Medical Knowledge Representation Research Articles

Mapping Chinese Medical Entities to the Unified Medical Language System.

Chinese medical entities have not been organized comprehensively due to the lack of well-developed terminology systems, which poses a challenge to processing Chinese medical texts for fine-grained medical knowledge representation. To unify Chinese medical terminologies, mapping Chinese medical entities to their English counterparts in the Unified Medical Language System (UMLS) is an efficient solution. However, their mappings have not been investigated sufficiently in former research. In this study, we explore strategies for mapping Chinese medical entities to the UMLS and systematically evaluate the mapping performance. First, Chinese medical entities are translated to English using multiple web-based translation engines. Then, 3 mapping strategies are investigated: (a) string-based, (b) semantic-based, and (c) string and semantic similarity combined. In addition, cross-lingual pretrained language models are applied to map Chinese medical entities to UMLS concepts without translation. All of these strategies are evaluated on the ICD10-CN, Chinese Human Phenotype Ontology (CHPO), and RealWorld datasets. The linear combination method based on the SapBERT and term frequency-inverse document frequency bag-of-words models perform the best on all evaluation datasets, with 91.85%, 82.44%, and 78.43% of the top 5 accuracies on the ICD10-CN, CHPO, and RealWorld datasets, respectively. In our study, we explore strategies for mapping Chinese medical entities to the UMLS and identify a satisfactory linear combination method. Our investigation will facilitate Chinese medical entity normalization and inspire research that focuses on Chinese medical ontology development.

Clinical decision support system for hypertension medication based on knowledge graph

BackgroundHigh prevalence of hypertension and complicated medication knowledge have presented challenges to hypertension clinicians and general practitioners. Clinical decision support systems (CDSSs) are developed to aid clinicians in decision making. Current clinical knowledge is stored in fixed templates, which are not intuitive for clinicians and limit the knowledge reusability. Knowledge graphs (KGs) store knowledge in a way that is not only intuitive to humans but also processable by computers directly. However, existing medical KGs such as UMLS and CMeKG are general purpose and thus lack enough knowledge to enable hypertension medication. MethodsWe first construct a KG specific to hypertension medication according to the Chinese hypertension guideline and then develop the corresponding CDSS to implement hypertension medication and knowledge management. Current advances in knowledge graph representation and modelling are researched and applied in the complex medical knowledge representation. Traditional knowledge representation and KG representation are innovatively combined in the storage of the KG to enable convenient knowledge management and easy application by the CDSS. Along a predefined reasoning path in the KG, the CDSS finally accomplishes the hypertension medication by applying knowledge stored in the KG. 124 health records of a hypertension Chief Physician from Beijing Anzhen Hospital, Capital Medical University, are collected to evaluate the system metrics on the single drug recommendation task. Results and conclusionThe proposed CDSS has functions of medication knowledge graph management and hypertension medication decision support. With elaborate design on knowledge representation, knowledge management is intuitive and convenient. By virtue of the KG, medication recommendations are highly visualized and explainable. Experiments on 124 health records with 90% guideline compliance collected from hospitals in single class recommendation task achieve 91%, 83% and 77% on recall, hit@3 and MRR metrics respectively, which demonstrates the quality of the KG and effectiveness of the system.

An Ontology Model for Medical Tourism Supply Chain Knowledge Representation

An Ontology Model for Medical Tourism Supply Chain Knowledge Representation

PercolationDF: A percolation-based medical diagnosis framework.

Goal: With the continuing shortage and unequal distribution of medical resources, our objective is to develop a general diagnosis framework that utilizes a smaller amount of electronic medical records (EMRs) to alleviate the problem that the data volume requirement of prevailing models is too vast for medical institutions to afford. Methods: The framework proposed contains network construction, network expansion, and disease diagnosis methods. In the first two stages above, the knowledge extracted from EMRs is utilized to build and expense an EMR-based medical knowledge network (EMKN) to model and represent the medical knowledge. Then, percolation theory is modified to diagnose EMKN. Result: Facing the lack of data, our framework outperforms naïve Bayes networks, neural networks and logistic regression, especially in the top-10 recall. Out of 207 test cases, 51.7% achieved 100% in the top-10 recall, 21% better than what was achieved in one of our previous studies. Conclusion: The experimental results show that the proposed framework may be useful for medical knowledge representation and diagnosis. The framework effectively alleviates the lack of data volume by inferring the knowledge modeled in EMKN. Significance: The proposed framework not only has applications for diagnosis but also may be extended to other domains to represent and model the knowledge and inference on the representation.

