Temporal detection and analysis of guideline interactions

A Community-of-Practice-based Evaluation Methodology for Knowledge Intensive Computational Methods and its Application to Multimorbidity Decision Support

OBJECTIVE

The study has dual objectives. Our first objective (1) is to develop a community-of-practice-based evaluation methodology for knowledge-intensive computational methods. We target a whitebox analysis of the computational methods to gain insight on their functional features and inner workings. In more detail, we aim to answer evaluation questions on (i) support offered by computational methods for functional features within the application domain; and (ii) in-depth characterizations of the underlying computational processes, models, data and knowledge of the computational methods. Our second objective (2) involves applying the evaluation methodology to answer questions (i) and (ii) for knowledge-intensive clinical decision support (CDS) methods, which operationalize clinical knowledge as computer interpretable guidelines (CIG); we focus on multimorbidity CIG-based clinical decision support (MGCDS) methods that target multimorbidity treatment plans.

MATERIALS AND METHODS

Our methodology directly involves the research community of practice in (a) identifying functional features within the application domain; (b) defining exemplar case studies covering these features; and (c) solving the case studies using their developed computational methods-research groups detail their solutions and functional feature support in solution reports. Next, the study authors (d) perform a qualitative analysis of the solution reports, identifying and characterizing common themes (or dimensions) among the computational methods. This methodology is well suited to perform whitebox analysis, as it directly involves the respective developers in studying inner workings and feature support of computational methods. Moreover, the established evaluation parameters (e.g., features, case studies, themes) constitute a re-usable benchmark framework, which can be used to evaluate new computational methods as they are developed. We applied our community-of-practice-based evaluation methodology on MGCDS methods.

RESULTS

Six research groups submitted comprehensive solution reports for the exemplar case studies. Solutions for two of these case studies were reported by all groups. We identified four evaluation dimensions: detection of adverse interactions, management strategy representation, implementation paradigms, and human-in-the-loop support.Based on our whitebox analysis, we present answers to the evaluation questions (i) and (ii) for MGCDS methods.

DISCUSSION

The proposed evaluation methodology includes features of illuminative and comparison-based approaches; focusing on understanding rather than judging/scoring or identifying gaps in current methods. It involves answering evaluation questions with direct involvement of the research community of practice, who participate in setting up evaluation parameters and solving exemplar case studies. Our methodology was successfully applied to evaluate six MGCDS knowledge-intensive computational methods. We established that, while the evaluated methods provide a multifaceted set of solutions with different benefits and drawbacks, no single MGCDS method currently provides a comprehensive solution for MGCDS.

CONCLUSION

We posit that our evaluation methodology, applied here to gain new insights into MGCDS, can be used to assess other types of knowledge-intensive computational methods and answer other types of evaluation questions. Our case studies can be accessed at our GitHub repository (https://github.com/william-vw/MGCDS).

Monitoring hybrid process specifications with conflict management: An automata-theoretic approach

Complexity of medical treatments can vary from prescribing medicine for a specific ailment to managing a complex set of simultaneous medical issues. In the latter case, doctors are assisted by clinical guidelines which outline standard medical procedures, tests, treatments, etc. To facilitate the use of such guidelines, they can be digitized as processes and adopted in complex process engines offering additional help to health providers such as decision support while monitoring active treatments so as to detect flaws in treatment procedures and suggest possible reactions on them. For example, a patient may present symptoms of multiple diseases simultaneously (requiring multiple clinical guidelines to be followed), while also being allergic to some often-used drugs (requiring additional constraints to be respected). This can easily lead to treating a patient based on a set of process specifications which are not fully compatible with each other. While a scenario like that commonly occurs in practice, research in that direction has thus far given little consideration to how to specify multiple clinical guidelines and how to automatically combine their specifications in the context of the monitoring task. In our previous work (Alman et al., 20222), we presented a conceptual framework for handling the above cases in the context of monitoring. In this paper, we present the algorithms necessary for implementing key components of this conceptual framework. More specifically, we provide formal languages for representing clinical guideline specifications and formalize a solution for monitoring the interplay of such specifications expressed as a combination of (data-aware) Petri nets and temporal logic rules. The proposed solution seamlessly handles combination of the input process specifications and provides both early conflict detection and decision support during process execution. We also discuss a proof-of-concept implementation of our approach and present the results of extensive scalability experiments.

