Object-oriented software development is a powerful methodology for development of large hospital information systems. We think use-case driven approach is particularly useful for the development. In the use-cases driven approach, use-cases are documented at the first stage in the software development process and they are used through the whole steps in a variety of ways. Therefore, it is important to exchange and share the usecases and make effective use of them through the overall lifecycle of a development process. In this paper, we propose a method of sharing and exchanging use-case models between applications, developers, and projects. We design an XML based exchange format for use-cases. We then discuss an application of the exchange format to support several software development activities. We preliminarily implemented a support system for objectoriented analysis based on the exchange format. The result shows that using the structural and semantic information in the exchange format enables the support system to assist the object-oriented analysis successfully.
Today, the clinical trial process remains slow and paperbased. The creation of a Cancer Informatics Infrastructure (CII) can provide the architectural base across the continuum of cancer research and cancer care. Recommendations of a Long Range Planning Committee identified near-term activities for the Office of Informatics at the National Cancer Institute (NCI). These include participating in national standards development; fostering oncology-related terminology and standards, e.g., Common Data Elements (CDEs); and leveraging mainstream informatics and Internet technologies, using the successful Internet model that focuses on facilitating stakeholder participation, sponsoring the CII rather than subsidizing it, and providing a test bed as well as an infrastructure. Diffusion tactics include extending the CII concept beyond its “early adopters” to the wider community through recommendations for the near-term and development of a major document defining next phase activities.
Cognitive science is a rich source of insight for creative use of new Web technologies by medical informatics workers. I outline a project to Web-enable an existing computer-based patient record (CPR) in the context of ideas from philosophy, linguistics, artificial intelligence, and cognitive psychology. Web prototypes play an important role (a) because Web technology lends itself to rapid prototype development, and (b) because prototypes help team members bridge among disparate medical, computing, and business ontologies. Six Web-enabled CPR prototypes were created and ranked. User scenarios were generated using a user communication matrix. Resulting prototypes were compared according to the degree to which they satisfied medical, computing, and business constraints. In a different organization, or at different time, candidate prototypes and their ranking might have been different. However, prototype generation and comparison are fundamentally influenced by factors usefully understood in a cognitive science framework.
Healthcare policies in many countries, in the European Union and of the United Nations stress the importance of using information and communications technology to achieve the goals of improving health for all while controlling accelerating costs. This paper reviews the major areas where standards actions are required on a national, European and global level.
The purpose of this study was to develop a health-related information evaluation system to assure the quality of health information on the Internet. Literature on information control and information appraisal on the Internet was reviewed. Based on the literature review a health information evaluation system consisting of an evaluation tool that includes 8 criteria that have 32 items was developed. The validity of the tool was tested via an email survey of 15 content and informatics experts.
In today's ICUs clinicians routinely integrate huge numbers of discrete data points to arrive at a coherent picture of their patients' status. Often the clinician must obtain those data elements from many devices, which makes the problem more difficult. Because presenting data visually amplifies cognition by capitalizing on well-known human perceptual capabilities, it is not surprising that a growing body of research is directed at the effective presentation of visual information in clinical displays. However, developing clinical displays that effectively support clinicians' integration and understanding of many discrete data elements in complex, high technology work domains such as ICUs remains elusive. It may be that traditional analysis and design methods simply are inadequate for this kind of complex environment. Vicente has described a new methodology, called “cognitive work analysis” (CWA), which is targeted at the analysis of complex work domains. The analysis differs from traditional analytic methods in significant ways, particularly in its primary focus on analysis of the work domain, but also in its prescription for explicitly collecting information at five levels (the work domain, diagnostic and treatment tasks, diagnostic strategies, socio-organizational, and clinician skills) that place constraints on the ultimate display design. In this model, the order of data collection is also crucial. Because the work domain constraints tend to be the most permanent, they are likely to have the most impact on design, and so analysis starts there. As the analysis proceeds through the subsequent levels, additional design constraints are identified. We recently used CWA to analyze the information needs for interactive graphical displays that will integrate and represent data in structures that help clinicians visualize a patient's physiological status. We found that the analysis was an effective way to identify information needs at multiple levels. Based on our experience, CWA is a generic methodology that is highly applicable to medical informatics.
