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A systems engineering perspective on the human-centered design of health information systems.

The discipline of systems engineering, over the past five decades, has used a structured systematic approach to managing the "cradle to grave" development of products and processes. While elements of this approach are typically used to guide the development of information systems that instantiate a significant user interface, it appears to be rare for the entire process to be implemented. In fact, a number of authors have put forth development lifecycle models that are subsets of the classical systems engineering method, but fail to include steps such as incremental hazard analysis and post-deployment corrective and preventative actions. In that most health information systems have safety implications, we argue that the design and development of such systems would benefit by implementing this systems engineering approach in full. Particularly with regard to bringing a human-centered perspective to the formulation of system requirements and the configuration of effective user interfaces, this classical systems engineering method provides an excellent framework for incorporating human factors (ergonomics) knowledge and integrating ergonomists in the interdisciplinary development of health information systems.

Artificial Intelligence↗

An artificial intelligence system for computer-assisted menu planning.

Planning nutritious and appetizing menus is a complex task that researchers have tried to computerize since the early 1960s. We have attempted to facilitate computer-assisted menu planning by modeling the reasoning an expert dietitian uses to plan menus. Two independent expert systems were built, each designed to plan a daily menu meeting the nutrition needs and personal preferences of an individual client. One system modeled rule-based, or logical, reasoning, whereas the other modeled case-based, or experiential, reasoning. The 2 systems were evaluated and their strengths and weaknesses identified. A hybrid system was built, combining the best of both systems. The hybrid system represents an important step forward because it plans daily menus in accordance with a person's needs and preferences; the Reference Daily Intakes; the Dietary Guidelines for Americans; and accepted aesthetic standards for color, texture, temperature, taste, and variety. Additional work to expand the system's scope and to enhance the user interface will be needed to make it a practical tool. Our system framework could be applied to special-purpose menu planning for patients in medical settings or adapted for institutional use. We conclude that an artificial intelligence approach has practical use for computer-assisted menu planning.

Artificial Intelligence↗

Health care telematics: who is liable?

This paper deals with questions of liability that may arise with the implementation and use of telematics and informatics in the health care sector. Traditionally liability has evolved around the responsible health care professionals. However, with increasing reliance on informatics and telematics in health care there may come a shift away from this concept of liability to the idea of shared liability between the responsible health care professionals and those who have provided this technology.

Artificial Intelligence↗

CT-guided interstitial implantation of gynecologic malignancies.

PURPOSE: To establish the efficacy of computed tomography (CT)-based planning and analysis of transperineal implants. METHODS AND MATERIALS: For patients with bulky disease or geometrically unfavorable anatomy, transperineal interstitial implantation of gynecologic tumors offers an alternative to standard intracavitary techniques. Control of dose rate and total dose distributions to produce a homogenous, low dose rate implant presents a challenge to the radiation oncologist in these complex implants, as does the relationship of these distributions to the patients's anatomy. We have used CT imaging following needle implantation, prior to source loading, in 25 patients (28 implants), as an aid in both the planning of the implant and the analysis of the dosimetry. RESULTS: The spatial relationship between the needles and the normal anatomy can be clearly defined, despite the presence of some artifacts. Tumor volume is less clearly visualized but the adequacy of needle placement can be assessed and adjusted if necessary. Modifications of the planned source placement, based upon the location of specific needles and critical structures, can be made prior to loading the patient. Dose rate and total dose distributions are displayed with the appropriate anatomy on axial images and on reconstructed sagittal and coronal planes. Multiple points of dose specification for the rectum and the bladder are easily defined. Dose rate adjustment can be made by selectively changing the activity associated with a particular needle or needles. Multiple implants as well as external beam irradiation can also be integrated. CONCLUSIONS: CT-based dosimetry has permitted intelligent planning decisions to be made prior to and during these implants. It has further allowed more accurate anatomically based dosimetric analysis, with visualization and control of dose rate and total dose distributions displayed together with the patient's anatomy. This more elaborate analysis should ultimately lead to a better understanding of the reasons for local control and complications and their relationships to dose rate, total dose, and volume.

Brachytherapy↗

S-TREE: self-organizing trees for data clustering and online vector quantization.