Decision support for comorbid conditions via execution-time integration of clinical guidelines using transaction-based semantics and temporal planning

In case of comorbidity, i.e., multiple medical conditions, Clinical Decision Support Systems (CDSS) should issue recommendations based on all relevant disease-related Clinical Practice Guidelines (CPG). However, treatments from multiple comorbid CPG often interact adversely (e.g., drug-drug interactions) or introduce operational inefficiencies (e.g., redundant scans). A common solution is the a-priori integration of computerized CPG, which involves integration decisions such as discarding, replacing or delaying clinical tasks (e.g., treatments) to avoid adverse interactions or inefficiencies. We argue this insufficiently deals with execution-time events: as the patient's health profile evolves, acute conditions occur, and real-time delays take place, new CPG integration decisions will often be needed, and prior ones may need to be reverted or undone. Any realistic CPG integration effort needs to further consider temporal aspects of clinical tasks-these are not only restricted by temporal constraints from CPGs (e.g., sequential relations, task durations) but also by CPG integration efforts (e.g., avoid treatment overlap). This poses a complex execution-time challenge and makes it difficult to determine an up-to-date, optimal comorbid care plan. We present a solution for dynamic integration of CPG in response to evolving health profiles and execution-time events. CPG integration policies are formulated by clinical experts for coping with comorbidity at execution-time, with clearly defined integration semantics that build on Description and Transaction Logics. A dynamic planning approach reconciles temporal constraints of CPG tasks at execution-time based on their importance, and continuously updates an optimal task schedule.

Towards a goal-oriented methodology for clinical-guideline-based management recommendations for patients with multimorbidity: GoCom and its preliminary evaluation

Patients with chronic multimorbidity are becoming more common as life expectancy increases, making it necessary for physicians to develop complex management plans. We are looking at the patient management process as a goal-attainment problem. Hence, our aim is to develop a goal-oriented methodology for providing decision support for managing patients with multimorbidity continuously, as the patient's health state is progressing and new goals arise (e.g., treat ulcer, prevent osteoporosis). Our methodology allows us to detect and mitigate inconsistencies among guideline recommendations stemming from multiple clinical guidelines, while consulting medical ontologies and terminologies and relying on patient information standards. This methodology and its implementation as a decision-support system, called GoCom, starts with computer-interpretable clinical guidelines (CIGs) for single problems that are formalized using the PROforma CIG language. We previously published the architecture of the system as well as a CIG elicitation guide for enriching PROforma tasks with properties referring to vocabulary codes of goals and physiological effects of management plans. In this paper, we provide a formalization of the conceptual model of GoCom that generates, for each morbidity of the patient, a patient-specific goal tree that results from the PROforma engine's enactment of the CIG with the patient's data. We also present the "Controller" algorithm that drives the GoCom system. Given a new problem that a patient develops, the Controller detects inconsistencies among goals pertaining to different comorbid problems and consults the CIGs to generate alternative non-conflicted and goal-oriented management plans that address the multiple goals simultaneously. In this stage of our research, the inconsistencies that can be detected are of two types - starting vs. stopping medications that belong to the same medication class hierarchy, and detecting opposing physiological effect goals that are specified in concurrent CIGs (e.g., decreased blood pressure vs. increased blood pressure). However, the design of GoCom is modular and generic and allows the future introduction of additional interaction detection and mitigation strategies. Moreover, GoCom generates explanations of the alternative non-conflicted management plans, based on recommendations stemming from the clinical guidelines and reasoning patterns. GoCom's functionality was evaluated using three cases of multimorbidity interactions that were checked by our three clinicians. Usefulness was evaluated with two studies. The first evaluation was a pilot study with ten 6th year medical students and the second evaluation was done with 27 6th medical students and interns. The participants solved complex realistic cases of multimorbidity patients: with and without decision-support, two cases in the first evaluation and 6 cases in the second evaluation. Use of GoCom increased completeness of the patient management plans produced by the medical students from 0.44 to 0.71 (P-value of 0.0005) in the first evaluation, and from 0.31 to 0.78 (P-value < 0.0001) in the second evaluation. Correctness in the first evaluation was very high with (0.98) or without the system (0.91), with non-significant difference (P-value ≥ 0.17). In the second evaluation, use of GoCom increased correctness from 0.68 to 0.83 (P-value of 0.001). In addition, GoCom's explanation and visualization were perceived as useful by the vast majority of participants. While GoCom's detection of goal interactions is currently limited to detection of starting vs. stopping the same medication or medication subclasses and detecting conflicting physiological effects of concurrent medications, the evaluation demonstrated potential of the system for improving clinical decision-making for multimorbidity patients.

