Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
02 • 110-130
ABSTRACT
Introduction : Malaria is a public health problem that still causes mortality, particularly in high risk
population. Kabupaten Nias is one of the malaria endemic areas. Malaria diagnosis is mainly determined
according to physical examination, despite the fact that laboratory examination is the gold standard of
malaria diagnosis. To help health workers in diagnosing malaria accurately, it is necessary to develop a
decision support system for malaria diagnosis.
Objectives: To develop a prototype of malaria diagnostic decision support system.
Methods: It was a descriptive study with action research design to explore each phase in the development
of a prototype of malaria diagnostic decision support system. Participants of the study consisted of 5
general practitioners in RSU Gunungsitoli and 2 nurses in Puskesmas Gunungsitoli.
Results: The study created an application model of computer-based malaria diagnostic decision support
system designed using PHP programming language and MySQL database. This system worked by entering
malaria clinical symptoms into the expert system, and data of symptoms were processed by the expert system
to determine diagnosis and medical advice that was useful to assist health staff in making decision.
Conclusion: Malaria diagnostic decision support system that had been developed attracted the interest of
health workers and help them in diagnosing malaria clinically.
Keywords: diagnostic decision support system, prototype, malaria, computer application, Gunungsitoli
INTISARI
Pendahuluan: Malaria merupakan masalah kesehatan masyarakat yang masih menyebabkan kematian,
terutama pada populasi risiko tinggi. Kabupaten Nias merupakan salah satu daerah endemik malaria.
Di Nias, diagnosis malaria terutama ditentukan sesuai dengan pemeriksaan fisik, meskipun diketahui
bahwa pemeriksaan laboratorium merupakan standar emas diagnosis malaria. Untuk membantu petugas
kesehatan dalam mendiagnosis malaria secara akurat, diperlukan pengembangan suatu sistem pendukung
keputusan untuk diagnosis malaria.
Tujuan: Untuk mengembangkan prototipe sistem pendukung keputusan diagnosis malaria.
Metode: Penelitian ini merupakan penelitian deskriptif yang diikuti dengan rancangan action research
untuk mengeksplorasi setiap tahap dalam pengembangan prototipe sistem pendukung keputusan
diagnosis malaria. Partisipan penelitian terdiri dari 5 dokter umum di RSU Gunungsitoli dan 2 perawat di
Puskesmas Gunungsitoli.
Hasil: Penelitian ini menghasilkan sistem pendukung keputusan diagnosis malaria berbasis aplikasi
komputer yang dirancang dengan menggunakan bahasa pemrograman PHP dan database MySQL. Sistem
ini bekerja dengan memasukkan gejala malaria klinis ke dalam sistem pakar. Data gejala diproses oleh
sistem pakar sehingga diperoleh diagnosis dan saran medis yang berguna untuk membantu petugas
kesehatan dalam mengambil keputusan.
Simpulan: Prototipe sistem pendukung keputusan diagnosis malaria yang dikembangan menarik minat
tenaga kesehatan dan membantu mereka dalam mendiagnosis malaria klinis.
Kata kunci: sistem pendukung keputusan diagnosis, prototype, malaria, aplikasi komputer, Gunungsitoli
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INTRODUCTION
Nias was 85.78‰ and 52.03‰, respectively.
Malaria has been one of the public health Although the number has decreased, it was still
problems which causes mortality, particularly included in High Incidence Area (HIA). In 2006
in high-risk population and also decreases work and 2007, AMI of Kabupaten Nias was 42.08‰
productivity1. One of malaria endemic areas is and 41.13‰, respectively, which included in
Kabupaten Nias, situated in Pulau Nias, which is Medium Incidence Area (MIA).
