Presentation at AIME 2011
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This document discusses transforming clinical guidelines into care pathways to support patient treatment planning. It proposes using Asbru, a computer-interpretable guideline language, to model clinical guidelines, then automatically transforming the Asbru representation into a temporal hierarchical task network (HTN) planning domain model. The HTN model could then be used to interpret the domain and generate a personalized care pathway for a patient based on their profile and available resources. The goal is to provide doctors with visual care plans that can be deployed into a workflow engine to facilitate treatment.
![What is the most
important aim of
Knowledge
Engineering?
Turning the process of constructing
Knowledge Based Systems
from an Art into an Engineering
Discipline, using better
methodological approaches
[Studer et. al, 1998]
13
miércoles 6 de julio de 2011](https://image.slidesharecdn.com/careflowbled0507-13113303035792-phpapp02-110722052829-phpapp02/85/Presentation-at-AIME-2011-28-320.jpg)
Presentation at AIME 2011
- 1. Careflow Planning: From Time-annotated Clinical Guidelines to Temporal Hierarchical Task Networks Arturo González-Ferrer Annette ten Teije Juan Fdez-Olivares Krystyna Milian 1 miércoles 6 de julio de 2011
- 2. MOTIVATION • Real requirements by doctors of 7 hospitals in our region (Andalucía) in project Oncotheraper: • Virgen del Rocío (Sevilla) • Virgen Macarena (Sevilla) • Carlos Haya (Málaga) • Torre Cárdenas (Almería) • Reina Sofía (Córdoba) • Complejo Hospitalario (Jaén) • Virgen de las Nieves (Granada) 2 miércoles 6 de julio de 2011
- 3. MOTIVATION 3 miércoles 6 de julio de 2011
- 4. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology 3 miércoles 6 de julio de 2011
- 5. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology • They spend much time preparing the patient plan at hand 3 miércoles 6 de julio de 2011
- 6. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology • They spend much time preparing the patient plan at hand • These protocols are very constrained by multiple temporal annotations (chemotherapy cycles, delayed synchronizations, ...). 3 miércoles 6 de julio de 2011
- 7. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology • They spend much time preparing the patient plan at hand • These protocols are very constrained by multiple temporal annotations (chemotherapy cycles, delayed synchronizations, ...). • We did previous work where we used the BPMN graphical notation to model organizational processes and obtain process instances adapted to specific conditions 3 miércoles 6 de julio de 2011
- 8. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology • They spend much time preparing the patient plan at hand • These protocols are very constrained by multiple temporal annotations (chemotherapy cycles, delayed synchronizations, ...). • We did previous work where we used the BPMN graphical notation to model organizational processes and obtain process instances adapted to specific conditions • we found that the capability of BPMN to represent complex temporal constraints is still confusing and incomplete 3 miércoles 6 de julio de 2011
- 9. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology • They spend much time preparing the patient plan at hand • These protocols are very constrained by multiple temporal annotations (chemotherapy cycles, delayed synchronizations, ...). • We did previous work where we used the BPMN graphical notation to model organizational processes and obtain process instances adapted to specific conditions • we found that the capability of BPMN to represent complex temporal constraints is still confusing and incomplete • time-BPMN extension (Gagné & Trudel) is only theoretical, not practical 3 miércoles 6 de julio de 2011
- 10. MOTIVATION • Doctors in the project need IT support for planning, visualization and execution of a patient long-term treatment in pediatrics oncology • They spend much time preparing the patient plan at hand • These protocols are very constrained by multiple temporal annotations (chemotherapy cycles, delayed synchronizations, ...). • We did previous work where we used the BPMN graphical notation to model organizational processes and obtain process instances adapted to specific conditions • we found that the capability of BPMN to represent complex temporal constraints is still confusing and incomplete • time-BPMN extension (Gagné & Trudel) is only theoretical, not practical • We decided to move the modeling stage to using Computer-interpretable Guidelines 3 miércoles 6 de julio de 2011
