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A comparison of decision tree ensemble creation techniques.

We experimentally evaluate bagging and seven other randomization-based approaches to creating an ensemble of decision tree classifiers. Statistical tests were performed on experimental results from 57 publicly available data sets. When cross-validation comparisons were tested for statistical significance, the best method was statistically more accurate than bagging on only eight of the 57 data sets. Alternatively, examining the average ranks of the algorithms across the group of data sets, we find that boosting, random forests, and randomized trees are statistically significantly better than bagging. Because our results suggest that using an appropriate ensemble size is important, we introduce an algorithm that decides when a sufficient number of classifiers has been created for an ensemble. Our algorithm uses the out-of-bag error estimate, and is shown to result in an accurate ensemble for those methods that incorporate bagging into the construction of the ensemble.

Algorithms↗

Inducing NNC-Trees with the R4-rule.

An NNC-Tree is a decision tree (DT) with each non-terminal node containing a nearest neighbor classifier (NNC). Compared with the conventional axis-parallel DTs (APDTs), the NNC-Trees can be more efficient, because the decision boundary made by an NNC is more complex than an axis-parallel hyperplane. Compared with single-layer NNCs, the NNC-Trees can classify given data in a hierarchical structure that is often useful for many applications. This paper proposes an algorithm for inducing NNC-Trees based on the R4-rule, which was proposed by the author for finding the smallest nearest neighbor based multilayer perceptrons (NN-MLPs). There are mainly two contributions here. 1) A heuristic but effective method is given to define the teacher signals (group labels) for the data assigned to each nonterminal node. 2) The R4-rule is modified so that an NNC with proper size can be designed automatically in each nonterminal node. Experiments with several public databases show that the proposed algorithm can produce NNC-Trees effectively and efficiently.

Algorithms↗

Comparison of two knowledge bases on the detection of drug-drug interactions.

This paper describes a drug ordering decision support system that helps with the prevention of adverse drug events by detecting drug-drug interactions in drug orders. The architecture of the system was devised in order to facilitate its use attached to physician order entry systems. The described model focuses in issues related to knowledge base maintenance and integration with external systems. Finally, a retrospective study was performed. Two knowledge bases, developed by different academic centers, were used to detect drug-drug interactions in a dataset with 37,237 drug prescriptions. The study concludes that the proposed knowledge base architecture enables content from other knowledge sources to be easily transferred and adapted to its structure. The study also suggests a method that can be used on the evaluation and refinement of the content of drug knowledge bases.

Artificial Intelligence↗

OCIS: 15 years' experience with patient-centered computing.

In the mid-1970s, the medical and administrative staff of the Oncology Center at Johns Hopkins Hospital recognized a need for a computer-based clinical decision-support system that organized patients' information according to the care continuum, rather than as a series of event-specific data. This is especially important in cancer patients, because of the long periods in which they receive complex medical treatment and the enormous amounts of data generated by extremely ill patients with multiple interrelated diseases. During development of the Oncology Clinical Information System (OCIS), it became apparent that administrative services, research systems, ancillary functions (such as drug and blood product ordering), and financial processes should be integrated with the basic patient-oriented database. With the structured approach used in applications development, new modules were added as the need for additional functions arose. The system has since been moved to a modern network environment with the capacity for client-server processing.

Artificial Intelligence↗

Binary halftone image resolution increasing by decision tree learning.

This paper presents a new, accurate, and efficient technique to increase the spatial resolution of binary halftone images. It makes use of a machine learning process to automatically design a zoom operator starting from pairs of input-output sample images. To accurately zoom a halftone image, a large window and large sample images are required. Unfortunately, in this case, the execution time required by most of the previous techniques may be prohibitive. The new solution overcomes this difficulty by using decision tree (DT) learning. Original DT learning is modified to obtain a more efficient technique (WZDT learning). It is useful to know, a priori, sample complexity (the number of training samples needed to obtain, with probability 1 - delta, an operator with accuracy epsilon): we use the probably approximately correct (PAC) learning theory to compute the sample complexity. Since the PAC theory usually yields an overestimated sample complexity, statistical estimation is used to evaluate, a posteriori, a tight error bound. Statistical estimation is also used to choose an appropriate window and to show that DT learning has good inductive bias. The new technique is more accurate than a zooming method based on simple inverse halftoning techniques. The quality of the proposed solution is very close to the theoretical optimal obtainable quality for a neighborhood-based zooming process using the Hamming distance to quantify the error.

