Ezio Caffi

Architectures and tools for innovative Health Information Systems: The Guide Project

This paper describes the architecture of the Guide Project, a proposal for innovation of Health Information Systems, putting together medical and organizational issues through the Separation of Concerns paradigm. In particular, we focus on one building block of the architecture: the Guideline Management System handling the whole life cycle of computerized Clinical Practice Guidelines. The communication between the Guideline Management System and the other components of the project architecture is message-based, according to specific contracts that allow an easy integration of the components developed by different parties and, in particular, with legacy systems (i.e. existing electronic patient records). In turn, the Guideline Management System components are organized in a distributed architecture: an editor to formalize guidelines, a repository to store and publish them, an enactment system to implement guidelines instances in a multi-user environment and a reporting system able to completely trace any individual physicians guideline-based decision process. The repository is organized in different levels that can be international, national, regional, down to the specific health care organization, according to the healthcare delivery policy of a country. Different organizations can get Clinical Practice Guidelines from the repository, adapt and introduce them in clinical practice.

Simulation of a stroke unit careflow.

This paper describes the development and use of a simulation model representing part of the medical practice within a Stroke Unit. In particular, we modelled the medical activities as described in a guideline for the ischemic stroke treatment, adopted by the Stroke Unit of our hospital. The Petri net formalism has been chosen for the model representation. The numerical parameters have been estimated both using a database of about 100 patients collected during the last two years, and eliciting knowledge from the neurologists. A commercial tool was used for performing simulations, while ad-hoc routines were written for tailoring the result presentation to the specific context. We consider simulation a very useful preliminary step for the subsequent implementation of a patient workflow (careflow) management system. In fact, simulation is based on the process model (the clinical practice guideline) and on the organisation model (human and technological resources), so allowing to detect bottlenecks in the care delivery organisation and to find the optimal resource allocation. For example, we show that simulation has been able to find some of the causes of the delay in the patients treatment, and accordingly, to suggest changes in the organisation.

The NewGuide Project: Guidelines, Information Sharing and Learning from Exceptions

Among the well agreed-on benefits of a guideline computerisation, with respect to the traditional text format, there are the disambiguation, the possibility of looking at the guideline at different levels of detail and the possibility of generating patient-tailored suggestions. Nevertheless, the connection of guidelines with patient records is still a challenging problem, as well as their effective integration into the clinical workflow. In this paper, we describe the evolution of our environment for representing and running guidelines. The main new features concern the choice of a commercial product as the middle layer with the electronic patient record, the consequent possibility of gathering information from different legacy systems, and the extension of this “virtual medical record” to the storage of process data. This last feature allows managing exceptions, i.e. decisions that do not comply with guidelines.

Modular representation of the guideline text: an approach for maintaining and updating the content of medical education.

One of the principal challenges in the medical practice is the update of their knowledge. One of the prime roles of the Continuing Medical Education is to train the medical practitioners with the latest advances in health care, specialized to their needs. Online courses and classroom teaching with computer-based representations have become an established mode of delivering medical education. This paper deals with the modularized representation of a medical text concerning clinical practice guidelines. The proposed system takes into consideration the semantics of the Unified Medical Language System and is based upon the marking up and display of the knowledge using the XML and XSLT languages. This modularization of the concepts leads to the determination of the context of a portion or the whole document. Thus, after marking up using our system, the text components can be exchanged, modified or reconstructed, which, in turn, would help to maintain the updates in medical knowledge.

Implementation of an automated system for monitoring adherence to hemodialysis treatment: A report of seven years of experience

OBJECTIVE In this paper we present the clinical deployment and evaluation of a computerized system, EMOSTAT, aimed at improving the quality of hemodialysis sessions. EMOSTAT automatically imports data from the hemodialysis monitoring software tools and analyzes the delivered treatment looking at six clinically relevant parameters. Failures-to-adhere (FtAs) to the planned treatment are detected and reported to the care-givers. METHODS EMOSTAT has been used for more than seven years in the management of a dialysis service located in Mede, Italy. A total of 72 patients were monitored and 21251 dialyses were collected. Data analysis is performed on the periods 2002-2005 and 2005-2008, corresponding to two different software releases. RESULTS The system had been exploited into everyday clinical practice for the entire considered period. The number of FtAs significantly decreased along the first period: the bulk blood flow FtAs decreased after the introduction of the system. Hemodialysis sessions lasted longer in the second period. Co-occurring FtAs, highlighting the presence of complex FtAs patterns, were also detected. CONCLUSIONS EMOSTAT provides an effective way to re-focus the attention of the dialysis department on the treatment plan and on its implementation. The automatic data collection and the design philosophy of EMOSTAT allowed the routine use of the system.

An automated voice response system for anticoagulant therapy management

The system described in this paper is aimed at improving the clinical workflow of post-stroke patients under oral anticoagulant therapy (OAT). The system helps both physicians and patients during the periodic control visits necessary to assess the anticoagulation status and the next therapeutic plan. Controls represent a burden for both patients, which after blood drawing must wait for the result, and for physicians, that, after assessing the therapy plan, must communicate it to patients, face-to-face or by telephone. A system is proposed, which embeds an algorithm for the patient-tailored calculation of the drug dosage and scheduling, and an automatic telephone dialogue for the communication of the therapy plan, once it has been validated or adjusted by the physician.