Enhancing reasoning through reduction of vagueness using fuzzy OWL-2 for representation of breast cancer ontologies.

The need to address the challenge of vagueness across several domains of applicability of ontology is gaining research attention. The presence of vagueness in knowledge represented with description logic impairs automating reasoning and inference making. The importance of reducing this vagueness in the formalization of medical knowledge representation is rising, considering the vulnerability of this domain to the expression of vague concepts or terms. This vagueness may be addressed from the perspective of ontology modeling language application such as ontology web language (OWL). Although several attempts have been made to tackle this problem in other disease prognoses such as diabetes and cardiovascular diseases, a similar effort is missing for breast cancer. Minimizing vagueness in breast cancer ontology is necessary to enhance automated reasoning and handle knowledge representation problems. This study proposes a framework for reducing vagueness in breast cancer ontology. The approach obtained breast cancer crisp ontology and applied fuzzy ontology elements based on the Fuzzy OWL2 model to formulate breast cancer fuzzy ontology. This was achieved by extending the elements of OWL2 (a more expressive version of OWL) with annotation properties to fuzzify the breast cancer crisp ontology. Results obtained showed a significant reduction of vagueness in the domain, yielding 0.38 for vagueness spread and 1.0 for vagueness explicitness. In addition, ontology metrics such as completeness, consistency, correctness and accuracy were also evaluated, and we obtained impressive performance. The implication of this result is the reduction of vagueness in breast cancer ontology, which provides increased computational reasoning support to applications using the ontology.

Unknown Disease Outbreaks Detection: A Pilot Study on Feature-Based Knowledge Representation and Reasoning Model.

Background: The outbreak of COVID-19 in 2019 has rapidly swept the world, causing irreparable loss to human beings. The pandemic has shown that there is still a delay in the early response to disease outbreaks and needs a method for unknown disease outbreak detection. The study's objective is to establish a new medical knowledge representation and reasoning model, and use the model to explore the feasibility of unknown disease outbreak detection.Methods: The study defined abnormal values with diagnostic significances from clinical data as the Features, and defined the Features as the antecedents of inference rules to match with knowledge bases, achieved in detecting known or emerging infectious disease outbreaks. Meanwhile, the study built a syndromic surveillance base to capture the target cases' Features to improve the reliability and fault-tolerant ability of the system.Results: The study combined the method with Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and early COVID-19 outbreaks as empirical studies. The results showed that with suitable surveillance guidelines, the method proposed in this study was capable to detect outbreaks of SARS, MERS, and early COVID-19 pandemics. The quick matching accuracies of confirmed infection cases were 89.1, 26.3–98%, and 82%, and the syndromic surveillance base would capture the Features of the remaining cases to ensure the overall detection accuracies. Based on the early COVID-19 data in Wuhan, this study estimated that the median time of the early COVID-19 cases from illness onset to local authorities' responses could be reduced to 7.0–10.0 days.Conclusions: This study offers a new solution to transfer traditional medical knowledge into structured data and form diagnosis rules, enables the representation of doctors' logistic thinking and the knowledge transmission among different users. The results of empirical studies demonstrate that by constantly inputting medical knowledge into the system, the proposed method will be capable to detect unknown diseases from existing ones and perform an early response to the initial outbreaks.

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.

Rough set based lattice structure for knowledge representation in medical expert systems: Low back pain management case study

The aim of medical knowledge representation is to capture detailed domain knowledge in a clinically efficient manner, and to offer reliable resolution with the acquired knowledge. The knowledge base should allow incremental growth with inclusion of updated knowledge over the time. Accommodating the knowledge acquired from a variety of knowledge sources by different knowledge engineers may lead to a redundant and inconsistent design of the knowledge base, increasing the storage size and the time for knowledge retrieval. In this paper, we have proposed a rough set based lattice framework for representation of knowledge in medical expert systems which overcomes the problem of redundancy and inconsistency in knowledge and offers computational efficiency with respect to both time and space. The proposed knowledge representation offers a flexible scheme for expressing diverse possibilities of inter-relatedness among the symptoms and diseases in a systematic manner within the lattice structures.Through our design, we generate an optimal set of decision rules for use during inference. Reliability of each rule is measured using a new metric called credibility factor, and the certainty and coverage factors of a decision rule have been re-defined. During inference, the medical expert system considers the highly reliable and certain rules first, and the possible and uncertain rules at the later stages, if recommended by physicians. The proposed scheme ensures completeness, consistency, integrity, non-redundancy, and ease of access. These qualities are automatically preserved in the designed knowledge base while being updated with the new knowledge of medical advancements. As a result, the overall maintenance cost of a medical expert system is significantly reduced. The proposed knowledge representation technique has been illustrated using an example from the domain of low back pain.Though the proposed technique has been demonstrated for low back pain, it offers a generalized scheme for knowledge representation and may be adopted by medical expert systems (e.g. pathology, psychology, and many other specialties) having complexity similar to this one; no application-specific knowledge representation technique needs to be designed. The medical expert system developed using this scheme may act as a standardized example for development of different unexplored or semi-explored health care automated systems. This scheme may also be applied for pattern recognition, rule mining, and conflict analysis in complex medical data domains. Our design will have a wide ranging impact towards finding low-cost, reliable and available healthcare solutions for different diseases, especially in primary care units where expert physicians are scarce.

