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GLARE: a Domain-Independent System for Acquiring, Representing and Executing Clinical Guidelines. Paolo Terenziani, Stefania Montani, Alessio Bottrighi, DI, Universita’ del Piemonte Orientale “Amedeo Avogadro”, Alessandria, Italy Gianpaolo Molino, Mauro Torchio

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glare a domain independent system for acquiring representing and executing clinical guidelines
GLARE: a Domain-Independent System for Acquiring, Representing and Executing Clinical Guidelines

Paolo Terenziani, Stefania Montani, Alessio Bottrighi,

DI, Universita’ del Piemonte Orientale “Amedeo Avogadro”, Alessandria, Italy

Gianpaolo Molino, Mauro Torchio

Laboratorio di Informatica Clinica, Azienda Ospedaliera S. Giovanni Battista, Torino, Italy

- The GLARE system

- Advances: support to decision making

- Advances: management of temporal constraints (see AMIA06 poster T020)

- Advances: contextualization facilities (see AMIA06 poster M010)

- Advances: model-checking facilities (see AMIA06 presentation in session S52)

introduction
Introduction

Clinical guidelines are a means for specifying the “best” clinical procedures and for standardizing them

Adopting (computer-based) clinical guidelines is advantageous

Different roles:

- support

- critique

- evaluation

- education

- …...

Many different computer systems managing clinical guidelines

(e.g., Asgaard, GEM, Gliff, Guide, PROforma,…)

glare guideline acquisition representation and execution
GLARE(GuideLine Acquisition Representation and Execution)

- Joint project:

Dept. Comp. Sci., Univ. Alessandria (It): P. Terenziani, S.Montani, A.Bottrighi

Dept. Comp. Sci., Univ. Torino (It): L.Anselma,G.Correndo

Az. Osp. S. Giovanni Battista, Torino (It): G.Molino, M.Torchio

- Domain independent

(e.g., bladder cancer, reflux esophagitis, heart failure)

- Phisician-oriented & User-friendly

Some recent pubblications:

Terenziani et al., AIIMJ 01,07a,07b, AMIA 00,02,03, Medinfo 04, CGP’04a,04b, AI*IA 03,05, GIN 04,05, AIME 05a,05b,05c

AMIA’06 posters T020 and M010

AMIA’06 paper in session S52

representation formalism

CG

D

A

B

C

B

B1

B2

B1

B2.3

B1.2

B2.1

B1.1

B2.2

B2

Representation Formalism

Tree of graphs

Atomic actions

Composite actions (plans)

Control relations between actions:

- sequence

- “controlled”

- alternative

- repetition (e.g. “3 times each 2

days for a month”)

representation formalism hierarchy of action types
Representation FormalismHierarchy of Action Types

Action

Plan

Work action

Query

Decision

Conclusion

Clinical

action

Pharmacol.

prescription

Diagnostic

decision

Therapeutic

decision

therapeutic decisions

Surgical

treatment

Treatment

choice

Expectant

management

Litholitic

therapy

Therapeutic decisions

Fixed set of parameters (effectiveness, cost, side-effects, compliance, duration)

Treatment choice for symptomless gallbladder stones

local information associated with treatment choice in the symptomless gallbladder stones guideline
Local information associated with treatment choice (in the symptomless gallbladder stones guideline)
diagnostic decisions
Diagnostic Decisions

* Decision parameters

<finding, attribute, value>

* Decision criteria

score-based mechanism

For each alternative

For each parameter

 score

 (additive) threshold range

diagnostic decisions gastro esophageal reflux disease
Diagnostic Decisions(Gastro Esophageal Reflux Disease)

PARAMETERS: heartburn absent (“no-hb”), heartburn lasted not more than 3 months (“hb=<3”), heartburn r lasted more than 3 months (“hb>3m”); dysphagia absent (“no-dys”); dysphagia present (“dys”); occurrence of weight loss (“wl”) or non-occurrence (“no-wl”); hemathemesis absence (“no-hem”); hemathemesis presence (“hem”); postural reflux absent (“no-ref”), postural reflux lasted not more than 3 months (“ref=<3”); postural reflux lasted more than three months (“ref>3m”). THRESHOLD:>9.

(One should conclude “no GERD” only if heartburn, dysphagia, weight loss, hematemesis and postural reflux are all absent.)

architecture of the system

Clinical DB

Expert

Physician

User

Physician

Pharmac. DB

Acquisition

Interface

Execution

Interface

Resource DB

Knowledge

Manager

Execution

Module

ICD DB

Guidelines

DB

Guidelines

Instantiation DB

Patient

DB

Architecture of the system
acquisition
Acquisition

Strict interaction with DB’s

Clinical DB  hierarchically organized vocabulary

 Standardization

 Data sharing

 Support for semantic checks (e.g., legal attribute values)

NOTE: the organization (schema) of Patients DB is equal to the one of the Clinical DB

 During acquisition, GLARE gets the information used at execution-time to retrieve automatically the patient’s data (via automatically generated dynamic-SQL queries)

acquisition intelligent helps syntactic semantic checks
Acquisition“Intelligent” helps (syntactic & semantic checks)

- “legal” names & “legal” values for attributes

- “logical” design criteria (no unstructured cycles, well-formed alternatives & decisions)

- “semantic” checks: consistency of temporal constraints

agenda based execution
Agenda-based execution

In the agenda

- next actions to be executed

- execution time (earliest and latest e.t.)

