What are the essential steps for the overall guideline...

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The Importance of Creatingan Ontology-SpecificConsensus Before a Markup-Based Specificationof Clinical Guidelines

Erez Shalom1, Yuval Shahar1 Eitan Lunenfeld2, MeiravTaieb-Maimon1, Ohad Young1, Guy Bar2, SusanaB.Martins3, Laszlo Vaszar3, Yair Liel2, Avi Yarkoni2,Mary K.Goldstein3, Akiva Leibowitz2, and Tal Marom4

1 The Medical Informatics Research Center, Ben Gurion University, Beer Sheva, Israel2 Soroka Medical Center, Ben Gurion University, Beer Sheva, Israel3 Veterans Administration Palo Alto Heath Care System, Palo Alto,CA4 E.Wolfson Medical Center, Holon, Israel

AI techniques in healthcare: evidence-based guidelines and protocols ; ECAI Workshop 29/8/2006


The Required Infrastructure tosupport automation of GLs


What are the essentialsteps for the overallguideline specificationprocess?


A Methodology for GL Specification& for its Evaluation

KE

KE

Before Markup

1.

KE ChooseSpecification

Language

KEsInstructing

the EPs

2.

EP

KE

Choosing

together GL

for

Specification

EP

KE

3.Creating

together anOntology-

Specific

Consensus

4.

SEP

KE

EPs Trainingin the

Markup Tool

5.

EP

KE

Creatingtogether

Gold

Standard

Markup

EP

6.

KE

KE

•The methodology is embedded within the Digital GuidelineLibrary (DeGeL) architecture•Creating an Ontology-Specific Consensus (OSC) is a crucial,mandatory step before markup

1.


The Importance of an Ontology-Specific Consensus (OSC)

An OSC is a document that describes thecore objectives and means of the GL

Refers to the knowledge roles of thechosen (target) specification ontology

Enhances accuracy of the mark-up Decreases variability during mark-up and

during application of the GL

2


The Consensus-Creation Methodology Clinical consensus –the pathway of the GL

KE +EP add proceduralknowledge semantics to thepathway (e.g parallel orderbetween the regimens)

Ontology-Specific Consensus

1

2

3

4

KE+EP add declarativeknowledge to the pathway(e.g filter condition to themain root of the GL)


The second stage in forming anOntological consensus

OR

OR

OR

Inpatient treatment (sequential)

note :give any one of the regimens

Parenteral Regimen B (parallel)

Clindamycin 900 mg IV every 8hours

PLUS

Gentamicin loading dose IV orIM (2 mg/kg of body weight)followed by a maintenance dose(1.5 mg/kg) every 8 hours. Singledaily dosing may be substituted.PLUS

Doxycycline 100 mg orallyor IV every 12 hours.

Parenteral Regimen A

(parallel)

Cefotetan or Cefoxitin

Cefotetan 2 g IV every12 hours

ORCefoxitin 2 g IV every6 hours

PLUS

Doxycycline 100 mg orally or IV every 12hours.

Alternative Parenteral Regimens(parallel)

Ofloxacin 400 mg IV every 12hours

ORLevofloxacin 500 mg IV once daily

WITH or WITHOUT

Metronidazole 500 mg IV every 8hours

ORAmpicillin/Sulbactam 3 g IVevery 6 hours

(Ofloxacin or Levofloxacin) +/-(Metronidazole or Ampicillin/

Sulbactam)


The third stage in forming anOntological consensus


Results (I): Procedural Complexityof the GLs

Guidelines

Plan Type PID COPD HypoThyrd Total

Cyclic (Periodic) 24 2 2 28

If-Then-Else 16 4 6 26

Plan Reference 9 NA 3 12

Parallel Plan 11 8 2 21

Sequential Plan 14 3 4 21

Simple Plan 28 36 14 78

To be Defined 4 6 NA 10

Sum of Plans 106 59 31 196


Results (II): Quality of markups EPs can perform markup! High completeness: 91% of the plans and

97% of the KRs were recreated,compared to Gold Standard markup

Variable correctness, but proportion ofperfect scores significantly high (P<0.05)

Several clusters of KRs can be formed bylevel of difficulty to structure

Creating an OSC is crucial for achievinghigh quality


Results (III): Types of errorsMarkup Error Rate(MER) per KR, per EP

0.55

0.41

0.12

0.31 0.31

0.09

0.24

0.09

0.03

0

0.1

0.2

0.3

0.4

0.5

0.6

PID COPD HypoThyrd

GLs

ME

R

Total Ontological Clinical

360

199

360

112

360

87

194

79

194

61

194

1898

12

98

9

98

3

2*.

