Silvia Panzarasa

Interacting agents through a web-based health serviceflow management system

The management of chronic and out-patients is a complex process which requires the cooperation of different agents belonging to several organizational units. Patients have to move to different locations to access the necessary services and to communicate their health status data. From their point of view there should be only one organization (Virtual Health-Care Organization) which provides both virtual and face-to-face encounters. In this paper we propose the Serviceflow Management System as a solution to handle these information and the communication requirements. The system consists of: (a) the model of the care process represented as a Serviceflow and developed using the Workflow Management System YAWL; (b) an organizational ontology representing the VHCO; and (c) agreements and commitments between the parties defined in a contract (represented as an XML document). On the basis of a general architecture we present an implementation in the area of Diabetes management.

Workflow management systems for guideline implementation.

The activities of care providers need to be coordinated within a process properly designed on the basis of available best practice medical knowledge. It requires a rethinking of the management of care processes within health-care organisations. The current workflow technology seems to offer the most convenient solution to build such cooperative systems. However, some of its present weaknesses still require an intense research effort to find solutions allowing its exploitation in real medical practice. This paper presents an approach to design and build evidence- based workflow management systems (WfMS). They can be viewed as components of a knowledge management infrastructure each health care organisation should be provided with, to increase its performance in delivering high-quality care, by efficiently exploiting the available knowledge resources. On the basis of a general methodology, we describe a WfMS implementation in the area of Stroke management; such a system, after intensive testing in our research laboratory, is now in the process of being transferred in a real working setting (a stroke unit) and integrated with an existing electronic patient record.

A careflow management system for chronic patients.

The management of chronic patients is a complex process, which requires the cooperation of all primary care professionals and their interaction with specialists, laboratories and personnel of different organizations. In this paper we show how a Careflow Management System (CfMS) may represent an essential component of an innovative Health Information System (HIS) able to handle the information and communication needs underlying chronic diseases management. On the basis of a general architecture designed for chronic diseases, we describe a CfMS implementation in the area of diabetes management; such a system embeds EPR and telemedicine functionalities as end-users applications as well as a module for inter-organizational communication based on contracts and on XML messages.

Computerised Guidelines Implementation: Obtaining Feedback for Revision of Guidelines, Clinical Data Model and Data Flow

In this paper we describe a module that allows to collect (a) motivations for non-compliance to guidelines, (b) motivations for poor data entry into the electronic patient record, and (c) comments on medical aspects of guideline recommendations, on their formalisation into computerised rules, and on the guideline integration into the computerised clinical chart. We organised a well-structured taxonomy of non-compliance motivations in such a way that the main hierarchical levels correspond to different medical or technical roles suitable for feedback managing. We analysed about 400 consecutive cases of patients with ischemic stroke. About 40 non-compliances, as well as several incomplete data forms have been identified and motivated.

From Decision to Shared-Decision: Introducing Patients’ Preferences in Clinical Decision Analysis - A Case Study in Thromboembolic Risk Prevention

In the context of the EU project MobiGuide, the development of a patient-centric decision support system based on clinical guidelines is the main focus. The project is addressed to patients with chronic illnesses, including atrial fibrillation (AF). In this paper we describe a shared-decision model framework to address those situations, described in the guideline, where the lack of hard evidence makes it important for the care provider to share the decision with the patient and/or his relatives. To illustrate this subject we focus on an important subject tackled in the AF guideline: thromboembolic risk prevention. We introduce a utility model and a cost model to collect patient’s preferences. On the basis of these preferences and of literature data, a decision model is implemented to compare different therapeutic options. The development of this framework increases the involvement of patients in the process of care focusing on the centrality of individual subjects.

Technical solutions for integrating clinical practice guidelines with electronic patient records

The success of a decision support system based on clinical practice guidelines does not only depend on the quality of the decision model used to represent and execute guideline recommendations, but also on the design of interactions of the system with the end-user interface and the electronic patient record. This paper describes technical solutions adopted to add decision support functionalities to two existing information systems for stroke patients. Despite the specific medical application, the approach is quite general, relying on two main functionalities: a real-time decision support system based on workflow technology (careflow) and an off-line tool for non-compliance detection, called “Reasoning on Medical Action” (RoMA). The integration has been developed maintaining independence between data management and knowledge management, and minimizing changes to existing users interfaces. The paper illustrates in particular the middleware layer created to allow communication between the evidence-based system and the electronic patient record.

Combining Decision Support System-Generated Recommendations with Interactive Guideline Visualization for Better Informed Decisions

The main task of decision support systems based on computer-interpretable guidelines (CIG) is to send recommendations to physicians, combining patients’ data with guideline knowledge. Another important task is providing physicians with explanations for such recommendations. For this purpose some systems may show, for every recommendation, the guideline path activated by the reasoner. However the fact that the physician does not have a global view of the guideline may represent a limitation. Indeed, there are instances (e.g. when the clinical presentation does not perfectly fit the guideline) in which the analysis of alternatives that were not activated by the system becomes warranted. Furthermore possibly valid alternatives could not be activated due to lack of data or wrong knowledge representation. This paper illustrates a CIG implementation that complements the two functionalities, i.e., sending punctual recommendations and allowing a meaningful navigation of the entire guideline. The training example concerns atrial fibrillation management.

Applying 3D Graphics to Computerized Cognitive Rehabilitation

Cognitive rehabilitation is usually administered in form of paper-based exercises the patient is required to solve. With the availability of new and advanced technologies, computer science is gaining more and more importance in the treatment routine. In this paper a software system for the rehabilitation of cognitively impaired subjects will be presented. Its features guarantee many advantages, both for patients and therapists, but to prevent the risk of reduced compliance, which, considering the intended target of the system- typically elderly people with low computer skills- cannot be ignored, 3D technology has been introduced. The project choices made and implementation strategies applied to increase immersion and entertainment and prevent boredom and drops in compliance will be described. Open issues and future works will also be illustrated.

Guideline recommendation text disambiguation, representation and testing

This paper describes a knowledge acquisition tool for translating a guideline recommendation into a computer-interpretable format. The novelty of the tool is that it is addressed to the domain experts, and it helps them to disambiguate the natural language, by decomposing the recommendation into elements, eliciting tacit and implicit knowledge hidden into a recommendation and its context, mapping patients data, available from the electronic record, to standard terms and immediately testing the formalised rule using past cases data.

Segmentation Techniques for Automatic Region Extraction: An Application to Aphasia Rehabilitation

We describe a system that facilitates speech therapists to administer cognitive rehabilitation exercises and to evaluate treatment outcomes. We started by augmenting a commercial tool with a more user-friendly interface, meeting the needs of the healthcare professionals involved. Then we integrated, into the same tool, a new type of exercise, that is particularly patient-tailored, being based on the recognition of familiar images within a picture (such as a relative, a domestic animal, a home object, etc). Segmentation techniques are used to elaborate an input picture and individuate areas including interestingobjects, that will be semi-automatically linked to text and sound. The picture and associated information are then stored in the system database and may be subsequently used as objects for the new exercise. Any number of images may be elaborated, personalised and stored for each patient. The performance has been tested on voluntary subjects with good results.