 “On-line” execution: wait until the next e.t.

(support physician in clinical activity)

 “Simulated” execution: jump to the next e.t.

(education, critique, evaluation)

executing atomic actions
Executing atomic actions

Work actions:

- evaluate pre-conditions

- execute action within its range of time

- delete from the agenda

Query actions:

- retrieve data from patient’s DB

- wait for data not already in the DB, or for the update of “expired” data

Conclusion actions:

- insert conclusion into the patient’s DB

Decision actions: (see alternatives)

executing composite actions
Executing composite actions

Sequence:

- evaluate next action e.t. (given current time and delay)

- execute it

Concurrent actions:

- execute actions according with the temporal constraints

Decision + alternative actions (e.g., diagnostic decision):

- evaluate parameter values for each alternative, using patient’s DB

- determine the score for each alternative

- compare the score with the threshold

- show the alternatives to the user-physician (distinguishing between “suggested” and “not suggested” ones, and showing parameters and scores)

- execute the alternative chosen by the physician (warning available)

executing clinical guidelines other issues
Executing Clinical Guidelines: other issues

 Repeated actions and user-defined periodicities

- expressive language for user-defined periodicities [IEEE TKDE, 97]

- computing next execution time

 Exits

 Failures

return to previous decisions (chronological vs. guided backtracking)

 A user-friendly graphical interface

implementation testing
Implementation & Testing

Prototypical version (Java + Access) under revision

TESTS

(1) Using GLARE to build guidelines from scratch

take advantage of grafical and “intelligent checks” facilities

- bladder cancer algorithm

(2) Converting guidelines on paper to GLARE

inconsistencies/ambiguities detected!

- reflux esophagitis, heart failure, ischemic stroke

advanced features in glare supporting medical decision making
Advanced features in GLARE:Supporting medical decision making

“local information”: considering just the decision criteria associated with the specific decision at hand

“global information”: information stemming from relevant alternative pathways in the guideline

advanced features in glare supporting medical decision making the what if facility
Advanced features in GLARE:Supporting medical decision making:the “What if” facility

Facility for gathering the chosen parameter (e.g, resources, costs, times) from the “relevant” alternative paths on the guideline

It provides an idea of what could happen in the rest of the guideline if the physician selects a given alternative for the patient, and supports for comparisons of the alternatives

Enhanced with an application of “Decision Theory” methodology, to provide an advanced tool to consider costs (money, time, resources) and utility of alternative sequences of actions (QALYs)

syntomless gallbladder stones treatment choice global information

Laparoscopy

Surgical

treatment

Laparoscopy

Choice of

surgical appr.

Treatment

choice

Expectant

management

Laparotomy

Laparotomy

Litholitic

therapy

Litholitic

treatment

Syntomless gallbladder stonestreatment choice: “global information”
syntomless gallbladder stones treatment choice global information23

Laparoscopy

Surgical

treatment

Laparoscopy

Choice of

surgical appr.

Treatment

choice

Expectant

management

Laparotomy

Laparotomy

Litholitic

therapy

Litholitic

treatment

Syntomless gallbladder stonestreatment choice: “global information”

Duration min:2 days Max:3 days

syntomless gallbladder stones treatment choice global information24

Laparoscopy

Surgical

treatment

Laparoscopy

Choice of

surgical appr.

Treatment

choice

Expectant

management

Laparotomy

Litholitic

therapy

Litholitic

treatment

Syntomless gallbladder stonestreatment choice: “global information”

Laparotomy

Duration min:6 days Max:8 days

syntomless gallbladder stones treatment choice global information25

Laparoscopy

Surgical

treatment

Laparoscopy

Choice of

surgical appr.

Treatment

choice

Expectant

management

Laparotomy

Laparotomy

Litholitic

therapy

Litholitic

treatment

Syntomless gallbladder stonestreatment choice: “global information”

Duration min:1 day Max: all life long

syntomless gallbladder stones treatment choice global information26

Laparoscopy

Surgical

treatment

Laparoscopy

Choice of

surgical appr.

Treatment

choice

Expectant

management

Laparotomy

Laparotomy

Litholitic

therapy

Litholitic

treatment

Syntomless gallbladder stonestreatment choice: “global information”

Duration min:2 months Max:1 year

local information associated with treatment choice in the symptomless gallbladder stones guideline27
Local information associated with treatment choice (in the symptomless gallbladder stones guideline)
digression 2 why don t we put global info about paths locally in the decision actions
Digression 2Why don’t we put “global info (about paths)” locally in the decision actions?

Given “local info” in each node, collecting & storing might be automatic

HOWEVER:

- exponential space in each node

- data duplication (consistency after updates?)

- not user friendly (too many data!)

- not all aternatives are “relevant”

- data not always necessary

>> global data only at execution time, on request

advanced features in glare
Advanced features in GLARE

Management of temporal constraints

>>>>> AMIA06 poster T020 Session S50

Terenziani et al., Proc. AMIA’03

Terenziani et al., Artificial Intelligence in Medicine Journal, to appear

Contextualization facilities

>>>>>> AMIA06 poster M010 Session S13

Terenziani et al., Proc. Medinfo’04, AIME’05

Model-checking facilities

>>>>> AMIA06 paper, session S52

Terenziani et al., ECAI’06 Guidelines worshop