Knowledge Engineering in Health Informatics PDF
Preview Knowledge Engineering in Health Informatics
Computers and Medicine Helmuth F. Orthner, Series Editor Springer-Science+Business Media, LLC Computers and Medicine Use and Impact of Computers in Clinical Medicine James G. Anderson and Stephen J. Jay (Editors) Information Systems for Patient Care Bruce I. Blum (Editor) A Clinical Information System for Oncology John P. Enterline, Raymond E. Lenhard, Jr., and Bruce I. Blum (Editors) The PACE System: An Expert Consulting System for Nurses Steven Evans Evaluation Methods in Medical Informatics Charles P. Friedman and Jeremy C. Wyatt (Editors) HELP: A Dynamic Hospital Information System Gilad J. Kuperman, Reed M. Gardner, and T. Allan Pryor Expert Critiquing Systems Perry L. Miller Selected Topics in Medical Artificial Intelligence Perry L. Miller (Editor) Implementing Health Care Information Systems Helmuth F. Orthner and Bruce I. Blum (Editors) Computer-Assisted Medical Decision Making, Volume 1 James A. Reggia and Stanley Tuhrim (Editors) Computer-Assisted Medical Decision Making, Volume 2 James A. Reggia and Stanley Tuhrim (Editors) Nursing and Computers: An Anthology Virginia K. Saba, Karen A. Rieder, and Dorothy B. Pocklington (Editors) Knowledge Engineering in Health Informatics Homer R. Warner, Dean K. Sorenson, and Omar Bouhaddou Homer R. Warner Dean K. Sorenson Omar Bouhaddou Knowledge Engineering in Health Informatics Springer Homer R. Warner, M.D., Ph.D. Dean K. Sorenson, Ph.D. Former Chairman and Professor Assistant Research Professor Emeritus Department of Medical Informatics Department of Medical Informatics University of Utah School of Medicine University of Utah School of Salt Lake City, UT 84132, USA Medicine Salt Lake City, UT 84132, USA Omar Bouhaddou, Ph.D. Chief Knowledge Engineer Mosby Consumer Health Salt Lake City, UT 84109, USA Series Editor Helmuth F. Orthner, Ph.D. Professor of Medical Informatics University of Utah Health Sciences Center Salt Lake City, UT 84132, USA Library of Congress Cataloging-in-Publication Data Warner, Homer R., 1922- Knowledge engineering in health informatics 1 by Homer R. Warner, Dean K. Sorenson, Omar Bouhaddou. p. cm.-(Computers and medicine) Includes bibliographical references and index. Additional material to this book can be downloaded from http://extras.springer.com. ISBN 978-1-4612-7299-1 ISBN 978-1-4612-1822-7 (eBook) DOI 10.1007/978-1-4612-1822-7 1. Medicine-Decision making-Data processing. 2. Expert systems (Computer science) 3. Knowledge acquisition (Expert systems) 4. Medical informatics. 5. Diagnosis-Data processing. 1. Sorenson, Dean K., 1947- . II. Bouhaddou, Omar. III. Title. IV. Series: Computers and medicine (New York, N.Y.) R859.7.D52W37 1997 610'.285'633-dc20 96-44233 Printed on acid-free paper. © 1997 Springer Science+ Business MediaN ew York Originally published by Springer-Verlag New York in 1997 Softcover reprint of the hardcover 1st edition 1997 Ali rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Science+Business Media, LLC), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereatter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production managed by Victoria Evarretta; manufacturing supervised by Jeffrey Taub. Typeset by Best-set Typesetter Ltd., Hong Kong. 9 8 7 6 5 4 3 2 1 ISBN 978-1-4612-7299-1 SPIN 10552855 Series Preface This monograph series is intended to provide medical information scien tists, health care administrators, physicians, nurses, other health care pro viders, and computer science professionals with successful examples and experiences of computer applications in health care settings. Through these computer applications, we attempt to show what is effective and efficient, and hope to provide guidance on the acquisition or design of medical information systems so that costly mistakes can be avoided. Health care provider organizations such as hospitals and clinics are experiencing large demands for clinical information because of a transition from a "fee-for-service" to a "capitation-based" health care economy. This transition changes the way health care services are being paid for. Previ ously, nearly all health care services were paid for by insurance companies after the services were performed. Today, many procedures need to be pre approved and many charges for clinical services must be justified to the insurance plans. Ultimately, in a totally capitated system, the more patient care services are provided per patient, the less profitable the health care provider organization will be. Clearly, the financial risks have shifted from the insurance carriers to the health care provider organizations. For hospitals and clinics to assess these financial risks, management needs to know what services are to be provided and how to reduce them without impacting the quality of care. The balancing act of reducing costs but maintaining health care quality and patient satisfaction requires accurate information about the clinical services. The only way this information can be collected cost effectively is through the automation of the health care process