HEALS: Health Examination Automatic Logic System
Kuan-Liang Kuo, MD *#
Chiou-Shann Fuh, PhD *
*Family Medicine Department, Taipei City Hospital, Taipei, Taiwan
#Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
Download
• Related files on:
http://www.csie.ntu.edu.tw/~d93009/AMIA2006/
Introduction
Health Examinations
• Health examinations play important roles in preventive medicine.
• The clinical condition of an individual
continuously changes and needs a series of observations and follow-up.
• In the past, in order to meet such requirement,
clinical workers have to fetch health examination data from scattered sources, such as medical charts or general-purpose hospital information system.
Health Examinations
• The lack of a health examination information system meant that the
availability, efficiency, and quality of
further health care management would
degrade.
Asymmetry between Rural and Urban Medical Settings
• Scale
• Equipment
• Quality
• Information technology
HEALS: History
• A health care system developed in Taipei City Hospital since 1996 (original Taipei Municipal Jen Ai Hospital)
• Dedicated for health examinations
HEALS: Overview
• Fully web-based application
• Services provided via ubiquitous Internet accessing
• Enormous applications of the database
• Integrate healthcare domain knowledge to provide sophisticated user-defined functions and interfaces
• Built-in decision-support system for automatic report generation including medical data
interpretation, automatic summary, and suggestion
HEALS: Overview
• Provides a user-friendly, intelligent, fully- functional application experience to clinical workers in a distributed way
• Rural clinics can seamlessly share the services provided by HEALS via web-browsing
• Customers can also easily derive integrated
healthcare information from HEALS under certain security authentication
HEALS: Overview
• Web-based:
– PHP – Java
• Database:
– SQL compliant
PHP: Personal Home Page
SQL: Structured Query Language
HEALS: Integrated into HIS
HIS: Health Information System DB: Data Base
JDBC: Java Data Base Connectivity
HEALS: Integrated into HIS
Screen Shots
HEALS: Portal Page
HEALS : Results Input
HEALS: Automatic Summary
HEALS: Report Preview
HEALS: Maintenance of Phrases and
Inference Information
HEALS: Maintenance of Inference
Information
HEALS: Maintenance of Inference
Information
Implementation of CDSS in HEALS
CDSS: Clinical Decision Support System
Implementation of CDSS in HEALS:
Inference Engine
Database
Field Name Value Field1 Text Field2 Numeric Field3 Symbolic
Rule Name Boolean Value
Rule1 TRUE
Rule2 FALSE
Rule3 TRUE
Rule Rule1 Cond1 Rule Rule2 Cond2 Rule Rule3 Cond3
Rule Name Action Caption Rule1 Action1 Caption1 Rule3 Action3 Caption3 False
True
Update
Caption Action Caption G R S D L
Rule-Codes Table Rule Action Table
Inference Engine
Rules
Ignore Case Data
Effective Inference Result
Presentation Rule Value Table
Implementation of CDSS in HEALS:
Rules Syntaxes
limitdef <name> <condition>
rangedef <name> <condition>
clausedef <name> <condition>
ruledef <name> <condition>
Implementation of CDSS in HEALS:
Rule Example
Syntax:
limitdef <name> <condition>
Example:
limitdef HBSAG_pos HBSAG == "+"
Implementation of CDSS in HEALS:
Rule Example
Syntax:
rangedef <name> <condition>
Example:
rangedef HB_mildLow HB [10 12) Description:
HB>=10 and HB<12 (HB: hemoglobin)
Implementation of CDSS in HEALS:
Rule Example
Syntax:
clausedef <name> <condition>
Example:
clausedef RFT_H CR_H || BUN_H Description:
CR_H: pre-defined rule with the condition of high Creatinine
BUN_H : pre-defined rule with the condition of high BUN
Implementation of CDSS in HEALS:
Rule Example
Syntax:
ruledef <name> <condition>
Example:
ruledef HBV_nnn HBSAG_neg && HBSAB_neg
&& HBCAB_neg && !AGE_50 Description:
HBSAG_neg: pre-defined rule with the condition of negative HBsAg.
Implementation of CDSS in HEALS:
Inference Results
Triggered action:
Section code; Suggestion Codes Example:
1;D20,G24R2,T82 Description:
1: Division of Family Medicine
D20: To be under observation. Please visit the Outpatient Clinic of
$$ for a follow-up diagnosis and treatment, in the event of doubts or discomfort.
