Development and implementation of clinical guidelines : an artificial intelligence perspective

Clinical practice guidelines in paper format are still the preferred form of delivery of medical knowledge and recommendations to healthcare professionals. Their current support and development process have well identified limitations to which the healthcare community has been continuously searching solutions. Artificial intelligence may create the conditions and provide the tools to address many, if not all, of these limitations.. This paper presents a comprehensive and up to date review of computer-interpretable guideline approaches, namely Arden Syntax, GLIF, PROforma, Asbru, GLARE and SAGE. It also provides an assessment of how well these approaches respond to the challenges posed by paper-based guidelines and addresses topics of Artificial intelligence that could provide a solution to the shortcomings of clinical guidelines. Among the topics addressed by this paper are expert systems, case-based reasoning, medical ontologies and reasoning under uncertainty, with a special focus on methodologies for assessing quality of information when managing incomplete information. Finally, an analysis is made of the fundamental requirements of a guideline model and the importance that standard terminologies and models for clinical data have in the semantic and syntactic interoperability between a guideline execution engine and the software tools used in clinical settings. It is also proposed a line of research that includes the development of an ontology for clinical practice guidelines and a decision model for a guideline-based expert system that manages non-compliance with clinical guidelines and uncertainty.This work is funded by national funds through the FCT – Fundação para a Ciência e a Tecnologia (Portuguese Foundation for Science and Technology) within project PEst-OE/EEI/UI0752/2011"

Clinical decision support: Knowledge representation and uncertainty management

Programa Doutoral em Engenharia BiomédicaDecision-making in clinical practice is faced with many challenges due to the inherent risks of being a health care professional. From medical error to undesired variations in clinical practice, the mitigation of these issues seems to be tightly connected to the adherence to Clinical Practice Guidelines as evidence-based recommendations The deployment of Clinical Practice Guidelines in computational systems for clinical decision support has the potential to positively impact health care. However, current approaches to Computer-Interpretable Guidelines evidence a set of issues that leave them wanting. These issues are related with the lack of expressiveness of their underlying models, the complexity of knowledge acquisition with their tools, the absence of support to the clinical decision making process, and the style of communication of Clinical Decision Support Systems implementing Computer-Interpretable Guidelines. Such issues pose as obstacles that prevent these systems from showing properties like modularity, flexibility, adaptability, and interactivity. All these properties reflect the concept of living guidelines. The purpose of this doctoral thesis is, thus, to provide a framework that enables the expression of these properties. The modularity property is conferred by the ontological definition of Computer-Interpretable Guidelines and the assistance in guideline acquisition provided by an editing tool, allowing for the management of multiple knowledge patterns that can be reused. Flexibility is provided by the representation primitives defined in the ontology, meaning that the model is adjustable to guidelines from different categories and specialities. On to adaptability, this property is conferred by mechanisms of Speculative Computation, which allow the Decision Support System to not only reason with incomplete information but to adapt to changes of state, such as suddenly knowing the missing information. The solution proposed for interactivity consists in embedding Computer-Interpretable Guideline advice directly into the daily life of health care professionals and provide a set of reminders and notifications that help them to keep track of their tasks and responsibilities. All these solutions make the CompGuide framework for the expression of Clinical Decision Support Systems based on Computer-Interpretable Guidelines.A tomada de decisão na prática clínica enfrenta inúmeros desafios devido aos riscos inerentes a ser um profissional de saúde. Desde o erro medico até às variações indesejadas da prática clínica, a atenuação destes problemas parece estar intimamente ligada à adesão a Protocolos Clínicos, uma vez que estes são recomendações baseadas na evidencia. A operacionalização de Protocolos Clínicos em sistemas computacionais para apoio à decisão clínica apresenta o potencial de ter um impacto positivo nos cuidados de saúde. Contudo, as abordagens atuais a Protocolos Clínicos Interpretáveis por Maquinas evidenciam um conjunto de problemas que as deixa a desejar. Estes problemas estão relacionados com a falta de expressividade dos modelos que lhes estão subjacentes, a complexidade da aquisição de conhecimento utilizando as suas ferramentas, a ausência de suporte ao processo de decisão clínica e o estilo de comunicação dos Sistemas de Apoio à Decisão Clínica que implementam Protocolos Clínicos Interpretáveis por Maquinas. Tais problemas constituem obstáculos que impedem estes sistemas de apresentarem propriedades como modularidade, flexibilidade, adaptabilidade e interatividade. Todas estas propriedades refletem o conceito de living guidelines. O propósito desta tese de doutoramento é, portanto, o de fornecer uma estrutura que possibilite a expressão destas propriedades. A modularidade é conferida pela definição ontológica dos Protocolos Clínicos Interpretáveis por Maquinas e pela assistência na aquisição de protocolos fornecida por uma ferramenta de edição, permitindo assim a gestão de múltiplos padrões de conhecimento que podem ser reutilizados. A flexibilidade é atribuída pelas primitivas de representação definidas na ontologia, o que significa que o modelo é ajustável a protocolos de diferentes categorias e especialidades. Quanto à adaptabilidade, esta é conferida por mecanismos de Computação Especulativa que permitem ao Sistema de Apoio à Decisão não só raciocinar com informação incompleta, mas também adaptar-se a mudanças de estado, como subitamente tomar conhecimento da informação em falta. A solução proposta para a interatividade consiste em incorporar as recomendações dos Protocolos Clínicos Interpretáveis por Maquinas diretamente no dia a dia dos profissionais de saúde e fornecer um conjunto de lembretes e notificações que os auxiliam a rastrear as suas tarefas e responsabilidades. Todas estas soluções constituem a estrutura CompGuide para a expressão de Sistemas de Apoio à Decisão Clínica baseados em Protocolos Clínicos Interpretáveis por Máquinas.The work of the PhD candidate Tiago José Martins Oliveira is supported by a grant from FCT - Fundação para a Ciência e a Tecnologia (Portuguese Foundation for Science and Technology) with the reference SFRH/BD/85291/ 2012