around 85 miles from Sibolga (Sumatera Utara). In December 2005, Health Office of Sumatera
Kabupaten Nias is an area of 27 small islands. The Utara Province together with Health Office of
area of Kabupaten Nias is 3,495.39 km² (4.88% Kabupaten Nias conducted basic Malariometric
of Sumatera Utara area), parallel to and situated Survey on 0-9 years old cildren in 7 villages in
in the west of Sumatera, and surrounded by 3 areas of Puskesmas. Result showed that the
Indonesian Ocean. Based on geographic location, Parasite Rate (PR) of 2-9 years old children
Kabupaten Nias is situated at 0012’-1032’ NL and was 7.84-59.8%. Species of parasites found
970-980 EL, near the equator, causing high annual in the survey were P. falciparum and P. vivax,
rainfall. In 2005, the rainfall was 2,805 mm per with P. falciparum as the dominant species. PR
year, or on average of 234 mm per month, with value of 0.9 meant that all surveyed villages
246 rainy days in a year or on average 21 rainy were included in HPA (High Prevalence Area).
days per month, and sun illumination was on Confirmed vectors of malaria in Sumatera Utara
average 53% per month. The highest rainfall was were Anopheles kocki, Anopheles sundaicus, and
in October (595 mm), with 30 rainy days and Anopheles tesselatus, while potential/suspected
sun illumination of 39%. Dry and rainy seasons vectors were Anopheles maculatus, Anopheles
alternate in a year. Lowest rainfall and total rainy nigerrimus, and Anopheles umbrosus (Namru’s
days was in February (52 mm and 14 rainy days, document). Anophelessundaicus was reported to
with sun illumination of 61%). Yearly high rainfall have breeding site in freshwater, while generally
causes Kabupaten Nias to be very humid and this vector chose brackish water as its breeding
wet, with average humidity between 89-92%, site3.
and it frequently had flood2. Malaria was included in the 10 most common
Malaria is one the infectious diseases which diseases in the patients of Rumah Sakit Umum
is anticipated to be emerged after the tsunami. (RSU) Gunungsitoli in 2006-2007. Based on the
After tectonic earthquake and tsunami in result of a study on clinical behavior of health
Pulau Nias, another earthquake ensued. The providers about the management of malaria in
considerable life lost and the migration of the RSU Gunungsitoli, Kabupaten Nias, it is concluded
population have caused the change in population that clinical behavior of health providers was less
and social and economic condition, resulted in supportive to the management and treatment
the increased risk to be infected. The change of malaria in RSU Gunungsitoli4. It could be
in physical environment causing a condusive observed in the establishment of malaria
environment for the growth of vector of diseases diagnosis. Some health providers said that when
also increased the risk to be infected by infectious the patient history and clinical symptoms had
diseases. Health care was not provided in lead to malaria, antimalarial drugs could be given
optimum level, because earthquake and tsunami to the patients. However, there were several
had caused the loss of infrastructure and human health providers who suggested that laboratory
resources3. In 2004 and 2005, AMI in Kabupaten examination to establish malaria diagnosis had
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to be conducted, although the patients history of the provinces in Indonesia6. Effort to decrease
and clinical symptoms had supported the the morbidity and mortality rates was conducted
diagnosis of malaria. There was also a difference through malaia eradication program, which
in the response between health providers and activities included early diagnosis, quick and
the result of laboratory examination. It resulted appropriate treatment, surveillance and control
in the treatment of malaria patients tended to of the vector, which aimed to cut the malaria
follow the inclination of the health provider, and transmission link. Malaria diagnosis is establised
not based on the available standard treatment. based on history taking, physical examination,
Clinical behavior ofhealthproviderswhichnot and laboratory examination. Definitive diagnosis
supportive to the management and treatment of malaria has to be establised by blood
of malaria in RSU Gunungsitoli was caused by microscopic examination or rapid diagnostic test.
predisposing, enabling, and reinforcing factors. Early diagnosis of malaria is conducted by history
Result of a study showed that from predisposing taking and physical examination by identifying
factor, health providers in RS Gunungsitoli were clinical symptoms in malaria patients1.
not included in training about malaria yet, and This study was conducted with the objective
it was difficult to find opportunity to join any to identify the user’sneedofprototype ofmalaria
training. From the aspect of enabling factor, it diagnostic decision support system, develop a
showed that Standard Operating Procedure prototype of malaria diagnostic decision support
(SOP) of malaria was not available in RSU system, and evaluate the user acceptance of the
Gunungsitoli, therefore, in managing malaria, prototype of malaria diagnostic decision support
health providers only based on books and their system.