G24R2: group 24, rank 2 T82: r/o Thalassemia
Implementation of CDSS in HEALS:
Effective Inference Results
……..
Action nAction 1 Action 2
•Classification
•Translation
•Format
Human-Readable Results
Summary and
Conclusion
Advantages of HEALS
• 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
Common Misses in Health Reports
• Fail to correctly detect problems from multiple examination results
• Fail to give proper suggestions for further medical management or life style
modification
• Fail to write a well-edited report
• Fail to meet the deadline for sending reports
Common Misses in Health Reports:
Fail to correctly detect problems from multiple examination results
• Anemia:
– RBC (red blood cell count) – Hb (hemoglobin)
– MCV (mean corpuscle volume)
Common Misses in Health Reports:
Fail to correctly detect problems from multiple examination results
• Hepatitis B:
– HBsAg (hepatitis B surface antigen)
– Anti-HBs (hepatitis B surface antibody) – Anti-HBc (hepatitis B core antibody) – HBeAg (hepatitis B e antigen)
– Liver enzymes
– Abdominal sonography
Common Misses in Health Reports:
Fail to give proper suggestions for further medical management or life style
modification
• To give a succinct and complete suggestion
at a time is a difficult job.
Common Misses in Health Reports:
Fail to write a well-edited report
• Different quality by different doctors
• Different quality by a doctor at different time
Common Misses in Health Reports:
Fail to meet the deadline for sending reports
• Regular workload of a doctor in the health examination center
– 20 reports/day
• Per report’s conclusion time requirement:
– With CDSS: in seconds
– Without CDSS: 10 minutes to half an hour
CDSS: Clinical Decision Support System
Possible Disadvantages of CDSS
• Changing relation between patient and the physician
• Limiting professionals’ possibilities for independent problem solving
• Legal implications - with whom does the
onus of responsibility lie?
Evaluation Results
• 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
Perspective of HEALS
• To be one of the references of health examination information systems
• Future improvement of the CDSS in HEALS
– Analyze the database to extract stochastic or
domain-specific methods to improve healthcare quality and efficacy
References
• S. Russell and P. Norvig, Artificial Intelligence: A Modern Approach, 2nd Ed., Prentice Hall, New York, 2002.
• E. Bernstern, “Decision Support and Computers in
Education,” HI5300: Introduction to Health Informatics, School of Health Information Sciences and Department of Internal Medicine, University of Texas – Houston, 2004.
• HL7 Working Group, “Standards in Clinical Decision Support: Using Arden Syntax,”
http://cslxinfmtcs.csmc.edu/hl7/arden/, 2003.
• P. Caleb-Solly, "Clinical Decision Support Systems,"
Seminar for the Health Informatics, 2001.
The Decision Support System Used in HEALS (Health Examination Automatic Logic System)
Chiou-Shann Fuh, PhD # Kuan-Liang Kuo, MD * #
*Family Medicine Department, Taipei City Hospital, Taipei, Taiwan
#Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
Download
• Related files on:
http://www.csie.ntu.edu.tw/~d93009/AMIA2006/
Introduction
HEALS: Overview
• Fully web-based application
• Services provided via ubiquitous Internet accessing
• Enormous applications of the database
• Integrate healthcare domain knowledge to
provide sophisticated user-defined functions and interfaces
• Built-in decision-support system for automatic report generation including medical data
interpretation, automatic summary, and suggestion
HEALS: Overview
• Provides a user-friendly, intelligent, fully- functional application experience to
clinical workers in a distributed way
• Rural clinics can seamlessly share the services provided by HEALS via web- browsing
• Customers can also easily derive
integrated healthcare information from HEALS under certain security
authentication
Clinical Diagnosis
• Infer a disease state that is not directly observable
• Forms of a physician’s knowledge:
– Rule – Pattern
Knowledge-Based Agents
• Knowledge base
– The center component – A set of sentences (rules)
• Knowledge representation language
• Inference
– Reasoning engine
Define the Task Environment of an Intelligent Agent
• PEAS
– Performance measure – Environment
– Actuators – Sensors
Define the Task Environment - Performance Measure
• Minimizing error
• Minimizing operating time
• Maximizing quality
• Maximizing reports output
– Over 6000 reports per year now
Define the Task Environment - Environment
• Known examination items
– Physical examinations – Laboratory tests
– Others
• Known examination types
– Laboratory
• Numerical (glucose, liver function, …)
• Symbolic (hepatitis markers, …)
– Others
• Text (gastroenteroscopy, …)
Define the Task Environment - Actuators
• Output the diagnoses
– Possible diseases
• Output the suggestions
– Life style modification – Medical suggestion
Define the Task Environment - Sensors
• Examination results
– From database system
• Personal Health History
CDSS of HEALS
CDSS: Clinical Decision Support System
Algorithm
Reasoning Engine Exam.
