The Decision Support System Used in The Decision Support System Used in

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The Decision Support System Used in The Decision Support System Used in

HEALS

(H lth E i ti A t ti L i (Health Examination Automatic Logic

System) y )

Chiou-Shann Fuh, PhD # Kuan-Liang Kuo, MD * #

*Family Medicine Department, Taipei City Hospital, Taipei Taiwan

Taipei, Taiwan

#Department of Computer Science and Information Engineering, National Taiwan University, Taipei,

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Engineering, National Taiwan University, Taipei,

Taiwan

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Download

Related files on:

http://www.csie.ntu.edu.tw/~d93009/AMIA2006/ p

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Introduction

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HEALS: Overview

Fully web-based application

Services provided via ubiquitous Internet Se ces p o ded a ub qu tous te et accessing

Enormous applications of the database pp

Integrate healthcare domain knowledge to provide sophisticated user-defined

p p

functions and interfaces

Built-in decision-support system for pp y

automatic report generation including

medical data interpretation, automatic

summary, and suggestion

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HEALS: Overview

Provides a user-friendly, intelligent, fully-functional application experience fully functional application experience to clinical workers in a distributed way

Rural clinics can seamlessly share the

Rural clinics can seamlessly share the services provided by HEALS via web- browsing

browsing

Customers can also easily derive i t t d h lth i f ti f

integrated healthcare information from HEALS under certain security

h i i

authentication

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Clinical Diagnosis

I f di t t th t i t di tl

Infer a disease state that is not directly observable

Forms of a physician’s knowledge:

Rule

– Rule

– Pattern

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Knowledge-Based Agents

K l d b

Knowledge base

– The center component

– A set of sentences (rules)

• Knowledge representation language Knowledge representation language

Inference

– Reasoning engine

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Define the Task Environment of an

Intelligent Agent

PEAS PEAS

– Performance measure – Environment

– Actuators Actuators

– Sensors

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Define the Task Environment - Performance Measure Mi i i i

Minimizing error

Minimizing operating time g p g

Maximizing quality

M i i i t t t

Maximizing reports output

– Over 6000 reports per year now p p y

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Define the Task Environment - Environment

Known examination items

Physical examinations – Physical examinations – Laboratory tests

– Others Others

Known examination types

– Laboratory Laboratory

• Numerical (glucose, liver function, …)

• Symbolic (hepatitis markers, …) Symbolic (hepatitis markers, …) – Others

• Text (gastroenteroscopy, …) (g py )

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Define the Task Environment - Actuators

O t t th di

Output the diagnoses

– Possible diseases

Output the suggestions

Life style modification – Life style modification – Medical suggestion

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Define the Task Environment - Sensors

E i ti lt

Examination results

– From database system

Personal Health History

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CDSS of HEALS

CDSS: Clinical Decision Support System

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CDSS: Clinical Decision Support System

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Algorithm go t

Exam Other

Exam.

Results

Other Information

Reasoning Engine Rules

Rule-Codes Table

Diagnoses and Suggestion Codes

Presentation Engine

Codes-Text Tables

R t

Presentation Engine

Reports

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Rule-Codes Table

Rule Name Description

Section

Code Suggestion codes

Rule Name Description Code Suggestion codes

MCVLHBN1 Low MCV, normal HB, MCV/RBC>13 1 d20,602,g24r1,t84

MCVLHBN2 1 d20 G24R2 t82

MCVLHBN2 (r/o Thalassemia) Low MCV, normal HB 1 d20,G24R2,t82 MCVLHBL1 (Microcytic anemia) low MCV, low HB, MCV/RBC>13 1 G24R2,t83 MCVLHBL2 (r/oThalassemia) low MCV, low HB, MCV/RBC<13 1 d20,G24R2,t81

MCVNHBL1 Normal MCV HB10 12 1 t10 d50 40 403 g24r1 MCVNHBL1 Normal MCV, HB10-12 1 t10,d50,40,403,g24r1 MCVNHBL2 Normal MCV, HB<10 1 t11,d50,40,403,g24r1

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Code-Text Table:

Code Text Table:

Diagnoses g

Code Diagnosis Code Diagnosis

81 r/o Thalassemia 82 r/o Thalassemia 83 Microcytic anemia 84 L MCV

84 Low MCV

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Code Text Table: Suggestion Code-Text Table: Suggestion

601 目前不需治療

601e No medical treatment required at the moment.