experience while managing malaria cases. From
the aspect of reinforcing factor, it was known
that there was the lack of appreciation and MATERIALS AND METHODS
reward from RS Gunungsitoli for their health
providers over their work load. Result of a study This study is a descriptive study with
by Hulu suggested that the prevalence of medical action research design to explore each phase
errors in the management of malaria in RSU of the development of the prototype of
Gunungsitoli in May 2007 was very high, where malaria diagnostic decision support system.
medical errors related with the management of Total participants in this study were 5 general
malaria was 1.87 times per patient, consisted practitioners in RSU Gunungsitoli and 2 nurses
of diagnosis error in 80 patients (86.96%), in Puskesmas Gungungsitoli Nias. Samples
treatment error in 92 patients (100%), error of were taken by purposive sampling. General
omission in 35 patients (38.04%), and error of practitioners were chosen as subjects because
commission in 149 patients (161.96%)5. Clinical they had direct contact with the patients in
behavior of health providers such as frequently establishing diagnosis in Puskesmas, while nurses
giving antimalarial drugs to the patients without were chosen as subjcets because they were
laboratory examination might cause resistance. establishing diagnosis in Puskesmas in certain
Report on resistance to the previous antimalarial conditions. Therefore, in these participants,
drugs (for example, chloroquine, sulphadoxine, their needs were identified and their acceptance
pyrimethamine, and quinine) in the last decade to the prototype of malaria diagnostic decision
had become a concern, affecting more than 25% support system were evaluated.
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Sudarta Yabesman Harefa et.al, Development of A Prototype of Malaria
Clinical Diagnostic Decision Support System
The variables of this sudy were: (a) Clinical participants in prototype trial. This study had
malaria, is an infectious disease suffered by a received approval from Gadjah Mada University,
patient who experiences the clinical symptoms Director of RSU Direktur Gunungsitoli Nias, and
of malaria, (b) Malaria diagnosis, is diagnosis the Head of Puskesmas Gunungsitoli.
establishedbasedonclinicalsymptomsofmalaria
which experienced by a patient, (c) Malaria
treatment, is treatment given to malaria patients RESULTS AND DISCUSSIONS
with the objective to eradicate all the parasites
in the human body, (d) Needs identification, is RSU Gunungsitoli is a type C (non-education)
a stage in identifying problems associated with hospital and the property of government of
the needs of the development of a prototype, Kabupaten Nias, with 206 civil workers and 191
(e) Prototype design, is a stage to analyze the non-permanent staff. RSU Gunungsitoli has
system appearance and how the system solve outpatient units (specialist polyclinics: internal
the problems, design to determine the aspects medicine, surgery, obstetry, dentistry and
(segments) which included in the prototype, pediatric polyclinic), inpatient units (internal
and the rules to be used, development process medicine inpatient unit, surgery inpatient unit,
of knowledge base, pilot test, reviewing, and pediatric inpatient unit, obstetry/postnatal
continuing improvement, (f) Implementation, is unit, and ICU) with total capacity of 105 beds,
a stage when the prototype has been tested and consisted of 80% class III and 20% class II.
improved and received suggestions from the Study was also conducted in Puskesmas
users since the start of application until usage. Gunungsitoli, one of the technical units
Main instrument used in this study was the of Health Office in Kabupaten Nias, which
researcher (human instrument), supported situated in Kecamatan Gunungsitoli. Puskesmas
by guideline of indepth interview, recording Gunungsitolihas 11 Puskesmas pembantu (Pustu)
device (MP4 player), digital camera, computer, which distributed in several villages. Recently, it
and software with operating system Windows/ also has inpatient unit, with 88 staffs.