Results
Rules
Diagnoses and Suggestion Codes
Codes-Text Tables
Reports
Other Information
Rule-Codes Table
Presentation Engine
Rule-Codes Table
Rule Name Description
Section
Code Suggestion codes MCVLHBN1
Low MCV, normal HB, MCV/RBC>131 d20,602,g24r1,t84 MCVLHBN2
(r/o Thalassemia) Low MCV, normal HB1 d20,G24R2,t82 MCVLHBL1
(Microcytic anemia) low MCV, low HB, MCV/RBC>131 G24R2,t83 MCVLHBL2
(r/oThalassemia) low MCV, low HB, MCV/RBC<131 d20,G24R2,t81
MCVNHBL1
Normal MCV, HB10-121 t10,d50,40,403,g24r1
MCVNHBL2
Normal MCV, HB<101 t11,d50,40,403,g24r1
Code-Text Table:
Diagnoses
Code Diagnosis
81 r/o Thalassemia
82 r/o Thalassemia
83 Microcytic anemia
84 Low MCV
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
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
603e
No marked classification abnormality is found
concurrently with any other pathological change in blood cells, thus no medical treatment is required at the
moment.
604 疑因過敏體質所致,
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
The value is usually relatively high among kids and teenagers who grow rapidly.
BNF Grammar of Rules
declaration ::= limit_declaration
| range_declaration
| clause_declaration
| rule_declaration
BNF: Backus-Naur Form
Full text on:
http://www.csie.ntu.edu.tw/~d93009/AMIA2006/
BNF Grammar of Rules (cont.)
limit_declaration ::= limitdef limit_name limit
range_declaration ::= rangedef range_name range
clause_declaration ::=
clausedef clause_name clauses rule_declaration ::= ruledef
rule_name rules
Examples of Rules
limitdef UWBC2 UWBC > 20 rangedef UWBC1 UWBC (5 20]
clausedef UWBC6 UWBC2 || UWBC4 ruledef UWBCABNH UWBC1 &&
URBCN && !URBC4
Reasoning Engine
• Forward chaining reasoning
– Data-driven reasoning
• Procedural approach part of this implementation
– Initiation of variables used in rules
• Processing rules
• Generating result codes
Examples of Encoding Domain Knowledge into Rules
• Some Hepatitis B Markers
– Hepatitis B surface antigen (HBsAg)
• Outer surface coat
– Hepatitis B surface antibody (HBsAb)
• Antibody to HBsAg
– Hepatitis B core antibody (HBcAb)
• Antibody to inner nucleocapsid core
Interpretation of Hepatitis B Markers
limitdef HBSAG_pos HBSAG == "+“
** HBsAg is positive
limitdef HBSAG_neg HBSAG == "-“
** HBsAg is negative
limitdef HBSAB_pos HBSAB == "+“
** HBsAb is positive
limitdef HBSAB_neg HBSAB == "-“
** HBsAb is negative
Interpretation of Hepatitis B Markers
limitdef HBCAB_pos HBCAB == "+“
** HBcAb is positive
limitdef HBCAB_neg HBCAB == "-“
** HBcAb is negative
Interpretation of Hepatitis B Markers
limitdef OLD_HBSAG_pos OLD_HBSAG == "+“
** any of the previous HBsAg tests is positive limitdef OLD_HBSAG_neg OLD_HBSAG == "-“
** 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
Interpretation of Hepatitis B Markers
limitdef OLD_HBCAB_pos OLD_HBCAB
== "+“
** any of the previous HBcAb tests is positive
limitdef OLD_HBCAB_neg OLD_HBCAB
== "-“
** all of the previous HBcAb tests are negative
Interpretation of Hepatitis B 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 HBcAb is negative now and any of the previous HBcAb tests is positive
Interpretation of Hepatitis B 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
Interpretation of Hepatitis B 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, thus it is recommended that you receive vaccine injections.