602 疑帶有地中海型貧血基因

602 i d h h h l i

602e It is suspected that you have a thalassemia gene.

603 因無明顯分類異常或伴隨其他血球變化，可觀察

No marked classification abnormality is found No marked classification abnormality is found

concurrently with any other pathological change in blood cells, thus no medical treatment is required at the

603e moment.

604 疑因過敏體質所致，

No medical treatment is required as the disorder is 604e

No medical treatment is required, as the disorder is caused by an irritable body.

605 正值發育期間的小孩及青少年，其值常見偏高，

605e 17

The value is usually relatively high among kids and teenagers who grow rapidly.

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BNF Grammar of Rules

declaration ::= limit_declaration

| range_declaration

| clause declaration

| clause_declaration

| rule_declaration

BNF: Backus-Naur Form ac us au o

Full text on:

http://www.csie.ntu.edu.tw/~d93009/AMIA2006/

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BNF Grammar of Rules BNF Grammar of Rules

(cont ) (cont.)

limit declaration ::= limitdef limit_declaration ::= limitdef

limit_name limit

range declaration ::= rangedef range_declaration ::= rangedef

range_name range

clause declaration ::= clausedef clause_declaration ::= clausedef

clause_name clauses

rule declaration ::= ruledef rule_declaration ::= ruledef

rule_name rules

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Examples of Rules

limitdef UWBC2 UWBC > 20 limitdef UWBC2 UWBC > 20

d f UWBC1 UWBC (5 20]

rangedef UWBC1 UWBC (5 20]

clausedef UWBC6 UWBC2 || UWBC4

ruledef UWBCABNH UWBC1 && URBCN

&& !URBC4

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Reasoning Engine

Forward chaining reasoning

– Data-driven reasoning

Procedural approach part of this implementation

– Initiation of variables used in rules

Processing rules Processing rules

Generating result codes

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Examples of Encoding p g Domain Knowledge into

Rules

Some Hepatitis B Markers Some Hepatitis B Markers

– Hepatitis B surface antigen (HBsAg)

( g)

• Outer surface coat

– Hepatitis B surface antibody (HBsAb)

• Antibody to HBsAg

H titi B tib d

– Hepatitis B core antibody (HBcAb)

• Antibody to inner Antibody to inner

nucleocapsid core

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

limitdef HBSAG_pos HBSAG == "+“

** HBsAg is positiveg p

limitdef HBSAG_neg HBSAG == "-“

** HBsAg is negative

limitdef HBSAB pos HBSAB == "+“

limitdef HBSAB_pos HBSAB == +

** HBsAb is positive

limitdef HBSAB_neg HBSAB == "-“

** HBsAb is negative

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

limitdef HBCAB_pos HBCAB == "+“

** HBcAb is positive HBcAb is positive

limitdef HBCAB_neg HBCAB == "-“

** HBcAb is negative

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

limitdef OLD_HBSAG_pos OLD_HBSAG == "+“

** any of the previous HBsAg tests is positive

** any of the previous HBsAg tests is positive limitdef OLD_HBSAG_neg OLD_HBSAG == "-“

** ll f h i i

** all of the previous HBsAg tests are negative limitdef OLD_HBSAB_pos OLD_HBSAB == "+“

** any of the previous HBsAb tests is positive limitdef OLD_HBSAB_neg OLD_HBSAB == "-“

** all of the previous HBsAb tests are negative

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

limitdef OLD_HBCAB_pos OLD_HBCAB == "+“

** any of the previous HBcAb tests is positive

limitdef OLD HBCAB neg OLD HBCAB == "-“_ _ g _

** all of the previous HBcAb tests are negative

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBSAG_nil !HBSAG_pos && !HBSAG_neg

** If HBsAg is not tested

ruledef HBSAB_nil !HBSAB_pos && !HBSAB_neg

** If HBsAb is not tested

ruledef HBCAB_nil !HBCAB_pos && !HBCAB_neg

** If HBcAb is not tested

ruledef HBCAB_diff HBCAB_neg && OLD_HBCAB_pos

** If HB Ab i ti d f th

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** If HBcAb is negative now and any of the previous HBcAb tests is positive

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_nnn HBSAG_neg && HBSAB_neg &&

HBCAB_neg && !AGE_50

** If HBsAg is negative, HBsAb is negative, HBcAb is negative, and age is less than 50

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_nnn HBSAG_neg && HBSAB_neg &&

HBCAB_neg && !AGE_50

HBsAg: negative; Anti-HBs: negative; Anti-HBc: negative

˙You have never got hepatitis B infection,

h i i d d h i

thus it is recommended that you receive vaccine injections.