Linux, PHP programming language, and MySQL
database. 1. Initialization
The study was conducted according to the Initialization phase was the first step in the
prototyping approach, with steps as follows: development of expert system. The objective
1. Identify main problems underlying the was to identify the problems and prepare for
development of prototype associated with the next step in the development of prototype
malaria diagnosis, 2. Analyze and design the of malaria diagnostic decision support system.
malaria diagnostic decision support system, Based on medical record data of patients in
3. Build a prototype of the malaria diagnostic RSU Gunungsitoli, total malaria cases in January
decision support system based on standard and February 2009 was 52, consisted of 38
management of malaria in Indonesia and the cases in January 2009 and 14 cases in February
result of indepth interview with the general 2009. Total patients who were diagnosed as
practitioners and nurses, 4. Evaluate the user malaria and treated with drugs, but never had
acceptanceoftheprototype ofmalariadiagnostic laboratory examinations, were 16 (30.77%),
decision support system, and 5. Complete the while those with laboratory examination were
prototype based on the suggestions of users/ 36 (69.23%) patients. RSU Gunungsitoli Nias and
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Puskesmas Gunungsitoli did not have SOP to the description of participant as follows:
manage malaria, therefore, there was no specific
guideline for management of malaria. “Ya...Kita secara umum.. ya kalau itu sudah
prosedur yang baku seorang dokter itu pasti
”...mmmmm, kalau di rumah sakit kita pertama dulu ya menanyakan keluhan-keluhan
belum ada protap resmi atau SOP, dokter pasiennya apa, yang berkaitan dengan gejala-
biasanya memberikan terapi berdasarkan gejala malaria. Kemudian setelah dianamnesis,
pengalamannya...” ditanyakankeluhannyaapa,laludiperiksafisiknya.
(Participant 2) Adakah tanda-tanda yang mengarah ke penyakit
malaria. Kalau masih kira-kira ada keraguan
”...mmmmm, in our hospital, there are no dan untuk mendiagnosis secara pasti, ya kita
official prototypes or SOPs, doctors usually give biasanya periksakan darah di laboratorium, baru
treatment based on their experience...” kita bisa mengambil kesimpulan, mendignosis
(Participant 2) malaria atau tidak”.
(Participant 2)
”...gimanayadek,standaryangadayastandar
nasional dari Depkes, kalau dari puskesmas tidak “Well, generally .. it is a standard procedure
ada. Puskesmas belum membuatnya secara when doctors first ask for the complaints from
khusus. Ini pun punya saya yang dari Depkes. the patients, associated with malaria symptoms.
Jadi, penjabarannya sesuai kondisi di sini belum Afterhistorytaking,theyaskedforthecomplaints,
ada. Itulah dek kondisi di Puskesmas kita ini” and then they had physical examination, if there
(Participant 5) are any signs lead to malaria. When there is
doubt, and to establish definitive diagnosis, we
”... well, available standard is the one from usually do laboratory examination, and after
MoH, there are no standards from Puskesmas. that, we can make a conclusion, whether it is
Puskesmas did not develop it specifically. What I malaria or not”.
have here is the one from MoH. Therefore, there (Participant 2)
is no explanation which adjusted to the condition
here. That is the condition of this Puskesmas.” “…Biasanya kan kita anamnesis dulu,
(Participant 5) ditanyakankeluhanpasiensaatberobatterutama
untuk malaria, kemudian diperiksa keadaan
Thisisnotconsistentwiththerecommendation fisikny,a dan untuk faktor penunjang dilakukan
of MoH, which one of the efforts is to achieve pemeriksaan pasien”.
quality-safety, by preventing the medical errors (Participant 1)
by using hospital service standard, which is
described in SOP and appropriate with the “…We usually take the patient history, and
situation and condition of the hospital7. then we ask the patient complaints when they
Based on indepth interview conducted on come to visit for malaria, and they have physical
participants to identiftthe needs of the users, the examination, andforinvestigationalexamination,
steps obtained to establish diagnosis of malaria patient was examined”.
were history taking, physical examination, and (Participant 1)
for definitive diagnosis, blood examination, like
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Clinical Diagnostic Decision Support System
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”...pemeriksaan laboratorium itu penting dan Treatment for patients with malaria in
sudah menjadi syarat utama untuk menegakkan Nias was by giving drugs such as chloroquine,
diagnosis pasti malaria. Tapi dek, pengalaman sulphadoxine, quinine, and Fansidar.
saya kalau mendesak untuk diobati dan sudah
yakin sekali, langsung diobati. Kalau masih ragu ”...kalau saya biasanya pakai kloroquin,
baru diperiksa labnya.” Fansidar, sulfadoxin untuk obat malaria.