Hypermedia data browsing is a mean for improving information access. However, the overload and the heterogeneity of medical information, as well as the multitude of possible navigational paths, turn the consultation of data into a difficult task. We present in this paper a solution for the development of adaptive user interfaces in a hypermedia data browsing environment. It is based on the capitalization of the users knowledge in the decision-making process, expressed in terms of navigational paths and of data presentation modes that are customized to the user's preferences. This capitalization offers the user a way to reuse the cumulative experiences in browsing through patient records. We illustrate our approach with the implementation of HEMA, a clinical workstation prototype.
Healthcare has been recognised as one of the most important areas for enterprise applications and services. Presently, information technologists and systems engineers all over the world are working towards achieving better efficiency and quality of service in various sectors of healthcare, such as telemedicine, hospital management, patient-care, and treatment. This paper addresses the issue of more effective and efficient handling of doctor patient relationship. The idea is to use Software Agent technology to extend the patient-doctor relationship beyond the physical and logistical limitation of face-to-face consultations in patient management. Software agents can provide an extension of the doctor by interacting with the patient via a computer and the Internet. The agent is visualised as an anthropomorphic figure to further enhance the patient interaction.
Direct electronic acquisition of data from patients possesses accuracy and diagnostic value. The mechanics of how best to capture historical information from patients using electronic interfaces are not well studied. We undertook an iterative usability experiment to answer 2 questions: 1) How can maximal electronic data input from a patient be achieved, and 2) Do varying structures for data entry promote differential documentation of specified data elements? Methods: A series of four trials comprised the testing cycle. Unstructured text entry, directed text entry, and closed ended questions were tested in combination against outcomes of word count, time to task completion, and user preferences. Covariates of interest included participants ‘ technologic experience and ergonomic experience with keyboards, as well as self-report of educational status, literacy, and primary language. Results: Participants clearly preferred the order of initial closed-ended questions followed by unstructured text entry, and this ordering was not associated with decrements in word count or increase in time. When compared to unstructured text entry, directed text entry provided higher documentation of data for past medical history and questions which parents wished to discuss with the clinician. A closed-end question structure, when compared to directed text entry, provided higher capture of parents' questions for discussion. Conclusions: Optimal design of an electronic interview for the capture of medical histories will benefit from a mixed structure of directed text entry and closed-ended questions. For historical or clinically relevant items where maximal capture of data is desired, a structure with closed-ended questions would be preferred.
Some difficulties occur during the implementation of NIT in medicine. This may be due to an incomplete knowledge about the real activities of GPs and Hospital practitioners. We assume that medical activity must be considered to be devoted to the supervision of a dynamic process, the “PATIENT”, where the role of medical actors is to maintain the process “PATIENT” within an acceptable range of values. To validate this hypothesis we analyzed EPR from two physicians. The quantitative analysis demonstrated that the activities of GPs are not devoted only to diagnosis but more to gathering information and archiving traces of decisions and action, which is compatible with our general hypothesis. New EPR and NIT will have to take this dimension into account to design more usable and acceptable applications.
The purpose of this study is to describe the patterns of usage of defined Internet resources by persons following coronary arterial bypass graft surgery. Three different methods of measuring usage were employed: counts of accesses, duration of accesses and persistence of activity during the study. Four different patterns of usage were identified.
We evaluated the utility of the CEN Categorial Structure for Nursing Diagnoses as a terminology model for integrating nursing diagnosis concepts into SNOMED. First, we dissected nursing diagnosis term phrases from two source terminologies (North American Nursing Diagnosis Association (NANDA) Taxonomy 1 and Omaha System) into the semantic categories of the CEN categorial structure. Second, we critically analyzed the similarities between the semantic links in the CEN model and the semantic links used to formally define diagnostic concepts in SNOMED RT and SNOMED CT. Our findings demonstrated that focus, bearer, and judgment were present in 100% of the NANDA and Omaha term phrases. The Omaha term phrases contained no additional descriptors beyond those considered mandatory in the CEN model. In contrast, at least 3% of NANDA diagnoses included a term in each semantic category of the categorial structure. The comparison among the semantic links showed that neither SNOMED RT and SNOMED CT currently contain all the semantic links needed to model the two source terminologies for integration. In conclusion, our findings support the potential utility of the CEN categorial structure as a terminology model for dissecting nursing diagnostic concepts for integration into SNOMED RT and SNOMED CT. However, in order to accomplish this task, appropriate semantic links must be added to SNOMED RT and SNOMED CT.
