Capturing a Picture of Health


“The human mind simply cannot carry all the information about the patients in a practice or store all the information about every single medical diagnosis.”


Larry Weed delivering lectureThese words of wisdom, paraphrased from a 1984 lecture by the late Lawrence Weed, M.D., a professor of medicine at the University of Vermont (pictured at left), sparked an idea in a young medical student’s mind. That spark led the future doctor to envision and create a clinical decision tool that visually shows, describes, and categorizes thousands of diseases. Used in clinics and medical schools throughout the nation and across the globe, this tool, VisualDx, delivers time-sensitive, clinically relevant information for diagnosing and treating common and rare diseases and brings public health to the point of care.

Art Papier, M.D.’88, was a first-year medical student in Vermont when he attended Dr. Weed’s brown-bag lunch lecture 40 years ago. Papier was fascinated by Weed’s work, which focused on the advantages of keeping detailed, shareable medical records to improve patient care and health outcomes. Weed devised the now widely used problem-oriented medical record (POMR) to organize patient data by diagnosis and SOAP notes (Subjective, Objective, Assessment, and Plan), a standardized method for organizing and guiding patient information and thinking. Following Weed’s lecture, the future Dr. Papier began working for Weed’s medical software company, Problem-Knowledge Couplers (PKC), where Papier entered medical literature information into a data bank for physicians and learners.

“In his small attic office, I was introduced to the problem of cognitive biases in medical decision-making and the limitation of the human mind in handling complexity. I began to appreciate that individual practitioners could not possibly store every single diagnosis in their heads and—just as important—it was impossible to know all the right questions to ask for each potential complaint the patient might have,” says Dr. Papier, associate professor in dermatology and medical informatics at the University of Rochester and dermatologist at University of Rochester Medical Center. “With the explosion of medical knowledge, if we are to deliver high-level care, we need to augment our brains with reliable information as we make decisions.”

This revelation stuck with Papier as he started his residency in 1990 in Rochester, New York, where Kodak—the photographic film company—was headquartered. The digital photography revolution was beginning, and Kodak had recently designed a system for digitizing Kodachrome slides onto compact discs. By 1999, digital cameras had become ubiquitous, and Papier was creating prototype digital tools under the company name Logical Images. The product software was released in 2001, but at the time, few people could use it.

“There were no computers in medical exam rooms (to run the software), no smart phones, and no electronic health records being used (to share the information), so there was little commercial interest in our product,” Papier recalls. “Then 9/11 [terrorist attacks] happened, and Anthrax [deadly bacterium] was spread in the mail.” These momentous events set VisualDx on trajectory to success, he says.

In November 2001, Papier received a phone call from D.A. Henderson, M.D., M.P.H., a renowned physician who had led the effort to eradicate smallpox. Dr. Henderson was leading U.S. preparedness to address the threat of intentional dissemination of biological agents, including smallpox. The George W. Bush’s administration intended to mandate smallpox vaccination for 60 million Americans in six months, with Henderson overseeing the rollout. The smallpox vaccine carried risks that concerned Dr. Henderson, including a potentially fatal complication in people with eczema or the immunocompromised. Henderson engaged VisualDx to create a website and print materials for the Centers for Disease Control to visually show health care workers normal and adverse reactions to the vaccine.

“We then met with health departments to show how VisualDx could assist professionals with patients with fever, rash, and possible bioterrorism diseases,” says Papier. “We could give them software they can use daily for common things, and the bioterrorism information will be there if they need it.” Within two years, health departments in five states and New York City, Los Angeles County, and San Antonio licensed VisualDx, establishing it as a tool in public health preparedness.

Fast forward to 2007 and the proliferation of smartphones with cameras and internet connectivity. With this new technology, VisualDx returned to its core idea of bringing pattern-recognition skills for any medical problem to the point of care.

Art Papier (left) and VisualDX

(left) Art Papier, M.D.’88 and (right) VisualDx brings public health to point of care.

How it Works
VisualDx is a digital resource that guides clinicians in differential diagnosis, treatment decisions and patient education. Its library contains 47,000 skin, oral, eye, genital, hair, nail, radiographic, electrocardiogram, and pathologic images covering more than 3,400 diseases and public health threats, including COVID-19, mpox, Lyme disease, measles, and rabies. The content is created by an editorial board of invited experts and is continually updated. Additionally, a smartphone user can take a photo of a rash or lesion and the software’s AI-assisted tool will analyze the photo and guide the user through possible conditions, with narrative descriptions and images. The platform interfaces with Epic and other electronic health records, which improves information sharing, decision-making, and workflow in a busy health care setting.

VisualDx can be customized for state and local public health reporting, with alerts about whom to contact and links to reporting forms and phone numbers. The Vermont Department of Health launched a pilot project in November 2022 to provide the technology to all clinicians, residents, and nurse practitioner and medical students in Vermont. The initiative aims to remove barriers between public health goals and busy medical professionals, to improve Vermont’s readiness for emerging infectious diseases. The Vermont-customized platform allows public health alerts to go out unobtrusively, and clinicians can access reference information about emerging conditions and are guided to submit specimens to the Vermont Public Health laboratory.