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Sudarta Yabesman Harefa et.al, Development of A Prototype of Malaria
Clinical Diagnostic Decision Support System
Chloroquin berdasarkan pengalaman saya masih of the drug can bring cure to the patient.”
manjur kok di pulau kita Nias.” (Participant 2)
(Participant 3)
2. Building the Prototype
”...I usually use chloroquine, Fansidar, After indepth interview to the participants
sulphadoxine for malaria. Based on my to indentify the need of the users associated
experience, chloroquine is still sensitive in with the development of malaria diagnostic
Nias.” decision support system, system analysis and
(Participant 3) design to estimate the system functionality was
conducted. Researcher tried to give general idea
”...ya, obat yang umum aja saya berikan ke on the appearance of the system and how the
pasien. Chloroquin, Fansidar, sulfadoxin, dan pil system solved the problems.
kina. Tapi pil kina sudah jarang dipakai. Biasanya a. Design the DFD (Data Flow Diagram)
salah satu aja dari obat itu dipakai bisa sembuh DFD is system design tool oriented on
kok.” data flow with decomposition concept,
(Participant 2) used to describe the analysis and design
of system which easily communicated
”...well, I give the usual drugs to the patient. by system proffesionals to the users and
Chloroquine, Fansidar, sulphadoxine, and programmer. DFD level 0 in this sytem
quinine. But quinine is seldom used. Usually one design is shown in Figure 1.
Head of the
clinic or
hospital
Ouput
The doctor’s
diagnosis
Knowlegde of data
Expert system Malaria Expert
or doctor
System
Lab
Doctor or
Nurse
Figure 1. Data Flow Diagram (DFD) level 0 of the prototype of malaria diagnostic decision support
system
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b. Design the Entity Relationship Diagram Kabupaten Nias7. This study was aimed to
(ERD) find out the specific symptoms found in
Entity relationship diagram shows the patients who suffered from malaria and
relationship between entities (an item dominant parasites found in Kabupaten
data unit which explains an object), and Nias, and develop algorithm of malaria
the relationship type. With this entity diagnosis as the reference to determine
relationship, all data will be incorporated malaria cases. Subjects of the study were
in one integrated unit (Figure 2). one laboratory staff of Health Office in
c. List of diagnotic rules Kabupaten Nias, one staff in Polyclinic in
Diagnostic rules were derived from the Puskesmas, one staff who obtained blood
experts, previous study results, and samples in Puskesmas, and 50 patients
scientific literature. Previous study with symptoms of malaria in August until
on the development of algorithm for October 2007 who visited Puskesmas
malaria diagnosis was based on clinical Awa’ai. The result of the study is shown
symptoms with blood examination in Table 28. Data analysis of the studywas
of patients with suspected malaria in
Figure 2. Entity Relationship Diagram (ERD) design for the prototype of of malaria
diagnostic decision support system
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Sudarta Yabesman Harefa et.al, Development of A Prototype of Malaria
Clinical Diagnostic Decision Support System
Table 1. Clinical symptoms in patients with clinical and microscopic diagnosis of malaria
Fever
Shivering Headache
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Sudarta Yabesman Harefa et.al, Development of A Prototype of Malaria
Clinical Diagnostic Decision Support System
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5). Final diagnosis menu. In this final symptom data, update knowledge,
diagnosis menu, list of drugs used and identitiy data of the expert.
could be entered and in this feature, Diagnosis data were functioned as
doctors would display in detail the the location to name the diagnosis
identity of the patients to facilitate and to give medical advice after the
the medical provider to consider the analysis of symptoms were entered.
drugs and the doses given to patients. Symptoms associated with malaria
Treatment menu appearance can be were input into symptom data. To
seen in Figure 9. change or update the knowledge on
6). Expert menu. In expert menu, there malariasymptoms, Updateknowledge
were features such as diagnosis data, menu could be used. Identitiy data of
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Sudarta Yabesman Harefa et.al, Development of A Prototype of Malaria
Clinical Diagnostic Decision Support System
the expert contained the names of 7). Report menu. Report menu showed
the experts (health providers) who patient data based on age and patient
became participants for interview in daily visit data, so that the daily
the study of this malaria diagnostic total patients and general data of
decision support system. The the patients, or yearly patient data
appearance of several features in based on age could be shown. The
expert menu is shown in Figure 10. appearance of report menu can be
seen in Figure 11.
