Sandra J. Frawley

Using semantic constraints to help verify the completeness of a computer-based clinical guideline for childhood immunization

The paper describes Commander, a prototype computer program designed to help verify the completeness of a computer-based clinical practice guideline built using if then rules. It also describes the application of Commander to a guideline for childhood immunization. Commander is designed to help identify incomplete rule sets, where there are clinically meaningful conditions to which the guideline does not respond. To allow this, the user defines semantic constraints, in the form of if-then statements, which indicate combinations of conditions which are not meaningful. In an iterative process, Commander takes the guideline rules, together with an increasingly refined set of constraints and helps focus in on any combinations of conditions to which the guideline does not respond. When applied to the clinical guideline for childhood immunization, Commander was able to dramatically reduce the number of potential combinations of conditions for consideration and also identified several areas of incompleteness in the rules.

Lessons Learned from a Pilot Implementation of the UMLS Information Sources Map

OBJECTIVE To explore the software design issues involved in implementing an operational information sources map (ISM) knowledge base (KB) and system of navigational tools that can help medical users access network-based information sources relevant to a biomedical question. DESIGN A pilot biomedical ISM KB and associated client-server software (ISM/Explorer) have been developed to help students, clinicians, researchers, and staff access network-based information sources, as part of the National Library of Medicines (NLM) multi-institutional Unified Medical Language System (UMLS) project. The system allows the user to specify and constrain a search for a biomedical question of interest. The system then returns a list of sources matching the search. At this point the user may request 1) further information about a source, 2) that the list of sources be regrouped by different criteria to allow the user to get a better overall appreciation of the set of retrieved sources as a whole, or 3) automatic connection to a source. RESULTS The pilot system operates in client-server mode and currently contains coded information for 121 sources. It is in routine use from approximately 40 workstations at the Yale School of Medicine. The lessons that have been learned are that: 1) it is important to make access to different versions of a source as seamless as possible, 2) achieving seamless, cross-platform access to heterogeneous sources is difficult, 3) significant differences exist between coding the subject content of an electronic information resource versus that of an article or a book, 4) customizing the ISM to multiple institutions entails significant complexities, and 5) there are many design trade-offs between specifying searches and viewing sets of retrieved sources that must be taken into consideration. CONCLUSION An ISM KB and navigational tools have been constructed. In the process, much has been learned about the complexities of development and evaluation in this new environment, which are different from those for Gopher, wide area information servers (WAIS), World-Wide-Web (WWW), and MOSAIC resources.

Exploring a Clinically Friendly Web-Based Approach to Clinical Decision Support Linked to the Electronic Health Record: Design Philosophy, Prototype Implementation, and Framework for Assessment

Background Computer-based clinical decision support (CDS) is an important component of the electronic health record (EHR). As an increasing amount of CDS is implemented, it will be important that this be accomplished in a fashion that assists in clinical decision making without imposing unacceptable demands and burdens upon the provider’s practice. Objective The objective of our study was to explore an approach that allows CDS to be clinician-friendly from a variety of perspectives, to build a prototype implementation that illustrates features of the approach, and to gain experience with a pilot framework for assessment. Methods The paper first discusses the project’s design philosophy and goals. It then describes a prototype implementation (Neuropath/CDS) that explores the approach in the domain of neuropathic pain and in the context of the US Veterans Administration EHR. Finally, the paper discusses a framework for assessing the approach, illustrated by a pilot assessment of Neuropath/CDS. Results The paper describes the operation and technical design of Neuropath/CDS, as well as the results of the pilot assessment, which emphasize the four areas of focus, scope, content, and presentation. Conclusions The work to date has allowed us to explore various design and implementation issues relating to the approach illustrated in Neuropath/CDS, as well as the development and pilot application of a framework for assessment.

Maintaining and incrementally revalidating a computer-based clinical guideline: a case study.

The paper explores the issues involved in maintaining the logic within a complex computer-based clinical guideline, using as a case study IMM/Serve, an operational guideline whose domain is childhood immunization. For a period of more than a year and a half, we have maintained a log of (1) the national changes to the immunization recommendations, (2) the local customizations of IMM/Serves logic, and (3) certain logic problems that arose in the process of accommodating these changes and customizations. We describe the nature of these changes, customizations, and problems. We also discuss how different types of domain knowledge might assist in the automated process of validating successive versions of the logic. The papers goal is to use the immunization domain to provide specific examples of the issues and problems that arise in maintaining a computer-based clinical guideline.

Issues in computer-based decision support in public health illustrated using projects involving childhood immunization.

The article discusses issues that arise in implementing computer-based decision support using childhood immunization as a source of examples. The examples include (1) IMM/Serve, a program that provides patient-specific recommendations, (2) informatics tools developed to help validate IMM/Serves knowledge and functionality, and (3) tools developed to explore how computers can help ensure immunization data quality. Issues discussed include the complexity of creating computer-based decision support, the need for a continuing process of revision and testing as the health field evolves over time, and the potential value of computer-based tools to assist in this process.

IMM/SCRUB: A domain-specific tool for the deduplication of vaccination history records in childhood immunization registries

IMM/Scrub is a pilot tool developed to assist in the deduplication of vaccination history records in childhood immunization registries. This problem is complicated by a number of factors including that fact that: (1) some doses are numbered and some are not, (2) doses may have different dose numbers, (3) doses may specify different preparations within a vaccine series, (4) one dose may indicate a combination vaccine and the other dose may specify one component of that combination, (5) two doses may have slightly different dates, and (6) combinations of any of these problems may occur together. IMM/Scrub is designed to help detect 10 different types of vaccination dose duplicates and also allows the user to specify flexibly the conditions in which a duplicate dose might be automatically eliminated. In addition, IMM/Scrub is linked to the IMM/Serve immunization forecasting program, which can provide additional assistance in the data cleaning process. The paper describes (1) the design of the current pilot implementation of IMM/Scrub, (2) the lessons learned during its implementation, and (3) our preliminary experience applying it to data from three immunization databases, from a state, a metropolitan area, and an academic medical center.

Evaluating IAIMS at Yale: Information Access

Objective: To evaluate use of information resources during the first year of IAIMS implementation at the Yale - New Haven Medical Center. The evaluation asked: (1) Which information resources are being used? (2) Who uses information resources? (3) Where are information resources used? (4) Are multiple sources of information being integrated? Design: Measures included monthly usage data for resources delivered network-wide, in the Medical Library, and in the Hospital; online surveys of library workstation users; an annual survey of a random, stratified sample of Medical Center faculty, postdoctoral trainees, students, nurses, residents, and managerial and professional staff; and user comments. Results: Eighty-three percent of the Medical Center community use networked information resources, and use of resources is increasing. Both status (faculty, student, nurse, etc.) and mission (teaching, research, patient care) affect use of individual resources. Eighty-eight percent of people use computers in more than one location, and increases in usage of traditional library resources such as MEDLINE are due to increased access from outside the Library. Both survey and usage data suggest that people are using multiple resources during the same information seeking session. Conclusions: Almost all of the Medical Center community is using networked information resources in more settings. It is necessary to support increased demand for information access from remote locations and to specific populations, such as nurses. People are integrating information from multiple sources, but true integration within information systems is just beginning. Other institutions are advised to incorporate pragmatic evaluation into their IAIMS activities and to share evaluation results with decision-makers. n J Am Med Inform Assoc. 1997;4:138 - 149.