Separating Procedures and Criteria in Computerized Clinical Guidelines - A 3-Layer Approach.

Computerized guidelines have been utilized for several decades by now. Systems based on computerized-guidelines often intertwine (1) medical knowledge representation, (2) guideline procedures and (3) hospital workflows. This induces several drawbacks. Most prominent problems include non-shareability of the computerized guideline between hospitals, limited accessibility of the computerized guideline for humans, and an unclear, often confusing combination of hospital-specific workflow and guideline-induced control flows. This article proposes a 3-layer modelling approach strictly distinguishing the aforementioned three aspects to overcome the respective problems. We applied the 3-layer approach to the implementation of a guideline-interpreting software module in the context of the Medical Informatics Initiative Germany (here: SMITH Project) and comment on the resulting implications for the software design of that module.

Ten years of knowledge representation for health care (2009-2018): Topics, trends, and challenges.

In the last ten years, the international workshop on knowledge representation for health care (KR4HC) has hosted outstanding contributions of the artificial intelligence in medicine community pertaining to the formalization and representation of medical knowledge for supporting clinical care. Contributions regarding modeling languages, technologies and methodologies to produce these models, their incorporation into medical decision support systems, and practical applications in concrete medical settings have been the main contributions and the basis to define the evolution of this field across Europe and worldwide. Carry out a review of the papers accepted in KR4HC in the 2009-2018 decade, analyze and characterize the topics and trends within this field, and identify challenges for the evolution of the area in the near future. We reviewed the title, the abstract, and the keywords of the 112 papers that were accepted to the workshop, identified the medical and technological topics involved in these works, provided a classification of these papers in medical and technological perspectives and obtained the timeline of these topics in order to determine interest growths and declines. The experience of the authors in the field and the evidences after the review were the basis to propose a list of challenges of knowledge representation in health care for the future. The most generic knowledge representation methods are ontologies (31%), semantic web related formalisms (26%), decision tables and rules (19%), logic (14%), and probabilistic models (10%). From a medical informatics perspective, knowledge is mainly represented as computer interpretable clinical guidelines (43%), medical domain ontologies (26%), and electronic health care records (22%). Within the knowledge lifecycle, contributions are found in knowledge generation (38%), knowledge specification (24%), exception detection and management (12%), knowledge enactment (8%), temporal knowledge and reasoning (7%), and knowledge sharing and maintenance (7%). The clinical emphasis of knowledge is mainly related to clinical treatments (27%), diagnosis (13%), clinical quality indicators (13%), and guideline integration for multimorbid patients (12%). According to the level of development of the works presented, we distinguished four maturity levels: formal (22%), implementation (52%), testing (13%), and deployment (2%) levels. Some papers described technologies for specific clinical issues or diseases, mainly cancer (22%) and diseases of the circulatory system (20%). Chronicity and comorbidity were present in 10% and 8% of the papers, respectively. KR4HC is a stable community, still active after ten years. A persistent focus has been knowledge representation, with an emphasis on semantic-web ontologies and on clinical-guideline based decision-support. Among others, two topics receive growing attention: integration of computer-interpretable guideline knowledge for the management of multimorbidity patients, and patient empowerment and patient-centric care.

Formal Medical Knowledge Representation Supports Deep Learning Algorithms, Bioinformatics Pipelines, Genomics Data Analysis, and Big Data Processes.