itself. Unfortunately, current health information systems are not comprehensive enough and their level of integration is low and primitive at best. There are too many "islands" even within single health care provider organizations. With the rapid advance of digital communications technologies and the acceptance of standard interfaces, these "islands" can be bridged to satisfy v vi Series Preface most information needs of health care professionals and management. In addition, the migration of health information systems to client/server com puter architectures allows us to reengineer the user interface to become more functional, pleasant, and also responsive. Eventually, we hope, the clinical workstation will become the tool that health care providers use interactively without intermediary data entry support. Computer-based information systems provide more timely and legible information than traditional paper-based systems. In addition, medical in formation systems can monitor the process of health care and improve quality of patient care by providing decision support for diagnosis or therapy, clinical reminders for follow-up care, warnings about adverse drug interactions, alerts to questionable treatment or deviations from clinical protocols, and more. The complexity of the health care workplace requires a rich set of requirements for health information systems. Further, the systems must respond quickly to user interactions and queries to facilitate and not impede the work of health care professionals. Because of this and the requirement for a high level of security, these systems can be classified as very complex and, from a developer's perspective, also as "risky" systems. Information technology is advancing at an accelerated pace. Instead of waiting for 3 years for a new generation of computer hardware, we are now confronted with new computing hardware every 18 months. The forthcom ing changes in the telecommunications industry will be revolutionary. Within the next 5 years, or so, new digital communications technologies, such as the Integrated Services Digital Network (ISDN), Asynchronous Data Subscriber Loop (ADSL) technologies, and very high speed local area networks using efficient cell switching protocols (e.g., ATM), will change not only the architecture of our information systems but also the way we work and manage health care institutions. The software industry constantly tries to provide tools and productive development environments for the design, implementation, and mainte nance of information systems. Still, the development of information sys tems in medicine is an art, and the tools we use are often self-made and crude. One area that needs desperate attention is the interaction of health care providers with the computer. While the user interface needs improve ment and the emerging graphical user interfaces form the basis for such improvements, the most important criterion is to provide relevant and accurate information without drowning the physician in too much (irrel evant) data. To develop an effective clinical system requires an understanding of what is to be done and how to do it, and an understanding of how to integrate information systems into an operational health care environment. Such knowledge is rarely found in anyone individual; all systems described in this monograph series are the work of teams. The size of these teams is usually small, and the composition is heterogeneous, i.e., health profession- Series Preface vii als, computer and communications scientists and engineers, statisticians, epidemiologists, etc. The team members are usually dedicated to working together over long periods of time, sometimes spanning decades. Clinical information systems are dynamic systems, their functionality constantly changing because of external pressures and administrative changes in health care institutions. Good clinical information systems will and should change the operational mode of patient care, which, in turn, should affect the functional requirements of the information systems. This interplay requires that medical information systems be based on architec tures that allow them to be adapted rapidly and with minimal expense. It also requires a willingness by management of the health care institution to adjust its operational procedures, and, most of all, to provide end-user education in the use of information technology. While medical information systems should be functionally integrated, these systems should also be modular so that incremental upgrades, additions, and deletions of modules can be done to match the pattern of capital resources and investments available to an institution. We are building medical information systems just as automobiles were built early in this century, i.e., in an ad hoc manner that disregards even existent standards. Although technical standards addressing computer and communications technologies are necessary, they are insufficient. We still need to develop conventions and agreements, and perhaps a few regulations that address the principal use of medical information in com puter and communication