.

i

i

GLinKRsofNo

GLinerrorsofNo

= MER i.

The differences in the total numbers of errors betweenthe three GLs were highly significant in a proportion test(P<0.001)

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Conclusionso Markup is feasible by EPs!

o The more detailed and structured the OSC was, the lower the total number of errors committed by the EPs for each KR

o The need for a graphical OSC-forming graphical tool


Summary The need for gradual GL specification Creating an ontology-specific consensus

as a first step Using a well defined methodology for the

overall process to increase the quality ofthe markups

For more information:

[email protected]

http://medinfo.ise.bgu.ac.il/medlab


Questions?


The second stage in forming anOntological consensus

YESNO

is PID

severe? (*)

Patient Treatment and evaluation

Hospitalization and

discharged

(sequential)

Outpatient

Treatment

Outpatient Treatment and

evaluation (parallel)

Outpatient Evaluation

and follow up

See 1.2See 1.7

See 1.8

Hospitalization

Post DischargedSee 1.5


Creation of OSC – example:Textual Source in the PID Guideline


Cefotetan 2 g IV every 12 hours

OR

Cefoxitin 2 g IV every 6 hours

PLUS

Doxycycline 100 mg orally or IV every 12 hours.

Parenteral Regimen B

Clindamycin 900 mg IV every 8 hours

PLUS

Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a

maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be

substituted.

Alternative Parenteral Regimens

Ofloxacin 400 mg IV every 12 hours

OR

Levofloxacin 500 mg IV once daily

WITH or WITHOUT

Metronidazole 500 mg IV every 8 hours

OR

Ampicillin/Sulbactam 3 g IV every 6 hours

PLUS

Doxycycline 100 mg orally or IV every 12 hours.


The first stage in forming anOntology-Specific consensus


Cefotetan 2 g IV every 12hours

ORCefoxitin 2 g IV every 6hours

PLUS

Doxycycline 100 mg orallyor IV every 12 hours.

Parenteral Regimen B

Clindamycin 900 mg IV every8 hours

PLUS

Gentamicin loading dose IV orIM (2 mg/kg of body weight)followed by a maintenancedose (1.5 mg/kg) every 8 hours.Single daily dosing may besubstituted.

Alternative Parenteral Regimens

Ofloxacin 400 mg IV every 12hours

ORLevofloxacin 500 mg IV oncedaily

WITH or WITHOUT

Metronidazole 500 mg IV every8 hours

ORAmpicillin/Sulbactam 3 g IVevery 6 hours

PLUS

Doxycycline 100 mg orally or IVevery 12 hours.

Inpatient treatment -

Give one of the following regimens

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Results (III): Procedural Complexity of theGLs The Subjective Qualitative Ranking

Aspect ID Aspect Name Aspect Description EP1 EP2 EP3 EP4 Mean STDEV

1 Having Medical expertise All your expertise knowledge regarding the guideline 2 3 3 3 2.75 0.50

2Reading the guideline sources

before making ont. ConsensusReading the textual content of the guideline 2 2 3 3 2.50 0.58

3Knowing the multiple

representation level modelThe Hybrid Representation Model 3 0 3 3 2.25 1.50

4Understanding Asbru Krs –

Procedural partThe clinical pathway described as flow chart 2 2 3 2 2.25 0.50

5Understanding Asbru Krs -

Declarative part

Each plan includes some declerative KRs such as

Filter Conditions KR3 2 2 2 2.25 0.50

6 Using of Ontology Key concepts, properties and their relations1 0 2 3 1.50 1.29

7 Having more than one source The guideline has more then one source 3 3 0 0 1.50 1.73

8 Using DeGeL The Digital electronic Guideline Library 0 0 3 2 1.25 1.50

9 Using URUZ –main interface The tool for guideline markup 1 0 0 1 0.50 0.58

10 Using Plan-body wizard The tool for guideline structuring into tree of plans 1 0 1 0 0.50 0.58

11 Using IndexiGuide The tool for indexing the guideline 0 0 0 2 0.50 1.00

12 Using Vaidurya The tool for searching the guideline 0 0 0 1 0.25 0.50

13 Using Vocabulary serverThe tool for finding terms

In standard vocabularies such as Loinc, CPT0 1 0 0 0.25 0.50

14 Using Spock The tool for Applying the guidelines 0 0 0 0 0.00 0.00

1.29 0.93 1.43 1.57 1.30 0.28 Mean Score


Results (I): The Guidelines

Pelvic Inflammatory Disease (PID) Chronic Obstructive Pulmonary

Disease (COPD) Hypothyroidism (HypoThyrd)

What are the essential steps for the overall guideline...

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