˙Please visit the Outpatient Clinic of Family Medicine Division for a follow-up diagnosis and treatment.
Interpretation of Hepatitis B Markers
ruledef HBV_pnp HBSAG_pos &&
HBSAB_neg && HBCAB_pos
** If HBsAg is positive, HBsAb is negative, and HBcAb is positive
Interpretation of Hepatitis B Markers
ruledef HBV_pnp HBSAG_pos && HBSAB_neg &&
HBCAB_pos
HBsAg: positive; Anti-HBs: negative; Anti-HBc: positive
˙Don't take medication without a
physician's instructions, so as to avoid augmenting the workload of liver.
˙Take a rest, as appropriate; avoid being physically and mentally exhausted.
˙You are a hepatitis B carrier. Please have a follow-up consultation in the Outpatient
Clinic every half a year.
Interpretation of Hepatitis B 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
Interpretation of Hepatitis B Markers
ruledef HBV_nn HBSAG_neg && HBSAB_neg &&
HBCAB_nil && !AGE_50
HBsAg: negative; Anti-HBs: 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.
Interpretation of Hepatitis B 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 is positive
Interpretation of Hepatitis B Markers
ruledef HBV_nnp1 HBSAG_neg && HBSAB_neg &&
HBCAB_pos && OLD_HBSAG_pos
HBsAg: negative; Anti-HBs: negative; Anti-HBc: positive;
Previous HBsAg: positive
˙Do not take medication without physician's instructions, to avoid augmenting the workload of liver.
˙Take a rest, as appropriate; avoid being physically and mentally exhausted.
˙You are a hepatitis B carrier. Please have a
follow-up consultation in the Outpatient Clinic every half a year.
Examples of Encoding Domain Knowledge into Rules
• Anemia
– RBC (Red Blood Cell)
– MCV (Mean Corpuscle Volume) – Hb (Hemoglobin)
Anemia
rangedef MCV_Low78 MCV [78 80) rangedef MCV_Low MCV (0 80) 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 RBC_High RBC > 7 limitdef RBC_mildHigh RBC > 5
Anemia
rangedef MCV_DIV_RBC_Low MCV_DIV_RBC (0 13)
** 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
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)
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.
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)
Anemia
ruledef MCVLHBL1 !MCVABNL21 && MCV_Low && HB_Low
&& !MCV_DIV_RBC_Low
RBC: 3.00*106/ul, Hb: 8.0g/dL, MCV: 70fl Microcytic anemia
˙Please visit the Outpatient Clinic of Division of Family Medicine
for a follow-up diagnosis and treatment.
Anemia
ruledef MCVLHBL2 !MCVABNL21 && MCV_Low && HB_Low
&& MCV_DIV_RBC_Low
** If MCVABNL21 is false, MCV<80, Hb<12, and MCV/RBC<13 (Thalassemia)
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.
Anemia
ruledef MCVNHBL2 !MCV_Low && HB_severeLow
** If MCV>=80 and Hb<10
Anemia
ruledef MCVNHBL2 !MCV_Low && HB_severeLow RBC: 3.00*106/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.
Summary and
Conclusion
HEALS:
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
CDSS of HEALS: Advantages
• A way of using clinical guidelines in medical practices.
• Simple and clear rule syntax
• Efficient reasoning algorithm
• To ensure the state-of-the-art of the
knowledge base, the rules can be readily
updated by domain experts easily
Evaluation Results
• 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
HEALS: Next
• To be one of the references of health examination information systems
• Future improvement of the CDSS in HEALS
– Analyze the database to extract stochastic or
domain-specific methods to improve healthcare quality and efficacy
References
• S. Russell and P. Norvig, Artificial Intelligence: A Modern Approach, 2nd Ed., Prentice Hall, New York, 2002.
• 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.
• E. Bernstern, “Decision Support and Computers in Education,”
HI5300: Introduction to Health Informatics, School of Health Information Sciences and Department of Internal Medicine, University of Texas – Houston, 2004.
• HL7 Working Group, “Standards in Clinical Decision Support:
Using Arden Syntax,” http://cslxinfmtcs.csmc.edu/hl7/arden/, 2003.
• P. Caleb-Solly, "Clinical Decision Support Systems," Seminar for the Health Informatics, 2001.