“We believe this first-of-its-kind initiative will improve public health by supporting our health professionals with intuitive tools for timely diagnosis, testing, and patient education,” said Vermont Health Commissioner Mark Levine, M.D., professor of medicine. “Connecting Vermont’s time-strapped medical professionals with the information they need right when they need it ensures that they will be ready for the ever-changing and seemingly constantly emerging public health emergencies.”

By Janet Essman Franz

VisualDX examples on mobile phone

VisualDx covers more than 3,400 diseases and public health threats.

Educational Tool
VisualDx has gained attention in medical education, with 113 medical schools in the U.S. currently using it. As part of the Vermont health department initiative, Larner medical students can access VisualDx through an app on their smartphones and through the university’s electronic library. Students and faculty find it helpful for learning and discussing skin maladies on a variety of skin tones.

“It is a strong educational resource for students as they encounter common and uncommon dermatologic entities. The descriptive rubric VisualDx uses provides a useful way to demonstrate the best terminology to typify skin lesions in a clinical setting,” says Jonathan Rosen, M.D., professor of psychological science and director of undergraduate medical education at the UVM clinical branch campus.

Keith MorleyKeith Morley, M.D., assistant professor of medicine (pictured left), uses VisualDx both in his clinical practice as a pediatric dermatologist and as a teacher of residents and medical students. “Dermatology is a field where you really need to train your eyes. Rashes, skin cancers, and birth marks can be quite nuanced and have a wide range of appearances,” he says. “To be able to see a wide variety of high-quality images, particularly in patients across all skin tones, truly this helps provide better care to our patients and better teaching to our learners.”

Dr. Morley is one of 50 expert contributors across the U.S. who prepares VisualDx entries that are published online for other providers to use in their practice. He has prepared more than 20 entries with UVM medical students and residents. “Writing for VisualDx is an amazing opportunity to stay up to date on the latest research within our field.”

“It is a great way to learn more about different diseases and how they may present in the clinical setting,” says Negar Esfandiari, M.D. a dermatology resident at UVM Medical Center and VisualDx contributor. “Writing VisualDx articles helped me learn about the cutaneous manifestations of diseases and how they can present in individuals with different skin tones, which has been invaluable to my medical training.”

In clinic, VisualDx expands differential diagnoses, the list of possible diseases considered when seeing a patient. “It’s easy to get locked in to the first diagnosis that comes to mind, but in medicine it’s important to stay open minded. VisualDx has a well-organized section on differential diagnoses for almost every skin condition, which easily links to the full article on those similar but distinct diseases with photographs to compare,” Morley says.

Patient adherence to follow-up plans improve when the patient understands the diagnosis and shares in medical decision-making. “We throw a lot of information at our patients during a routine visit, and it often takes longer than 20 minutes to fully absorb these complicated discussions. VisualDx has patient handouts on most conditions that we can print out and provide to patients so that we can ensure they have the best information,” says Morley.

Dermatology shortages drive interest in VisualDx. Many skin complaints are handled by non-dermatologists, including emergency medicine and primary care physicians, and 15 percent of primary care visits have a skin complaint as a primary or secondary complaint, says Papier. Most non-dermatologists have had brief training in dermatology and may not recognize some rashes or lesions, so misdiagnosis is not uncommon. Additionally, dermatology educational sources typically don’t cover patients of varied ethnic backgrounds or skin tones, yet darker skin tones can present differently than lighter skin, with subtle variations and manifestations requiring unique therapies. VisualDx allows the user to filter images by skin color and body location.

Robert Holland, M.D.’72, a physician in the emergency department at North Country Hospital in Newport, Vermont, attests to the value of this feature: “I recently had an African American female patient present with complaints of weakness, feeling cold, and new onset of a graphic rash on her posterior thighs that was a repetitive reticulated pattern. I had never seen the rash before despite significant clinical experience, and I certainly had not seen it in an African American patient. The patient was extremely disappointed that I could not explain her rash,” says Dr. Holland, who also worked for Dr. Weed during medical school. “I checked VisualDx. Using the differential diagnosis features, I had a diagnosis within two minutes: Livedo Reticularis (mottled skin linked to constricted blood vessels). I showed the VisualDx picture to the patient. She agreed that it was her rash. We ordered additional tests, and she planned on follow-up with her primary care provider. Having a firm diagnosis was reassuring to the patient, and to me.”

Today, VisualDx employs 80 people, including image specialists, editors, medical librarians, software engineers, quality assurance, and marketing professionals, at its headquarters in Rochester, and the platform is a standard professional resource at more than 2,300 hospitals and clinics worldwide. As VisualDx marks its 25th year, the company is developing a new application, supported by a Bill & Melinda Gates Foundation grant, to help health care workers identify neglected tropical diseases. Additional grants support delivering VisualDx to free and charitable clinics throughout the U.S. Papier retired from clinical practice last year but continues to oversee VisualDx and work with public health agencies to bring public health to point of care. VM