Automated conflict resolution between multiple clinical pathways:A technology report

Background The number of people in the UK with three or more long-term conditions continues to grow and the management of patients with co-morbidities is complex. In treating patients with multimorbidities, a fundamental problem is understanding and detecting points of conflict between different guidelines which to date has relied on individual clinicians collating disparate information. Objective We will develop a framework for modelling a diverse set of care pathways, and investigate how conflicts can be detected and resolved automatically. We will use this knowledge to develop a software tool for use by clinicians that can map guidelines, highlight root causes of conflict between these guidelines and suggest ways they might be resolved. Method Our work consists of three phases. First, we will accurately model clinical pathways for six of the most common chronic diseases; second, we will automatically identify and detect sources of conflict across the pathways and how they might be resolved. Third, we will present a case study to prove the validity of our approach using a team of clinicians to detect and resolve the conflicts in the treatment of a fictional patient with multiple common morbidities and compare their findings and recommendations with those derived automatically using our novel software. Discussion This paper describes the development of an important software-based method for identifying a conflict between clinical guidelines. Our findings will support clinicians treating patients with multimorbidity in both primary and secondary care settings

Retrospective checking of compliance with practice guidelines for acute stroke care: a novel experiment using openEHR’s Guideline Definition Language

BACKGROUND: Providing scalable clinical decision support (CDS) across institutions that use different electronic health record (EHR) systems has been a challenge for medical informatics researchers. The lack of commonly shared EHR models and terminology bindings has been recognised as a major barrier to sharing CDS content among different organisations. The openEHR Guideline Definition Language (GDL) expresses CDS content based on openEHR archetypes and can support any clinical terminologies or natural languages. Our aim was to explore in an experimental setting the practicability of GDL and its underlying archetype formalism. A further aim was to report on the artefacts produced by this new technological approach in this particular experiment. We modelled and automatically executed compliance checking rules from clinical practice guidelines for acute stroke care. METHODS: We extracted rules from the European clinical practice guidelines as well as from treatment contraindications for acute stroke care and represented them using GDL. Then we executed the rules retrospectively on 49 mock patient cases to check the cases’ compliance with the guidelines, and manually validated the execution results. We used openEHR archetypes, GDL rules, the openEHR reference information model, reference terminologies and the Data Archetype Definition Language. We utilised the open-sourced GDL Editor for authoring GDL rules, the international archetype repository for reusing archetypes, the open-sourced Ocean Archetype Editor for authoring or modifying archetypes and the CDS Workbench for executing GDL rules on patient data. RESULTS: We successfully represented clinical rules about 14 out of 19 contraindications for thrombolysis and other aspects of acute stroke care with 80 GDL rules. These rules are based on 14 reused international archetypes (one of which was modified), 2 newly created archetypes and 51 terminology bindings (to three terminologies). Our manual compliance checks for 49 mock patients were a complete match versus the automated compliance results. CONCLUSIONS: Shareable guideline knowledge for use in automated retrospective checking of guideline compliance may be achievable using GDL. Whether the same GDL rules can be used for at-the-point-of-care CDS remains unknown

Ontology modeling for generation of clinical pathways

Purpose: Increasing costs of health care, fuelled by demand for high quality, cost-effective healthcare has drove hospitals to streamline their patient care delivery systems. One such systematic approach is the adaptation of Clinical Pathways (CP) as a tool to increase the quality of healthcare delivery. However, most organizations still rely on are paper-based pathway guidelines or specifications, which have limitations in process management and as a result can influence patient safety outcomes. In this paper, we present a method for generating clinical pathways based on organizational semiotics by capturing knowledge from syntactic, semantic and pragmatic to social level. Design/methodology/approach: The proposed modeling approach to generation of CPs adopts organizational semiotics and enables the generation of semantically rich representation of CP knowledge. Semantic Analysis Method (SAM) is applied to explicitly represent the semantics of the concepts, their relationships and patterns of behavior in terms of an ontology chart. Norm Analysis Method (NAM) is adopted to identify and formally specify patterns of behavior and rules that govern the actions identified on the ontology chart. Information collected during semantic and norm analysis is integrated to guide the generation of CPs using best practice represented in BPMN thus enabling the automation of CP. Findings: This research confirms the necessity of taking into consideration social aspects in designing information systems and automating CP. The complexity of healthcare processes can be best tackled by analyzing stakeholders, which we treat as social agents, their goals and patterns of action within the agent network. Originality/value: The current modeling methods describe CPs from a structural aspect comprising activities, properties and interrelationships. However, these methods lack a mechanism to describe possible patterns of human behavior and the conditions under which the behavior will occur. To overcome this weakness, a semiotic approach to generation of clinical pathway is introduced. The CP generated from SAM together with norms will enrich the knowledge representation of the domain through ontology modeling, which allows the recognition of human responsibilities and obligations and more importantly, the ultimate power of decision making in exceptional circumstances