This paper introduces S-TREE (Self-Organizing Tree), a family of models that use unsupervised learning to construct hierarchical representations of data and online tree-structured vector quantizers. The S-TREE1 model, which features a new tree-building algorithm, can be implemented with various cost functions. An alternative implementation, S-TREE2, which uses a new double-path search procedure, is also developed. The performance of the S-TREE algorithms is illustrated with data clustering and vector quantization examples, including a Gauss-Markov source benchmark and an image compression application. S-TREE performance on these tasks is compared with the standard tree-structured vector quantizer (TSVQ) and the generalized Lloyd algorithm (GLA). The image reconstruction quality with S-TREE2 approaches that of GLA while taking less than 10% of computer time. S-TREE1 and S-TREE2 also compare favorably with the standard TSVQ in both the time needed to create the codebook and the quality of image reconstruction.

Algorithms↗

Three learning phases for radial-basis-function networks.

In this paper, learning algorithms for radial basis function (RBF) networks are discussed. Whereas multilayer perceptrons (MLP) are typically trained with backpropagation algorithms, starting the training procedure with a random initialization of the MLP's parameters, an RBF network may be trained in many different ways. We categorize these RBF training methods into one-, two-, and three-phase learning schemes. Two-phase RBF learning is a very common learning scheme. The two layers of an RBF network are learnt separately; first the RBF layer is trained, including the adaptation of centers and scaling parameters, and then the weights of the output layer are adapted. RBF centers may be trained by clustering, vector quantization and classification tree algorithms, and the output layer by supervised learning (through gradient descent or pseudo inverse solution). Results from numerical experiments of RBF classifiers trained by two-phase learning are presented in three completely different pattern recognition applications: (a) the classification of 3D visual objects; (b) the recognition hand-written digits (2D objects); and (c) the categorization of high-resolution electrocardiograms given as a time series (ID objects) and as a set of features extracted from these time series. In these applications, it can be observed that the performance of RBF classifiers trained with two-phase learning can be improved through a third backpropagation-like training phase of the RBF network, adapting the whole set of parameters (RBF centers, scaling parameters, and output layer weights) simultaneously. This, we call three-phase learning in RBF networks. A practical advantage of two- and three-phase learning in RBF networks is the possibility to use unlabeled training data for the first training phase. Support vector (SV) learning in RBF networks is a different learning approach. SV learning can be considered, in this context of learning, as a special type of one-phase learning, where only the output layer weights of the RBF network are calculated, and the RBF centers are restricted to be a subset of the training data. Numerical experiments with several classifier schemes including k-nearest-neighbor, learning vector quantization and RBF classifiers trained through two-phase, three-phase and support vector learning are given. The performance of the RBF classifiers trained through SV learning and three-phase learning are superior to the results of two-phase learning, but SV learning often leads to complex network structures, since the number of support vectors is not a small fraction of the total number of data points.

Algorithms↗

Integrating classification trees with local logistic regression in Intensive Care prognosis.

Health care effectiveness and efficiency are under constant scrutiny especially when treatment is quite costly as in the Intensive Care (IC). Currently there are various international quality of care programs for the evaluation of IC. At the heart of such quality of care programs lie prognostic models whose prediction of patient mortality can be used as a norm to which actual mortality is compared. The current generation of prognostic models in IC are statistical parametric models based on logistic regression. Given a description of a patient at admission, these models predict the probability of his or her survival. Typically, this patient description relies on an aggregate variable, called a score, that quantifies the severity of illness of the patient. The use of a parametric model and an aggregate score form adequate means to develop models when data is relatively scarce but it introduces the risk of bias. This paper motivates and suggests a method for studying and improving the performance behavior of current state-of-the-art IC prognostic models. Our method is based on machine learning and statistical ideas and relies on exploiting information that underlies a score variable. In particular, this underlying information is used to construct a classification tree whose nodes denote patient sub-populations. For these sub-populations, local models, most notably logistic regression ones, are developed using only the total score variable. We compare the performance of this hybrid model to that of a traditional global logistic regression model. We show that the hybrid model not only provides more insight into the data but also has a better performance. We pay special attention to the precision aspect of model performance and argue why precision is more important than discrimination ability.

Artificial Intelligence↗

Acquiring background knowledge for machine learning using function decomposition: a case study in rheumatology.

Domain or background knowledge is often needed in order to solve difficult problems of learning medical diagnostic rules. Earlier experiments have demonstrated the utility of background knowledge when learning rules for early diagnosis of rheumatic diseases. A particular form of background knowledge comprising typical co-occurrences of several groups of attributes was provided by a medical expert. This paper explores the possibility of automating the process of acquiring background knowledge of this kind and studies the utility of such methods in the problem domain of rheumatic diseases. A method based on function decomposition is proposed that identifies typical co-occurrences for a given set of attributes. The method is evaluated by comparing the typical co-occurrences it identifies as well as their contribution to the performance of machine learning algorithms, to the ones provided by a medical expert.

