Toward a Guideline Authoring Workbench

1. Toward a Guideline Authoring Workbench Session #1 May 6, 1999 Barry G. Silverman, PhD

2. Lab for Informatics & Intelligent Systems Tech (LIIST) Barry Silverman, PhD Chen Tony Yuan Penn Database Group Peter Bunneman, PhD Val Tannen, PhD Arnaud Sahuguet Realtime Systems Performance Lab Insup Lee, PhD Oleg Sikolski, PhD Penn People

3. Outline • Purpose & Challenges • Authoring Process 1. Protocol Eligibility 2. Wellness/Prevention 3. Chronic (Ambulatory Care) Guidelines 4. Acute Care Guidelines 5. Critical Pathways 6. Education & Decision Support Materials • Maintenance Requirements • Summary

4. Purpose & Challenges • Purpose of Today’s Session • Hypothetical “Tour” of finished CADSE • Challenges to be Resolved Today

5. Challenges for Today • Expose the Dream • Work Toward a Unified DSS View • Define Guideline Workbench Components • Breadth • Analyze Alternative Implementations (Depth) • Make vs. Buy • Usefulness, Scalability, & Usability • Synthesize a number of Workbench Requirements

6. Figure 1 - A Proposal to Merge Knowledge Life Cycle Management, Open Standards, and Integrated Environment Authoring Test & Eval Maintaining Elicitation Wizards Debugging Agents Guideline Project Mgt Support Sys. KB Models, Skeletons Clarity Checks Coherence Verifiers HL7 RIM, XML/Kona Milestone & WBS Viewer IRM Correspon- dence Validators Module History, Documentation Rqmts Mapper Common Medical Term Server Workability Testers Knowl. Grapher Performance Enhancers Change Control Parser Open-SW Canonical Form Guideline Repository Execution Environment Rules for Workflow Templates for Notes Alerts/Remdrs for Orders Semantic Messaging (Publish, Notify, Remind) Data Handline Presentation

7. Deployment Map Enterprise Guideline Repository Kn. Mgt. Workbench Enter- prise Kn. Administrators Local Division- Specific Guideline Repos. Clinic- Specific Guideline Repos. Clinic- Access to KM Toolkit, Guideline Changes, & OLTP System HFHS Vendor Components Division-Wide Clinic-Specific

8. CADSE Ingredients (ATP Diagram)

9. KNOWLEDGE MANAGEMENT GRANDCHALLENGE National repository to capture/share “practice decision rules” and electronic guidelines (open, reusable, machine form) JIT Filtered Push, Not Pull NOTE1: Need intuitive editing yet guaranteed reliability for knowledge-ware. NOTE2: Local user toggles/adapts desired widgets, NOTE3: The Infrastructure Challenge (NCIS is assumed)

10. RQ - Guidelines-in-Use (tackling the authoring component) • Can a terminology-enabled, visual editor/wizard be created that: • Is easy for medical professionals to use (cognitive fit)? • Supports guideline knowledge representations (e.g, eligibilities, algorithms, rules, decision tables, etc.) • Causes guidelines to be better written (coherence, clarity, completeness, workability, etc.) • Permits local revising/adapting to prevailing practice • Helps authors produce guidelines that “make the right thing the easiest thing”

11. Knowledge Engineering Paradox • Expert clinicians know what they don’t know, but don’t know what they know. • Expertise is situationally triggered • Its hard to do a data dump a priori • We need to spend this time together to “discover” your knowledge of guideline authoring • there ain’t no shortcut -- clinician time is essential to design CADSE right

12. Work Toward a Unified DSS View(requires clinicians to specify it) What are you trying to put in front of the clinician-author ??????? What should they put in front of clinician-practitioners ?????? AGAIN: KE theory says you aren’t able to elaborate this fully a priori (so lets walk through some situations together)

13. The CADSE “Dream” A Tour of what it could be. (with apologies to Asymetrix Multimedia Toolbook Instructor)

14. Knowledge Management Workbench - Prototype Implementationver. 1.0 alpha (CADSE) Guidelines Representation Toolkit - Prototype Implementation ver. 1.0 alpha

15. For the rest of this talk Try to picture yourself as a clinician-AUTHOR using the CADSE workbench

16. Scenario • Tom, the head of Guideline Development for Best HMO, purchased • CADSE in order to develop a suite of guidelines including but not • limited to: • 1. Protocol Eligibility • 2. Wellness/Prevention • 3. Chronic (Ambulatory Care) Guidelines • 4. Acute Care Guidelines • 5. Clinical Pathways • 6. Education & Decision Support Materials • Tom found that CADSE ate up these tasks like a knife through butter. • One thing he particularly liked was CADSE’s breadth as a toolbox:

