Arden Syntax Research Articles

Infection Control Through Clinical Pipelines Built with Arden Syntax MLM Building Blocks.

Healthcare-associated infections (HAIs) may have grave consequences for patients. In the case of sepsis, the 30-day mortality rate is about 25%. HAIs cost EU member states an estimated 7 billion Euros annually. Clinical decision support tools may be useful for infection monitoring, early warning, and alerts. MONI, a tool for monitoring nosocomial infections, is used at University Hospital Vienna, but needs to be clinically and technically revised and updated. A new, completely configurable pipeline-based system for defining and processing HAI definitions was developed and validated. A network of data access points, clinical rules, and explanatory output is arranged as an inference network, a clinical pipeline as it is called, and processed in a stepwise manner. Arden-Syntax-based medical logic modules were used to implement the respective rules. The system was validated by creating a pipeline for the ECDC PN5 pneumonia rule. It was tested on a set of patient data from intensive care medicine. The results were compared with previously obtained MONI output as a suitable reference, yielding a sensitivity of 93.8% and a specificity of 99.8%. Clinical pipelines show promise as an open and configurable approach to graphically-based, human-readable, machine-executable HAI definitions.

Evaluation of the Proposed Arden Syntax v3.0 to Represent Query Data Mappings Using FHIR.

Arden Syntax is a standard that encodes knowledge as Medical Logic Modules but lacks a standard query data model and terminology. Assess FHIR-enabled data access in a proposed version of Arden Syntax. Queries in 340 MLMs were tabulated. FHIR can serve as the Arden Syntax data model, but nonstandard terminologies still impede interoperability. The proposed Arden Syntax v3.0 FHIR-enabled data access is adequate as a query data model for MLMs.

Use of an open-source electronic health record to establish a “virtual hospital”: A tale of two curricula

BackgroundThe electronic health record (EHR) is central to medical informatics. Its use is also recognized as an important skill for future clinicians. Typically, medical students' first exposure to an EHR is when they start their clinical internships, and medical informatics students may or may not get experience with an EHR before graduation. We describe the process of implementing an open-source EHR in two curricula: Medicine and Medical informatics. For medical students, the primary goals were to allow students to practice analyzing information from the EHR, creating therapeutic plans, and communicating with their colleagues via the EHR before they start their first clinical rotations. For medical informatics students, the primary goal was to give students hands-on experience with creating decision support in an EHR. ApproachWe used the OpenMRS electronic health record with a custom decision support module based on Arden Syntax. Medical students needed a secure, stable environment to practice medical reasoning. Medical informatics students needed a more isolated system to experiment with the EHR's internal configuration. Both student groups needed synthetic patient cases that were realistic, but in different aspects. For medical students, it is essential that these cases are clinically consistent, and events unfold in a logical order. By contrast, synthetic data for medical informatics students should mimic the data quality problems found in real patient data. OutcomesMedical informatics students show more mature reasoning about data quality issues and workflow integration than prior to using the EHR. Comments on both course evaluations have been positive, including comments on how working with a real-world EHR provides a realistic experience. ConclusionThe open-source EHR OpenMRS has proven to be a valuable addition to both the medicine and medical informatics curriculum. Both sets of students experience use of the EHR as giving them valuable, realistic learning experiences.

Exploration of the Decision Model and Notation (DMN) Standard for Representation of Knowledge Bases Encoded in the Arden Syntax.

Arden Syntax encodes knowledge as Medical Logic Modules (MLMs). Current work involves improvement of its representation of business processes. Assess how DMN can represent decision-making in MLMs. A sample of 340 MLMs was tabulated for DMN representation. While DMN can represent all MLMs at the decision requirements level, some are not supported at the decision logic level. DMN facilitates representation of business processes but would not address all decision logic.

Contemporary clinical decision support standards using Health Level Seven International Fast Healthcare Interoperability Resources.

To facilitate the development of standards-based clinical decision support (CDS) systems, we review the current set of CDS standards that are based on Health Level Seven International Fast Healthcare Interoperability Resources (FHIR). Widespread adoption of these standards may help reduce healthcare variability, improve healthcare quality, and improve patient safety. This tutorial is designed for the broad informatics community, some of whom may be unfamiliar with the current, FHIR-based CDS standards. This tutorial covers the following standards: Arden Syntax (using FHIR as the data model), Clinical Quality Language, FHIR Clinical Reasoning, SMART on FHIR, and CDS Hooks. Detailed descriptions and selected examples are provided.

