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Medical Planning

David Glasspool Advanced Computation Laboratory, Cancer Research UK. Medical Planning. Outline. Review The place of planning in healthcare The cognitive psychology of planning New Directions How can IT assist plan execution? How can IT assist plan creation?. Part I Review. “Planning”.

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Medical Planning

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  1. David Glasspool Advanced Computation Laboratory, Cancer Research UK Medical Planning

  2. Outline • Review • The place of planning in healthcare • The cognitive psychology of planning • New Directions • How can IT assist plan execution? • How can IT assist plan creation?

  3. Part IReview

  4. “Planning” • No mention in Schwartz & Griffin book • Plenty of work on clinical decisions • Little work on clinical planning • i.e. Plans in medical thinking • Plenty of work on medical plans; Plans are ubiquitous in clinical practice

  5. Planning in healthcare • Types of clinical plan • Protocols • Guidelines • “Integrated care pathways” • Operations on plans • Plan generation • Plan modification • Plan enactment • Use models for plans • Clinician guidance • Patient guidance • Problem solving (individual and joint) • Integration of services & treatment

  6. Types of plan: 1. Healthcare Strategy

  7. Types of plan: 2. Protocol

  8. A B C D Many people “use” the plan Senior clinician plans treatment Family plan around hospital visits Junior clinician performs one particular task Pharmacist checks prescriptions

  9. A D B C Plan as mediator between agents Planners : Exercise judgement, set goals, use “expertise”, modify plans Actors : Perform actions, modify to local environment, react to events (Using Plans) (Generating/Manipulating Plans)

  10. Cognitive psychology of planning

  11. Central (reasoning, planning) Engineering solutions from scratch Experimental Psychology AI Making sense of empirical evidence Peripheral (sensory/motor)

  12. Early work was AI-inspired • Planning as problem solving. • Miller, Galanter & Pribram (1960): Plans and the structure of behaviour. • Plans are hierarchically structured – as is our knowledge. • Plans are the interconnection between knowledge and behaviour. • Newell: GPS; Production systems.

  13. Planning as problem-solving and the Tower Tasks • “Tower of Hanoi” / “Tower of London” • Objective: move from start state to goal state. • Constraints: • Only one disc can be moved at a time. • All discs not being moved must be placed on a peg. • A larger disc must not be placed on a smaller disc.

  14. Preconditions • Disk A Clear • Disk A on Disk B • Disk C Clear • Disk A < Disk C • Operator • Move Disk A to Disk C • Postconditions • Disk A Clear • Disk A on Disk C • Disk B Clear A A C B B C Goal Start

  15. Naturalistic planning • Hayes-Roth & Hayes-Roth (1979). • Partial • On-line & opportunistic • Partly bottom-up • Klein: “Recognition-primed planning” • Experts' plans are usually: • Simple. • Based on stereotyped initial plan, then developed. • Satisficing approach • Alternative plans are rarely compared

  16. Empirical evidence • Evidence that working memory and executive processes are heavily involved (Owen 1997). • The number of variables and interactions within a plan appear critical, and skilled planners in real-world planning tasks form only relatively simple mental plans (Klein, 1998). • The level of detail in which a planner considers the future consequences of planned actions influences their plans (Hirt & Sherman, 1985; Huys, Evers-Kiebooms & d'Ydwalle, 1992).

  17. Well-learned plans • Planning is limited by cognitive resources • Experts develop strategies to compensate. • Scripts/schemas/MOPs • Representation and use of plan knowledge. • Understanding situations by reference to stereotyped plans. • Potential relevance to much of clinical procedural knowledge (“The art of medicine”?)

  18. Incompetent Competent Conscious Unconscious Trainee Graduate Complete novice Expert Novice vs. Expert Skill Representation

  19. Dual-process models • Deliberative • Miller et al. • Newell & colleagues • Tower tasks • Mixed • Hayes-Roth & Hayes-Roth • Klein & colleagues • Automatic • Scripts & schemas • Contention scheduling Deliberative processing Automatic processing

  20. Part IINew Directions • Executing plans • Generating/modifying plans

  21. Intelligent plan execution • What does it mean to execute a plan intelligently? • Generalisation: Not having to specify every last detail. • Flexibility: Ability to change details to suit circumstances while preserving overall intentions. • Resilience: Ability to detect when situation is not developing as expected and either adapt the plan or request re-planning (or other problem solving).

  22. Supervisory Attention (SAS) Contention Scheduling Action system World The Norman & Shallice (1980) framework Deliberative processing, planning & reasoning Automatic processing of routine behaviour Motor level action control

  23. Goal Plan Plan Plan Goal Goal Goal Plan Plan Plan Contention scheduling Alternative plans that can achieve the same goal (Possibly ordered) set of sub-goals which must be achieved to implement this plan. Alternative plans that can achieve the same goal

  24. Goal-oriented sequencing • Flexible execution • Execution can be allowed to adapt itself to the prevailing circumstances by providing alternative plans for achieving each goal. • Automatic recovery from (mild) error. • Preference order over plans can allow back-up action. • (Alternatively recovery action(s) may be explicitly specified)

  25. Assisting plan creation

  26. Cognitive demands of planning 1. Hold plan in memory. 2. Identify options at each step. 3. Identify pros and cons. 4. Track constraints & dependencies. 5. Track effect of plan with respect to its goals.

  27. A scenario • A woman tests positive for a mutation to one of the two known genes predisposing to breast cancer (BRCA1/BRCA2). If no action is taken to mitigate the risk, the chances are high that she will contract a potentially fatal cancer during her lifetime. • A genetics counsellor now works with the woman to plan a strategy of intervention.

  28. Demo

  29. 1. Memory for plan 2. Identification of options 3. Monitoring wrt Goals 4. Identification of pros and cons 5. Identification of conflicts and interactions The REACT approach

  30. Evaluation • Aims • Feasibility, usability, attitudes. • Participants • 8 cancer genetic counsellors • Method • Actresses playing patients. • with/without REACT. • Videotape, questionnaire, interview.

  31. Results • 7/8 participants at least somewhat negative before sessions. • 7/8 participants highly positive after sessions. • Appreciated: • Dynamic visual display. • Arguments were useful “bullet-points” for discussion. • Accurate, detailed, up-to-date information.

  32. Conclusions • Plenty of work on medical decision making & medical plans, little work on medical planning. • Like other experts, clinicians use stereotyped plans to reduce cognitive demands of full planning. • “Goal-oriented” hierarchical partial planning can support intelligent plan execution. • REACT supports plan generation/modification by targeting cognitive load.

  33. With thanks to • Ayelet Oettinger • James Smith-Spark • John Fox • Jon Bury • Kirsty Bradbrook • Fred Kavalier • Pete Yule

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