Summary Objective : To select, present, and summarize the best papers published in 2018 in the field of Knowledge Representation and Management (KRM). Methods : A comprehensive and standardized review of the medical informatics literature was performed to select the most interesting papers published in 2018 in KRM, based on PubMed and ISI Web Of Knowledge queries. Results : Four best papers were selected among the 962 publications retrieved following the Yearbook review process. The research areas in 2018 were mainly related to the ontology-based data integration for phenotype-genotype association mining, the design of ontologies and their application, and the semantic annotation of clinical texts. Conclusion : In the KRM selection for 2018, research on semantic representations demonstrated their added value for enhanced deep learning approaches in text mining and for designing novel bioinformatics pipelines based on graph databases. In addition, the ontology structure can enrich the analyses of whole genome expression data. Finally, semantic representations demonstrated promising results to process phenotypic big data.

Visual metaphors in medical knowledge representation

Understanding the role of mental images and embodiment in metaphorical thought is fundamental to the study of metaphor in science in general, and in medicine in particular. And analysing typologies of metaphorical images and their function is a key issue in assessing their success in disseminating knowledge, since knowledge construction depends on the interaction between verbal and visual information (Ketola, 2016). In this article, we describe the premises and methodological steps followed in analysing and describing visual metaphorical information in medical texts for lay audiences. We follow a data-driven approach in which images were extracted from the VariMed database, a multimodal terminographical tool for translation, linguistic research and knowledge dissemination. An experiment was carried out to explore how successfully metaphorical images used as illustrations for specific medical concepts were identified and understood. We conclude that metaphorical images were preferred over non-metaphorical illustrations for medical concepts, which may point to lay audiences’ familiarity with metaphorical multimodal references.

Анатомические вотивы античного Средиземноморья: культурно-исторический феномен представления биологического и медицинского знания (по литературным данным)

Анатомические вотивы античного Средиземноморья: культурно-исторический феномен представления биологического и медицинского знания (по литературным данным)

Using Compact Coevolutionary Algorithm for Matching Biomedical Ontologies.

Over the recent years, ontologies are widely used in various domains such as medical records annotation, medical knowledge representation and sharing, clinical guideline management, and medical decision-making. To implement the cooperation between intelligent applications based on biomedical ontologies, it is crucial to establish correspondences between the heterogeneous biomedical concepts in different ontologies, which is so-called biomedical ontology matching. Although Evolutionary algorithms (EAs) are one of the state-of-the-art methodologies to match the heterogeneous ontologies, huge memory consumption, long runtime, and the bias improvement of the solutions hamper them from efficiently matching biomedical ontologies. To overcome these shortcomings, we propose a compact CoEvolutionary Algorithm to efficiently match the biomedical ontologies. Particularly, a compact EA with local search strategy is able to save the memory consumption and runtime, and three subswarms with different optimal objectives can help one another to avoid the solution's bias improvement. In the experiment, two famous testing cases provided by Ontology Alignment Evaluation Initiative (OAEI 2017), i.e. anatomy track and large biomed track, are utilized to test our approach's performance. The experimental results show the effectiveness of our proposal.

Using data-driven sublanguage pattern mining to induce knowledge models: application in medical image reports knowledge representation

BackgroundThe use of knowledge models facilitates information retrieval, knowledge base development, and therefore supports new knowledge discovery that ultimately enables decision support applications. Most existing works have employed machine learning techniques to construct a knowledge base. However, they often suffer from low precision in extracting entity and relationships. In this paper, we described a data-driven sublanguage pattern mining method that can be used to create a knowledge model. We combined natural language processing (NLP) and semantic network analysis in our model generation pipeline.MethodsAs a use case of our pipeline, we utilized data from an open source imaging case repository, Radiopaedia.org, to generate a knowledge model that represents the contents of medical imaging reports. We extracted entities and relationships using the Stanford part-of-speech parser and the “Subject:Relationship:Object” syntactic data schema. The identified noun phrases were tagged with the Unified Medical Language System (UMLS) semantic types. An evaluation was done on a dataset comprised of 83 image notes from four data sources.ResultsA semantic type network was built based on the co-occurrence of 135 UMLS semantic types in 23,410 medical image reports. By regrouping the semantic types and generalizing the semantic network, we created a knowledge model that contains 14 semantic categories. Our knowledge model was able to cover 98% of the content in the evaluation corpus and revealed 97% of the relationships. Machine annotation achieved a precision of 87%, recall of 79%, and F-score of 82%.ConclusionThe results indicated that our pipeline was able to produce a comprehensive content-based knowledge model that could represent context from various sources in the same domain.