A semantics and a logic for Fuzzy Arden Syntax

Fuzzy programming languages, such as the Fuzzy Arden Syntax (FAS), are used to describe behaviours which evolve in a fuzzy way and thus cannot be characterized neither by a Boolean outcome nor by a probability distribution. This paper introduces a semantics for FAS, focusing on the weighted parallel interpretation of its conditional statement. The proposed construction is based on the notion of a fuzzy multirelation which associates with each state in a program a fuzzy set of weighted possible evolutions. The latter is parametric on a residuated lattice which models the underlying semantic ‘truth space’. Finally, a family of dynamic logics, equally parametric on the residuated lattice, is introduced to reason about FAS programs.

Patient Cohort Identification on Time Series Data Using the OMOP Common Data Model.

The identification of patient cohorts for recruiting patients into clinical trials requires an evaluation of study-specific inclusion and exclusion criteria. These criteria are specified depending on corresponding clinical facts. Some of these facts may not be present in the clinical source systems and need to be calculated either in advance or at cohort query runtime (so-called feasibility query). We use the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) as the repository for our clinical data. However, Atlas, the graphical user interface of OMOP, does not offer the functionality to perform calculations on facts data. Therefore, we were in search for a different approach. The objective of this study is to investigate whether the Arden Syntax can be used for feasibility queries on the OMOP CDM to enable on-the-fly calculations at query runtime, to eliminate the need to precalculate data elements that are involved with researchers' criteria specification. We implemented a service that reads the facts from the OMOP repository and provides it in a form which an Arden Syntax Medical Logic Module (MLM) can process. Then, we implemented an MLM that applies the eligibility criteria to every patient data set and outputs the list of eligible cases (i.e., performs the feasibility query). The study resulted in an MLM-based feasibility query that identifies cases of overventilation as an example of how an on-the-fly calculation can be realized. The algorithm is split into two MLMs to provide the reusability of the approach. We found that MLMs are a suitable technology for feasibility queries on the OMOP CDM. Our method of performing on-the-fly calculations can be employed with any OMOP instance and without touching existing infrastructure like the Extract, Transform and Load pipeline. Therefore, we think that it is a well-suited method to perform on-the-fly calculations on OMOP.

A Digital Clinical Guideline Based on HL7 Arden Syntax for the Treatment of Children with Traumatic Brain Injury.

Intracranial hypertension is a serious complication accompanying the intensive care of children with traumatic brain injury. Intensive care of these patients is based on internationally accepted guidelines and their local editions. The goal was to develop a software system for digital implementation of the clinical protocol for the treatment of intracranial hypertension in children, based on HL7 Arden Syntax clinical decision support. Arden Syntax, an HL7 medical knowledge representation and processing standard, was used to develop a digital version of the local guideline. Comparison of 37 patients given conventional treatment with a second group of 84 patients treated with the digital clinical guideline yielded statistically significant differences. The digital clinical guideline system undoubtedly improves the doctor's awareness of the patient's existing condition and potential complications of intracranial hypertension.

Exploring Methods of Implementing Arden Syntax for CDS Hooks.

Specifications for Arden Syntax lack provisions for the standardized access of clinical decision support (CDS) services. The CDS Hooks standard provides such access. To extend an ArdenSuite reference implementation of the Arden Syntax by providing a CDS-Hooks-compatible interface. With the use case Hepaxpert, an Arden-Syntax-based expert system for the interpretation of hepatitis serology test results, a needs analysis was performed to identify changes required in the ArdenSuite reference implementation to support the CDS Hooks API. Arden Syntax language support for CDS Hooks was also assessed. The needs assessment was performed in three phases: hook assessment, hook context definition, and Card definition. For the use case, the ArdenSuite was modified to include a new hook and hook context, which defines the type of CDS service as well its input parameters. Card definitions were created in the ArdenSuite. Examples of Arden Syntax support for the use case are presented for all three phases. Minor changes in the ArdenSuite made it compatible with the CDS Hooks specification.

Implementation of an Open-Source Electronic Health Record for Decision-Support Education in Medical Informatics.