18. This interface allowed Tom to quickly complete his range of authoring needs • Using Templates of Guideline Types • Selecting Objects From Library (add new ones) • Setting Objects’ Properties • Filling Out Object Content • Adding Behavior (via Script) • Getting Wizard Help (where needed)

19. Working with templates Tom began his guideline authoring using one of the many templates. A template is a prebuilt “book” that you customize by adding your own content. Templates save time and lend a consistent look and feel to your guidelines. In addition to using one of the templates provided with CADSE, you can create your own, custom template to distribute to other guideline authors. TOP DOWN GUIDANCE PRINCIPLE

20. Author your Guideline After Tom chose a template, he then added his content. CADSE’s easy-to- use authoring and development tools make this task simple. And CADSE is powerful enough to handle a wide variety of technical tasks—from creating and managing new guideline objects to adapting those in a reuse library. PRINCIPLE OF REUSE

21. Select objects from CADSE’s Library He added features to his guideline by selecting from the wide variety of objects available in the CADSE Library. Library objects have built-in behavior to handle such tasks as eligibility, decision tables, workflow and logic charts, and clinical paths, among others. ECOLOGICAL ARTIFACTS PRINCIPLE

22. ELICITATION TOOLS CONTAINER (Word processor, WWW browser) Terminology-Enabled, Visual Guideline Editing Component GenericTasks Assembly Wizard Sentence Logic Constructors Reusable parts libraries interface Generic Tasks Parts Clinician Input Parts Consumer Input Parts User Communication Parts Semantic & Vocabulary Servers Interface Syntax structures • Patient profile forms • Consumer self-assessment • Guidln Qualif • Risk Assmnt • Severity Lev. • Diagnosis • Treatment • Education • Parameter tables • Decision tables • Rule structures/MLMs • Intention-based relations • Intermed Guidelines Syntax Structures • email generators • Paging facility • XML generators HL7 RIM Interface GLIF Semantic Primitives ARDEN Syntax Data & knowledge representation & access parts (OO and XML) Datapath forms GLIF-Electronic Guideline Objects (EGO) and XML/DTDs • ARDEN Curly Braces/Term Server • HL7 EDI

23. Setting object properties Tom customized objects in his guideline by setting their properties. Each object, such as an eligibility assessment or clinical path, has properties that define its appearance and behavior. Tom could easily set an object’s properties using the Properties dialog box or by responding to a wizard. POLYMORPHISM PRINCIPLE (Cmd Keys, DMI or Agents)

24. Customize guideline behavior without limit using JavaScript (ECMA) With CADSE’s easy-to-learn JavaScript, Tom further customized guidelines to meet unique needs. He created new objects, customize existing objects, and programmed guidelines to exhibit unique behaviors or to simulate special processes. If he doesn’t want to write script the wizard copies his actions and produces script for him ADAPTIVITY PRINCIPLE

25. How to Implement Tom’s CADSE “Dream” • Analyze Alternative Implementations? • Make vs. Buy(& integrate) • Usefulness, Scalability, & Usability • Make Option: Case Study • Protégé = dozens of person-years of effort (scalability & usability still issues!!) • One could spend all the budget and not be done!

26. The Buy (& integrate) Option • Identify Best of Breed DSS Authoring Tools • Scalable, usable, generic, open-standards based • Identify Next Release Change Requirements • Lobby effort needed, evolvable API concept • Assure Workbench is an Integration Platform • Interface Definitions • Common Presentation Layer Issues • Fill In Missing Components

27. Top Down Support Templates Reusables Sharing Existing Objects Libraries Bottom Up Support Free-form Creations Custom Designs Local Adapting Capture of New Objects Learning Indexing Goals of a Knowledge Management Workbench • Group Development, Version Tracking, & Administration NOTE: Guideline Checking is an Extensive Topic for the Workshop

28. Power vs. Learning Tradeoff Curve Shallow Workbench (visual, with wizards) Learnability Hybrid Powerful Workbench (programming lang’s) Power of Expression

