GLARE-SSCPM: an Intelligent System to Support the Treatment of Comorbid Patients

The development of software tools supporting physicians in the treatment of comorbid patients is a challenging goal and a hot topic in Medical Informatics and Artificial Intelligence. Computer Interpretable Guidelines (CIGs) are consolidated tools to support physicians with evidence-based recommendations in the treatment of patients affected by a specific disease. However, the applications of two or more CIGs on comorbid patients is critical, since dangerous interactions between (the effects of) actions from different CIGs may arise. GLARE-SSCPM is the first tool supporting, in an integrated way, (i) the knowledge-based detection of interactions, (ii) the management of the interactions, and (iii) the final merge of (part of) the CIGs operating on the patient. GLARE-SSCPM is characterized by being very supportive to physicians, providing them support for focusing, interaction detection, and for an hypothesize and test approach to manage the detected interactions. To achieve such goals, it provides advanced Artificial Intelligence techniques. Preliminary tests in the educational context, within the RoPHS project, have provided encouraging results

Personalized conciliation of clinical guidelines for comorbid patients through multi-agent planning

[EN] The conciliation of multiple single-disease guidelines for comorbid patients entails solving potential clinical interactions, discovering synergies in the diagnosis and the recommendations, and managing clinical equipoise situations. Personalized conciliation of multiple guidelines considering additionally patient preferences brings some further difficulties. Recently, several works have explored distinct techniques to come up with an automated process for the conciliation of clinical guidelines for comorbid patients but very little attention has been put in integrating the patient preferences into this process. In this work, a Multi-Agent Planning (MAP) framework that extends previous work on single-disease temporal Hierarchical Task Networks (HTN) is proposed for the automated conciliation of clinical guidelines with patient-centered preferences. Each agent encapsulates a single-disease Computer Interpretable Guideline (CIG) formalized as an HTN domain and conciliates the decision procedures that encode the clinical recommendations of its CIG with the decision procedures of the other agents' CIGs. During conciliation, drug-related interactions, scheduling constraints as well as redundant actions and multiple support interactions are solved by an automated planning process. Moreover, the simultaneous application of the patient preferences in multiple diseases may potentially bring about contradictory clinical decisions and more interactions. As a final step, the most adequate personalized treatment plan according to the patient preferences is selected by a Multi-Criteria Decision Making (MCDM) process. The MAP approach is tested on a case study that builds upon a simplified representation of two real clinical guidelines for Diabetes Mellitus and Arterial Hypertension.This work has been partially supported by Spanish Government Projects MINECO TIN2014-55637-C2-2-R and TIN2015-71618-R.Fernández-Olivares, J.; Onaindia De La Rivaherrera, E.; Castillo Vidal, L.; Jordán, J.; Cózar, J. (2019). Personalized conciliation of clinical guidelines for comorbid patients through multi-agent planning. Artificial Intelligence in Medicine. 96:167-186. https://doi.org/10.1016/j.artmed.2018.11.003S1671869

Shaping up to improve health: the strategic leadership role of the new Health Authority

The latest return to service planning in the NHS, while harnessing the perceived benefits of previous market approaches, nevertheless signals a radical change in the long-term role of the Health Authority. It is timely to examine the actual objectives of Health Authorities in view of their envisaged strategic leadership role. The emphasis on improving health and ironing out unacceptable local inequalities places the ‘quality’ agenda at the forefront of Health Authority policies. Notwithstanding the role of Regional Offices, Health Authorities will in effect become the overseer of clinical governance arrangements, including the implementation of a more evidencebased approach to service delivery and organisation. The new all-inclusive Health Improvement Programmes represent the raison d’Ltre of the Health Authority of the future. It is argued that insufficient attention has been paid to the legal framework required to support prioritisation decisions for which Health Authorities and PCGs will be held accountable. Available case law suggests that the extent to which central guidance has been followed will be critical in reviewing commissioning decisions. Given the trend towards National Service Frameworks and the development of the National Institute for Clinical Excellence, the question arises of what incentives exist for Health Authorities to pursue the evidence-based approach to its natural conclusion (i.e. as one means of rationing scarce resources). Perhaps the key objective of commissioners will in fact be to avoid adverse publicity in the face of increasingly complex (and open) rationing decisions. In addition, the implication that national guidelines on clinical and cost-effectiveness will have to be adhered to sits somewhat uneasily with recent government assurances regarding clinical freedom and professional self-regulation. Attention is given to equity considerations, the difficulty of identifying common objectives and maintaining productive relationships across organisations, and barriers to changing clinical practice. Conflicting incentives are likely in applying different dimensions of the National Performance Assessment Framework, making the Health Authority’s long-term role (regulator of resource use, quality and service configuration?) a particularly difficult balancing act in ensuring administrative, clinical and political accountability in health care.Health Authorities