Access to electronic medical record systems is limited in many medical informatics education programs. The objective of this study was to inventory open-source patient record systems with decision support capabilities, implement a system for educational use, and test the effect of the system on students' learning. We sought systems that were under active development, with source code available, having an SQL-queryable database, and having decision support capabilities. We identified 20 candidate electronic health record systems, of which 6 mentioned decision support capabilities in their documentation. Of these, the OpenMRS system appeared to meet all of the requirements for use in our course; however, decision support capabilities needed to be added by use of a custom module implementing Arden2Bytecode, an Arden Syntax interpreter. Students who used this system showed an improvement in their knowledge of decision support systems and their capabilities. We conclude that there are a number of promising open-source electronic patient record systems currently under active development, but decision support capabilities are still immature. We anticipate further developments in this area in the coming years.

Implementation and Analysis of Two Knowledge Base Approaches for the Treatment of Chronic Wounds.

The access to data in healthcare is an enabler for the implementation of clinical decision support systems (CDSS) in practice. The usage of CDSS aims to be of efficient assistance to healthcare providers. The aim of the BMBF project "PosiThera", is to support the involved professions in the treatment process of chronic wounds. In this study we implemented the formalized knowledge of chronic wound diagnosis into two different knowledge base approaches, the HL7 Arden Syntax and a Petri net approach. The motivating factor behind our study was to use both approaches for the implementation of the projects knowledge base and to compare the results. We implemented the formalized knowledge successfully in both approaches. The results of our comparison showed similarities and differences of the Arden Syntax and the Petri net approach, which might support the evolution of both approaches in the future.

Mapping the Entire Record-An Alternative Approach to Data Access from Medical Logic Modules.

This study aimed to describe an alternative approach for accessing electronic medical records (EMRs) from clinical decision support (CDS) functions based on Arden Syntax Medical Logic Modules, which can be paraphrased as "map the entire record." Based on an experimental Arden Syntax processor, we implemented a method to transform patient data from a commercial patient data management system (PDMS) to tree-structured documents termed CDS EMRs. They are encoded in a specific XML format that can be directly transformed to Arden Syntax data types by a mapper natively integrated into the processor. The internal structure of a CDS EMR reflects the tabbed view of an EMR in the graphical user interface of the PDMS. The study resulted in an architecture that provides CDS EMRs in the form of a network service. The approach enables uniform data access from all Medical Logic Modules and requires no mapping parameters except a case number. Measurements within a CDS EMR can be addressed with straightforward path expressions. The approach is in routine use at a German university hospital for more than 2 years. This practical approach facilitates the use of CDS functions in the clinical routine at our local hospital. It is transferrable to standard-compliant Arden Syntax processors with moderate effort. Its comprehensibility can also facilitate teaching and development. Moreover, it may lower the entry barrier for the application of the Arden Syntax standard and could therefore promote its dissemination.

Comprehensive analysis of rule formalisms to represent clinical guidelines: Selection criteria and case study on antibiotic clinical guidelines.

The over-use of antibiotics in clinical domains is causing an alarming increase in bacterial resistance, thus endangering their effectiveness as regards the treatment of highly recurring severe infectious diseases. Whilst Clinical Guidelines (CGs) focus on the correct prescription of antibiotics in a narrative form, Clinical Decision Support Systems (CDSS) operationalize the knowledge contained in CGs in the form of rules at the point of care. Despite the efforts made to computerize CGs, there is still a gap between CGs and the myriad of rule technologies (based on different logic formalisms) that are available to implement CDSSs in real clinical settings. To helpCDSS designers to determine the most suitable rule-based technology (medical-oriented rules, production rules and semantic web rules) with which to model knowledge from CGs for the prescription of antibiotics. We propose a framework of criteria for this purpose that is extensible to more generic CGs. Our proposal is based on the identification of core technical requirements extracted from both literature and the analysis of CGs for antibiotics, establishing three dimensions for analysis: language expressivity, interoperability and industrial aspects. We present a case study regarding the John Hopkins Hospital (JHH) Antibiotic Guidelines for Urinary Tract Infection (UTI), a highly recurring hospital acquired infection. We have adopted our framework of criteria in order to analyse and implement these CGs using various rule technologies: HL7 Arden Syntax, general-purpose Production Rules System (Drools), HL7 standard Rule Interchange Format (RIF), Semantic Web Rule Language (SWRL) and SParql Inference Notation (SPIN) rule extensions (implementing our own ontology for UTI). We have identified the main criteria required to attain a maintainable and cost-affordable computable knowledge representation for CGs. We have represented the JHH UTI CGs knowledge in a total of 12 Arden Syntax MLMs, 81 Drools rules and 154 ontology classes, properties and individuals. Our experiments confirm the relevance of the proposed set of criteria and show the level of compliance of the different rule technologies with the JHH UTI CGs knowledge representation. The proposed framework of criteria may help clinical institutions to select the most suitable rule technology for the representation of CGs in general, and for the antibiotic prescription domain in particular, depicting the main aspects that lead to Computer Interpretable Guidelines (CIGs), such as Logic expressivity (Open/Closed World Assumption, Negation-As-Failure), Temporal Reasoning and Interoperability with existing HIS and clinical workflow. Future work will focus on providing clinicians with suggestions regarding new potential steps for CGs, considering process mining approaches and CGs Process Workflows, the use of HL7 FHIR for HIS interoperability and the representation of Knowledge-as- a-Service (KaaS).