˙Please visit the Outpatient Clinic of Family Please visit the Outpatient Clinic of Family Medicine Division for a follow-up diagnosis and treatment.

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_pnp HBSAG_pos && HBSAB_neg &&

HBCAB_pos

** If HBsAg is positive, HBsAb is negative, and HBcAb is positive

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV pnp HBSAG pos && HBSAB neg && _p p _p _ g HBCAB_pos

HB A iti A ti HB ti A ti HB iti

HBsAg: positive; Anti-HBs: negative; Anti-HBc: positive

˙Don't take medication without a

physician's instructions so as to avoid physician s instructions, so as to avoid augmenting the workload of liver.

˙Take a rest, as appropriate; avoid being g physically and mentally exhausted.

˙You are a hepatitis B carrier. Please have a

f ll lt ti i th O t ti t

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follow-up consultation in the Outpatient

Clinic every half a year.

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_nn HBSAG_neg && HBSAB_neg &&

HBCAB_nil && !AGE_50

** If HBsAg is negative, HBsAb is negative, HBcAb is not tested, and age is less than 50

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_nn HBSAG_neg && HBSAB_neg &&

HBCAB nil && !AGE 50_ _

HBsAg: negative; Anti-HBs: negative

˙Your antibody test is negative Your antibody test is negative.

It is recommended that you go to the

OPD and pay for a test for core antibody.

If the subsequent test is negative again,

you may consider receiving vaccine injections.

˙Please visit the Outpatient Clinic of

Family Medicine Division for a follow-up diagnosis and treatment

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diagnosis and treatment.

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_nnp1 HBSAG_neg && HBSAB_neg &&

HBCAB_pos && OLD_HBSAG_pos

** If HBsAg is negative, HBsAb is negative, HBcAb is negative, and any of the previous HBsAb tests

i iti

is positive

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Interpretation of Hepatitis B Interpretation of Hepatitis B

Markers Markers

ruledef HBV_nnp1 HBSAG_neg && HBSAB_neg &&

HBCAB pos && OLD HBSAG pos HBCAB_pos && OLD_HBSAG_pos

HBsAg: negative; Anti-HBs: negative; Anti-HBc: positive;

P i HB A i i

Previous HBsAg: positive

˙Do not take medication without physician's

instructions, to avoid augmenting the workload instructions, to avoid augmenting the workload of liver.

˙Take a rest, as appropriate; avoid being physically and mentally exhausted

and mentally exhausted.

˙You are a hepatitis B carrier. Please have a

follow-up consultation in the Outpatient Clinic

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p p

every half a year.

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Examples of Encoding p g Domain Knowledge into

Rules

A i

Anemia

– RBC (Red Blood Cell)

– MCV (Mean Corpuscle Volume)

– Hb (Hemoglobin) Hb (Hemoglobin)

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Anemia

rangedef MCV_Low78 MCV [78 80) rangedef MCV Low MCV (0 80)g _ ( ) rangedef HB_N HB [12 19]

rangedef HB_Low HB (0 12) rangedef HB_mildLow HB [10 12) rangedef HB_severeLow HB (0 10) limitdef HB High HB > 19

limitdef HB_High HB > 19 limitdef RBC_High RBC > 7 limitdef RBC mildHigh RBC > 5_ g

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Anemia

rangedef MCV DIV RBC Low MCV DIV RBC (0 13)g _ _ _ _ _ ( )

** MCV/RBC > 0, and < 13

limitdef AGE_YOUNG AGE < 21

** age less than 21

ruledef MCVABNL21 AGE_YOUNG && MCV_Low78 &&

HB_N

** If age less than 21, MCV>=78 and <80, and Hb is normal

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Anemia

ruledef MCVLHBN2 !MCVABNL21 && MCV_Low && HB_N

&& MCV_DIV_RBC_Low

** If MCVABNL21 is false, MCV<80, Hb is normal, and MCV/RBC<13 (r/o Thalassemia carrier)

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Anemia

ruledef MCVLHBN2 !MCVABNL21 && MCV_Low && HB_N

&& MCV_DIV_RBC_Low

RBC: 6.00*10⁶/ul, Hb: 12.8g/dL, MCV: 63fl r/o Thalassemia carrier

˙To be under observation. Please visit the Outpatient Clinic of

Family Medicine Division

for a follow-up diagnosis and treatment, in the event of doubts or discomfort.