Guidelines for Evaluators During a PASS, PASSING, or Similar Assessment of Human Service Quality

https://digitalcommons.unmc.edu/wolf_books/1008/thumbnail.jp

Reviving Full-Service Family Practice in British Columbia

Describes innovative operational reforms made in the province's fee-for-service system to improve quality of care and reduce costs, including incentive payments for chronic disease management and enhanced training. Outlines lessons learned and challenges

Temporal detection and analysis of guideline interactions

Background Clinical practice guidelines (CPGs) are assuming a major role in the medical area, to grant the quality of medical assistance, supporting physicians with evidence-based information of interventions in the treatment of single pathologies. The treatment of patients affected by multiple diseases (comorbid patients) is one of the main challenges for the modern healthcare. It requires the development of new methodologies, supporting physicians in the treatment of interactions between CPGs. Several approaches have started to face such a challenging problem. However, they suffer from a substantial limitation: they do not take into account the temporal dimension. Indeed, practically speaking, interactions occur in time. For instance, the effects of two actions taken from different guidelines may potentially conflict, but practical conflicts happen only if the times of execution of such actions are such that their effects overlap in time. Objectives We aim at devising a methodology to detect and analyse interactions between CPGs that considers the temporal dimension. Methods In this paper, we first extend our previous ontological model to deal with the fact that actions, goals, effects and interactions occur in time, and to model both qualitative and quantitative temporal constraints between them. Then, we identify different application scenarios, and, for each of them, we propose different types of facilities for user physicians, useful to support the temporal detection of interactions. Results We provide a modular approach in which different Artificial Intelligence temporal reasoning techniques, based on temporal constraint propagation, are widely exploited to provide users with such facilities. We applied our methodology to two cases of comorbidities, using simplified versions of CPGs. Conclusion We propose an innovative approach to the detection and analysis of interactions between CPGs considering different sources of temporal information (CPGs, ontological knowledge and execution logs), which is the first one in the literature that takes into account the temporal issues, and accounts for different application scenarios

Necessary improvement of the brazilian autocompositive system: proposals for changes in the training of conciliators and mediators

This article aims to expose reflections on the autocompositional system in Brazil. Its objective is to formulate a proposal for remodeling the syllabus of the Training and Training Course for Conciliators and Mediators, because a well-structured training for the professional, which also introduces general notions about the mental universe of the human being, can guarantee self-composing sessions in a more complete way. Using the deductive method, based on descriptive research, it is concluded that such reformulation needs to be carried out, as a way of giving effectiveness to the Brazilian autocompositional system.Este artículo tiene como objetivo exponer reflexiones sobre el sistema autocompositivo en Brasil. Tiene como objetivo formular una propuesta de remodelación curricular del Curso de Formación de Conciliadores y Mediadores, como una formación bien estructurada para el profesional, que además introduzca nociones generales sobre el universo psíquico del ser humano, pueda garantizar el autocuidado a componer las sesiones de una forma más completa. Utilizando el método deductivo, basado en una investigación descriptiva, se concluye que tal reformulación necesita ser realizada, como una forma de dar efectividad al sistema de autocomposición brasileño

It Takes Two to Tango, and to Mediate: Legal Cultural and Other Factors Influencing United States and Latin American Lawyers’ Resistance to Mediating Commercial Disputes

This article examines legal cultural and other factors influencing the resistance to mediating commercial disputes displayed by U.S. and Latin American lawyers. After surveying current contexts in which commercial mediation occurs in the United States and in Latin American countries and summarizing data regarding commercial actors’ knowledge of the benefits of mediating, it analyzes the relatively infrequent use of mediation despite its potential advantages over adjudicating. Focusing on lawyers, the article next explores factors that influence U.S. and Latin American lawyers when they converse with commercial clients about selecting dispute resolution methods

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

It Takes Two to Tango, and to Mediate: Legal Cultural and Other Factors Influencing United States and Latin American Lawyers’ Resistance to Mediating Commercial Disputes

This article examines legal cultural and other factors influencing the resistance to mediating commercial disputes displayed by U.S. and Latin American lawyers. After surveying current contexts in which commercial mediation occurs in the United States and in Latin American countries and summarizing data regarding commercial ac- tors’ knowledge of the benefits of mediating, it analyzes the relatively infrequent use of mediation despite its potential advantages over adju- dicating. Focusing on lawyers, the article next explores factors that influence U.S. and Latin American lawyers when they converse with commercial clients about selecting dispute resolution methods. Analyzing similarities arising from universal decision-making biases and shared legal cultural traditions, and differences flowing from common law and civil system influences, this article argues that all of these factors strongly influence U.S. and Latin American lawyers toward adjudicating and explains why mediation is not used more often to re- solve commercial disputes. This article concludes by presenting reasons why carefully assessing mediation as a pre-adjudication option helps lawyers counter perceptual, decision-making, and legal cultural biases while allowing commercial clients to avoid the risks and substantial transaction costs inherent in adjudicating disputes