Search by content in a large corpus of free texts in the medical domain is, today, only partially solved. The socalled GREP approach (Get Regular Expression and Print), based on highly efficient string matching techniques, is subject to inherent limitations, especially its inability to recognize domain specific knowledge. Such methods oblige the user to formulate his or her query in a logical Boolean style; if this constraint is not fulfilled, the results are poor.
The authors present an enhancement to string matching search by the addition of a light conceptual model behind the word lexicon. The new system accepts any sentence as a query and radically improves the quality of results. Efficiency regarding execution time is obtained at the expense of implementing advanced indexing algorithms in a pre-processing phase. The method is described and commented and a brief account of the results illustrates this paper.
Several information models have been developed for the Unified Medical Language System (UMLS). While some models are term-oriented, a knowledge-oriented model is needed for representing semantic locality, i.e. the various semantic links among concepts. We propose an objectoriented model in which the semantic features of the UMLS are made available through four major classes for representing Metathesaurus concepts, semantic types, interconcept relationships and Semantic Network relationships. Additional semantic methods for reducing the complexity of the hierarchical relationships represented in the UMLS are proposed. Implementation details are presented, as well as examples of use. The interest of this approach is discussed.
The use of language for communication purposes introduces a semantic gap in data processing. We have developed a new tool called semantic distance to overcome this gap. A previous presentation of our tool was based on an empirical approach. Here, we examine the properties and theoretical foundation of semantic distance from a rationalistic perspective. We present an epistemological framework to explain the meaning of semantic distance.
As a tool, the purpose of semantic distance is the exchange of data or knowledge based on linguistic expressions between software components. We propose a review of the relationship between language and its representation for data processing based on the underlying philosophical assumptions. Description logic is a new paradigm in the medical informatics community to express relations between terms in “is-a” hierarchies. The utility of semantic distance is compared to description logic for communication purposes in different use cases.
Objective: To characterize the relationships among UMLS concepts that co-occur as MeSH descriptors in MEDLINE citations (1990-1999). Design: 18,485 UMLS concepts involved in 7,928,608 directed pairs of co-occurring concepts were studied. For each directed pair of concepts Cl-C2: (i) the “family” of Cl was built, using the UMLS Metathesaurus, and we tested whether or not C2 belonged to Cl's family; (ii) we used the semantic categorization of Metathesaurus concepts through the UMLS Semantic Network and Semantic Groups to represent the semantics of the relationships between Cl and C2. Results: In 6.5% of the directed pairs, the co-occurring concept C2 was found within the “family” of Cl. Detailed results are given. The most frequent co-occurrences involved “Chemicals & Drugs” and “Chemicals & Drugs”, as well as “Disorders” and “Chemicals & Drugs”. Discussion: This work takes advantage of both symbolic and statistical information represented in the UMLS, and analyzes their overlap. Further research is suggested.
The purpose of this paper is to report the work of the Interventions Group of the first Nursing Terminology Summit (1999) and to describe the challenges and insights of this group as they have evolved a reference terminology model for nursing interventions. When the group began its work as part of the first meeting of the Nursing Terminology Summit, it had the overall objective of proposing the intervention component of a reference terminology model for nursing. Although there is not a definitive proposal for this to date, the group’s exploration and analysis has clarified and explicated both the types of models of clinical information and the current “state of the art” of formal representations of nursing interventions as well as the relationship of nursing languages to these formal representations. In addition, it is our perspective that the work of this group is representative of the process and challenges facing many similar groups currently engaged in modeling efforts. Consequently, critical success factors of such efforts are identified and discussed. This paper reports both the specific outputs of the group related to progress in defining a terminology model of nursing interventions and observations and lessons learned regarding consensus modeling work.