EMR-based medical knowledge representation and inference via Markov random fields and distributed representation learning.

Electronic medical records (EMRs) contain medical knowledge that can be used for clinical decision support (CDS). Our objective is to develop a general system that can extract and represent knowledge contained in EMRs to support three CDS tasks-test recommendation, initial diagnosis, and treatment plan recommendation-given the condition of a patient. We extracted four kinds of medical entities from records and constructed an EMR-based medical knowledge network (EMKN), in which nodes are entities and edges reflect their co-occurrence in a record. Three bipartite subgraphs (bigraphs) were extracted from the EMKN, one to support each task. One part of the bigraph was the given condition (e.g., symptoms), and the other was the condition to be inferred (e.g., diseases). Each bigraph was regarded as a Markov random field (MRF) to support the inference. We proposed three graph-based energy functions and three likelihood-based energy functions. Two of these functions are based on knowledge representation learning and can provide distributed representations of medical entities. Two EMR datasets and three metrics were utilized to evaluate the performance. As a whole, the evaluation results indicate that the proposed system outperformed the baseline methods. The distributed representation of medical entities does reflect similarity relationships with respect to knowledge level. Combining EMKN and MRF is an effective approach for general medical knowledge representation and inference. Different tasks, however, require individually designed energy functions.

Metaphoric nomination for the representation of medical knowledge

The aim of the research is to reflect the metaphoric nomination as a way of representation of medical knowledge, to identify semantic groups of terms formed by means of secondary nomination with the help of metaphoric transfers, sources of metaphorization, to reveal internal connections between the primary meaning and the scientific concept formed on its basis in clinical terminology in infectious diseases. Methods of investigation: a method of observation, a de-scriptive method for the systematization of terminological units, the method of analysis for the evaluation of each complex term in the semantic and cognitive aspects, as well as for the generalization of linguistic facts were applied in the research. To clarify the semantic structure of lexical units, the methods of component analysis were used, and for the isolation the linguis-tic phenomenon into separate groups, the method of systematization based on differentiated characteristics was used. The scientific novelty of the research is that it is the first experience in description and systematization of the medical terms of the subsystem of infectious diseases formed by metaphorization. Conclusions. It is argued that when creating a secondary nomination by metaphorization method, the dominant motivational characteristic is selected from the original meaning – the similarity of generally unequal objects or phenomena according to their char-acteristic properties, attributes or relations that perform the function of internal semantic motivation. New metaphorical denominations are based on thinking proc-esses and mental representations of a man about the world; create new specific metaphorical concepts through which the language structures reflect the new cognitive frameworks of knowledge, concepts, related to the sphere of human activities associated with medicine. Metaphorical terminological nominations are subjectively meaningful, processed and reinforced by the experience ofprevious generations medical knowledge.

A review of medical terminology standards and structured reporting

Much effort has been invested in standardizing medical terminology for representation of medical knowledge, storage in electronic medical records, retrieval, reuse for evidence-based decision making, and for efficient messaging between users. We only focus on those efforts related to the representation of clinical medical knowledge required for capturing diagnoses and findings from a wide range of general to specialty clinical perspectives (e.g., internists to pathologists). Standardized medical terminology and the usage of structured reporting have been shown to improve the usage of medical information in secondary activities, such as research, public health, and case studies. The impact of standardization and structured reporting is not limited to secondary activities; standardization has been shown to have a direct impact on patient healthcare.