Parkinson's Disease Management through ICT

Parkinson's Disease (PD) is a neurodegenerative disorder that manifests with motor and non-motor symptoms. PD treatment is symptomatic and tries to alleviate the associated symptoms through an adjustment of the medication. As the disease is evolving and this evolution is patient specific, it could be very difficult to properly manage the disease.The current available technology (electronics, communication, computing, etc.), correctly combined with wearables, can be of great use for obtaining and processing useful information for both clinicians and patients allowing them to become actively involved in their condition.Parkinson's Disease Management through ICT: The REMPARK Approach presents the work done, main results and conclusions of the REMPARK project (2011 – 2015) funded by the European Union under contract FP7-ICT-2011-7-287677. REMPARK system was proposed and developed as a real Personal Health Device for the Remote and Autonomous Management of Parkinson’s Disease, composed of different levels of interaction with the patient, clinician and carers, and integrating a set of interconnected sub-systems: sensor, auditory cueing, Smartphone and server. The sensor subsystem, using embedded algorithmics, is able to detect the motor symptoms associated with PD in real time. This information, sent through the Smartphone to the REMPARK server, is used for an efficient management of the disease

Parkinson's Disease Management through ICT

Parkinson's Disease (PD) is a neurodegenerative disorder that manifests with motor and non-motor symptoms. PD treatment is symptomatic and tries to alleviate the associated symptoms through an adjustment of the medication. As the disease is evolving and this evolution is patient specific, it could be very difficult to properly manage the disease.The current available technology (electronics, communication, computing, etc.), correctly combined with wearables, can be of great use for obtaining and processing useful information for both clinicians and patients allowing them to become actively involved in their condition.Parkinson's Disease Management through ICT: The REMPARK Approach presents the work done, main results and conclusions of the REMPARK project (2011 – 2015) funded by the European Union under contract FP7-ICT-2011-7-287677. REMPARK system was proposed and developed as a real Personal Health Device for the Remote and Autonomous Management of Parkinson’s Disease, composed of different levels of interaction with the patient, clinician and carers, and integrating a set of interconnected sub-systems: sensor, auditory cueing, Smartphone and server. The sensor subsystem, using embedded algorithmics, is able to detect the motor symptoms associated with PD in real time. This information, sent through the Smartphone to the REMPARK server, is used for an efficient management of the disease