Information needs in clinical practice take the form of specific questions about a given clinical situation, and are best satisfied by concise and specific information retrieval. We sought to develop a comprehensive set of generic queries for information retrieval from electronic medical information resources. We collected one hundred and ten real-world questions asked at the point of care in a variety of settings, and from these developed a set of generic queries of which each of the real-world queries could be shown to be a special case. To provide allowed values for each of the concept terms in the queries, we defined generic nouns as unions of UMLS semantic types, and specified which of these were appropriate to each query. We have begun to use the set to index reference texts from general and subspecialty medicine, and found it capable of full text indexing in the clinical domain. We hypothesize that the query set can serve as a basis for more specialized query sets, and that it will remain generalizable to other electronic medical resources, indexing tasks, and non- UMLS controlled vocabularies.
Medical decision making is one of the most difficult daily tasks for physicians. Guidelines have been designed to reduce variance between physicians in daily practice, to improve patient outcomes and to control costs. In fact, few physicians use guidelines in daily practice.
A way to ease the use of guidelines is to implement computerised guidelines (computer reminders). We present in this paper a method of computerising guidelines. Our objectives were: 1) to propose a generic model that can be instantiated for any specific guidelines; 2) to use eXtensible Markup Language (XML) as a guideline representation language to instantiate the generic model for a specific guideline.Our model is an object representation of a clinical algorithm, it has been validated by running two different guidelines issued by a French official Agency. In spite of some limitations, we found that this model is expressive enough to represent complex guidelines devoted to diabetes and hypertension management.
We conclude that XML can be used as a description format to structure guidelines and as an interface between paperbased guidelines and computer applications.
Developers and purchasers of controlled health terminologies require valid mechanisms for comparing terminological systems. By Controlled Health Vocabularies we refer to terminologies and terminological systems designed to represent clinical data at a granularity consistent with the practice of today's healthcare delivery. Comprehensive criterion for the evaluation of such systems are lacking and the known criteria are inconsistently applied. Although there are many papers, which describe specific desirable features of a controlled health vocabulary, to date there is not a consistent guide for evaluators of terminologies to reference, which will help them compare implementations of terminological systems on an equal footing1,2 This guideline serves to fill the gap between academic enumeration of desirable terminological characteristics and the practical implementation or rigorous evaluations which will yield comparable data regarding the quality of one or more controlled health vocabularies.
In order to develop an Internet-based decision support system, making available for French general practitioners several prevention guidelines is was necessary to implement paper based guideline. We propose a framework allowing to transform paper based practice guideline into their electronic form. Three different problems were identified: computability (e.g. determinism of the eCPG), logic (e.g. ambiguities when combining Booleans operators) and external validity (i.e. stability of decision for variations around thresholds and proportion of subjects classified in the various terminal nodes). The last problem concerned documentation of evidence: the level of evidence was associated only with the terminal decision node and not with the pathway through the decision tree. We concluded that computerisation of guidelines is not possible without expertise or authors advices. To improve computability it is necessary to provide authors with a framework that checks ambiguities, and logical errors.
Clinical practice guideline automation at the point of care is of growing interest, yet most guidelines are authored in unstructured narrative form. Computer-based execution depends on a formal structured representation, and also faces a number of other challenges at all stages of the guideline lifecycle: modeling, authoring, dissemination, implementation, and update. This is because of the multiplicity of conceptual models, authoring tools, authoring approaches, intended applications, implementation platforms, and local interface requirements and operational constraints. Complexity and time required for development and structure are also huge obstacles. These factors argue for convergence on a common shared model for representation that can be the basis of dissemination. A common model would facilitate direct interpretation or mapping to multiple implementation environments. GLIF (GuideLine Interchange Format) is a formal representation model for guidelines, created by the InterMed Collaboratory as a proposed basis for a shared representation. GLIF currently addresses the process of authoring and dissemination; the InterMed team's major focus now is on tools to facilitate these tasks and the mapping to clinical information system environments. Because of limitations in what can be done by a single team with finite resources, however, and the variety of additional perspectives that need to be accommodated, the InterMed team has determined that further development of a shared representation would be best served as an open process in which the world community is engaged. Under the auspices of the HL7 Decision Support Technical Committee, a GLIF Special Interest Group has been established, which is intended to be a forum for collaborative refinement and extension of a standard representation that can support the needs of the guideline lifecycle. Significant areas for future work will need to include demonstrations of effective means for incorporating guidelines at point of care, reconciliation of functional requirements of different models and identification of those most important for supporting practical implementation, improved means for authoring and management of complexity, and methods for automatically analyzing and validating syntax, semantics, and logical consistency of guidelines.