Ontological framework for standardizing and digitizing clinical pathways in healthcare information systems

Taxonomy of hybrid architectures involving rule-based reasoning and machine learning in clinical decision systems: A scoping review

BACKGROUND

As the application of Artificial Intelligence (AI) technologies increases in the healthcare sector, the industry faces a need to combine medical knowledge, often expressed as clinical rules, with advances in machine learning (ML), which offer high prediction accuracy at the expense of transparency of decision making.

PURPOSE

This paper seeks to review the present literature, identify hybrid architecture patterns that incorporate rules and machine learning, and evaluate the rationale behind their selection to inform future development and research on the design of transparent and precise clinical decision systems.

METHODS

PubMed, IEEE Explore, and Google Scholar were queried in search for papers from 1992 to 2022, with the keywords: "clinical decision system", "hybrid clinical architecture", "machine learning and clinical rules". Excluded articles did not use both ML and rules or did not provide any explanation of employed architecture. A proposed taxonomy was used to organize the results, analyze them, and depict them in graphical and tabular form. Two researchers, one with expertise in rule-based systems and another in ML, reviewed identified papers and discussed the work to minimize bias, and the third one re-reviewed the work to ensure consistency of reporting.

RESULTS

The authors screened 957 papers and reviewed 71 that met their criteria. Five distinct architecture archetypes were determined: Rules are Embedded in ML architecture (REML) (most used), ML pre-processes input data for Rule-Based inference (MLRB), Rule-Based method pre-processes input data for ML prediction (RBML), Rules influence ML training (RMLT), Parallel Ensemble of Rules and ML (PERML), which was rarely observed in clinical contexts.

CONCLUSIONS

Most architectures in the reviewed literature prioritize prediction accuracy over explainability and trustworthiness, which has led to more complex embedded approaches. Alternatively, parallel (PERML) architectures may be employed, allowing for a more transparent system that is easier to explain to patients and clinicians. The potential of this approach warrants further research.

OTHER

A limitation of the study may be that it reviews scientific literature, while algorithms implemented in clinical practice may present different distributions of motivations and implementations of hybrid architectures.

Systematized Nomenclature of Medicine-Clinical Terminology (SNOMED CT) Clinical Use Cases in the Context of Electronic Health Record Systems: Systematic Literature Review

BACKGROUND

The Systematized Medical Nomenclature for Medicine-Clinical Terminology (SNOMED CT) is a clinical terminology system that provides a standardized and scientifically validated way of representing clinical information captured by clinicians. It can be integrated into electronic health records (EHRs) to increase the possibilities for effective data use and ensure a better quality of documentation that supports continuity of care, thus enabling better quality in the care process. Even though SNOMED CT consists of extensively studied clinical terminology, previous research has repeatedly documented a lack of scientific evidence for SNOMED CT in the form of reported clinical use cases in electronic health record systems.

OBJECTIVE

The aim of this study was to explore evidence in previous literature reviews of clinical use cases of SNOMED CT integrated into EHR systems or other clinical applications during the last 5 years of continued development. The study sought to identify the main clinical use purposes, use phases, and key clinical benefits documented in SNOMED CT use cases.

METHODS

The Cochrane review protocol was applied for the study design. The application of the protocol was modified step-by-step to fit the research problem by first defining the search strategy, identifying the articles for the review by isolating the exclusion and inclusion criteria for assessing the search results, and lastly, evaluating and summarizing the review results.

RESULTS

In total, 17 research articles illustrating SNOMED CT clinical use cases were reviewed. The use purpose of SNOMED CT was documented in all the articles, with the terminology as a standard in EHR being the most common (8/17). The clinical use phase was documented in all the articles. The most common category of use phases was SNOMED CT in development (6/17). Core benefits achieved by applying SNOMED CT in a clinical context were identified by the researchers. These were related to terminology use outcomes, that is, to data quality in general or to enabling a consistent way of indexing, storing, retrieving, and aggregating clinical data (8/17). Additional benefits were linked to the productivity of coding or to advances in the quality and continuity of care.

CONCLUSIONS

While the SNOMED CT use categories were well supported by previous research, this review demonstrates that further systematic research on clinical use cases is needed to promote the scalability of the review results. To achieve the best out-of-use case reports, more emphasis is suggested on describing the contextual factors, such as the electronic health care system and the use of previous frameworks to enable comparability of results. A lesson to be drawn from our study is that SNOMED CT is essential for structuring clinical data; however, research is needed to gather more evidence of how SNOMED CT benefits clinical care and patient safety.

Automated clinical pathway standardization using SNOMED CT- based semantic relatedness

The increasing number of patients and heavy workload drive health care institutions to search for efficient and cost-effective methods to deliver optimal care. Clinical pathways are promising care plans that proved to be efficient in reducing costs and optimizing resource usage. However, most clinical pathways are circulated in paper-based formats. Clinical pathway computerization is an emerging research field that aims to integrate clinical pathways with health information systems. A key process in clinical pathway computerization is the standardization of clinical pathway terminology to comply with digital terminology systems. Since clinical pathways include sensitive medical terms, clinical pathway standardization is performed manually and is difficult to automate using machines. The objective of this research is to introduce automation to clinical pathway standardization. The proposed approach utilizes a semantic score-based algorithm that automates the search for SNOMED CT terms. The algorithm was implemented in a software system with a graphical user interface component that physicians can use to standardize clinical pathways by searching for and comparing relevant SNOMED CT retrieved automatically by the algorithm. The system has been tested and validated on SNOMED CT ontology. The experimental results show that the system reached a maximum search space reduction of 98.9% within any single iteration of the algorithm and an overall average of 71.3%. The system enables physicians to locate the proper terms precisely, quickly, and more efficiently. This is demonstrated using case studies, and the results show that human-guided automation is a promising methodology in the field of clinical pathway standardization and computerization.

The use of SNOMED CT, 2013-2020: a literature review

OBJECTIVE

This article reviews recent literature on the use of SNOMED CT as an extension of Lee et al's 2014 review on the same topic. The Lee et al's article covered literature published from 2001-2012, and the scope of this review was 2013-2020.

MATERIALS AND METHODS

In line with Lee et al's methods, we searched the PubMed and Embase databases and identified 1002 articles for review, including studies from January 2013 to September 2020. The retrieved articles were categorized and analyzed according to SNOMED CT focus categories (ie, indeterminate, theoretical, pre-development, implementation, and evaluation/commodity), usage categories (eg, illustrate terminology systems theory, prospective content coverage, used to classify or code in a study, retrieve or analyze patient data, etc.), medical domains, and countries.

RESULTS

After applying inclusion and exclusion criteria, 622 articles were selected for final review. Compared to the papers published between 2001 and 2012, papers published between 2013 and 2020 revealed an increase in more mature usage of SNOMED CT, and the number of papers classified in the "implementation" and "evaluation/commodity" focus categories expanded. When analyzed by decade, papers in the "pre-development," "implementation," and "evaluation/commodity" categories were much more numerous in 2011-2020 than in 2001-2010, increasing from 169 to 293, 30 to 138, and 3 to 65, respectively.

CONCLUSION

Published papers in more mature usage categories have substantially increased since 2012. From 2013 to present, SNOMED CT has been increasingly implemented in more practical settings. Future research should concentrate on addressing whether SNOMED CT influences improvement in patient care.