29. How should a workbench support guideline creation efforts? ANSWER: A mix of approaches is required (HYBRID)

30. Figure 1 - Overview of the Three Layers of the Knowledge Management: Tasks Ring, Tools Ring, and Repository Core 12 1 Make Guidelines Computer Operational Find/View Existing Guidelines 11 Answer/Define Information Gathering Questions 2 Show/Draw Algorithm Diagram (Adapt reusables) Parsers & Compilers Task Completion Wizards/Help 10 • Syntactic/semantic checkup • Data & knowledge binding • Executable generation View/Identify Data Collection Needs Interface Files 9 Study/Draw Temporal Dependency Flows 4 See/Provide Encounter Materials (Multimedia Links) 8 5 See/Author Pseudo Rules View/Add Consultation Tables 7 6 View/Create Decision Tables See/Fill out Procedure Triggers Level 3 Registration Guidelines Development Cycle Level 2 Test/Execution Environment VGR Administration • Ontology • CBR /Search • Version • Workability • Benckmarking/Quality Ass. • Integration (R2Do2,CDR, Careweb) Level 1 Registration Guidelines Deployment Development Tools (HOLON) Tools (COPE) 3 Level 2 Registration See/Fill In Textual Annotations & Explanations Canonical Guidelines Repository (CGR) Critics • Clarity • Completeness • Logic • Lexicon Syntactic and Semantic Tools (Servers) Semantics, Syntax, Structure Models Exchange Protocol Definition Models • Knowledge Mediators • Info Agents TOOLS LAYER • ARDEN syntax • HL7 RIM • GLIF & EGO Vocabulary Server • SNOMED RT • LOINC • CPT 4 • NDC TASK LAYER

31. Outline • Purpose & Challenges • Authoring Process 1. Protocol Eligibility 2. Wellness/Prevention 3. Chronic (Ambulatory Care) Guidelines 4. Acute Care Guidelines 5. Clinical Pathways 6. Education & Decision Support Materials • Maintenance Requirements • Summary

33. Starting a New Guideline • Pick a Type • Automatically Create a “Container” • Wizard Asks Author for Boilerplate*: • Authors, Date, etc. • Target population, needs, & cost implications • Rate of change & Practice variation • Evidence (degree of vs. opinion) • Difficulty of development, maintenance, implementation * - KPNW’s “CPG Policy & Procedures” Paper (7/98), p. 8

34. The Knowledge Model • IoM’s 5 Guideline Types (others?) • screening & prevention, • diagnosis & pre-diagnosis mgt of patients, • indications for use of surgical procedures • approp. use of techs/tests for clinical care • guidelines for care of clinical conditions

35. The Knowledge Model (cont’d) For each Generic Type of Guideline, Need to Model: • Skeletal Plans/Chapters & Sections • Sorted by Workflow Element (Person-type, Sequential Step, Timing Points, etc.) • Locally Adaptable

37. Importance of a Layout/eForms Manager • Adapt all eforms (container GUI, eligibility objects, reusable components) • Use to Create Many Items • Progress Note Forms • Clinical Path Tables • Educational Materials • Other • Use to Create Other Tools (e.g., PocketCards)

38. Container Layout Manager/”Visual Forms Designer” • REQUIRED: Highly Scalable/Usable/Adaptable Forms Layout Manager • Design electronic forms in a Visual Forms Designer & fill them out using: • Web-based Visual Forms Builder • Visual Forms Application Builder • Visual Forms Webpage Plug-in • Workflow for eForm Artifact • Support for other Form Designer Tools and interchange standards • e.g., Visual Forms Designer can also read FormFlow, OmniForm and • JetForm forms after they are converted via the Visual Converter.

43. Uses Advanced Basic

44. Sample Visual Designer Screens Examine some of the screens to assess role of clinician-authors Www.mmacorp.comvfftw.htm

45. Make vs. Buy - Layout Manager

47. Authoring Process:1. Protocol Eligibility • At 1st Blush Eligibility Seems Straightforward • Inclusion Criteria • Exclusion Criteria (Mutable, Immutable) • BUT, ….

48. There seem to be numerous “eligibility” type problems • Standard inclusion/exclusion lists (“simple” branching) • Level of care/risk stratification (multiple entry points, multi-workflows, more probabilistic?) • Caremap progression checking (temporal issues) • Health risk assessments (consumer-run pre-eligibility checks + lifestyle/self-care advice) • Tools may differ somewhat for each

49. Assessment During Rehab • Assessment After Discharge from Rehab

50. What kind of authoring will clinicians do? • Decision tree? (e.g., Lumina/Spreadsheet) • has a well-grounded semantics • probability handled readily • fuzzy membership • Visual Object Questionnaire “Programming” (e.g., Toolbook CBT) • may be the ECOLOGICAL artifact • convert to HTML/XML • what about script?