J Fox, D Glasspool, T Hope, V Patkar, M Austin, L Black, M South, D Robertson, C Vincent "Delivering clinical decision support services: there is nothing so practical as a good theory" Provisionally accepted for publication, subject to revisions, in Journal of Biomedical Informatics
Abstract: Sittig et al (2008) set out ten “grand challenges” for the successful development and deployment of Clinical Decision Support services in order to “inspire stakeholders in a position to advance the state of CDS technology and practice”. The 10 challenges were identified and prioritized on the basis of empirical experience and with the expectation that overcoming these challenges will depend heavily on practical problem solving and finding out “what works” in clinical use. As active participants in this field we take the position that a pragmatic approach to design must be accompanied by sound theoretical principles and safe engineering methods. We illustrate this with an approach to CDS design that starts with a formal model of knowledge-based decision-making, clinical processes and distributed care services, identifying four key pillars of theory, and relationships between them. Sittig et al’s challenges are reviewed to consider how such a framework can facilitate application design and implementation, clinical use, service interoperability etc. We do not claim a formal approach to design is an alternative to empirical evolution of clinical services but is a foundation on which practical experience can be understood, shared and built upon.
P Besana, V Patkar, A Barker, D Robertson, D Glasspool "Sharing Choreographies in OpenKnowledge: A Novel Approach to Interoperability" To appear in Journal of Software, Special Issue on Semantic Extensions to Middleware, August 2009
Abstract: Software systems are becoming ever more complex, and one source of complexity lies in integrating heterogeneous subsystems. Service Oriented Architectures are part of the answer: they decouple the components of the system. However normally service oriented architectures are still designed and enacted from a centralised perspective: a single process invokes remote services, unaware of being part of a larger, more complex workflow. We claim that the orchestration-based approach does not scale well with increasing complexity and heterogeneity of the components. We propose a choreography-based approach, where choreographies are the shared contracts that actors agree to follow. We first present the OpenKnowledge framework, designed according to choreography-based principles. We then demonstrate how the implementation of a complex, distributed model such as the triple assessment, used for the diagnosis of patients suspected with breast cancer, can benefit from this framework.
E.Black, D. Glasspool, M. A. Grando, V. Patkar and J. Fox. "Goal-based decisions for dynamic planning. In Proceedings of the Twelfth Conference on Artificial Intelligence in Medicine (AIME09, Verona, Italy), LNAI 5651, pp. 96-100, 2009. Springer-Verlag (In press).
Abstract: The need for clinical guidelines to be implemented at different sites, to adapt to rapidly changing environments, and to be carried out by distributed clinical teams, implies a degree of flexibility beyond that of current guideline languages. We propose an extension to the PROforma language allowing hierarchical goal-based plans. Sub-plans to achieve goals are proposed at runtime so that changing circumstances may be flexibly accommodated without redefining the workflow.
A Barker, P Besana, M South and J Fox "Towards Decentralised Clinical Guidelines" (internal report)
Abstract: Task based modelling of clinical processes has been clearly demonstrated to improve the delivery and safety of healthcare services. This paper focuses on the modelling and execution of computer interpretable clinical guidelines (CIGs) in a decentralised environment, where all services, knowledge and data may be distributed. Through a motivating scenario taken from the field of cancer research, we argue against complete centralisation and towards an open, decentralised architecture, allowing domain experts to curate and maintain their own processes and data sets. As a solution, we propose an architecture based on Tallis, a framework for describing and enacting clinical guidelines and OpenKnowledge, an enabling technology for choreography based services. We claim this architecture, although more complex to initially model, scales with increasing complexity, is more flexible and reliable than architectures which rely on centralisation. A mini roadmap is presented which outlines our key objectives in advancing this field.
J Fox, V Patkar, I Chronakis "From practice guidelines to clinical decision support: experience in oncology" J Roy Soc Med (in press).
Abstract: The last ten years has seen international recognition that most healthcare services do not offer patients the best possible outcomes and safest care that current medical knowledge makes possible. The demands of modern clinical medicine frequently overwhelm the capacity of human beings to make the best possible clinical decisions, and healthcare organizations often fail to implement decisions correctly, whether correct or not. Efforts to translate the results of clinical research and evidence-based guidelines into routine clinical practice are having mixed success, according to several articles in the JRSM (10/100 2007). A remark by Chedgey et al in that issue suggests that computerised decision support systems (CDSSs) may play a role in mitigating these problems. This has been a longstanding focus of our own research and we believe we have shown in oncology and other clinical disciplines that CDSSs can make a major contribution by offering patient-specific, evidence-justified guidance at the point of care. This paper briefly reviews some key recent advances in this field, comments on a number of other benefits for supporting the translation of clinical research into practice, and identifies some new emerging challenges to the widespread adoption of CDSS technology.
