Towards a Learning Health System: a SOA based platform for data re-use in chronic infectious diseases

Abstract Information and Communication Technology (ICT) tools can efficiently support clinical research by providing means to collect automatically huge amount of data useful for the management of clinical trials conduction. Clinical trials are indispensable tools for Evidence-Based Medicine and represent the most prevalent clinical research activity. Clinical trials cover only a restricted part of the population that respond to particular and strictly controlled requirements, offering a partial view of the overall patients\u2019 status. For instance, it is not feasible to consider patients with comorbidities employing only one kind of clinical trial. Instead, a system that have a comprehensive access to all the clinical data of a patient would have a global view of all the variables involved, reflecting real-world patients\u2019 experience. The Learning Health System is a system with a broader vision, in which data from various sources are assembled, analyzed by various means and then interpreted. The Institute of Medicine (IOM) provides this definition: \u201cIn a Learning Health System, progress in science, informatics, and care culture align to generate new knowledge as an ongoing, natural by-product of the care experience, and seamlessly refine and deliver best practices for continuous improvement in health and health care\u201d. The final goal of my project is the realization of a platform inspired by the idea of Learning Health System, which will be able to re-use data of different nature coming from widespread health facilities, providing systematic means to learn from clinicians\u2019 experience to improve both the efficiency and the quality of healthcare delivery. The first approach is the development of a SOA-based architecture to enable data collection from sparse facilities into a single repository, to allow medical institutions to share information without an increase in costs and without the direct involvement of users. Through this architecture, every single institution would potentially be able to participate and contribute to the realization of a Learning Health System, that can be seen as a closed cycle constituted by a sequential process of transforming patient-care data into knowledge and then applying this knowledge to clinical practice. Knowledge, that can be inferred by re-using the collected data to perform multi-site, practice-based clinical trials, could be concretely applied to clinical practice through Clinical Decision Support Systems (CDSS), which are instruments that aim to help physicians in making more informed decisions. With 4 this objective, the platform developed not only supports clinical trials execution, but also enables data sharing with external research databases to participate in wider clinical trials also at a national level without effort. The results of these studies, integrated with existing guidelines, can be seen as the knowledge base of a decision support system. Once designed and developed, the adoption of this system for chronical infective diseases management at a regional level helped in unifying data all over the Ligurian territory and actively monitor the situation of specific diseases (like HIV, HCV and HBV) for which the concept of retention in care assumes great importance. The use of dedicated standards is essential to grant the necessary level of interoperability among the structures involved and to allow future extensions to other fields. A sample scenario was created to support antiretroviral drugs prescription in the Ligurian HIV Network setting. It was thoroughly tested by physicians and its positive impact on clinical care was measured in terms of improvements in patients\u2019 quality of life, prescription appropriateness and therapy adherence. The benefits expected from the employment of the system developed were verified. Student\u2019s T test was used to establish if significant differences were registered between data collected before and after the introduction of the system developed. The results were really acceptable with the minimum p value in the order of 10 125 and the maximum in the order of 10 123. It is reasonable to assess that the improvements registered in the three analysis considered are ascribable to this system introduction and not to other factors, because no significant differences were found in the period before its release. Speed is a focal point in a system that provides decision support and it is highly recognized the importance of velocity optimization. Therefore, timings were monitored to evaluate the responsiveness of the system developed. Extremely acceptable results were obtained, with the waiting times of the order of 10 121 seconds. The importance of the network developed has been widely recognized by the medical staff involved, as it is also assessed by a questionnaire they compiled to evaluate their level of satisfaction

A clinical decision support system for detecting and mitigating potentially inappropriate medications

Background: Medication errors are a leading cause of preventable harm to patients. In older adults, the impact of ageing on the therapeutic effectiveness and safety of drugs is a significant concern, especially for those over 65. Consequently, certain medications called Potentially Inappropriate Medications (PIMs) can be dangerous in the elderly and should be avoided. Tackling PIMs by health professionals and patients can be time-consuming and error-prone, as the criteria underlying the definition of PIMs are complex and subject to frequent updates. Moreover, the criteria are not available in a representation that health systems can interpret and reason with directly. Objectives: This thesis aims to demonstrate the feasibility of using an ontology/rule-based approach in a clinical knowledge base to identify potentially inappropriate medication(PIM). In addition, how constraint solvers can be used effectively to suggest alternative medications and administration schedules to solve or minimise PIM undesirable side effects. Methodology: To address these objectives, we propose a novel integrated approach using formal rules to represent the PIMs criteria and inference engines to perform the reasoning presented in the context of a Clinical Decision Support System (CDSS). The approach aims to detect, solve, or minimise undesirable side-effects of PIMs through an ontology (knowledge base) and inference engines incorporating multiple reasoning approaches. Contributions: The main contribution lies in the framework to formalise PIMs, including the steps required to define guideline requisites to create inference rules to detect and propose alternative drugs to inappropriate medications. No formalisation of the selected guideline (Beers Criteria) can be found in the literature, and hence, this thesis provides a novel ontology for it. Moreover, our process of minimising undesirable side effects offers a novel approach that enhances and optimises the drug rescheduling process, providing a more accurate way to minimise the effect of drug interactions in clinical practice

