Modelling Medical Knowledge and Processes

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Modelling Medical Knowledge and Processes

• Tony Rose and Ayelet Oettinger
• ACL

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Contents

• CR-UK and the Advanced Computation Lab
• Cognitive science the clinical context
• Clinical guidelines modelling languages
• The Credo Trial
• Usability issues
• How you can help

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Cancer Research UK

• History
• Europe's largest independent cancer research
  organisation
• 2002 merger of ICRF and CRC
• Vision
• to conquer cancer through world-class research,
  aiming to control the disease within two
  generations
• Funding
• research spend for 2002/2003 191 million
• Structure
• In-house research labs
• External research grants

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Advanced Computation Lab

• One of CR-UKs in-house labs, based in London
• Mission
• research in the computer and cognitive sciences,
  including AI and cognitive psychology, as a basis
  for developing innovative information
  technologies to support patient care
• Structure
• Scientists developers

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Research Aims

• To carry out fundamental research in theories of
  computation and intelligent systems
• To develop novel technologies based on
  theoretical results
• To demonstrate the practical value of these
  technologies in biomedical applications for
  clinical research and patient care

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Research at the ACL
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The Clinical Context

• Perhaps 16,000 lives a year could be saved if
  the quality of cancer services was uniformly high
  and the best treatment practices applied to all
• ICRF Vision for Cancer, 1995

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The Knowledge Crisis

• Modern medicine is becoming a humanly impossible
  task
• New knowledge is being generated too quickly for
  individuals to absorb and for organisations to
  assimilate into mainstream clinical practice

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The Role of Clinical Guidelines

• CGs based on best available evidence from
  systematic research
• Following clinical guidelines helps to save lives
• improve care quality and standardize care
• Various sources
• National Institute for Clinical Excellence
• National Guideline Clearinghouse
• many more

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CGs and CIGs

• Most CGs are deployed in textual form
• Narrative, flowcharts, diagrams
• Our aim is to provide evidence-based decision
  support in executable form

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CIG Modelling Languages

• Various paradigms, e.g.
• procedural
• rule-based
• e.g. Arden syntax
• task-based
• GLIF, Eon, Asbru, PROforma

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PROforma

• Formal language for modelling clinical knowledge
  and processes
• supports the definition of clinical guidelines
  and protocols in terms of
• a set of primitive tasks which are composed into
  networks representing clinical processes
• logical constructs that allow the details of
  tasks and their inter-relationships to be defined

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Task hierarchy

• Uses Argumentation for decision making
• weigh up arguments for or against a particular
  proposition

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PROforma

• Plans container structures that hold any number
  of task instances
• Enquiries requests for information or data from
  an external agent (e.g. the end-user)
• Actions typically clinical procedures (such as
  the administration of an injection) to be carried
  out
• Decisions choices of some kind, such as a choice
  of investigation, diagnosis or treatment

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Tallis

• Software environment for developing and executing
  clinical decision support and workflow
  applications
• Clinical processes are modelled using the Tallis
  Composer
• Processes can be enacted to provide workflow and
  DS via a web browser

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Knowledge Sharing

• Tallis supports knowledge sharing through a
  repository server, e.g. OpenClinical.net
• leverage work done by others
• reduce development costs
• Leads to knowledge publishing lifecycle
• iterative development and review process

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The Credo Trial

• as a basis for developing innovative
  information technologies to support patient care
  -gt the Credo Trial
• multi-centre trial of integrated software package
  designed to support breast cancer care throughout
  the patient journey
• Collaborators
• Guys Hospital Breast Unit, London
• Addenbrookes Hospital Breast Unit, Cambridge
• Carol Franc Buck Breast Care Centre, UCSF

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Credo Core Service Model
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Credo Trial

• Phase 1 (2003-2004)
• pilot trials of Work-up and Treatment services,
  using paper patients
• Phase 2
• multi-centre trials of individual Work-up and
  Treatment services at clinical sites
• development of technical infrastructure
• electronic patient records, messaging and
  integration (e.g. medical imaging)

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Credo Trial

• Phase 3
• RCT of integrated patient journey system
• Quantitative assessment of clinical outcomes
• compliance with pathway
• effectiveness and timeliness of communication
• patient satisfaction

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Credo Phase 1 Results

• Aim trial of support for initial assessment
  (Triple Assessment) of women with breast symptoms
• Methodsoftware assists clinician in calculation
  of familial risk, selection of appropriate
  investigations and subsequent management of
  patient
• Study design Crossover experiment with balanced
  blocked design, each clinician managing a set of
  10 simulated cases, 5 with and 5 without DS

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Credo Phase 1 Results

• Outcome measures deviation from the guidelines
  (as agreed in advance by a panel of experts

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Usability Issues

• High level (conceptual)
• How best to model medical knowledge?
• What kind of conceptual structures do clinicians
  use?
• What kind of decision making framework?
• How should those concepts be represented by the
  system (UI)?
• Low(er) level
• Does the UI employ HCI best practice?
• Does it support the users task appropriately?

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The Tallis Usability Trial

• Aim to compare Tallis Composer 1.3 with Tallis
  Composer 1.5
• Hypothesis Tallis 1.5 is more usable for new
  users
• Study design between-groups trial with each
  participant performing 6 tasks with 1.3 or 1.5
• Outcome measures
• For each task
• Definition of successful, unsuccessful partial
  completion
• A score for each level of the above
• Overall average score across all
  tasks/participants

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Paper Prototyping

• Tallis 1.3 is a working prototype, BUT -
• Tallis 1.5 is a design proposal it exists on
  paper only
• How do we test a design on paper?
• Use paper prototyping
• paper versions of screens widgets
• one person acts as computer
• both UIs are mocked up

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How you can help

• By volunteering!
• Whats involved
• 30 minute primer on knowledge modelling
• 90 minute trial at CR-UK
• using paper prototypes
• think-aloud protocol
• video recording