Conformance analysis for comorbid patients in Answer Set Programming

The treatment of comorbid patients is a hot problem in Medical Informatics, since the plain application of multiple Computer-Interpretable Guidelines (CIGs) can lead to interactions that are potentially dangerous for the patients. The specialized literature has mostly focused on the "a priori" or "execution-time" analysis of the interactions between multiple Computer-Interpretable Guidelines (CIGs), and/or CIG "merge". In this paper, we face a complementary problem, namely, the a posteriori analysis of the treatment of comorbid patients. Given the CIGs, the history of the status of the patient, and the log of the clinical actions executed on her, we try to explain the actions executed on the patient (i.e., the log) in terms of the actions recommended by the CIGs, of their potential interactions, and of the possible ways of managing each such interaction, pointing out (i) deviations from CIG recommendations not explained in terms of interaction management (if any) and (ii) unmanaged interactions (if any). Our approach is based on Answer Set Programming, and, to face realistic problems, devotes specific attention to the temporal dimension.

Supporting the distributed execution of clinical guidelines by multiple agents

Clinical guidelines (GLs) are widely adopted in order to improve the quality of patient care, and to optimize it. To achieve such goals, their application on a specific patient usually requires the interventions of different agents, with different roles (e.g., physician, nurse), abilities (e.g., specialist in the treatment of alcohol-related problems) and contexts (e.g., many chronic patients may be treated at home). Additionally, the responsibility of the application of a guideline to a patient is usually retained by a physician, but delegation of responsibility (of the whole guideline, or of a part of it) is often used\required (e.g., delegation to a specialist), as well as the possibility, for a responsible, to select the executor of an action (e.g., a physician may retain the responsibility of an action, but delegate to a nurse its execution). To manage such phenomena, proper support to agent interaction and communication must be provided, providing agents with facilities for (1) treatment continuity (2) contextualization, (3) responsibility assignment and delegation (4) check of agent "appropriateness". In this paper we extend GLARE, a computerized GL management system, to support such needs. We illustrate our approach by means of a practical case study.

Execution-time integration of clinical practice guidelines to provide decision support for comorbid conditions

Patients with multiple medical conditions (comorbidity) pose major challenges to clinical decision support systems, since the different Clinical Practice Guidelines (CPG) often involve adverse interactions, such as drug-drug or drug-disease interactions. Moreover, opportunities often exist for optimizing care and resources across multiple CPG. These challenges have been taken up in the state of the art, with many approaches focusing on the static integration of comorbid CIG. Nevertheless, we observe that many aspects often change dynamically over time, in ways that cannot be foreseen - such as delays in care tasks, resource availability, test outcomes, and acute comorbid conditions. To ensure the clinical safety and effectiveness of integrating multiple comorbid CIG, these execution-time difficulties must be considered. Further, when dealing with comorbid conditions, we remark that clinical practitioners typically consider multiple complex solutions, depending on the patient's health profile. Hence, execution-time flexibility, based on dynamic health parameters, is needed to effectively and safely cope with comorbid conditions. In this work, we introduce a flexible, knowledge-driven and execution-time approach to comorbid CIG integration, based on an OWL ontology with clearly defined integration semantics.

Formalization and acquisition of temporal knowledge for decision support in medical processes

BACKGROUND

In medical practice, long term interventions are common and they require timely planning of the involved processes. Unfortunately, evidence-based statements about time are hard to find in Clinical Practice Guidelines (CPGs) and in other sources of medical knowledge. At the same time, health care centers use medical records and information systems to register data about clinical processes and patients, including time information about the encounters, prescriptions, and other clinical actions. Consequently, medical records and health care information systems are promising sources of data from which we can detect temporal medical knowledge.

OBJECTIVE

The objectives were to (1) Analyze and classify the sorts of time constraints in medical processes, (2) Propose a formalism to represent these sorts of clinical time constraints, (3) Use these formalisms to enable the automatic generation of temporal models from clinical data, and (4) Study the adherence of these intervention models to CPG recommendations.