Optical and visual quality of two scleral lenses

Dissertação de mestrado em Optometria AvançadaAtualmente, as lentes esclerais são bastante adaptadas em pacientes que sofrem de doenças da superfície ocular. Estes dispositivos são também indicados em várias doenças ou irregularidades corneais devido à sua capacidade de criarem um reservatório de líquido, que irá compensar a maior parte das irregularidades da superfície. As inovações tecnológicas têm providenciado uma larga diversidade de desenhos e materiais de lentes esclerais. Contudo, ainda existem poucos estudos que reportem o uso prolongado destas lentes e como a qualidade ótica pode ser influenciada por este uso prolongado. Assim, com este trabalho pretende-se avaliar a resposta da superfície ocular quando uma lente nova e diferente é adaptada bem como entender se é possível readaptar usuários habituais de lentes esclerais a partir dos dados obtidos com a topografia corneal. Neste estudo, os resultados com uma lente escleral (Senso Mini Sclera, 16.4 mm), usada durante mais de 12 meses, foram comparados com os resultados de uma nova lente de outra marca de lentes esclerais (ICD, 16.5 mm), readaptada e usada durante 1 mês. Dos principais resultados obtidos, observou-se que existiam algumas diferenças na qualidade ótica entre a Senso Mini Sclera e a ICD, no entanto os resultados subjetivos não mostraram diferenças significativas relativamente à visão e ao conforto entre ambas as lentes. Os dados da resposta da superfície ocular mostraram valores significativamente mais baixos de hiperemia bulbar, hiperemia limbar, tingido limbar e tingido corneal após 1 mês de uso da lente ICD, quando comparados aos valores obtidos imediatamente após retirar a Senso Mini Sclera. Os resultados mostraram que os dados de elevação na corda de 6mm, obtidos com um topografo corneal comum, estavam correlacionados com as alturas sagitais das lentes ICD diagnóstico e finais. Os resultados com a lente ICD em duas visitas diferentes (após 3h, na visita de entrega, e após 1 mês) não revelaram diferenças significativas, mostrando que a avaliação a curto prazo é um bom preditor dos resultados a médio prazo. Em conclusão, com este estudo foi verificado que pode ser possível readaptar usuários habituais de lentes esclerais com outra lente escleral, apesar de possuírem características diferentes, mantendo a qualidade ótica e o conforto. As pequenas diferenças entre as duas lentes podem estar relacionadas com o tempo de uso da Senso Mini Sclera, que pode ter um pequeno impacto na degradação da qualidade ótica. Os resultados deste estudo sugerem que as maiores respostas da superfície ocular com a Senso Mini Sclera podem ser devido à degradação que a lente sofre com o tempo ou devido às diferenças nos materiais das lentes.Nowadays, scleral lenses are largely fitted to patients who suffer from ocular surface diseases. These devices are also indicated in several corneal disorders or irregularities due to the capability of create a fluid reservoir, which will compensate most of the surface irregularities. Technological innovations have provided a large diversity of scleral lenses designs and materials. However, there are still very few studies reporting the long-term use of these lenses and how optical quality could be influenced by this long-term use. This work intents to evaluate the ocular surface response when a new different lens is fitted and to understand if it is possible to refit habitual scleral lenses users, from the data obtained with corneal topography. In this study, the results with a scleral lens (Senso Mini Sclera, 16.4 mm), used for more than 12 months, were compared to the results of a new lens from another scleral lens (ICD, 16.5 mm), refitted and used during 1 month. From the main outcomes obtained, it was observed that there were a few differences on optical quality between Senso Mini Sclera and ICD, although the subjective results showed no significant differences relatively to vision and comfort between both lenses. The data from ocular surface response showed lower statistically significant values of bulbar hyperemia, limbal hyperemia, limbal staining and corneal staining after 1 month of ICD lens wear when compared to the values immediately after Senso Mini Sclera removal. The results showed that the 6mm chord elevation data, obtained with a common corneal topographer, was correlated with diagnostic and final sagittal depth of ICD lenses. The results with ICD in two different visits (after 3h on the dispensing visit and after 1 month) did not reveal significative differences, showing that the short-term evaluation is a good predictor of the medium-term behavior. In conclusion, with this study we verified that might be possible to refit habitual scleral lens users with another scleral lens, despite the different characteristics, maintaining the optical quality and comfort. The small differences between the two lenses may be correlated with Senso Mini Sclera lifetime, which could have a small impact on optical quality degradation. The results of this study suggest that the highest ocular surface response values with Senso Mini Sclera might be due to the degradation that lens suffered over time or due to the differences on lenses material