1. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 1 An Event-Driven Approach to Computerizing Clinical Guidelines Using XML Presented By Essam Mansour School of Computing Dublin Institute of Technology Ireland

2. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 2 Presentation Outline Introduction  Computerised Clinical Guidelines (CGs)  Related Work  Shortcomings  Project Aim and Objective Event-Driven Approach and Framework for Computerising CGs AIM-SL: An Event-Driven Guideline Specification Language An Event-Driven Guideline Execution Model for the Patient Plan AIMS: A Prototype System for Managing CGs Future Work Summary

3. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 3 Introduction Clinical Guidelines (CGs) (Field 1992) provide guides for doctors and patients in determining recommended strategies for monitoring the patient’s condition. Clinical Guidelines as Active Information The management aspects required for CG automation are:  Specification  Customization  Execution  Query and Manipulation  Distributed Collaboration and Sharing Computerised Clinical Guidelines

4. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 4 Introduction Related Work Computerised Clinical Guidelines Approaches  Mainly, focus on specifying and executing CGs(Clercq 2004)  They adopt several techniques, such as AI and DB Clinical Events  Detect and respond to clinical events (McDonald 1976) ECA Rule paradigm  Arden Syntax (Clayton 1989)  HyperCare (Caironi 1997) XML  XML-based languages for formalising CGs (Dubey 2000, Fox 2001, Greenes 2001)  Facilitates the sharability and distribution Incorporating ECA rule into XML  Active XQuery (Bonifati 2002)  An Event-Condition-Action language for XML (Bailey 2002)  AXML (Abiteboul 2002)  XChange (Bry 2005)

5. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 5 Introduction In existing CG approaches, there are little or no:  Support for Clinical events.  Support for manipulating and querying clinical guidelines information.  Temporal support for the computerized clinical guidelines.  Support for sharing the execution history of the CGs. The event-driven approaches to computerising CGs:  Arden Syntax does not distinguish between the generic CG and its generated instances  Arden Syntax Specifications are stored as text file.  HyperCare does not provide a generic mechanism to be applied to other CGs. In providing an implemented triggering mechanism for a native XML DBMS. In supporting temporal triggers over XML documents. Shortcomings

6. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 6 Introduction The project aims at developing an information management framework and approach to computerizing clinical guidelines. The developed framework and approach should  provide support for specifying, executing, manipulating and querying clinical guidelines  Facilitate the distribution of CGs among heterogeneous systems  provide temporal support for the computerized clinical guidelines  Facilitate the integration of the clinical guidelines system into the electronic healthcare record (EHR) system. Project Aim and Objectives

7. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 7 XML ECA Rule Paradigm Clinical Guidelines Clinical Events Event Driven Approach for CG Computerisation Using XML Event-Driven Approach and Framework Our event-driven approach to computerising CG Event Driven Based for specifying and executing Clinical Guidelines Clinical Event supported by ECA XML-Based Clinical Guidelines XML-Based Clinical Events Facilitates the integration into EHR Facilitates the distribution and sharing

8. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 8 Relies on the ECA rule paradigm and XML technology. Provides the infrastructure for an Internet-enabled unified framework for CG management:  Event-driven Specification Language for CG  ECA rule execution mechanism  Easy integration into EHR management system  Manipulation and Query language  Easy dissemination Event-Driven Approach and Framework Our event-driven approach

9. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 9 Query, Manipulation Customization Query, Manipulation Execution Replay Instantiation Change Propagation SpEM Kernel -XML Technologies -ECA rule Mechanism -Temporal Support -Web Services Manipulation Plane Specification Plane Execution Plane Event-Driven Approach and Framework The SpEM Framework

10. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 10 An Event-Driven Specification Language Active Information Management (AIM) Language for Clinical Guidelines AIM AIM-SL AIM-QL *High-level *Declarative language - Supports Specification Plane * Model *Formal language - Is based on ECA rule and XML - Supports The Manipulation Plan *Customization *Query and Manipulation *Execution Replay - Extends the XQuery language

11. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 11 An Event-Driven Specification Language Attribute Element Sequence 0-1 Global Rules 1-M Protocol Library Protocols 0-1 Protocol Rules 1-M Rule Scope Ontology Mapping Rule Type Priority Condition Rule ID Name Header Properties Body Event Action The XML Schema Model for AIM-SL 1-M Category ID Schedules Header Name Protocol ID Release Info Didactic Info Schedule Rules Header Schedule Name ID

12. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 12 An Event-Driven Specification Language - microalbuminuria screening (MAS) protocol CID316 + - Basic MAS + - + AIM-SL Specification for Microalbuminuria Screening (MAS) Protocol

13. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 13 An Event-Driven Specification Language - Rule 2 of basic MAS + - + - TestResultRecieved + - + TestResultRecieved insert AIMS_TESTORDERRESULT /TestResult [testName=‘ACR’] TestResult AIM-SL Specification for MAS Protocol Customizatio n Process Rule MAS2: ON receiving the result of test ACR IF the ACR result is greater than 25 DO Add rule 3 and 4 to order a ACR test at day number 6 and 38

14. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 14 An Event-Driven Execution Model − + − + Patient Plan  Is an instance of a protocol for a specific patient.  Has an active part and a passive part  Is dynamically changing  grows over time The Active Part That shall be registered in the system The Passive Part That logs the history of the execution

15. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 15 Passive Part Event Condition Action CG ActionHM Action Patient Plan Active Part Event Manager Absolute Time Event Episode Event Related Time Event ExternalInternal Register an event Notify Register an event Notify Log the changes Internal DB External DB Register an event An Event-Driven Execution Model

16. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 16 1-Now 1-3 Element Attribute Text Node edge 1-3 validity 1-2 1-3 1-2 Value terminated 2-2 Value terminated 3-3 MAS3 state ready Value 3-Now MAS4 state ready Value 3-Now 1-2 ready MAS1 state Value Schedule 1-Now 1-3 MAS2 state ready Value 1-Now Rule MAS1: ON day 2 of the patient admission, DO order the ACR test. Day 2 Day 3 Rule MAS2: ON receiving the ACR test result IF the ACR result is greater than 25 DO Add rule 3 and 4 to order ACR test at day number 6 and 38 What is PP in Day 4? Replay PP from Day 3 to 5 An Event-Driven Execution Model Temporal Query Support

17. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 17 AIMS: A Prototype System for Managing CPGs Patient Plan EHR ECA Rule Mechanism Notifier Listener Message Processor Time Trigger Manager The XML Repository AIM-SL Specification Clinical Guidelines Management Module AIMS Manager An Active DBMS The ECA Rule Extension Module External Systems and Users DB Access Module SQL/XML Triggers SQL/XML Procedures An Active DBMS, such as Oracle and DB2, provides support to store and retrieve XML The XML Repository could be queried using SQL/XML or XQuery This layer extends the Active DBMS to support time triggers, and external communication mechanism This layer allows user to manage the CPGS and the external system to supply and receive information. Active EHR

18. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 18 A Prototype System for Managing CPGs Query and Manipulation UPDATE aims_protocol_tab SET OBJECT_VALUE = insertChildXML( OBJECT_VALUE, '//scheduleRules/rule[2]//AIM-QLAction/add', 'rule', XMLType(Rule5 )) WHERE existsNode( OBJECT_VALUE, '//scheduleRules/rule[2]//AIMQLAction/add' ) = 1 - Rule 2 of basic MAS + - + - TestResultRecieved + - + Update Rule 2 by adding rule 5 to its action. We might need to propagate this changes to the generated patient plan. Oracle SQL/XML Update statement

19. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 19 A Prototype System for Managing CPGs Query and Manipulation 1-3 1-2 1-3 1-2 Value terminated 2-2 Value terminated 3-3 MAS3 state ready Value 3-Now MAS4 state ready Value 3-Now 1-2 ready MAS1 state Value Schedule MAS2 state ready Value Retrieve all the schedule rules, which are currently ready for execution X Select p.OBJECT_VALUE.extract('/patientPlan[@PatNo=''PIDA'']// rule[state/value=''ready'']') From aims_pplan_tab p;

20. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 20 A Prototype System for Managing CPGs The modern active DBMS, such as Oracle, provides the primitive support to query and manipulate the CGs information. A high level query and manipulation language is required Temporal query support is needed Query and Manipulation

21. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 21 AIMS: A proof-of-concept system.  Developing AIM-QL  Extending XQuery to provide a temporal query support  Distributed Management for the patient plan  Evaluating AIMS system Future Work

22. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 22 A background, related work, and shortcoming The project aim and objectives Our event-driven approach and framework for computerizing CG. AIM-SL: A specification language for CGs. The execution model for the patient plan AIMS: A Prototype System for Managing CGs Summary

23. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 23 T haknY uo

24. An Event-Driven Approach to Computerizing Clinical Guidelines Using XML EDA-PS 2006: Chicago, USA Page No. 24 An Event-Driven Approach to Computerizing Clinical Guidelines Using XML Authors Essam Mansour Bing Wu Kudakwashe Dube Jian Xing Li