Decision support linked to Laboratory Information systems Dr Gerard Boran Adelaide and Meath Hospital Dublin Incorporating the National Children’s Hospital

Overview of presentation Definition of DSS What do they do? Target areas and users Methodologies Some examples of applications

Decision Support Systems Support for Health Care Professionals What is a decision support system? –"A DSS/KBS is any computer program designed to help health professionals make clinical decisions" [Shortliffe, 1987] e.g... Information management Focussing attention (alarms) Consultation

Decision Support Systems Support for Health Care Professionals Desirable DSS Features: –can be configured by the local users –have measurable benefits for patients and staff –control “data intoxication” –promote cost-effectiveness and efficient use of resources –improve co-operation between central and remote labs –based on appropriate informatics and telematic standards –can be integrated with existing LIS, order communication systems, and relevant clinical information systems

DSS versus KBS Knowledge-based systems (KBS) are computer programs which seek to imitate human intelligence and expertise through the use of symbolic reasoning DSS emphasise SUPPORT for the decision- making process

Do labs need DSS? Advances in laboratory technology –Automation –Integrated laboratories –distributed laboratories (satellite labs, point-of- care facilities, etc) Increases in workload Limitations on staff and resources

What should they do? Have measurable benefits for patients and staff Measurable improvements in quality and efficiency Be configurable by local users Control data intoxication promote efficient use of resources

What do they do? Information management –e.g activity, financial reports Focusing attention –alarms on critical data Consultation –Looking up manuals, protocols

Target Users Medical Staff Nurses, e.g. ICU nurses General Practitioners e.g... –Test ordering protocols –Access to lab manuals –Alarms/alerts for critical data –Interpretative reports

Target Users Laboratory Scientists –QC procedures –instrument fault diagnosis –preventive maintenance Managers –Monitor changes in costs, activity,etc

Decision Support Systems Support for Health Care Professionals Module Development –Structured Software Engineering Approach

Decision Support Systems Support for Health Care Professionals Techniques available –statistical/mathematical/graphical –algorithms –biodynamic models –knowledge-based systems (KBS) –Neural networks –Hypertext markup language

Decision Support Systems Support for Health Care Professionals Features of KBS technology –Reasoning ability –Explanation facilities –Learning by experience –Sensory perception (vision, hearing) –Language understanding (speech, writing) –Motor functions (robots, speech synthesis)

Decision Support Systems Support for Health Care Professionals KBS Structure –Knowledge Base Rule List List of comments/interpretations Database –Inference Engine Human-computer interface Rule handling procedures

Decision Support Systems Support for Health Care Professionals Forward Chaining propagation Rule (1) IF ((Condition-1 is TRUE) (Condition-2 is TRUE) ( )) THEN ((Condition-3 is TRUE) (Output Solution-1)) (Output Solution-1)).. Rule (209) IF ((Condition-3 is TRUE) (Condition-4 is TRUE)) THEN ((Output Solution-1) (Terminate))

Decision Support Systems Support for Health Care Professionals Support for ordering investigations Support for performing investigations Support for interpretation

Physician Test Requesting Result Interpretation Sample Collection Result Reporting Analysis Sample Preparation Decision Support Systems Total Testing Cycle

Decision Support Systems Support for Health Care Professionals Support for ordering investigations –Scheduling of Investigations –Dynamic Scheduling of Tests –Lab Information Need to work with order communication systems

Support for performing investigations –Advanced Instrument Interface –Remote Maintenance of Instruments –Instrument Fault Diagnosis/Troubleshooting –Quality Control –Validation of Results Decision Support Systems Support for Health Care Professionals

Support for interpretation –Alarms and Alerts –Graphical Presentation –Interpretative Reporting –Drug Alarms Feedback for use with order communication systems

Decision Support Systems Relevant Decision Support Modules –Patient Result Validation –Thyroid Function –Lipid –Alarm/Alert –Acid-Base –Drug Interference –Haematology Image Interpretation –MI markers –Organ Profile interpretation –Cytology applications –Microbiology applications

Integration Integrate with routinely used IS Data collection a by-product of routine activity Absence of key data (often clinical data) hampers progress

Integration With LIS, e.g –HELP system –OpenLabs –Connolly With HIS, e.g. –Order Communication systems With other Clinical Systems, e.g. –Departmental systems (data feeds...) –Shared Care system

OpenLabs architecture

General Practicioner GP DMS Patient St. James ConsultantSynapses Server Hos. DB Laboratory Renal Clinic Diabetic Day Centre Diabetic Clinic Eye Clinic Lipid Clinic Consultant Synapses ServerHos. DBLaboratoryRenal ClinicDiabetic Day CentreDiabetic ClinicEye ClinicLipid Clinic Tallaght SHARED CARE Integrating Lab Data with other clinical systems

The Test Cycle PRE INTRA POST

InvestigateInterpret NPT/Satellite Lab Reporting 3. QC/Validation 2. Analysis 1. Sample Prep Transport to Lab PTS/Porters Collect Sample (Phlebotomy,etc) Request Form/OCS Order Main Lab Clinician

Pre-laboratory applications Ordering protocols Order communications LUMPS/BUMPS (Peters et al, 1991) Dutch GP Guidelines

Order communications

Intra-laboratory Applications QA Server Patient Result Validation (Valdiguie, OpenLabs) Lab Watch

Post-laboratory Applications Thyroid interpretation protein electrophoresis interpretation interpretive reporting (college guidelines) Alarm systems Data feeds to other DSS - e.g. diabetes register