Evaluation of the Fast Healthcare Interoperability Resources (FHIR) Standard for Representation of Knowledge Bases Encoded in the Arden Syntax.

Arden Syntax is a standard that encodes knowledge as Medical Logic Modules (MLMs) but lacks a standard query data model and terminology. Assess to what extent FHIR can represent MLMs. A convenience sample of 340 MLMs were examined and tabulated for representation using the PlanDefinition resource. While alignment between structured subsections is uneven, the PlanDefinition resource adequately represents procedural medical knowledge encoded as MLMs. FHIR adequately represents Arden Syntax MLMs.

A detailed analysis of the Arden Syntax expression grammar

ObjectiveThe Arden Syntax for Medical Logic Systems is a standard for encoding and sharing medical knowledge in the form of Medical Logic Modules. To improve accessibility for clinicians, the originators of the standard deliberately designed Arden Syntax expressions to resemble natural language, and parentheses around operands are not generally required. For certain patterns of nested expressions, however, the use of parentheses is mandatory, otherwise they are not accepted by an Arden Syntax environment. In this study, we refer to such patterns as anomalies. The purpose of this paper is to investigate the extent and the circumstances of such anomalies, and to outline a solution based on an alternative grammar encoding approach. MethodsTo analyze the distribution of anomalies in nested expressions, we developed two custom-made complementary utilities. The first utility, termed parser, checks a single expression pattern against the specification-compliant grammar for syntactic correctness. The second utility, termed composer, automatically creates an extensive amount of expression patterns by permuting and nesting operators without the use of parentheses, and stores these together with the expected syntactic correctness. By means of these utilities we conducted a comprehensive analysis of anomalies by comparing the expected correctness with the actual correctness. Any detected anomalies are stored into a set of files, grouped by the respective top-level operator, for a subsequent analysis. ResultsThe composer utility nested 165 unary, binary, or ternary operators of Arden Syntax version 2.8 to a depth of two, resulting in a set of 76,533 expression patterns, of which 18,978 (24.8%) have been identified as anomalies. An automated assessment of their practical relevance for medical knowledge encoding is infeasible. Manual screening of selected samples indicated that only a small proportion of the detected anomalies would be relevant. The cause of the anomalies lies in the encoding of the grammar. A change of the basic encoding approach with some additional customizations eliminates the anomalies. A working expression parser is included in the supplementary material. ConclusionArden Syntax expressions are affected by anomalies. Since only a small proportion of them have practical relevance and they cannot cause false calculations or clinical decisions, their practical impact is likely limited. However, they may be potential points of confusion for knowledge engineers. An alternative expression grammar, based on a different encoding approach, would not only eliminate the anomalies, but could considerably facilitate both maintenance and further development of the standard.

