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Development of an advanced clinical decision support system : enriching the guideline-based knowledge with experience
No full textLa médecine fondée sur les preuves a permis de formaliser des guides de pratique clinique qui définissent des flux de travail et des recommandations à suivre pour un domaine clinique concis. Ces guides se sont construits dans le but de standardiser les soins de santé et d'obtenir les meilleurs résultats possibles pour les patients. Néanmoins, les médecins n’adhèrent pas toujours à ces directives en raison de diverses limitations cliniques et de mise-en-œuvre. D’une part, les médecins n’ont pas toujours familiarisés ou en accord avec les lignes directrices des guides de pratique clinique, doutant ainsi de leur efficacité et des résultats attendus par rapport aux pratiques antérieures. D'autre part, maintenir ces guides à jour en incluant les dernières preuves établies requiert une gestion continue d’une documentation établie sur support papier. Les systèmes d'aide à la décision clinique sont ainsi proposés comme aide durant le processus de prise de décision clinique, par la mise en œuvre informatisée des guides pour promouvoir leur consultation et l’adhésion des médecins. Bien que ces systèmes aident à améliorer la conformité des guides, il subsiste certains obstacles hérités des guides sur support papier qui ne sont pas résolus avec leur mise en œuvre informatisée, comme le traitement des cas complexes non-définis dans les directives ou le manque de représentation d'autres facteurs externes qui peuvent influer sur les traitements fournis et faire dévier des recommandations des guides (c.-à-d. les préférences du patient). La présente thèse propose un système avancé d'aide à la décision clinique pour faire face aux limitations du soutien purement basé en guides et aller au-delà des connaissances formalisées en analysant les données cliniques, les résultats et les performances de toutes les décisions prises au fil du temps. Pour atteindre ces objectifs, une approche de modélisation des connaissances et performances cliniques de manière sémantique validée et informatisée a été présentée, en s'appuyant sur une ontologie et avec la formalisation du concept d'Événement Décisionnel. De plus, un cadre indépendant du domaine a été mis en place pour faciliter le processus d'informatisation, de mise à jour et de mise en œuvre des guides de pratique clinique au sein d'un système d'aide à la décision clinique afin de fournir un soutien clinique à pour chaque patient interrogé. Pour répondre aux limites des guides, une méthodologie permettant d’augmenter les connaissances cliniques en utilisant l'expérience a été présentée ainsi qu'une évaluation de la performance clinique et de la qualité au fil du temps, en fonction des différents résultats cliniques étudiés, tels que l'utilisabilité et la fiabilité clinique derrière les connaissances cliniques formalisées. Enfin, les données du monde réel accumulées ont été explorées pour soutenir les cas futurs, promouvoir l'étude de nouvelles hypothèses cliniques et aider à la détection des tendances et des modèles sur les données à l'aide d'outils d'analyse visuelle. Les modules présentés ont été développés et mis en œuvre dans leur majorité dans le cadre du projet européen Horizon 2020 DESIREE, dans lequel le cas d'utilisation était axé sur le soutien des unités de soins du sein au cours du processus décisionnel pour la prise en charge des patientes atteintes d'un cancer du sein primaire, en effectuant une validation technique et clinique sur l'architecture présentée, dont les résultats sont présentés dans cette thèse. Néanmoins, certains des modules ont également été utilisés dans d'autres domaines médicaux tels que le développement des guides de pratique clinique pour le diabète gestationnel, mettant en évidence l'interopérabilité et la flexibilité du travail présenté.Evidence-Based Medicine has been formalized as Clinical Practice Guidelines, which define workflows and recommendations to be followed for a given clinical domain. These documents were formalized aiming to standardize healthcare and seeking the best patient outcomes. Nevertheless, clinicians do not adhere as expected to these guidelines due to several clinical and implementation limitations. On one hand, clinicians do not feel familiar, agree with and or are unaware of guidelines, hence doubting their self-efficacy and outcome expectancy compared to previous or more common practices. On the other hand, maintaining these guidelines updated with the most recent evidence requires continuous versioning of these paper-based documents. Clinical Decision Support Systems are proposed to help during the clinical decision-making process with the computerized implementation of the guidelines to promote their easy consultation and increased compliance. Even if these systems help improving guideline compliance, there are still some barriers inherited from paper-based guidelines that are not solved, such as managing complex cases not defined within the guidelines or the lack of representation of other external factors that may influence the provided treatments, biasing from guidelines’ recommendations (i.e. patient preferences). Retrieving observational data and patients’ quality of life outcomes related to the provided healthcare during routine clinical practice could help to identify and overcome these limitations and would generate Real World Data representing the real population and going beyond the limitations of the knowledge reported in the Randomized Clinical Trials. This thesis proposes an advanced Clinical Decision Support System for coping with the purely guideline-based support limitations and going beyond the formalized knowledge by analyzing the clinical data, outcomes, and performance of all the decisions made over time. To achieve these objectives, an approach for modeling the clinical knowledge and performance in a semantically validated and computerized way has been presented, leaning