WISE

Fakultät Wirtschaftswissenschaften, Lehrstuhl für Wirtschaftsinformatik, insbes. Systementwicklung

From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Hannes Schlieter 1 , Werner Esswein 1

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering, Dresden, Germany

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Agenda

§ Project Background § Theoretical Foundations

• Clinical Pathway (CP) vs Clinical Practice Guideline • Fundamentals of Reference Modeling • Framework for Clinical Recommendations

§ Motivation § Prior Research

§ The Reference Model­Based Approach § Analysis & Results § Future Research

24.09.2010 2 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Project Background The SOS­NET

24.09.2010 3 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Actually ca. 500 participants

www.carusconsilium.de

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Project Background The SOS­NET

§ Founded in 2007 § 13 hospitals within the network § Healthcare network for regional

stroke care (most important stroke § structure in Saxony) § Based on tele­medicial

infrastructure § Goal:

• quality treatment of all stroke patients independent to the regional location

• Lyse indication in small time slot

24.09.2010 4 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

SOS­Net ­ Stroke Network of Saxony

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

The Internal Quality as „Greybox“

Care process in a network

process quality

structure quality

Subresults visible Subresults visible

­ The internal quality is not visible ­ Fulfillment of requirements can be checked

visible

Implication: The processes in the network can not unified, however, a minimum standard of the processes, of coordination and communication of network members need to defined.

outcome quality

24.09.2010 5 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

The Clinical Practice Guideline (CPG)

Characteristics:

§ CPGs are recommendations for action (no binding instructions)

§ Systematically developed recommendations to support clinical activities

§ Classified into different development stages (Level 1 to 3)

§ Aggregation of evidence­based medicine

Aim: § Improvement of clinical care and cost reduction § Faster dissemination of evidence­based medicine § Patient information of the good clinical practice

6

Level 1: ­expert opinion Level 2: ­ consensus­based guideline Level 3: ­ evidence­based guideline

24.09.2010 6 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Characteristics: § Instrument for clinical process management § CPs are interdisciplinary and multi­professional aspects § Creation at local level („From the hospital for the hospital“)

Aim: § Improvement of cost and process transparency

§ Facilitate an active quality management (process quality improvement processes)

§ Improvement of medical outcome

§ Support of clinical documentation

§ Definition of local standards

7

The Clinical Pathway (CP)

[Roed+2003], S.20 ff

24.09.2010 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Framework for Clinical Recommendations

Scenarion I: § Derivation of CPs based on

CPGs Goal: § Reduction of manual work § Methodological adaptation § =>Improve Process quality Scenario II: § Revision of CPGs § Integrations and alignment of

CPG and CP

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WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

To­Be­Situation

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Stroke Unit Dresden

Advanced CPGs and Method for application

Network Members

Guarantee of quality level

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

?

Rules

Standards

Ziel Prozessübersicht Kennzahl Res­ source

Clinical Practice Guideline Specific Models of CPs

Motivation

24.09.2010 10 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Process

Evidence Medicine

Goals KPI ….

Clinical Practice

Gap

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Prior Research 1/3

11 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Nomenclatur of MDM: •Published modeling language of Society of Medical Decision Making •Goal: Comparison of CPGs

Critics: •Insufficient adequacy of modelling language •No Methodic for Adaption / No Construction Techniques [Broc2003]

24.09.2010

[MDM1992]

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Prior Research 2/3

12 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Computer­interpretable formalization: •In discussion since 1980s •Different language with (GLIF, GUIDE, Proforma, GEM...) •Goal: Transformation in decision support system

Critics: •Formal, not good human understandable •Only parts of information system, which can formalized

24.09.2010

[Ohno1998],S. 365 ff.

Modelling of computerized CPG­content

Trasnforamtion in formal format

Integration in Hospital inforamtion system

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Prior Research 3/3

13 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Approach of Jacobs: • First reference model based approach

• Applied for mamma carcinoma

Critics: •Arbitrary design decision

• No evaluation of modeling languages • Reduction on one construction technique

•Weak validity of results

[JACOBS2006], S. 74ff

24.09.2010

Reference Model Reference Model

Clinical Practice Guideline

Clinical Practice Guideline

CPG incl. Model CPG incl. Model Blank CP Blank CP

CP CP

+ Placeholder

+ Model of CPG

+ Replace the placeholder

+ key performance indicator, responsibilities

Science Science Practice Practice

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

I

[Bec+04]

<abstract>

<speciliciable> <strict>

II

<not allowed> Rules

Standards

Ziel Prozessübersicht Kennzahl Res­ source

The Reference Model­based Approach

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With Reuse

From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

For Reuse Process Goals KPI ….

CPG Specific Models of CPs

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Fundamentals of Reference Modeling Definition

§ In Information System (IS) research reference models are used to communicate best practice, common practice or normative rules [Becker2004].

§ They minimize the design risk and maximize the acceptance of model results. Reusing conceptual models or parts of models represent an integral area in research about effective and efficient software engineering and organizational design [Hammel1999].

§ The purpose of reference models usage is a reduction of development costs and of development time [Schuette1998]

§ Reference models specify rules and standards that guarantee the compliance to adaptability of a standardized application system or the compliance to organizational rules.