A Comparison of Business Rule Management Systems and Standards for the Implementation of Clinical Decision Support Systems Using Data from Structured CDA Documents

Background: Recently, the Austrian Patient Summary (APS) and Austrian Microbiology Report (AMR) document definitions were added to the Austrian national electronic health record repository. How to employ these standardized, structured patient data in clinical decision support (CDS) systems remains an interesting research subject. Objectives: To create a proof of concept for the emergency use of APS and AMR documents in a variety of CDS platforms and standards in an intensive care setting, in order to generate new insights by linking individual documents to different CDS approaches. Methods: APS and AMR definitions were stored using MongoDB, a document-oriented database system. For implementation of the clinical use case CDS, we selected the Drools business rule management system, as well as the ArdenSuite software for implementing the HL7 Arden Syntax for Medical Logic Systems standard. Results: Due to its manifold features, implementation of the CDS use case in Drools could be done quite efficiently without the need for additional coding of technical or algorithmic code, which results in smaller rules. In contrast, the use case implementations in Arden Syntax using the ArdenSuite required additional technical coding, distracting from the medical knowledge implementation. The Arden Syntax as a knowledge definition standard is, however, better understandable due to its resemblance to natural language compared to the Java-like definition language used in Drools. Conclusion: With the nation-wide availability of structured documents, the foundation for the implementation of clinical decision support systems has been laid. Commonly used open-source platforms offer extensive possibilities for the implementation of CDS systems. This evaluation of modern business rule management systems will advance the implementation of powerful clinical decision support solutions valuable to all stakeholders.

Multi-model-based interactive authoring environment for creating shareable medical knowledge

ObjectiveTechnologically integrated healthcare environments can be realized if physicians are encouraged to use smart systems for the creation and sharing of knowledge used in clinical decision support systems (CDSS). While CDSSs are heading toward smart environments, they lack support for abstraction of technology-oriented knowledge from physicians. Therefore, abstraction in the form of a user-friendly and flexible authoring environment is required in order for physicians to create shareable and interoperable knowledge for CDSS workflows. Our proposed system provides a user-friendly authoring environment to create Arden Syntax MLM (Medical Logic Module) as shareable knowledge rules for intelligent decision-making by CDSS. Methods and materialsExisting systems are not physician friendly and lack interoperability and shareability of knowledge. In this paper, we proposed Intelligent-Knowledge Authoring Tool (I-KAT), a knowledge authoring environment that overcomes the above mentioned limitations. Shareability is achieved by creating a knowledge base from MLMs using Arden Syntax. Interoperability is enhanced using standard data models and terminologies. However, creation of shareable and interoperable knowledge using Arden Syntax without abstraction increases complexity, which ultimately makes it difficult for physicians to use the authoring environment. Therefore, physician friendliness is provided by abstraction at the application layer to reduce complexity. This abstraction is regulated by mappings created between legacy system concepts, which are modeled as domain clinical model (DCM) and decision support standards such as virtual medical record (vMR) and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT). We represent these mappings with a semantic reconciliation model (SRM). ResultsThe objective of the study is the creation of shareable and interoperable knowledge using a user-friendly and flexible I-KAT. Therefore we evaluated our system using completeness and user satisfaction criteria, which we assessed through the system- and user-centric evaluation processes. For system-centric evaluation, we compared the implementation of clinical information modelling system requirements in our proposed system and in existing systems. The results suggested that 82.05% of the requirements were fully supported, 7.69% were partially supported, and 10.25% were not supported by our system. In the existing systems, 35.89% of requirements were fully supported, 28.20% were partially supported, and 35.89% were not supported. For user-centric evaluation, the assessment criterion was ‘ease of use’. Our proposed system showed 15 times better results with respect to MLM creation time than the existing systems. Moreover, on average, the participants made only one error in MLM creation using our proposed system, but 13 errors per MLM using the existing systems. ConclusionWe provide a user-friendly authoring environment for creation of shareable and interoperable knowledge for CDSS to overcome knowledge acquisition complexity. The authoring environment uses state-of-the-art decision support-related clinical standards with increased ease of use.

Executable medical guidelines with Arden Syntax-Applications in dermatology and obstetrics.