A model-driven transformation approach for the modelling of processes in clinical practice guidelines

Clinical Practice Guidelines (CPGs) include recommendations aimed at optimising patient care, informed by a review of the available clinical evidence. To achieve their potential benefits, CPG should be readily available at the point of care. This can be done by translating CPG recommendations into one of the languages for Computer-Interpretable Guidelines (CIGs). This is a difficult task for which the collaboration of clinical and technical staff is crucial. However, in general CIG languages are not accessible to non-technical staff. We propose to support the modelling of CPG processes (and hence the authoring of CIGs) based on a transformation, from a preliminary specification in a more accessible language into an implementation in a CIG language. In this paper, we approach this transformation following the Model-Driven Development (MDD) paradigm, in which models and transformations are key elements for software development. To demonstrate the approach, we implemented and tested an algorithm for the transformation from the BPMN language for business processes to the PROforma CIG language. This implementation uses transformations defined in the ATLAS Transformation Language. Additionally, we conducted a small experiment to assess the hypothesis that a language such as BPMN can facilitate the modelling of CPG processes by clinical and technical staff.Funding for open access charge: CRUE-Universitat Jaume

The suitability of care pathways for integrating processes and information systems in healthcare

Purpose: This paper examines the suitability of current care pathway modelling techniques for supporting business improvement and the development of information systems. This is in the light of current UK government policies advocating the use of care pathways as part of the £12.4 billion programme for IT and as a key strategy to reducing waiting times. Approach: We conducted a qualitative analysis of the variety in purpose, syntax and semantics in a selection of existing care pathways. Findings: Care pathways are typically modelled in an ad-hoc manner with little reference to formal syntax or semantics. Research limits: The research reviews a small selection of existing pathways. The feature set used for evaluation could be further refined. Future research should examine the suitability of applying existing process modelling techniques to care pathways and explore the motivations for modelling care pathways in an ad-hoc manner. Practical implications: The development of care pathways can aid process improvement and the integration of information systems. However, while syntax and semantics are not standardised the impact of care pathways in the work of Department of Health agencies, in particular Connecting for Health, is likely to be limited. Value: The results provide insight into the limitations of the state of the art in care pathway models. This highlights a significant omission in the Department of Health’s approach and identifies an important direction for further development that will aid Connecting for Health, healthcare organisations and healthcare professionals to deliver more effective services

Supporting the Refinement of Clinical Process Models to Computer-Interpretable Guideline Models

Clinical guidelines contain recommendations on the appropriate management of patients with specific clinical conditions. A prerequisite for using clinical guidelines in information systems is to encode them in a Computer-Interpretable Guideline (CIG) language. However, this is a difficult and demanding task, usually done by IT staff. The goal of the paper is to facilitate the encoding of clinical guidelines in CIG languages, while increasing the involvement of clinicians. To achieve this, it is proposed to support the refinement of guideline processes from a preliminary specification in a business process language to a detailed implementation in one of the available CIG languages. The approach relies on the use of the Business Process Model and Notation (BPMN) for the specification level, a CIG language for the implementation level, and on algorithms to semi-automatically transform guideline models in BPMN into the CIG language of choice. As a first step towards the implementation of the approach, in this work algorithms are implemented to transform a BPMN specification of clinical processes into the PROforma CIG language, and are successfully applied to several clinical guidelines

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