Maintaining and incrementally revalidating a computer-based clinical guideline: a case study

Toward a Symbolic AI Approach to the WHO/ACSM Physical Activity & Sedentary Behavior Guidelines

The World Health Organization and the American College of Sports Medicine have released guidelines on physical activity and sedentary behavior, as part of an effort to reduce inactivity worldwide. However, to date, there is no computational model that can facilitate the integration of these recommendations into health solutions (e.g., digital coaches). In this paper, we present an operational and machine-readable model that represents and is able to reason about these guidelines. To this end, we adopted a symbolic AI approach that combines two paradigms of research in knowledge representation and reasoning: ontology and rules. Thus, we first present HeLiFit, a domain ontology implemented in OWL, which models the main entities that characterize the definition of physical activity, as defined per guidance. Then, we describe HeLiFit-Rule, a set of rules implemented in the RDFox Rule language, which can be used to represent and reason with these recommendations in concrete real-world applications. Furthermore, to ensure a high level of syntactic/semantic interoperability across different systems, our framework is also compliant with the FHIR standard. Through motivating scenarios that highlight the need for such an implementation, we finally present an evaluation of our model that provides results that are both encouraging in terms of the value of our solution and also provide a basis for future work.

Discovering hidden knowledge through auditing clinical diagnostic knowledge bases

OBJECTIVE

Evaluate potential for data mining auditing techniques to identify hidden concepts in diagnostic knowledge bases (KB). Improving completeness enhances KB applications such as differential diagnosis and patient case simulation.

MATERIALS AND METHODS

Authors used unsupervised (Pearson's correlation - PC, Kendall's correlation - KC, and a heuristic algorithm - HA) methods to identify existing and discover new finding-finding interrelationships ("properties") in the INTERNIST-1/QMR KB. Authors estimated KB maintenance efficiency gains (effort reduction) of the approaches.

RESULTS

The methods discovered new properties at 95% CI rates of [0.1%, 5.4%] (PC), [2.8%, 12.5%] (KC), and [5.6%, 18.8%] (HA). Estimated manual effort reduction for HA-assisted determination of new properties was approximately 50-fold.

CONCLUSION

Data mining can provide an efficient supplement to ensuring the completeness of finding-finding interdependencies in diagnostic knowledge bases. Authors' findings should be applicable to other diagnostic systems that record finding frequencies within diseases (e.g., DXplain, ISABEL).

Computer-interpretable clinical guidelines: a methodological review

Clinical practice guidelines (CPGs) aim to improve the quality of care, reduce unjustified practice variations and reduce healthcare costs. In order for them to be effective, clinical guidelines need to be integrated with the care flow and provide patient-specific advice when and where needed. Hence, their formalization as computer-interpretable guidelines (CIGs) makes it possible to develop CIG-based decision-support systems (DSSs), which have a better chance of impacting clinician behavior than narrative guidelines. This paper reviews the literature on CIG-related methodologies since the inception of CIGs, while focusing and drawing themes for classifying CIG research from CIG-related publications in the Journal of Biomedical Informatics (JBI). The themes span the entire life-cycle of CIG development and include: knowledge acquisition and specification for improved CIG design, including (1) CIG modeling languages and (2) CIG acquisition and specification methodologies, (3) integration of CIGs with electronic health records (EHRs) and organizational workflow, (4) CIG validation and verification, (5) CIG execution engines and supportive tools, (6) exception handling in CIGs, (7) CIG maintenance, including analyzing clinician's compliance to CIG recommendations and CIG versioning and evolution, and finally (8) CIG sharing. I examine the temporal trends in CIG-related research and discuss additional themes that were not identified in JBI papers, including existing themes such as overcoming implementation barriers, modeling clinical goals, and temporal expressions, as well as futuristic themes, such as patient-centric CIGs and distributed CIGs.

Beyond the threshold: real-time use of evidence in practice

In two landmark reports on Quality and Information Technology, the Institute of Medicine described a 21st century healthcare delivery system that would improve the quality of care while reducing its costs. To achieve the improvements envisioned in these reports, it is necessary to increase the efficiency and effectiveness of the clinical decision support that is delivered to clinicians through electronic health records at the point of care. To make these dramatic improvements will require significant changes to the way in which clinical practice guidelines are developed, incorporated into existing electronic health records (EHR), and integrated into clinicians' workflow at the point of care. In this paper, we: 1) discuss the challenges associated with translating evidence to practice; 2) consider what it will take to bridge the gap between the current limits to use of CPGs and expectations for their meaningful use at the point of care in practices with EHRs; 3) describe a framework that underlies CDS systems which, if incorporated in the development of CPGs, can be a means to bridge this gap, 4) review the general types and adoption of current CDS systems, and 5) describe how the adoption of EHRs and related technologies will directly influence the content and form of CPGs. Achieving these objectives should result in improvements in the quality and reductions in the cost of healthcare, both of which are necessary to ensure a 21st century delivery system that consistently provides safe and effective care to all patients.

Computerization of workflows, guidelines, and care pathways: a review of implementation challenges for process-oriented health information systems

OBJECTIVE

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways.

METHODS

A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation 'challenge' themes.

RESULTS

One hundred and eight relevant studies were selected for review. Twenty-five underlying 'challenge' themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed.

DISCUSSION AND CONCLUSION

We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings.