PRO cesses &

1. A Guidelines Model PROcesses& Transactions Editable by USers Hemant Shah M.D., M. Surg. Scientist, Information Sciences City of Hope National Medical Center Duarte, CA hemant@proteme.org

2. In This Presentation … • A very brief introduction of Proteus • Demonstration of software tool Protean and other associated tools • Implications for healthcare • Potential uses of Proteus technology in healthcare tools

3. Proteus – A Brief Introduction

4. What Is Proteus? • A model for constructing clinical decision-support Guidelines with entities called Knowledge Components which are: • Executable • Editable • Reusable

5. Proteus is a Model for… • Creating clinical practice guideline based decision-support systems • EMR systems • Kernel of integrated healthcare information systems

6. Proteus Contains • A specification of an architecture for • Executable Guidelines • Systems to handle them • A notation system for Guidelines – human & machine readable

7. The Vision Diabetes Diabetes Cardiovascular Evaluation General Evaluation

8. The Vision Renal Evaluation Diabetes Cardiovascular Evaluation General Evaluation

9. The Vision Organization B Knowledge Component Server Organization A Knowledge Component Server Diabetes Diabetes Cardiovascular Evaluation Cardiovascular Evaluation General Evaluation

10. What is a knowledge component (KC)? • A software component with a discrete bit of knowledge • Complete in itself • Can manage its own internal affairs • Can be “connected” with other KCs to work cooperatively with them • Contains knowledge about a clinical activity: • Actions to be performed • Events to look for • Data to be collected from the actions and events • Interpretation and implications of that data • Supplementary information about the activities (e.g. links to websites)

11. Knowledge Component Knowledge Component (KC) Value of KC Abstraction Lump Tenderness Vomiting Temperature KC may contain data-fields describing the underlying clinical entity KC Represents • Clinical Process (e.g. diagnosis of acute abdomen pain) • Clinical Transaction Transaction may be • Clinical Event (e.g. vomiting) • Clinical Action (e.g. Palpation of liver)

12. Knowledge Component • KCs can be Nested • To represent composite processes • To reduce complexity

13. KC to Guidelines • KCs can be linked by Activity-links • To represent process • To define Guidelines

14. Guidelines to EMR Lump present Tendernesssevere Vomiting yes Temperature 102 F Instantiated (executed) KCs become medical record

15. Knowledge Component • Part of KC, yet separate • Just an interface • Technology neutral • Pluggable Inference tool • Decides • Abstraction – The value of the component • Activity within the component Abstraction Lump Tenderness Vomiting Temperature

16. Pluggable Inference Tool Inference Tool Inference tool reference Knowledge Component • Inference Tools • Algorithm • Decision Tables • Decision Theory • Rule Based System • Neural Network • Fuzzy System • Patient assisted decisions • Human expert (even user) • User Defined • User Specified • Combination of these Test A Action A Test B Action B Test C User’s System Network Inference Tool Inference Tool Internet

17. Two Types of Knowledge Components • Transaction KC • Process KC

18. Transaction KC Transaction KC Icon • Represents: • Action or • Event or • combination • Contains: • Data Elements • Abstraction Inference tool Transaction Icon Transaction Name Transaction Value • Data 1 - Value • Data 2 - Value • Data n - Value

19. Process KC Process Icon Process Name Process Value Transaction Process Nested KCs Transaction Links Process KC Icon • Represents Clinical process • Contains • Nested KCs • Activity Links • Abstraction inference tool • Action inference tool

20. Activity Links Activity Links   Inferential Link Sequential Link Synchronous Link Inferential Stop Link Sequential Stop Link • Represent the sequence of Triggering of KCs and how they are triggered

21. Proteus Model – UML Class Diagram

22. Proteus Model – UML Class Diagram – Proteus Guideline Component Class

23. Execution and Inference Process KC 1 is executed Process KC 2 is executed 1 1 Transaction KC A is executed Process KC 2’s abstraction is changed 2 3 2 3 Process KC 1’s abstraction is changed A B A B D D E E Guideline’s abstraction is changed Process KC 2’s inference tool decides next action. C The Cycle is repeated

24. Protean – A Software Environment for Proteus Guidelines And Other Ancillary Tools

25. Tutorial • To test some of the Proteus concepts in action, see the tutorial http://www.proteme.org/tutintro.html

26. Features of Protean • Loading and Display of Guideline • Execution • Inferencing and Decision Support • What actions to perform • What events to look for • Interpretation based on the data • Supplementary information • Data Entry Support • EMR

27. Features of Protean • Editing • Creating New Elements • Deleting • Modifying existing elements • Reuse • Changing the Inference tool • Changing the inference tool behavior • UMLS Knowledge Source Server access to associate an entity with a UMLS term • Extensibility – JIT feature

28. A patient has been selected as shown by the title of the Protean window. • Here the user in the process of selection of a guideline for the patient.

29. The guideline is loaded in Protean.

30. Guideline has been “started”. The first Process KC within it, “Magsulf Loading” gets triggered first, which leads to the triggering of the first Transaction KC, “Convulsions eval” in it. The Transaction KC is shown as a dialog box for the user to enter the data in it.

31. The guideline is shown partly executed here. Since the activity link between “Intravenous” and “Intramuscular” is a sequential one, anytime “Intravenous” is executed, after it terminates, the “Intramuscular” Transaction KC is always also triggered. Here a wait of twenty seconds has been specified for the activity link. Which means only after the duration has elapsed will the next KC be triggered. The yellow box is countdown clock telling the user the time remaining before the next activity is triggered. The edge that connects the box to the link, tells the user where the execution is stalled.

32. Here an incomplete guideline is loaded in Protean. The user is in the process of completing it. The tree on the left shows all the KCs that are available in the repository . The user drags a Process KC, “Diabetes Diagnosis” from the repository on the guideline.

33. The user has dragged the Process KC, “Diabetes Diagnosis” and has dropped it on the guideline.

34. The user creates a link between the pre-existing Process KC, “Management of PROM” and the newly dropped Process KC by dragging from one to the other. A dialog box opens up to allow the user to specify characteristics of the behavior of the new activity link.

35. The new link has been created

36. This shows the rule editing application GREEd (Graphical Rule Elements Editor). The Process KC, “Diabetes Diagnosis” is loaded into the application. The list on the top left shows all the rules in the KC. Using simple drag and drop actions the user has created a rule here. The main panel shows all the KCs contained in the “Diabetes Diagnosis” Process KC, on the left side. The right side of the main panel shows all the values (abstractions) that the “Diabetes Diagnosis” KC can possess The rule is shown as Java code in the lower panel. Since the interpreter for this rule is BeanShell which interprets Java as a script – the Tab says BSH rule. The User-view tab shows the same rule in user readable format. Tabs for Arden Syntax and Jess are being constructed

37. This shows the “Magsulf Loading” Process KC being edited. The user can type a broader term in the Term field, and click the [><] button to connect to UMLS Knowledge Source Server over the Internet to select a more specific term. • This feature allows every KC to be tagged with a concept in an Ontology/Vocabulary. The advantage is to index and search for KCs in a repository and to allow features like Just in Time information retrieval.

38. Extensibility for Non-Clinical Functionality

39. Clinical Process as a Skeleton Associated Process Data Data Decision Action Decision Action Action Action Core (clinical) Process • Almost everything in healthcare can be mapped to the elements of the Clinical Process • Proves that clinical process is the core • Gives unlimited extensibility

40. Layers for Unlimited Extensibility Administrator Researcher Physician Accountant

41. System Overview Human Expert as an “inference tool” Inference tool (b) Inference tool (a) Naming Server “Publish” KCs Knowledge Component Servers Get KC references Healthcare Delivery Organization Organization (a) Access KCs Access EMR Organization (b) Independent Clinician Expert Inference Tools Knowledge Managers Knowledge Users

42. Comparison with Other Approaches

43. Other models – Modularity Missing PROforma Inaccurate lines of separation • Workflow entities are part of the clinical activity entities. • Inferencing elements are part of clinical activity elements

44. Other models – why we cant have modularity GLIF Inaccurate lines of separation • Programmatic (inferencing) entities are represented as steps just like clinical activity entities.

45. Other models – why we cant have modularity GLIF Inaccurate lines of separation • next_step is an attribute in each step which is directive for the next action.

46. Other models – why we cant have modularity Eon Inaccurate lines of separation • Sequential Step has attribute followed_by within the Guideline entities.

47. Object oriented design principles • Encapsulation and information hiding Abstraction

48. Design - implications

49. Implications How systems based on Proteus can change the way healthcare is conducted?

50. Bridging the Research to Practice Gap The Gap • In the beginning, there was – The Gap Research Practise