Algorithms↗

DXplain on the Internet.

DXplain, a computer-based medical education, reference and decision support system has been used by thousands of physicians and medical students on stand-alone systems and over communications networks. For the past two years, we have made DXplain available over the Internet in order to provide DXplain's knowledge and analytical capabilities as a resource to other applications within Massachusetts General Hospital (MGH) and at outside institutions. We describe and provide the user experience with two different protocols through which users can access DXplain through the World Wide Web (WWW). The first allows the user to have direct interaction with all the functionality of DXplain where the MGH server controls the interaction and the mode of presentation. In the second mode, the MGH server provides the DXplain functionality as a series of services, which can be called independently by the user application program.

Artificial Intelligence↗

A model for medical decision making and problem solving.

Clinicians confront the classical problem of decision making under uncertainty, but a universal procedure by which they deal with this situation, both in diagnosis and therapy, can be defined. This consists in the choice of a specific course of action from available alternatives so as to reduce uncertainty. Formal analysis evidences that the expected value of this process depends on the a priori probabilities confronted, the discriminatory power of the action chosen, and the values and costs associated with possible outcomes. Clinical problem-solving represents the construction of a systematic strategy from multiple decisional building blocks. Depending on the level of uncertainty the physicians attach to their working hypothesis, they can choose among at least four prototype strategies: pattern recognition, the hypothetico-deductive process, arborization, and exhaustion. However, the resolution of real-life problems can involve a combination of these game plans. Formal analysis of each strategy permits definition of its appropriate a priori probabilities, action characteristics, and cost implications.

Artificial Intelligence↗

Gene expression data analysis of human lymphoma using support vector machines and output coding ensembles.

The large amount of data generated by DNA microarrays was originally analysed using unsupervised methods, such as clustering or self-organizing maps. Recently supervised methods such as decision trees, dot-product support vector machines (SVM) and multi-layer perceptrons (MLP) have been applied in order to classify normal and tumoural tissues. We propose methods based on non-linear SVM with polynomial and Gaussian kernels, and output coding (OC) ensembles of learning machines to separate normal from malignant tissues, to classify different types of lymphoma and to analyse the role of sets of coordinately expressed genes in carcinogenic processes of lymphoid tissues. Using gene expression data from "Lymphochip", a specialised DNA microarray developed at Stanford University School of Medicine, we show that SVM can correctly separate normal from tumoural tissues, and OC ensembles can be successfully used to classify different types of lymphoma. Moreover, we identify a group of coordinately expressed genes related to the separation of two distinct subgroups inside diffuse large B-cell lymphoma (DLBCL), validating a previous Alizadeh's hypothesis about the existence of two distinct diseases inside DLBCL.

Artificial Intelligence↗

Design of a standards-based external rules engine for decision support in a variety of application contexts: report of a feasibility study at Partners HealthCare System.

This project explored functional requirements for an institution-wide method, at Partners HealthCare, for interpreting clinical knowledge for decision support. Such knowledge is currently incorporated in a variety of clinical applications, yet the methods of representation and of execution vary and the ability to author/edit the rules by human experts is limited. We expanded on a 2002 "Knowledge Inventory" at Partners to evaluate feasibility of designing a single representation approach entailing: (a) exploration of specific needs of different applications, in terms of kinds of response required (synchronous/asynchronous, time criticality, etc.), context (e.g., implied patient, time frame, or episode), and kinds of actions to be triggered; (b) kind of representation of knowledge and feasibility of casting knowledge in the form of if em leader then statements; and (c) data and knowledge resources used (implied data model, and particular knowledge sources and terminology sources). The result of analysis was to design an architecture to accomplish this goal. We also did preliminary analysis of requirements for authoring for such a representation, and for implementation.

Artificial Intelligence↗

Evolution of a knowledge base for a clinical decision support system encoded in the Arden Syntax.

Clinical decision support systems (CDSS) are being used increasingly in medical practice. Thus, long-term maintenance of the knowledge bases (KB) of such systems becomes important. To quantify changes that occur as a KB evolves, we studied the KB at the Columbia-Presbyterian Medical Center. This KB has a total of 229 Medical Logic Modules (MLMs) encoded in the Arden Syntax. Eliminating those never used in practice, we retrospectively analyzed 156 MLMs developed over 78 months. We noted 2020 distinct versions of these MLMs that included 5528 changed statements over time. These changes occurred primarily in the logic slot (38.7% of all changes), the action slot (17.8%), in queries (15.0%) and in the data slot exclusive of queries (12.4%). We conclude that long-term maintenance of a KB for a CDSS requires significant changes over time. We discuss the implications of these results for the design of KB editors for the Arden Syntax.