- 11. “Hardly any of the existing Clinical Decision Support Systems (CDSS) appear to be aimed at supporting extended clinical workflows, management of information and decision-making in plans that unfold over time” J. Fox, D. Glasspool, V. Patkar, M. Austin, L. Black, M. South, D. Robertson, and C. Vincent. Delivering clinical decision support services: There is nothing as practical as a good theory. Journal of Biomedical Informatics, 43(5):831-843, 2010 4 miércoles 6 de julio de 2011
- 12. MOTIVATION • We need to represent and reason about actions and decisions, different patient profiles, temporal patterns and scheduling of resources, in order to automatically generate personalized care plans • We need these plans to be visually atractive, and useful for the doctors • We want to deploy these plans for the patient treatment into a workflow engine (i.e. careflow) • This way, both the patients and doctors could follow the treatment using a more efficient, safe, and high-quality healthcare process 5 miércoles 6 de julio de 2011
- 13. CLINICAL GUIDELINES • Clinical Practice Guidelines: Recommendations on the appropriate treatment and care of people with specific diseases and conditions, on the basis of the best available evidence. • Computer-interpretable Guidelines languages 6 miércoles 6 de julio de 2011
- 14. CARE PATHWAYS Care Pathways: Aim to model a timed process of patient-focused care, by specifying key events, clinical exams and assessments to produce the best prescribed outcomes, within the limits of the resources available, for an appropriate episode of care • It aims to reduce the patient’s stay time in the hospital, delivering a more efficient care process 7 miércoles 6 de julio de 2011
- 15. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Clinical Guidelines 8 miércoles 6 de julio de 2011
- 16. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Clinical Guidelines ? 8 miércoles 6 de julio de 2011
- 17. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Care Pathways Clinical Guidelines ? 8 miércoles 6 de julio de 2011
- 18. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Care Pathways Patient Profile Clinical Guidelines ? 8 miércoles 6 de julio de 2011
- 19. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Care Pathways Patient Profile Clinical Guidelines Temporal Patterns ? 8 miércoles 6 de julio de 2011
- 20. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Care Pathways Patient Profile Clinical Guidelines Temporal Patterns ? Resources 8 miércoles 6 de julio de 2011
- 21. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Care Pathways Patient Profile Clinical Guidelines Temporal Patterns ? Resources Visual Plan 8 miércoles 6 de julio de 2011
- 22. AIMS AND GOALS • Starting from the recommendations of a Computer Interpretable Guideline for a specific disease, we want to obtain a Care Pathway: Care Pathways Patient Profile Clinical Guidelines Temporal Patterns ? Resources Visual Plan Workflow 8 miércoles 6 de julio de 2011
- 23. ASBRU • It is an XML-based, time-oriented, CIG language, used to embody CPGʼs and protocols as skeletal plans. • Each one of these skeletal plans consists of a plan-body that can be composed of: • subplans (set of steps in parallel or sequentially), • cyclical-plans (repeated several times), • plan-activations (a call to another plan) or • user-performed steps (a specific action performed by the user). • In addition, time-annotated conditions can be attached for the selection of plans 9 miércoles 6 de julio de 2011
- 24. HTN PLANNING • HTN planning has shown to be very useful on practical human-centric domains, for the generation of customized plans (tourism, e-learning, emergencies, ...). • HPDL: It is HTN extension of PDDL language (derived from first-order logic), organized as: planning domain planning problem compound tasks hierarchy of objects primitive actions decomposition methods preconditions initial state predicates, functions set of goals 10 miércoles 6 de julio de 2011
- 25. Computer Interpretable Guidelines are very good for Representation of actions and decisions in Clinical Processes, but they need a counterpart Knowledge Reasoning step to be used as a basis for obtaining Care Pathways 11 miércoles 6 de julio de 2011
- 26. WHAT TO DO? • Temporal HTN planning is appropriate for the aim of generating care pathways • J. Fdez-Olivares et al. Supporting clinical processes and decisions by hierarchical planning and scheduling Computational Intelligence, 2011 • But : modeling HTN domains directly can be really complex. Sometimes, an Art! • We need a higher level language for representation of the guideline: • Let use Asbru • Then what? • We need some Knowledge Engineering 12 miércoles 6 de julio de 2011