on an ontology and the formalization of the Decisional Event concept. Moreover, a domain-independent framework has been implemented for easing the process of computerizing, updating and implementing Clinical Practice Guidelines within a Clinical Decision Support System in order to provide clinical support for any queried patient. For addressing the reported guideline limitations, a methodology for augmenting the clinical knowledge using experience has been presented along with some clinical performance and quality evaluation over time, based on different studied clinical outcomes, such as the usability and the strength of the rules for evaluating the clinical reliability behind the formalized clinical knowledge. Finally, the accumulated Real World Data was explored to support future cases, promoting the study of new clinical hypotheses and helping in the detection of trends and patterns over the data using visual analytics tools. The presented modules had been developed and implemented in their majority within the European Horizon 2020 project DESIREE, in which the use case was focused on supporting Breast Units during the decision-making process for Primary Breast Cancer patients management, performing a technical and clinical validation over the presented architecture, whose results are presented in this thesis. Nevertheless, some of the modules have been also used in other medical domains such as Gestational Diabetes guidelines development, highlighting the interoperability and flexibility of the presented work
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Identify facilitators and challenges in computerized checklist implementation
Get PDFSafety checklists have been considered as a promising tool for improving patient safety for decades. Computerized checklists have better performance compared with paper-based checklists, though there are barriers to their adoption. Given previous literature, it is still unclear what assists implementations and their challenges. To address this issue, this paper summarizes the implementation of two successful computerized checklist implementations in two countries for two different clinical scenarios and analyzes their facilitators and challenges.</p
Annotating Temporal Relations to Determine the Onset of Psychosis Symptoms
Get PDFFor patients with a diagnosis of schizophrenia, determining symptom onset is crucial for timely and successful intervention. In mental health records, information about early symptoms is often documented only in free text, and thus needs to be extracted to support clinical research. To achieve this, natural language processing (NLP) methods can be used. Development and evaluation of NLP systems requires manually annotated corpora. We present a corpus of mental health records annotated with temporal relations for psychosis symptoms. We propose a methodology for document selection and manual annotation to detect symptom onset information, and develop an annotated corpus. To assess the utility of the created corpus, we propose a pilot NLP system. To the best of our knowledge, this is the first temporally-annotated corpus tailored to a specific clinical use-case.</p
A Generic Rapid Evaluation Support Tool (GREST) for Clinical and Commissioning Decisions.
Get PDFA fast and frugal generic tool can provide decision support to those making decisions about individual cases, particularly clinicians and clinical commissioners operating within the budget and time constraints of their practices. The multi-national Generic Rapid Evaluation Support Tool (GREST) is a standard preference-sensitive Multi-Criteria Decision Analysis-based tool, but innovatory insofar as an equity criterion is introduced as one of six. Equity impact reflects the number of population QALYs lost or gained in moving from Old (current intervention) to New (contemplated intervention). In the exemplar UK implementation Claxton's NHS Willingness to Pay per QALY is the numeraire. Any weight from 0 to 100% may be assigned to the equity criterion but its presence affirms that it is persons-as-citizens who experience any opportunity harms or benefits arising from actions within the health service commons. A fully-operational but demonstration-only version is available on open access, as proof of concept and method
The Handover from Intensive Care Unit to General Ward: Baseline Performance and Par-ticipatory Design of an Electronic Follow-Up Plan
Get PDFThe transfer of patients from intensive care unit (ICU) to general ward involves risk to patient health. To mitigate this risk the present study investigates the current use of follow-up plans in the handover from ICU to general ward and pro-poses a novel design of follow-up plans. On the basis of a record audit we find that follow-up plans exist for only 16% of the audited transfers, that these plans are rarely used, and that 25% of the patients with a plan die within 24 hours of their transfer. In a subsequent series of participatory-design workshops with ICU and ward nurses we devised an electronic follow-up plan that consists of an attend-to list rather than a checklist. The attend-to list specifies the issues of concern but leaves the process of attaining them for the general-ward nurses to decide, thereby acknowledging and utilizing their expertise
Ontology-driven real world evidence extraction from clinical narratives
No full textUnstructured clinical notes contain a huge amount of information. We investigated the possibility of harvesting such information through an NLP-based approach. A manually curated ontology is the only resource required to handle all the steps of the process leading from clinical narrative to a structured data warehouse (i2b2). We have tested our approach at the Papa Giovanni XXIII hospital in Bergamo (Italy) on pathology reports collected since 2008.</p
Variations on the Author
Get PDF“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Get PDFWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
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