Artificial Intelligence↗

Implementing clinical practice guidelines while taking account of changing evidence: ATHENA DSS, an easily modifiable decision-support system for managing hypertension in primary care.

This paper describes the ATHENA Decision Support System (DSS), which operationalizes guidelines for hypertension using the EON architecture. ATHENA DSS encourages blood pressure control and recommends guideline-concordant choice of drug therapy in relation to comorbid diseases. ATHENA DSS has an easily modifiable knowledge base that specifies eligibility criteria, risk stratification, blood pressure targets, relevant comorbid diseases, guideline-recommended drug classes for patients with comorbid disease, preferred drugs within each drug class, and clinical messages. Because evidence for best management of hypertension evolves continually, ATHENA DSS is designed to allow clinical experts to customize the knowledge base to incorporate new evidence or to reflect local interpretations of guideline ambiguities. Together with its database mediator Athenaeum, ATHENA DSS has physical and logical data independence from the legacy Computerized Patient Record System (CPRS) supplying the patient data, so it can be integrated into a variety of electronic medical record systems.

Artificial Intelligence↗

Medical decision support: experience with implementing the Arden Syntax at the Columbia-Presbyterian Medical Center.

We began implementation of a medical decision support system (MDSS) at the Columbia-Presbyterian Medical Center (CPMC) using the Arden Syntax in 1992. The Clinical Event Monitor which executes the Medical Logic Modules (MLMs) runs on a mainframe computer. Data are stored in a relational database and accessed via PL/I programs known as Data Access Modules (DAMs). Currently we have 18 clinical, 12 research and 10 administrative MLMs. On average, the clinical MLMs generate 50357 simple interpretations of laboratory data and 1080 alerts each month. The number of alerts actually read varies by subject of the MLM from 32.4% to 73.5%. Most simple interpretations are not read at all. A significant problem of MLMs is maintenance, and changes in laboratory testing and message output can impair MLM execution significantly. We are now using relational database technology and coded MLM output to study the process outcome of our MDSS.

Academic Medical Centers↗

Building an explanation function for a hypertension decision-support system.

ATHENA DSS is a decision-support system that provides recommendations for managing hypertension in primary care. ATHENA DSS is built on a component-based architecture called EON. User acceptance of a system like this one depends partly on how well the system explains its reasoning and justifies its conclusions. We addressed this issue by adapting WOZ, a declarative explanation framework, to build an explanation function for ATHENA DSS. ATHENA DSS is built based on a component-based architecture called EON. The explanation function obtains its information by tapping into EON's components, as well as into other relevant sources such as the guideline document and medical literature. It uses an argument model to identify the pieces of information that constitute an explanation, and employs a set of visual clients to display that explanation. By incorporating varied information sources, by mirroring naturally occurring medical arguments and by utilizing graphic visualizations, ATHENA DSS's explanation function generates rich, evidence-based explanations.

Artificial Intelligence↗

Evaluation of a knowledge-based system providing ventilatory management and decision for extubation.

We evaluated whether a knowledge-based system (KBS) connected to a ventilator in pressure support mode could correctly predict the ability of patients to tolerate total withdrawal from ventilatory support. The KBS was designed to continuously adapt ventilatory assistance to the needs of the patient, to manage a strategy of gradually decreasing ventilatory assistance, and to indicate when the patient was able to breathe without assistance. Thirty-eight patients for whom weaning was being considered were evaluated using a conventional battery of parameters, including weaning criteria, tolerance of a T-piece trial, and outcome 48h after permanent withdrawal of ventilation. The results of this evaluation were compared with the suggestions made by the KBS at the end of a period of KBS-driven mechanical ventilation inserted in the conventional weaning procedure. The positive predictive value of the KBS was 89%, versus 77% for the conventional procedure and 81% for the rapid shallow breathing index alone. The KBS correctly predicted the course of five patients who tolerated a T-piece trial but required ventilation within 48 h. We conclude that our KBS ensured appropriate patient management during the weaning period and improved our ability to predict responses to weaning.

Adult↗

Design and implementation of a framework to support the development of clinical guidelines.

