Clinical Guidelines SIG
Meeting Minutes Salt Lake City
4th October 2001
Author Peter Johnson
Attendance
Ian Purves, SCHIN, Newcastle University, UK (ian.purves@ncl.ac.uk)
Bob Greenes, Brigham and Women’s Hospital, Boston (greenes@harvard.edu)
Joachim Dudeck, HL7 Germany (jud@uni.fiessen.de)
Sven Tiffe, Siemens (sven.tiffe@med.siemens.de)
Cyndalyon Tilley, IHC (lpctille@ihc.com)
Charlotte Halstead, Eclipsys (charlotte.halstead@eclipsys.com)
Roberto Rocha, IHC (lprrocha@ihc.com)
Rick Bradshaw, IHC (lprbrads@ihc.com)
Susan Harada, ?? HIS (skharada@mmm.com)
Peter Haug, IHC (lophaug@ihc.com)
Matt Sailors, UT Houston (matthew.sailors@uth.tmc.edu)
Robert Jenders, Columbia University (jenders@columbia.edu)
Pat Lyons, Siemens (pat.lyons@smed.com)
Mor Peleg, Stanford University (peleg@smi.stanford.edu)
Samson Tu, Stanford University (tu@smi.stanford.edu)
Peter Johnson, SCHIN, Newcastle University, UK (pete@mimir.demon.co.uk)
Sharon Smart, SCHIN, Newcastle University, UK (s.r.s.smart@ncl.ac.uk)
Michael Johnson, Cognitech Corporation, SLC, Utah (johnson@cognitech-ut.com)
Jeff Washburn, IHC, SLC, UT (cojwashb@ihc.com)
Beatriz Rocha, IHC, SLC, UT (lpbrocha@ihc.com)
Susan Welch, University of Utah (susan.welch@hci.utah.edu)
Thomson Kuhn, ACP-ASIM (tkuhn@mail.acponline.org)
John Dulcey, Applied Medical Informatics (john.dulcey@alum.mit.edu)
Agenda
I.
Flowchart language for modeling clinical guidelines – Samson Tu
Powerpoint Presentation with Protégé examples. Discussed problems with
traditional algorithm representations. Requirements of ideal. Proposal to
use Workflow process model, based on WfMC. With additions for decision
making. Example in Protégé: influenza vaccination
Discussion about limitations of split/join XOR/AND as a limitation.
Required by Petri net formalism underlying it, but limiting for guideline
representation. Demonstration of same guideline in Visio. Limitations of
Visio discussed.
PERT charts discussed as alternative; but no mathematical formalism
behind them, so can’t verify soundness, boundedness etc. which is
advantage of Petri net based algorithm representation.
Bob Greenes: Discussion of visualization metaphors – need more than
formalism? Currently too low level?
Discussion from Mor about extensions to do different synchronization
steps, e.g. ‘wait for k of n’
Motivation for petri net based model: well defined execution model, makes
semantics explicit. Boundedness, reachability analysis, etc. Petri net
analysis tools exist both free and commercially. Allows us also to write
guidelines about guidelines.
Samson: what process is being modeled? Step by step procedure for
decision/action (traditional clinical algorithm), clinical workflow or decision
making maps.
Next steps:
a)
Clarify processes being modeled – look at other industries
b)
Use alternative tools
c)
Experiments with different guidelines
d)
Formalise flowchart model, with minimal supporting/surrounding
structures
e)
Experimental working software
f)
Exchange format for diagrams.
g)
Visualizing, browsing, crafting using higher level constructs – authoring
metaphors, need to classify nature of processes being modeled. Visual
languages and conventions containing implicit. Not an action item yet.
Action items:
II.

Communication with M. Stefanelli Pavia. Italy; ongoing (Samson)

Jerome Soller, Cognitech volunteered to join Samson in further work;
clarifying processes being modeled, formalizing flowchart model

Sven, Neill Jones, Mor Peleg, volunteered to experiment modeling
different guidelines using Protégé representation + Visio.

IBM website thought to have downloadable workflow tool (John
Dulcey) download and experiment.
Benchmarking guideline models
Discussion about possibility of providing benchmark tests for guidelines
systems. Would need set of guidelines as resources, in categories.
Possible tests:

Import export

Portability

Verifiability, Reviewability

Authoring benchmarks

Comprehensiveness

Usability

Acceptance of guideline – a different problem, as this is benchmark of
guideline quality.
Measures have to be quick and cheap, otherwise not realistically usable.
Conclusion, there aren’t outcome measures we can apply easily to
benchmarking guidelines. However, we can provide resources and tools
for experimentation.
Discussion about resources which could be shared:
i) Documentation of models, to go on HL7 site too. Get permission, or put
links to OpenClinical site.
ii) (Neill Jones) Take standard guidelines and break them up in fragments,
e.g. using the standard expression language, produce the expressions
required to implement this guideline, as a standard resource. This would
test usability and capability of proposed expression language. Requires
tools. Protégé generates too many forms.when representing recursive
formalisms like this.
iii) Populated VMR’s for the guideline – e.g. hypertension.
Samson: collection of real life expressions would be very useful. Not sure
what language this should be in – perhaps English, as a test for the
expression language.
Bob: IMKI (Institute for Medical Knowledge Implementation
http://www.imki.org/)– set up with seed money from Eclipsys. Harvard,
Stanford and Indiana have signed up. Hopefully AMIA will to. Commitment
to provide public domain authoring tool, first program is to provide
expression language authoring tool and black box execution engine. (not
open source) by January. How do you create open, shareable knowledge
content. e.g. Arden – only Columbia shares their MLMs. This would be a
test to see if vendors will share content. Different from HL7 – sharing
content, not setting standards. Can we get to a mindset of sharing rather
than keeping things proprietary? Unclear whether this will be the case.
Is HELP going to be shared? Eclipsys has made a commitment to share
rule sets.
John Dulcey – 3 rule sets out there which would be useful to share.
Sometimes not owned by vendors (for liability reasons) owned by
customers.
What is the business case? Investigate open publishing model. Need
neutral parties to share/publish the material.
III.
Follow up guideline workshop
Bob: Interest in a third guideline workshop – one idea is to use
stakeholders who have content to share. Possibly Spring 2002. Maybe
funded by HL7. Will need planning committee. Motivation for participation
– if a corpus of material is created it validates the standards we are
producing.
Aims

To develop a community of interested people.

Getting a sense of commitment to launching a genome like community
aiming to share knowledge for the common good
Discussion about workshop – worries about number of meetings, and
about motivation for people to come.
Decision of group to take no further action at this time.
Action Items agreed from morning sessions:

Visual models for authoring and browsing – (Mor Peleg with Vimla
Patel & Sharon Smart)

Guideline Process modeling (workflow paradigm) - Samson

Create a Test Library – MLMs (DSG)

Test expressions for hypertension (Neill Jones)

Sample patients in VMR formalism (Neill Jones and Pete Johnson)

Sample MLMs with expressions represented in Gello for usability and
readability assessment (Pat Lyons)
(no early afternoon session)
IV.
Joint meeting with Structured Documents
Sharon Smart :presentation ‘Making prose based guidelines computable’
(powerpoint)
Discussion:
Is it possible to create one executable representation? Is the completely
instantiated version interchangeable between systems – only in a partially
complete stage.
Bob Dolan: access to the existing literature is a big win that we should aim
for first, by just putting headers on existing guideline prose text, semantic
indexing. Text search means you can find what you want very quickly.
Should aim for simple, quick ANSI standard on 80/20-rule basis, not trying
to achieve computability.
There is a cost to adding extra information, what are the drivers from the
industry to create this? What is the cost benefit analysis?
One driver is lifecycle – out of datedness – currently a problem with prose
guidelines.
Neill - there isn’t a legacy problem, because most guidelines only have a
life of 2-3 years, so the driver is to create structures for new guidelines,
not existing ones.
John Dulcey : Disagree about costs, e.g. test with GEM Cutter - it only
takes 15 minutes to mark up header, 3-4 hours to mark up the rest.
Computable vs. text – John Dulcey discussed ‘up to date’ – has metadata
structure, but not structured text. Very popular and successful. Agreement
that for small guidelines, simple recommendations, this architecture works
well. But you can’t represent complex guidelines with many drugs and comorbidities in this form.
Bob Dolan – maybe we should aim higher than exisitn level 1 for the base
representation. Maybe should in next version, extend to allow kinds of text
that Sharon expressed.
Liora Alschula: Challenge of implementing in HL7 is looking at metadata
required to capture cross application retrieval in the header, and what the
traffic will bear. How much latitude will be allowed in the structure?
Discussion of what should go in – only those bits that HL7 CG SIG has
agreed on as a standard – so the fully instantiated version isn’t
computable.
Discussion about level 1, 2, 3 vs. one model partially instantiated, which
will iterate versions as we agree on more standard areas.
Next Steps
Ongoing process with GEM and Rick Shiffman; more work at AMIA, report
back for January.
Aim to produce a structured document for guidelines.
Header: Define requirements first, then map into RIM and devise a v3
based header. Inclusion/Exclusion criteria a problem as they will need
defining exactly using the expression language, which isn’t yet a standard.
Body – more challenging. Not sure how to do this currently.
Action Items

Candidate header in conjunction with GEM – Neill Jones/Ian Purves

Mapping to RIM – Bob Dolan will undertake by January

Candidate body – provide an initial list of elements – Ian Purves
Next Meeting
Arranged all day, Thursday 10th January 2002 San Diego
Joint meeting with Structured documents, 3rd quarter