- 27. WHAT TO DO? • Temporal HTN planning is appropriate for the aim of generating care pathways • J. Fdez-Olivares et al. Supporting clinical processes and decisions by hierarchical planning and scheduling Computational Intelligence, 2011 • But : modeling HTN domains directly can be really complex. Sometimes, an Art! • We need a higher level language for representation of the guideline: • Let use Asbru Asbru to HPDL? • Then what? • We need some Knowledge Engineering 12 miércoles 6 de julio de 2011
- 28. What is the most important aim of Knowledge Engineering? Turning the process of constructing Knowledge Based Systems from an Art into an Engineering Discipline, using better methodological approaches [Studer et. al, 1998] 13 miércoles 6 de julio de 2011
- 29. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) 14 miércoles 6 de julio de 2011
- 30. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) • Automatically transform the Asbru representation into an HTN planning domain model, considering time constraints 14 miércoles 6 de julio de 2011
- 31. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) • Automatically transform the Asbru representation into an HTN planning domain model, considering time constraints • Interprete the domain to obtain a Care Pathway for a patient, using the available resources 14 miércoles 6 de julio de 2011
- 32. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) • Automatically transform the Asbru representation into an HTN planning domain model, considering time constraints • Interprete the domain to obtain a Care Pathway for a patient, using the available resources • Deploy the Care Pathway obtained into a BPM engine for ubiquitous execution. 14 miércoles 6 de julio de 2011
- 33. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) • Automatically transform the Asbru representation into an HTN planning domain model, considering time constraints • Interprete the domain to obtain a Care Pathway for a patient, using the available resources • Deploy the Care Pathway obtained into a BPM engine for ubiquitous execution. 14 miércoles 6 de julio de 2011
- 34. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) • Automatically transform the Asbru representation into an HTN planning domain model, considering time constraints • Interprete the domain to obtain a Care Pathway for a patient, using the available resources • Deploy the Care Pathway obtained into a BPM engine for ubiquitous execution. already done (see bibliography) 14 miércoles 6 de julio de 2011
- 35. METHODOLOGICAL APPROACH • Experts describe the CPG in text format • Knowledge Engineers model it using a CIG language (e.g. Asbru) • Automatically transform the Asbru representation into an HTN planning domain model, considering time constraints • Interprete the domain to obtain a Care Pathway for a patient, using the available resources • Deploy the Care Pathway obtained into a BPM engine for ubiquitous execution. already done (see bibliography) work in progress 14 miércoles 6 de julio de 2011
- 36. MAPPING ASBRU TO HPDL • Why is this useful? • HTN planning is capable to represent clinical protocols and reason to obtain a pathway: • not only representing, but also managing complex temporal patterns • representing custom constraints (e.g. resources) and reasoning about them • adapted to the specific conditions of the patient profile • very useful in low-frequency scenarios, where BPM tools could be interesting • CIG languages more user-friendly for knowledge representation • not only for humans, also for managing them in a computer • some of them use graphical notations, that are underneath stored as XML 15 miércoles 6 de julio de 2011
- 37. HIGH OR LOW FREQUENCY DOMAIN? ❖ Traditional use of Asbru in high-frequency domains (e.g. intensive care units) Asbru Guideline Time- Asbru annotated Interpreter input data What to do for every ICU input variable? 16 miércoles 6 de julio de 2011
- 38. HIGH OR LOW FREQUENCY DOMAIN? ❖ We want to use it for low-frequency domains (long/medium-term care plans) Asbru Guideline Translator Patient Conditions Long-term Guideline in IACTIVE Care Hospital HPDL planner Pathway Resources Deliberative Reasoning 17 miércoles 6 de julio de 2011
- 39. ASBRU & HPDL: SIMILARITIES • Both follow a similar Task Network Model (TNM) • This is also valid for other CIG languages (not only Asbru) • Asbru skeletal plans similar to HTN compound/primitive operators. • Both are able to represent multiple task ordering schemas • Both are able to represent multiple temporal patterns (e.g. Allen’s T.L. ) 18 miércoles 6 de julio de 2011