Integrative bioinformatics and graph-based methods for predicting adverse effects of developmental drugs

Adverse drug effects are complex phenomena that involve the interplay between drug molecules and their protein targets at various levels of biological organisation, from molecular to organismal. Many factors are known to contribute toward the safety profile of a drug, including the chemical properties of the drug molecule itself, the biological properties of drug targets and other proteins that are involved in pharmacodynamics and pharmacokinetics aspects of drug action, and the characteristics of the intended patient population. A multitude of scattered publicly available resources exist that cover these important aspects of drug activity. These include manually curated biological databases, high-throughput experimental results from gene expression and human genetics resources as well as drug labels and registered clinical trial records. This thesis proposes an integrated analysis of these disparate sources of information to help bridge the gap between the molecular and the clinical aspects of drug action. For example, to address the commonly held assumption that narrowly expressed proteins make safer drug targets, an integrative data-driven analysis was conducted to systematically investigate the relationship between the tissue expression profile of drug targets and the organs affected by clinically observed adverse drug reactions. Similarly, human genetics data were used extensively throughout the thesis to compare adverse symptoms induced by drug molecules with the phenotypes associated with the genes encoding their target proteins. One of the main outcomes of this thesis was the generation of a large knowledge graph, which incorporates diverse molecular and phenotypic data in a structured network format. To leverage the integrated information, two graph-based machine learning methods were developed to predict a wide range of adverse drug effects caused by approved and developmental therapies

The classification of gene products in the molecular biology domain: Realism, objectivity, and the limitations of the Gene Ontology

Background: Controlled vocabularies in the molecular biology domain exist to facilitate data integration across database resources. One such tool is the Gene Ontology (GO), a classification designed to act as a universal index for gene products from any species. The Gene Ontology is used extensively in annotating gene products and analysing gene expression data, yet very little research exists from a library and information science perspective exploring the design principles, philosophy and social role of ontologies in biology. Aim: To explore how molecular biologists, in creating the Gene Ontology, devised guidelines and rules for determining which scientific concepts are included in the ontology, and the criteria for how these concepts are represented. Methods: A domain analysis approach was used to devise a mixed methodology to study the design of the Gene Ontology. Concept analysis of a GO term and a critical discourse analysis of GO developer mailing list texts were used to test whether ontological realism is a tenable basis for constructing objective ontologies. A comparison of the current GO vocabulary construction guidelines and a study of the reasons why GO terms are removed from the ontology further explored the justifications for the design of the Gene Ontology. Finally, a content analysis of published GO papers examined how authors use and cite GO data and terminology. Results: Gene Ontology terms can be presented according to different epistemologies for concepts, indicating that ontological realism is not the only way objective ontologies can be designed. Social roles and the exercise of power were found to play an important role in determining ontology content, and poor synonym control, a lack of clear warrant for deciding terminology and arbitrary decisions to delete and invent new terms undermine the objectivity and universal applicability of the Gene Ontology. Authors exhibited poor compliance with GO data citation policies, and in re-wording and misquoting GO terminology, risk exacerbating the semantic problems this controlled vocabulary was designed to solve. Conclusions: The failure of the Gene Ontology to define what is meant by a molecular function, the exercise of power by GO developers in clearing contentious concepts from the ontology, and the strict adherence to ontological realism, which marginalises social and subjective ways of classifying scientific concepts, limits the utility of the ontology as a tool to unify the molecular biology domain. These limitations to the Gene Ontology design could be overcome with the development of lighter, pluralistic, user-controlled ‘open ontologies’ for gene products that can work alongside more traditional, ‘top-down’ developed vocabularies

Automatic Population of Structured Reports from Narrative Pathology Reports

There are a number of advantages for the use of structured pathology reports: they can ensure the accuracy and completeness of pathology reporting; it is easier for the referring doctors to glean pertinent information from them. The goal of this thesis is to extract pertinent information from free-text pathology reports and automatically populate structured reports for cancer diseases and identify the commonalities and differences in processing principles to obtain maximum accuracy. Three pathology corpora were annotated with entities and relationships between the entities in this study, namely the melanoma corpus, the colorectal cancer corpus and the lymphoma corpus. A supervised machine-learning based-approach, utilising conditional random fields learners, was developed to recognise medical entities from the corpora. By feature engineering, the best feature configurations were attained, which boosted the F-scores significantly from 4.2% to 6.8% on the training sets. Without proper negation and uncertainty detection, the quality of the structured reports will be diminished. The negation and uncertainty detection modules were built to handle this problem. The modules obtained overall F-scores ranging from 76.6% to 91.0% on the test sets. A relation extraction system was presented to extract four relations from the lymphoma corpus. The system achieved very good performance on the training set, with 100% F-score obtained by the rule-based module and 97.2% F-score attained by the support vector machines classifier. Rule-based approaches were used to generate the structured outputs and populate them to predefined templates. The rule-based system attained over 97% F-scores on the training sets. A pipeline system was implemented with an assembly of all the components described above. It achieved promising results in the end-to-end evaluations, with 86.5%, 84.2% and 78.9% F-scores on the melanoma, colorectal cancer and lymphoma test sets respectively