Algorithms↗

Prognostic methods in medicine.

Prognosis--the prediction of the course and outcome of disease processes--plays an important role in patient management tasks like diagnosis and treatment planning. As a result, prognostic models form an integral part of a number of systems supporting these tasks. Furthermore, prognostic models constitute instruments to evaluate the quality of health care and the consequences of health care policies by comparing predictions according to care norms with actual results. Approaches to developing prognostic models vary from using traditional probabilistic techniques, originating from the field of statistics, to more qualitative and model-based techniques, originating from the field of artificial intelligence (AI). In this paper, various approaches to constructing prognostic models, with emphasis on methods from the field of AI, are described and compared.

Artificial Intelligence↗

Cased-Based Reasoning for medical knowledge-based systems.

In this paper we present the results of the MIE/GMDS-2000 Workshop 'Case-Based Reasoning for Medical Knowledge-based Systems'. While in many domains Cased-Based Reasoning (CBR) has become a successful technique for knowledge-based systems, in the medical field attempts to apply the complete CBR cycle are rather exceptional. Some systems have recently been developed, which on the one hand use only parts of the CBR method, mainly the retrieval, and on the other hand enrich the method by a generalisation step to fill the knowledge gap between the specificity of single cases and general rules. And some systems rely on integrating CBR and other problem solving methodologies. In this paper we discuss the appropriateness of CBR for medical knowledge-based systems, point out problems, limitations and possible ways to cope with them.

Artificial Intelligence↗

Critical dimensions in medical informatics.

A typology of medical informatics applications is proposed around three dimensions: the dimension of care, the dimension of information and knowledge, and the aspects of the computerized society. These dimension can help both to evaluate application or research papers in the field or to derive long term goals for the discipline. In the first dimension medical informatics appears more as a technology driven by external forces such as the general progress of medicine or the integration of economical constraints in the choice of optimal procedures. It is argued that barriers to overcome as well as challenges for future research mainly remain in the two last dimensions.

Artificial Intelligence↗

Inductive analysis methods applied on questionnaires.

The am of this study was to evaluate subjective aspects from questionnaires dealing with dental trauma by applying different computerized inductive techniques within the field of artificial intelligence to questionnaires consisting of descriptive variables and of questions reflecting functional, personal, and social effects of patients' oral situation following dental trauma. As the methodology used is new to many readers in odontologic sciences, a detailed description of both the processes and the terminology is given. Utilizing a neural network as a first step in an analysis of data showed if relations existed in the training set, but the network could not make the relations explicit, so other methods, inductive methods, had to be applied. Inductive methods have the potential constructing rules from a set of examples. The rules combined with domain knowledge can reveal relations between the variables. It can be concluded that the usage of methods based on artificial intelligence can greatly improve explanatory value and make knowledge in databases explicit.

Algorithms↗

Modular representation of the guideline text: an approach for maintaining and updating the content of medical education.

One of the principal challenges in the medical practice is the update of their knowledge. One of the prime roles of the Continuing Medical Education is to train the medical practitioners with the latest advances in health care, specialized to their needs. Online courses and classroom teaching with computer-based representations have become an established mode of delivering medical education. This paper deals with the modularized representation of a medical text concerning clinical practice guidelines. The proposed system takes into consideration the semantics of the Unified Medical Language System and is based upon the marking up and display of the knowledge using the XML and XSLT languages. This modularization of the concepts leads to the determination of the context of a portion or the whole document. Thus, after marking up using our system, the text components can be exchanged, modified or reconstructed, which, in turn, would help to maintain the updates in medical knowledge.

Artificial Intelligence↗

Knowledge coupling: implementing outcomes measurement through the disciplined and routine control of inputs.

The successful implementation of outcomes measurement is jeopardized by its application within systems that do not control inputs. This systemic flaw within health care can be corrected by placing critical knowledge that is now in the minds of individual practitioners into computer-based knowledge coupling tools that can (1) track and control the inputs to the system in a disciplined and routine manner and (2) process information without error or bias. Outcomes then become a natural by-product of what amounts to a paradigm shift in the conceptualization and implementation of health care.

Artificial Intelligence↗