METHODS

In order to achieve these objectives, we carried out four studies: The identification of the sort of times involved in the long-term diagnostic and therapeutic medical procedures of fifty patients, the supervision of the indications about time contained in six CPGs on chronic diseases, the study of the time structures of two standard data models, as well as ten languages to computerize CPGs. Based on the provided studies, we synthesized two representation formalisms: Micro- and macro-temporality. We developed three algorithms for automatic generation of generalized time constraints in the form of micro- and macro-temporalities from clinical databases, which were double tested.

RESULTS

A full classification of time constraints for medical procedures is proposed. Two formalisms called micro- and macro-temporality are introduced and validated to represent these time constraints. Time constraints were generated automatically from the data about 8781 Arterial Hypertension (AH) patients. The generated macro-temporalities restricted visits to be between 1-7 weeks, whereas CPGs recommend 2-4 weeks. Micro-temporal constraints on drug-dosage therapies distinguished between the initial dosage and the target dosage, with visits every 1-6 weeks, and 2-5 months, respectively. Our algorithms obtained semi-complete maps of dosage increments and the maximum dosages for 7 drug types. Data-based time limits for lifestyle change counsels and blood pressure (BP) check-ups were fixed to 6 and 3 months, for patients with low- and high-BP, respectively, when CPGs specify a general 3-6 month range.

CONCLUSIONS

Experience-based temporal knowledge detected using our algorithms complements the evidence-based knowledge about clinical procedures contained in the CPGs. Our temporal model is simple and highly descriptive when dealing with general or specific time constraints' representations, offering temporal knowledge representation of varying detail. Therefore, it is capable of capturing all the temporal knowledge we can find in medical procedures, when dealing with chronic diseases. With our model and algorithms, an adherence analysis emerges naturally to detect CPG-compliant interventions, but also deviations whose causes and possible rationales can call into question CPG recommendations (e.g., our analysis of AH patients showed that the time between visits recommended by CPGs were too long for a proper drug therapy decision, dosage titration, or general follow-up).

Representing and querying now-relative relational medical data

Temporal information plays a crucial role in medicine. Patients' clinical records are intrinsically temporal. Thus, in Medical Informatics there is an increasing need to store, support and query temporal data (particularly in relational databases), in order, for instance, to supplement decision-support systems. In this paper, we show that current approaches to relational data have remarkable limitations in the treatment of "now-relative" data (i.e., data holding true at the current time). This can severely compromise their applicability in general, and specifically in the medical context, where "now-relative" data are essential to assess the current status of the patients. We propose a theoretically grounded and application-independent relational approach to cope with now-relative data (which can be paired, e.g., with different decision support systems) overcoming such limitations. We propose a new temporal relational representation, which is the first relational model coping with the temporal indeterminacy intrinsic in now-relative data. We also propose new temporal algebraic operators to query them, supporting the distinction between possible and necessary time, and Allen's temporal relations between data. We exemplify the impact of our approach, and study the theoretical and computational properties of the new representation and algebra.

The use of computer-interpretable clinical guidelines to manage care complexities of patients with multimorbid conditions: A review

Clinical practice guidelines (CPGs) document evidence-based information and recommendations on treatment and management of conditions. CPGs usually focus on management of a single condition; however, in many cases a patient will be at the centre of multiple health conditions (multimorbidity). Multiple CPGs need to be followed in parallel, each managing a separate condition, which often results in instructions that may interact with each other, such as conflicts in medication. Furthermore, the impetus to deliver customised care based on patient-specific information, results in the need to be able to offer guidelines in an integrated manner, identifying and managing their interactions. In recent years, CPGs have been formatted as computer-interpretable guidelines (CIGs). This enables developing CIG-driven clinical decision support systems (CDSSs), which allow the development of IT applications that contribute to the systematic and reliable management of multiple guidelines. This study focuses on understanding the use of CIG-based CDSSs, in order to manage care complexities of patients with multimorbidity. The literature between 2011 and 2017 is reviewed, which covers: (a) the challenges and barriers in the care of multimorbid patients, (b) the role of CIGs in CDSS augmented delivery of care, and (c) the approaches to alleviating care complexities of multimorbid patients. Generating integrated care plans, detecting and resolving adverse interactions between treatments and medications, dealing with temporal constraints in care steps, supporting patient-caregiver shared decision making and maintaining the continuity of care are some of the approaches that are enabled using a CIG-based CDSS.