Modelling evolving clinical practice guidelines: a case of Malawi

Electronic medical record (EMR) systems are increasingly being adopted in low- and middle-income countries. This provides an opportunity to support task-shifted health workers with guideline-based clinical decision support to improve the quality of healthcare delivery. However, the formalization of clinical practice guidelines (CPGs) into computer-interpretable guidelines (CIGs) for clinical decision support in such a setting is a very challenging task due to the evolving nature of CPGs and limited healthcare budgets. This study proposed that a CIG modelling language that considers CPG change requirements in their representation models could enable semi-automated support of CPG change operations thereby reducing the burden of maintaining CIGs. Characteristics of CPG changes were investigated to elucidate CPG change requirements using CPG documents from Malawi where EMR systems are routinely used. Thereafter, a model-driven engineering approach was taken to design a CIG modelling framework that has a novel domain-specific modelling language called FCIG for the modelling of evolving CIGs. The CIG modelling framework was implemented using the Xtext framework. The national antiretroviral therapy EMR system for Malawi was extended into a prototype with FCIG support for experimentation. Further studies were conducted with CIG modellers. The evaluations were conducted to answer the following research questions: i) What are the CPG change requirements for modelling an evolving CIG? ii) Can a model-driven engineering approach adequately support the modelling of an evolving CIG? iii) What is the effect of modelling an evolving CIG using FCIG in comparison with the Health Level Seven (HL7) standard for modelling CIGs? Data was collected using questionnaires, logs and observations. The results indicated that finegrained components of a CPG are affected by CPG changes and that those components are not included explicitly in current executable CIG language models. The results also showed that by including explicit semantics for elements that are affected by CPG changes in a language model, smart-editing features for supporting CPG change operations can be enabled in a language-aware code editor. The results further showed that both experienced and CIG modellers perceived FCIG as highly usable. Furthermore, the results suggested that FCIG performs significantly better at CIG modelling tasks as compared to the HL7 standard, Arden Syntax. This study provides empirical evidence that a model-driven engineering approach to clinical guideline formalization supports the authoring and maintenance of evolving CIGs to provide up-to-date clinical decision support in low- and middle-income countries

Une approche logicielle du traitement de la dyslexie : étude de modèles et applications

Neuropsychological disorders are widespread and generate real public health problems. In particular in our modern society, where written communication is ubiquitous, dyslexia can be extremely disabling. Nevertheless we can note that the diagnosis and remediation of this pathology are fastidious and lack of standardization. Unfortunately it seems inherent to the clinical characterization of dyslexia by exclusion, to the multitude of different practitioners involved in such treatment and to the lack of objectivity of some existing methods. In this respect, we decided to investigate the possibilities offered by modern computing to overcome these barriers. Indeed we have assumed that the democratization of computer systems and their computing power could make of them a perfect tool to alleviate the difficulties encountered in the treatment of dyslexia. This research has led us to study the techniques software as well as hardware, which can conduct to the development of an inexpensive and scalable system able to attend a beneficial and progressive changing of practices in this pathology field. With this project we put ourselves definitely in an innovative stream serving quality of care and aid provided to people with disabilities. Our work has been identifying different improvement areas that the use of computers enables. Then each of these areas could then be the subject of extensive research, modeling and prototype developments. We also considered the methodology for designing this kind of system as a whole. In particular our thoughts and these accomplishments have allowed us to define a software framework suitable for implementing a software platform that we called the PAMMA. This platform should theoretically have access to all the tools required for the flexible and efficient development of medical applications integrating business processes. In this way it is expected that this system allows the development of applications for caring dyslexic patients thus leading to a faster and more accurate diagnosis and a more appropriate and effective remediation. Of our innovation efforts emerge encouraging perspectives. However such initiatives can only be achieved within multidisciplinary collaborations with many functional, technical and financial means. Creating such a consortium seems to be the next required step to get a funding necessary for realizing a first functional prototype of the PAMMA, as well as its first applications. Some clinical studies may be conducted to prove undoubtedly the effectiveness of such an approach for treating dyslexia and eventually other neuropsychological disorders.Les troubles neuropsychologiques sont très répandus et posent de réels problèmes de santé publique. En particulier, dans notre société moderne où la communication écrite est omniprésente, la dyslexie peut s’avérer excessivement handicapante. On remarque néanmoins que le diagnostic et la remédiation de cette pathologie restent délicats et manquent d’uniformisation. Ceci semble malheureusement inhérent à la caractérisation clinique par exclusion de la dyslexie, à la multitude de praticiens différents impliqués dans une telle prise en charge ainsi qu’au manque d’objectivité de certaines méthodes existantes. A ce titre, nous avons décidé d’investiguer les possibilités offertes par l’informatique actuelle pour surmonter ces barrières. Effectivement, nous avons supposé que la démocratisation des systèmes informatiques et leur puissance de calcul pourraient en faire un outil de choix pour pallier les difficultés rencontrées lors de la prise en charge de la dyslexie. Cette recherche nous a ainsi mené à étudier les techniques, aussi bien logicielles que matérielles, pouvant conduire au développement d’un système bon marché et évolutif qui serait capable d’assister un changement bénéfique et progressif des pratiques qui entourent cette pathologie. Avec ce projet, nous nous plaçons définitivement dans un courant innovant au service de la qualité des soins et des aides apportées aux personnes souffrant d’un handicap. Notre travail a ainsi consisté à identifier différents axes d’amélioration que l’utilisation de l’outil informatique rend possible. Chacun de ces axes a alors pu faire l’objet de recherches exhaustives, de modélisations et de développements de prototypes. Nous avons également réfléchi à la méthodologie à mettre en œuvre pour concevoir un tel système dans sa globalité. En particulier, nos réflexions et ces différents accomplissements nous ont permis de définir un framework logiciel propice à l’implémentation d’une plate-forme logicielle que nous avons appelée la PAMMA. Cette plate-forme devrait théoriquement pouvoir disposer de tous les outils permettant le développement souple et efficace d’applications médicales intégrant des processus métiers. Il est ainsi attendu de ce système qu’il permette le développement d’applications, pour la prise en charges des patients dyslexiques, conduisant à un diagnostic plus rapide et plus précis ainsi qu’à une remédiation plus adaptée et plus efficace. De notre effort d’innovation ressortent des perspectives encourageantes. Cependant, ce type d’initiative ne peut se concrétiser qu’autour de collaborations pluridisciplinaires disposant de nombreux moyens fonctionnels, techniques et financiers. La constitution d’un tel consortium semble donc être la prochaine étape nécessaire à l’obtention des financements pour réaliser un premier prototype fonctionnel de la PAMMA, ainsi que de premières applications. Des études cliniques pourront être alors menées pour prouver indubitablement l’efficacité d’une telle approche dans le cadre de la prise en charge de la dyslexie, ainsi qu’éventuellement d’autres troubles neuropsychologiques