systems. Standardization allows the mass produc tion of low-cost parts that can be used to build more complex structures. What exactly are these parts in medical information systems? We need to identify them, classify them, describe them, publish their specifications, and, most importantly, use them in real health care settings. We must be sure that these parts are useful and cost effective even before we standardize them. Clinical research, health services research, and medical education will benefit greatly when controlled vocabularies are used more widely in the practice of medicine. For practical reasons, the medical profession has developed numerous classifications, nomenclatures, dictionary codes, and thesauri (e.g., lCD, CPT, DSM-III, SNOMED, COSTAR dictionary codes, BAlK thesaurus terms, and MESH terms). The collection of these terms represents a considerable amount of clinical activities, a large portion of the health care business, and access to our recorded knowledge. These terms and codes form the glue that links the practice of medicine with the business of medicine. They also link the practice of medicine with the literature of medicine, with further links to medical research and education. Because information systems are more efficient in retrieving information when con trolled vocabularies are used in large databases, the attempt to unify and build bridges between these coding systems is a great example of unifying the field of medicine and health care by providing and using medical viii Series Preface informatics tools. The Unified Medical Language System (UMLS) project of the National Library of Medicine, NIH, in Bethesda, Maryland, is an example of such an effort. The purpose of this series is to capture the experience of medical informatics teams that have successfully implemented and operated medi cal information systems. We hope the individual books in this series will contribute to the evolution of medical informatics as a recognized profes sional discipline. We are at the threshold where there is not just the need but already the momentum and interest in the health care and computer science communities to identify and recognize the new discipline called Medical Informatics. I would like to thank the editors of Springer-Verlag New York for the opportunity to edit this series. Also, many thanks to the present and past departmental chairmen who allowed me to spend time on this activity: William S. Yamamoto, M.D., and Thomas E. Piemme, M.D., ofthe Depart ment of Computer Medicine at George Washington University Medical Center in Washington, D.C., and Homer R. Warner, M.D., Ph.D., and Reed M. Gardner, Ph.D., of the Department of Medical Informatics at the Uni versity of Utah Health Sciences Center in Salt Lake City, Utah. Last, but not least, I thank all authors and editors of this monograph series for contributing to the practice and theory of Medical Informatics. HELMUTH F. ORTHNER Preface This book was conceived to meet three primary objectives. First, to make known the principles and methods of knowledge engineering developed over nine years of experience with the Iliad diagnostic medical expert system. Second, to provide a textbook to be used for a course in knowledge engineering in a medical informatics curriculum. Third, to provide "physi cian hackers" and other neophytes with the necessary information and software tools to develop their own expert systems. We have attempted to keep the presentation generic, but have also tried to use many examples. We have used examples from the Iliad medical expert system throughout the book because that is the system we are most familiar with. Other well-known comprehensive medical expert systems include QMR and DXplain. And, there are many other more specialized systems that have been reported, both in the U.S. and elsewhere. Many systems attest to the need that has been recognized and to the potential usefulness that many have tried to fill. The field is rapidly changing for a number of reasons, e.g., many disciplines are involved, funding and management of healthcare in general is in a rapid state of flux, and the underlying basic science that explains disease etiology and drives the devel opment of new therapies is rapidly changing. There is no perfect medical expert system; each has strengths and weaknesses. Likewise, there is no knowledge engineering method that has been proved to be superior to all others. It is our hope that readers of this book will come to appreciate the power and sophistication of the Iliad expert system. It is also our hope that many of the principles described here will be applicable to other medical expert systems and to other knowledge engineering environments. We have at tempted here to formulate general concepts and principles where possible and to point up potential problems in the knowledge engineering process ix x Preface necessary to build medical expert systems. The methods proposed here are not necessarily the only methods or the best methods for any given situation. HOMER R. WARNER DEAN K. SORENSON OMAR BOUHADDOU
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