Assessment of a personalized and distributed patient guidance system

ObjectivesThe MobiGuide project aimed to establish a ubiquitous, user-friendly, patient-centered mobile decision-support system for patients and for their care providers, based on the continuous application of clinical guidelines and on semantically integrated electronic health records. Patients would be empowered by the system, which would enable them to lead their normal daily lives in their regular environment, while feeling safe, because their health state would be continuously monitored using mobile sensors and self-reporting of symptoms. When conditions occur that require medical attention, patients would be notified as to what they need to do, based on evidence-based guidelines, while their medical team would be informed appropriately, in parallel. We wanted to assess the system’s feasibility and potential effects on patients and care providers in two different clinical domains. Materials and methodsWe describe MobiGuide’s architecture, which embodies these objectives. Our novel methodologies include a ubiquitous architecture, encompassing a knowledge elicitation process for parallel coordinated workflows for patients and care providers; the customization of computer-interpretable guidelines (CIGs) by secondary contexts affecting remote management and distributed decision-making; a mechanism for episodic, on demand projection of the relevant portions of CIGs from a centralized, backend decision-support system (DSS), to a local, mobile DSS, which continuously delivers the actual recommendations to the patient; shared decision-making that embodies patient preferences; semantic data integration; and patient and care provider notification services.MobiGuide has been implemented and assessed in a preliminary fashion in two domains: atrial fibrillation (AF), and gestational diabetes Mellitus (GDM). Ten AF patients used the AF MobiGuide system in Italy and 19 GDM patients used the GDM MobiGuide system in Spain. The evaluation of the MobiGuide system focused on patient and care providers’ compliance to CIG recommendations and their satisfaction and quality of life. ResultsOur evaluation has demonstrated the system’s capability for supporting distributed decision-making and its use by patients and clinicians. The results show that compliance of GDM patients to the most important monitoring targets – blood glucose levels (performance of four measurements a day: 0.87±0.11; measurement according to the recommended frequency of every day or twice a week: 0.99±0.03), ketonuria (0.98±0.03), and blood pressure (0.82±0.24) – was high in most GDM patients, while compliance of AF patients to the most important targets was quite high, considering the required ECG measurements (0.65±0.28) and blood-pressure measurements (0.75±1.33). This outcome was viewed by the clinicians as a major potential benefit of the system, and the patients have demonstrated that they are capable of self-monitoring – something that they had not experienced before. In addition, the system caused the clinicians managing the AF patients to change their diagnosis and subsequent treatment for two of the ten AF patients, and caused the clinicians managing the GDM patients to start insulin therapy earlier in two of the 19 patients, based on system’s recommendations. Based on the end-of-study questionnaires, the sense of safety that the system has provided to the patients was its greatest asset. Analysis of the patients’ quality of life (QoL) questionnaires for the AF patients was inconclusive, because while most patients reported an improvement in their quality of life in the EuroQoL questionnaire, most AF patients reported a deterioration in the AFEQT questionnaire. DiscussionFeasibility and some of the potential benefits of an evidence-based distributed patient-guidance system were demonstrated in both clinical domains. The potential application of MobiGuide to other medical domains is supported by its standards-based patient health record with multiple electronic medical record linking capabilities, generic data insertion methods, generic medical knowledge representation and application methods, and the ability to communicate with a wide range of sensors. Future larger scale evaluations can assess the impact of such a system on clinical outcomes. ConclusionMobiGuide’s feasibility was demonstrated by a working prototype for the AF and GDM domains, which is usable by patients and clinicians, achieving high compliance to self-measurement recommendations, while enhancing the satisfaction of patients and care providers.

Comprehensive mitigation framework for concurrent application of multiple clinical practice guidelines

In this work we propose a comprehensive framework based on first-order logic (FOL) for mitigating (identifying and addressing) interactions between multiple clinical practice guidelines (CPGs) applied to a multi-morbid patient while also considering patient preferences related to the prescribed treatment. With this framework we respond to two fundamental challenges associated with clinical decision support: (1) concurrent application of multiple CPGs and (2) incorporation of patient preferences into the decision making process.We significantly expand our earlier research by (1) proposing a revised and improved mitigation-oriented representation of CPGs and secondary medical knowledge for addressing adverse interactions and incorporating patient preferences and (2) introducing a new mitigation algorithm. Specifically, actionable graphs representing CPGs allow for parallel and temporal activities (decisions and actions). Revision operators representing secondary medical knowledge support temporal interactions and complex revisions across multiple actionable graphs. The mitigation algorithm uses the actionable graphs, revision operators and available (and possibly incomplete) patient information represented in FOL. It relies on a depth-first search strategy to find a valid sequence of revisions and uses theorem proving and model finding techniques to identify applicable revision operators and to establish a management scenario for a given patient if one exists. The management scenario defines a safe (interaction-free) and preferred set of activities together with possible patient states. We illustrate the use of our framework with a clinical case study describing two patients who suffer from chronic kidney disease, hypertension, and atrial fibrillation, and who are managed according to CPGs for these diseases.While in this paper we are primarily concerned with the methodological aspects of mitigation, we also briefly discuss a high-level proof of concept implementation of the proposed framework in the form of a clinical decision support system (CDSS). The proposed mitigation CDSS “insulates” clinicians from the complexities of the FOL representations and provides semantically meaningful summaries of mitigation results. Ultimately we plan to implement the mitigation CDSS within our MET (Mobile Emergency Triage) decision support environment.