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Anemia

ruledef MCVLHBL1 !MCVABNL21 && MCV_Low && HB_Low

&& !MCV_DIV_RBC_Low

** If MCVABNL21 is false, MCV<80, Hb<12, and MCV/RBC>=13 (microcytic anemia)

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Anemia

&& !MCV_DIV_RBC_Low

RBC: 3.00*10⁶/ul, Hb: 8.0g/dL, MCV: 70fl/ , g/ , Microcytic anemia

˙PlPlease visit the Outpatient Clinic ofi it th O t ti t Cli i f Division of Family Medicine

for a follow-up diagnosis and treatment.

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Anemia

&& MCV_DIV_RBC_Low

** If MCVABNL21 is false, MCV<80, Hb<12, and MCV/RBC<13 (Thalassemia)

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Anemia

ruledef MCVLHBL2 !MCVABNL21 && MCV_Low && HB_Low &&

MCV_DIV_RBC_Low

RBC: 6.00*10⁶/ul, Hb: 10.0g/dL, MCV: 62fl r/o Thalassemia

˙Please visit the Outpatient Clinic of Division of Family Medicine

for a follow-up diagnosis and treatment.

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Anemia

ruledef MCVNHBL2 !MCV_Low && HB_severeLow

** If MCV>=80 and Hb<10

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Anemia

ruledef MCVNHBL2 !MCV_Low && HB_severeLow RBC: 3.00*106⁶/ul, Hb: 8.0g/dL, MCV: 82fl

Anemia

˙Have a balanced diet, taking in all sorts of nutrients, avoid partiality for a particular kind of food; take sufficient amount of vitamins.

˙Refrain from blood donation.

˙Please visit the Outpatient Clinic of Division of Family Medicine for follow-up diagnoses and treatments.

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Summary Summary

and and

Conclusion Conclusion

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HEALS:

Advantages Advantages

Provide services beyond the territory boundary between rural and urban medical settings

Improve the quality of health examination information flow.

Improve the efficiency of health examination information flow.

Reduce the mundane daily work of clinical workers

Provide education for junior doctors

Eliminate common misses in health reports

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CDSS of HEALS:

Advantages Advantages

A way of using clinical guidelines in

A way of using clinical guidelines in medical practices.

Simple and clear rule syntax

Efficient reasoning algorithm g g

To ensure the state-of-the-art of the

knowledge base the rules can be readily knowledge base, the rules can be readily updated by domain experts easily

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Evaluation Results

HEALS has served in Taipei City Hospital for

HEALS has served in Taipei City Hospital for more than 40000 cases.

Time of editing a report markedly decreased from 20 minutes to 5 minutes per case

The ratio of customer complaints about the

health reports was decreased to nearly zero

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HEALS: Next

T b f th f f h lth

To be one of the references of health examination information systems

Future improvement of the CDSS in HEALS

HEALS

– Analyze the database to extract stochastic or domain specific methods to improve

or domain-specific methods to improve healthcare quality and efficacy

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References

S. Russell and P. Norvig, Artificial Intelligence: A Modern Approach, 2^nd Ed., Prentice Hall, New York, 2002.

C Chi li B f di K P Adl i M K ih l A H t W

C. Chizzali-Bonfadin, K. P. Adlassnig, M. Kreihsl,A. Hatvan,W.

Horak, "Knowledge-Based Interpretation of Serologic Tests for Hepatitis on the World Wide Web.” Clin. Perform. Qual. Health Care vol 5(2) pp 61 3 1997

Care, vol. 5(2), pp. 61-3, 1997.

E. Bernstern, “Decision Support and Computers in Education,”

HI5300: Introduction to Health Informatics, School of Health I f ti S i d D t t f I t l M di i

Information Sciences and Department of Internal Medicine, University of Texas – Houston, 2004.

HL7 Working Group, “Standards in Clinical Decision Support:

U i A d S t ” htt // l i f t d /hl7/ d / Using Arden Syntax,” http://cslxinfmtcs.csmc.edu/hl7/arden/, 2003.

P. Caleb-Solly, "Clinical Decision Support Systems," Seminar

f h l h f i

for the Health Informatics, 2001.

The Decision Support System Used in The Decision Support System Used in