24.09.2010 15 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Characteristics of Reference Models: • Generality • Adaptability • Recommendatory character

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Fundamentals of Reference Modeling Construction Techniques

§ Configuration

§ Specialization § Aggregation § Instantiation § Analogy

Not generating adaptation

Generating adaptation

24.09.2010

[Br03]

16 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Fundamentals of Reference Modeling Construction Technique: Specialization

24.09.2010

• Specialization of a gerneral model

freie An­ passung

Free Modification

17 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

24.09.2010

• Selection of reference model components in respect of criteria

• The way of composition is in general rule independent

Auswahl Kompo­ sition

partielle Regelunter­ stützung dekbar!

Selection Compo­ sition

Partial rule based

Fundamentals of Reference Modeling Construction Techniques: Aggregation

18 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

24.09.2010

• RM pre­defines model elements, which are needed to be concretize

• Concretion without limitation or with limitation of range

Füllen von "Platz­ haltern"

Fundamentals of Reference Modeling Construction Technique: Instantiation

Instantia­ tion

19 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

24.09.2010

• Rule based adaptation • Selection of forethought models • Result: Projection of variant of the model

• All variants of modification are defined ex ante

Regel

Fundamentals of Reference Modelling Construction Technique: Configuration

Rule

20 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Analysis & Results

24.09.2010 21 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Analysis & Results

24.09.2010 22 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Issue 1: Many­to­Many Relation between CPs and CPGs Issue 2: Different CPGs to one indication

Issue 3: No standardization CPGs in structure Issue 4: No standardization of modeling language

Issues 5: No definition of RM­ Grammar for clinical context

Issue 6: Network participant use different CP designs Issue 7: CPGs are more abstract than CPs Issue 8: CPs describe addition aspect than COGs

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Further Research

§ Tool support for reference model construction and application

§ Definition of standards for conceptual modeling of clinical practice guidelines including the RM techniques

§ Extension of reference model­language to a reference model­based method

24.09.2010 23 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Fakultät Wirtschaftswissenschaften, Lehrstuhl für Wirtschaftsinformatik, insbes. Systementwicklung

Thank you for your attention!

Contact: Hannes.Schlieter@tu­dresden.de

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

References

[AWMF2001] AWMF: Leitliniendatenbank. website. – http://www.uni­duesseldorf.de/AWMF/ll/ ll_list.htm;2008, Abruf 24.06.2009

[Bec+2004] Becker, J., Delfmann, P., Ralf, K.: Konstruktion von Referenzmodellierungssprachen ­ Ein Ordnungsrahmen zur Spezifikation von Adaptionsmechanismen für Informationsmodelle. 251­­264 (2004).

[FeLo2004] Fettke, P.; Loos P.: Systematische Erhebung von Referenzmodellen ­ Ergebnisse der Voruntersuchung ­ Papers of the Research Group Information Systems & Management, Paper 16, Mainz 2004.

[Ihle04] Ihle, J.: Leitlinien und Recht ­ Bericht zur Tagung des Instituts für Gesundheits­ und Medizinrecht der Universität Bremen (IGMR) am 7. und 8. Mai. In: MedR Medizinrecht, 22 (2004), August 8, S. 440

[Hev+04] Hevner, A. R.; March, S. T.; Park, J.; Ram, S.: Design Science in InformationSystems Research. In: MIS Quarterly, 28 (2004) 1, S. 75–105

[Hindle+2003] Hindle D.; et al.: Instrumente zur Behandlungsoptimierung ­ Klinische Behandlungspfade. In: Der Chirurg, 2003.

[Jacobs2006] Jacobs, B.; Oberhoff, C.; Stausberg, J., Ableitung von klinischen Pfaden aus evidenzbasierten Leitlinien am Beispiel der Behandlung des Mammakarzinoms der Frau, In: GMS Medizinische Informatik, Biometrie und Epidemiologie, S. 1­10, 2007.

[MDM1992] MDM : Proposal for Clinical Algorithm Standards, Sage Journal, 12, S. 149­154, 2002. [Roed+2003] Roeder, N.; Hindle, D.; Loskamp, N.; Juhra, C.; Hensen, P.; Bunzmeier, H.; Rochell,

B., Frischer Wind mit klinischen Behandlungspfaden (I), in: das Krankenhaus, vol 1., S. 20­27, 2003.

[Schütte1998] Schütte, R.: Grundsätze ordnungsmäßiger Referenzmodellierung: Konstruktion konfigurations­ und anpassungsorientierter Modelle. Gabler Verlag, 1998.

[Thomas2006] Thomas, O.: Das Referenzmodellverständnis in der Wirtschaftsinformatik: Historie, Literaturanalyse und Begriffsexplikation. Veröffentlichung des Instituts für Wirtschaftsinformatik im Deutschen Forschungszentrum für Künstliche

Intelligenz. Heft 187, 2006.

[Trengler2003] Trengler C.:Klinische Pfade helfen Risiken verringern. In: Klinik Aktuell, 2003.

24.09.2010 25 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

Consequences

24.09.2010 26 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based Approach

Issue 1: Many­to­Many Relation between CPs and CPGs Issue 2: Different CPGs to one indication

Issue 3: No standardization CPGs in structure Issue 4: No standadization

Issue Network participant use different CP designs

Method, which guarantees a comparable result

WISE

Department of Business Management and Economics, Chair for Information Systems, esp. Systems Engineering

!! Rules

Standards

Ziel Prozessübersicht Kennzahl Res­ source

Reference Model Specific Models of CPs

Results

24.09.2010 27 From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model­Based

Approach

Issues: • level of abstraction • different aspects • representation

Similarities: • Clinical Algorithm