This paper describes and discusses a framework that facilitates the development of clinical guideline application tasks. The framework, named GASTON covers all stages in the guideline development process, ranging from the definition of models that represent guidelines to the implementation of run-time systems that provide decision support, based on the guidelines that were developed during the earlier stages. The GASTON framework consists of (1) a newly developed guideline representation formalism that uses the concepts of primitives, problem-solving methods (PSMs) and ontologies to represent the guidelines of various complexity and granularity and different application domains, (2) a guideline authoring environment that enables guideline authors to define the guidelines, based on the newly developed guideline representation formalism and (3) a guideline execution environment that translates defined guidelines into a more efficient symbol level representation, which can be read in and processed by an execution time engine. The paper describes a number of design criteria that were formulated regarding the aspects of guideline representation, guideline authoring and guideline execution and explains the framework by example in terms of the four stages that were identified in the guideline development process and the tools that were developed to support each stage. It also shows examples of systems that were developed by means of the GASTON framework.

Artificial Intelligence↗

A decision-support system for the analysis of clinical practice patterns.

Several studies documented substantial variation in medical practice patterns, but physicians often do not have adequate information on the cumulative clinical and financial effects of their decisions. The purpose of developing an expert system for the analysis of clinical practice patterns was to assist providers in analyzing and improving the process and outcome of patient care. The developed QFES (Quality Feedback Expert System) helps users in the definition and evaluation of measurable quality improvement objectives. Based on objectives and actual clinical data, several measures can be calculated (utilization of procedures, annualized cost effect of using a particular procedure, and expected utilization based on peer-comparison and case-mix adjustment). The quality management rules help to detect important discrepancies among members of the selected provider group and compare performance with objectives. The system incorporates a variety of data and knowledge bases: (i) clinical data on actual practice patterns, (ii) frames of quality parameters derived from clinical practice guidelines, and (iii) rules of quality management for data analysis. An analysis of practice patterns of 12 family physicians in the management of urinary tract infections illustrates the use of the system.

Artificial Intelligence↗

The impact of computer-assisted test interpretation on physician decision making: the case of electrocardiograms.

This research investigated the effect of computer-assisted test interpretation (CATI) on physicians' readings of electrocardiograms (ECGs). The authors used an experimental method based on direct observations of 22 cardiologists, each reading 80 ECGs, for a total of 1,760 (of which 1,745 were used in the study). There were 40 sets of clinically-matched pairs of ECGs, one with CATI and one without. Reading time was observed and interpretation accuracy was measured by criterion-referenced aggregate scoring. To control for potential biases, the findings were subjected to multivariate analyses using ordinary least-squares regressions. The impact of CATI on cardiologists' readings of ECGs is demonstrably beneficial: the main empirical conclusion of this study is that, compared with conventional interpretation, the use of computer-assisted interpretation of ECGs cuts physician time by an average of 28% and significantly improves the concordance of the physician's interpretation with the expert benchmark, without increasing the false-positive rate. Moreover, CATI is the most accurate and saves the most time when the ECGs have many unambiguous diagnoses. Given that computers alone cannot perform the task of cardiovascular diagnosis, and that cardiologists' ECG interpretations are greatly enhanced by ubiquitous CATI technology, it appears that the best approach is one that combines person and machine.

Adult↗

AIDA--experiences in compensating the mutual weaknesses of knowledge-based and object-oriented development in a complex dental planning domain.

OBJECTIVES: Dentistry is a discipline with two properties that pose a serious challenge to knowledge based decision support: (1) It has to integrate six subdisciplines ranging from conservative measures to invasive disciplines, such as implantology; (2) A plan may have to cover a complex treatment often lasting one year or more. It is the aim of the AIDA-project to set up a planning strategy that is suited to incorporate all dental peculiarities in one methodology. METHODS: Generic tasks, that can be assigned to individual persons involved in dental treatment, have been designed with the help of KADS. They have been integrated into a planning super-structure for the planning of all dental solution alternatives, that can principally be applied on the basis of the given patient status. RESULTS: Besides an evaluation of the implemented planning system itself, it has been evaluated how well the development is supported by (1) knowledge-engineering methods and (2) object-oriented methods. CONCLUSION: Common knowledge-based tools are not powerful enough for the planning of complex dental constructions. Therefore, a solution combining object-oriented and knowledge-based methods is proposed.

Artificial Intelligence↗