disease needs to be ruled out from the diagnostic considerations .
Alternate disease probability is directly proportional to the degree of confidence in having another disease as an explanation for the patients diagnosis. For instance when the alternate disease probability is high the number of input symptoms not seen in the elements of the disease set is high. So then one has to look for other possibilities. But this does not mean the disease whose alternate disease probability is high is the disease to be considered. But any other disease might explain the patients problem. It cannot point to the alternate disease. Thus it cannot be called a rule in probability.
So these statistics gives the mathematical basis for the explanation module of the inference engine.

NOTES FOR FURTHER INFORMATION TO THE USERS

1. Give the patient population for which CAMEOS-P can be used and CAMEOS-C and CAMEOS-S can be used respectively :

CAMEOS - P - to be used in primary care adult consultations ONLY
CAMEOS - C - to be used in primary care pediatric consultations ONLY
CAMEOS - S - to be used in MEDICAL SELF DIAGNOSIS FOR MEDICAL SELF CARE only

2. Users of these programs are guaranteed to :

1. be EVIDENCE BASED
2. be at the cutting edge of the peer reviewed literature
3. be bound by the numerous clinical practice guidelines in Medicine
4. be making diagnosis at a higher level of probability than non-users

5. CAMEOS PRODUCT FUTURE

The health care sector can follow the successful strategies of financial sector. The advent of independent, for-profit
businesses that can create value by analyzing raw health care data and turning it into actionable summaries may
be the key to a fully interoperable health information exchange system. Following is an outline a business environment in which health information exchange platforms can generate substantial revenue from two sources:
(1) real-time data services to different healthcare providers and (2) asynchronous data analytics and customized reports. The value of these services can drive different entities in the health care market to willingly exchange their medical information. The revenue generated from these services can partially be transferred to different medical data providers in order to provide them with economic incentives to engage in higher levels of information exchange. In such business environment, complete interoperability would be achieved even without financial incentives from the federal government. I describe the details of these two types of services below

3) CAMEOS system will accommodate the concept of selfcare diagnosis for selfcare mangement of all the Non Communicable Diseases (NCDs) :

NCDS have common template in COC module of the EMR
HT =>

BENEFFITS OF CAMEOS SYSTEM - PHYSICIAN VERSION OR COMMON WEALTH VERSION
1. Raw patient data is converted into actionable summaries
2. Raw patient data is converted into information required for health information exchange
3. CAMEOS as a template for chronic disease managment

4. CAMEOS AND IOT

5. CAMEOS AND HEALTH CARE INTEROPERABILITY

6. Further development of the knowledge base particularly the knowledge representation to be improved in future versions

7. HEALTH CARE INTEROPERABILITY - this will be ensured by inerting the SNOMED CODES ans ICD11 CODES into the CAMEOS OUTPUT.