Figure 10. Update knowledge menu in malaria diagnostic decision support system
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Sudarta Yabesman Harefa et.al, Development of A Prototype of Malaria
Clinical Diagnostic Decision Support System
were not capable to operate notebook. This was showed that there were several suggestions, as
because in their daily work, they used computer shown below:
only once in awhile, therefore, researcher
explained first how to use the notebook. It was “..yaaaaaaaaa,secaraumumdektampilannya
different with the doctors, who were already menarik, mmmm…tetapi perlu di tambahkan
used to the notebook, so thay they did not need variasi warnanya, mungkin dengan latar biru
any explanation on how to operate notebook. atau hijau, jangan putihlah dek…” (Participant
7)
“…jaman sekarang sudah enak ya dek,
banyak laptop, kalau jaman kami dulu sekolah “..well, generally the appearance is
masih mesin tik.he.he.he...di kantor inilah saya interesting, mmm… but it needs more variations
baru belajar komputer, itu pun cuma dikit-dikit incolors, probablywithblueorgreenbackground,
bisanya. Kalau laptop kayak yang kamu bawa not white only…” (Participant 7)
ini belum pernah saya pake, makanya saya
tadi bingung tombol¬-tombolnya dikit beda After trying the consultation menu in this
tempatnya.he.he.he...” (Participant 6) expert system, there were suggestion from the
nurses and doctor, so that in general data menu
“…now it’s convenient, isn’t it, there are of the patient, the body weight was added, which
laptops everywhere, when we were in school, would be useful in the determination of patient
we still used typewriters… ha.. ha… ha… I only dosage, as mentioned below:
learned about computer in this office, and I know
it very little. I never used this laptop, so I am kind “…itu lho dek, data berat badan pasiennya
of confused because the buttons have rather belum ada, karena biasanya saya dalam
different locations ha..ha…ha…” (Participant 6) menentukan pasien terutama anak-anak, harus
melihat berat badannya...” (Participant 5)
“…ternyata sama aja cara menggunakan
laptopdengankomputerbiasayadek, maklumlah “…you know, patient’s body weight data is
di puskesmas kita ini cuma ada komputerbiasa…” not available, I usually use the body weight for
(Participant 7) determining the dosage for patients, particularly
children...” (Participant 5)
“…it turns out the use of laptop is similar with
the use of general computer, isn’t it, you have to ”...ada satu lagi dek yang perlu kamu
understand we only have desktop computer in tambahkan pada identitas pasien, biasanya
this Puskesmas…” (Participant 7) kalau saya ngasih obat untuk anak-anak, selain
melihat umurnya, saya juga melihat berat
After given explanation on how to use the badannya, biar tidak kelebihan dosis nantinya..”
application, they finally were able to use it (Participant 7)
smoothly. This trial had attracted the interest of
the nurses and doctor and encouraged them to ”...one more thing that you need to add in
know more of all menu available in the prototype the patient identity, I usually give treatment
of malaria diagnostic decision support system. to children based on their age and their body
Result of indepth interview on the appearance weight, so that there will be no overdose…”
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Identification of needs :
Depth interviews with :
- Doctor
- Nurse
(the time required for 3 weeks)
Manufactured of prototype :
- Researcher Rejected
- Programmer
(the time required for 3 months)
Implementation :
- Doctor
- Nurse
(the time required for 3 weeks)
Accepted
Post-implementatiton :
- Maintenance
- Expansion/development
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Clinical Diagnostic Decision Support System
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Clinical Diagnostic Decision Support System
inpatient unit, sometimes at night the doctor is learning. Bayesian probability is a way to solve
not available, so that the patient demands to the uncertainty when using Bayes formula, and
be given treatment. I can’t asked them to come it may also be useful to show the possibility
again tomorrow, particularly when they come value and the correctness of diagnosis9. Machine
from the distant village. Humanity reason, you learning is aimed to make computer/machine to
know. Probably you will do the same when you have inteligence16.
are in my position ...” (Participant 7)
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