- 40. MAPPING ASBRU TO HPDL Asbru HPDL 19 miércoles 6 de julio de 2011
- 41. MAPPING ASBRU TO HPDL Asbru HPDL plan-activations A B task calls activate B 19 miércoles 6 de julio de 2011
- 42. MAPPING ASBRU TO HPDL Asbru HPDL plan-activations A B task calls activate B A1 cond 1 A1 subplans parallel conditional compound tasks A A A2 cond 2 A2 if-then-else task methods A A1 A2 sequence 19 miércoles 6 de julio de 2011
- 43. MAPPING ASBRU TO HPDL Asbru HPDL plan-activations A B task calls activate B A1 cond 1 A1 subplans parallel conditional compound tasks A A A2 cond 2 A2 if-then-else task methods A A1 A2 sequence user-performed A durative-action 19 miércoles 6 de julio de 2011
- 44. MAPPING ASBRU TO HPDL Asbru HPDL 20 miércoles 6 de julio de 2011
- 45. MAPPING ASBRU TO HPDL Asbru HPDL duration A ?start, ?end, ?duration time annotations start end <,>,<=,>= 20 miércoles 6 de julio de 2011
- 46. MAPPING ASBRU TO HPDL Asbru HPDL duration A ?start, ?end, ?duration time annotations start end <,>,<=,>= time-annotated references to plans 28 days after (ref. points as plan A B temporal landmarks pointers) (all allen’s relations) 20 miércoles 6 de julio de 2011
- 47. MAPPING ASBRU TO HPDL Asbru HPDL duration A ?start, ?end, ?duration time annotations start end <,>,<=,>= time-annotated references to plans 28 days after (ref. points as plan A B temporal landmarks pointers) (all allen’s relations) repeat 5 times cyclical plans recursive cyclical task (based on temporal formalism A frequency of Anselma et. al) offset 20 miércoles 6 de julio de 2011
- 48. RESULTS • Proof of concept: We focused in the protocol for the Hodgkin’s disease. • around 70 text pages • We modeled it with a subset of the Asbru language (using DELT/A) 21 miércoles 6 de julio de 2011
- 49. RESULTS • We have developed a KE tool for the translation (Asbru2HPDL) • We identified and translated different patterns, not only the hierarchy of tasks: 22 miércoles 6 de julio de 2011
- 50. RESULTS • The translation only cover the workflow of the care process, but not the modeling of patient profiles and hospital resources Patient Profile ;;definition of predicates in the domain (sex ?patient ?s - gender) (group ?patient ?g - group) ;; instances for patient Alice in the problem (sex Alice M) (group Alice Group3) ;;start date for treatment (startdate Alice "07/11/2011 08:00:00") Resource Constraints (between "07/11/2011 00:00:00" and "07/12/2011 00:00:00" (available John)) (between "07/12/2011 00:00:00" and "07/01/2011 00:00:00" (available Paul)) (between "07/01/2012 00:00:00" and "07/02/2012 00:00:00" (available John)) (between "07/02/2012 00:00:00" and "07/03/2012 00:00:00" (available Paul)) (between "07/03/2012 00:00:00" and "07/04/2012 00:00:00" (available John)) 23 miércoles 6 de julio de 2011
- 51. RESULTS • A fragment of the generated pathway: • This pathway can afterwards be translated into a representation understandable by a BPM engine • González-Ferrer, A., Fdez-Olivares, J., Sánchez-Garzón, I., & Castillo, L. (2010). Smart Process Management: Automated Generation of Adaptive Cases based on Intelligent Planning Technologies. 8th BPM Conference, Demo Track 24 miércoles 6 de julio de 2011
- 52. RESULTS • Personalized access for each doctor to his/her list of time-annotated tasks • Patient’s follow-up procedure is supported by a BPM runtime console 25 miércoles 6 de julio de 2011
- 53. Conclusions • We presented an AI-based methodology to model and operationalize care pathways for oncology treatments • The patterns commonly found in a CIG representation (concretely Asbru) can be translated into a corresponding HTN representation. • The methodology could be used for other CIG languages as well • This is interesting because • Adding patients and resources information, we can obtain a customized care pathway that unfolds over time • CIGs are more user-friendly for the modeling than doing it directly with cumbersome HTN planning languages • We can finally deploy the care plan into a BPM execution engine 26 miércoles 6 de julio de 2011
- 54. FUTURE WORK • Use and evaluation in a real hospital scenario • Apply to other protocols, which patterns could be also interesting? • Flexibility: we are progressing to include monitoring, plan repair and replanning • Real integration with real HIS and EHR 27 miércoles 6 de julio de 2011
- 55. see more at ... • presentation @ KR4HC workshop • Dr. Juan Fernández-Olivares • Task Network based modeling, dynamic generation and adaptive execution of patient-tailored treatment plans based on Smart Process Management technologies 28 miércoles 6 de julio de 2011