Clinical decision support systems (CDSSs) are being developed to assist physicians in processing extensive data and new knowledge based on recent scientific advances. Structured medical knowledge in the form of clinical alerts or reminder rules, decision trees or tables, clinical protocols or practice guidelines, score algorithms, and others, constitute the core of CDSSs. Several medical knowledge representation and guideline languages have been developed for the formal computerized definition of such knowledge. One of these languages is Arden Syntax for Medical Logic Systems, an International Health Level Seven (HL7) standard whose development started in 1989. Its latest version is 2.10, which was presented in 2014. In the present report we discuss Arden Syntax as a modern medical knowledge representation and processing language, and show that this language is not only well suited to define clinical alerts, reminders, and recommendations, but can also be used to implement and process computerized medical practice guidelines. This section describes how contemporary software such as Java, server software, web-services, XML, is used to implement CDSSs based on Arden Syntax. Special emphasis is given to clinical decision support (CDS) that employs practice guidelines as its clinical knowledge base. Two guideline-based applications using Arden Syntax for medical knowledge representation and processing were developed. The first is a software platform for implementing practice guidelines from dermatology. This application employs fuzzy set theory and logic to represent linguistic and propositional uncertainty in medical data, knowledge, and conclusions. The second application implements a reminder system based on clinically published standard operating procedures in obstetrics to prevent deviations from state-of-the-art care. A to-do list with necessary actions specifically tailored to the gestational week/labor/delivery is generated. Today, with the latest versions of Arden Syntax and the application of contemporary software development methods, Arden Syntax has become a powerful and versatile medical knowledge representation and processing language, well suited to implement a large range of CDSSs, including clinical-practice-guideline-based CDSSs. Moreover, such CDS is provided and can be shared as a service by different medical institutions, redefining the sharing of medical knowledge. Arden Syntax is also highly flexible and provides developers the freedom to use up-to-date software design and programming patterns for external patient data access.

Evolution of the Arden Syntax: Key Technical Issues from the Standards Development Organization Perspective.

The initial version of the Arden Syntax for Medical Logic Systems was created to facilitate explicit representation of medical logic in a form that could be easily composed and interpreted by clinical experts in order to facilitate clinical decision support (CDS). Because of demand from knowledge engineers and programmers to improve functionality related to complex use cases, the Arden Syntax evolved to include features typical of general programming languages but that were specialized to meet the needs of the clinical decision support environment, including integration into a clinical information system architecture. Review of the design history and evolution of the Arden Syntax by workers who participated in this evolution from the perspective of the standards development organization (SDO). In order to meet user needs, a variety of features were successively incorporated in Arden Syntax. These can be grouped in several classes of change, including control flow, data structures, operators and external links. These changes included expansion of operators to manipulate lists and strings; a formalism for structured output; iteration constructs; user-defined objects and operators to manipulate them; features to support international use and output in different natural languages; additional control features; fuzzy logic formalisms; and mapping of the entire syntax to XML. The history and rationale of this evolution are summarized. In response to user demand and to reflect its growing role in clinical decision support, the Arden Syntax has evolved to include a number of powerful features. These depart somewhat from the original vision of the syntax as simple and easily understandable but from the SDO perspective increase the utility of this standard for implementation of CDS. Backwards compatibility has been maintained, allowing continued support of the earlier, simpler decision support models.

Computerized Clinical Decision Support: Contributions from 2015.

To summarize recent research and select the best papers published in 2015 in the field of computerized clinical decision support for the Decision Support section of the IMIA yearbook. A literature review was performed by searching two bibliographic databases for papers related to clinical decision support systems (CDSSs) and computerized provider order entry (CPOE) systems. The aim was to identify a list of candidate best papers from the retrieved papers that were then peer-reviewed by external reviewers. A consensus meeting between the two section editors and the IMIA editorial team was finally conducted to conclude in the best paper selection. Among the 974 retrieved papers, the entire review process resulted in the selection of four best papers. One paper reports on a CDSS routinely applied in pediatrics for more than 10 years, relying on adaptations of the Arden Syntax. Another paper assessed the acceptability and feasibility of an important CPOE evaluation tool in hospitals outside the US where it was developed. The third paper is a systematic, qualitative review, concerning usability flaws of medication-related alerting functions, providing an important evidence-based, methodological contribution in the domain of CDSS design and development in general. Lastly, the fourth paper describes a study quantifying the effect of a complex, continuous-care, guideline-based CDSS on the correctness and completeness of clinicians' decisions. While there are notable examples of routinely used decision support systems, this 2015 review on CDSSs and CPOE systems still shows that, despite methodological contributions, theoretical frameworks, and prototype developments, these technologies are not yet widely spread (at least with their full functionalities) in routine clinical practice. Further research, testing, evaluation, and training are still needed for these tools to be adopted in clinical practice and, ultimately, illustrate the benefits that they promise.