Executable medical guidelines with Arden Syntax - Applications in dermatology and obstetrics

INTRODUCTION Clinical decision support systems (CDSSs) are being developed to assist physicians in processing extensive data and new knowledge based on recent scientific advances. Structured medical knowledge in the form of clinical alerts or reminder rules, decision trees or tables, clinical protocols or practice guidelines, score algorithms, and others, constitute the core of CDSSs. Several medical knowledge representation and guideline languages have been developed for the formal computerized definition of such knowledge. One of these languages is Arden Syntax for Medical Logic Systems, an International Health Level Seven (HL7) standard whose development started in 1989. Its latest version is 2.10, which was presented in 2014. In the present report we discuss Arden Syntax as a modern medical knowledge representation and processing language, and show that this language is not only well suited to define clinical alerts, reminders, and recommendations, but can also be used to implement and process computerized medical practice guidelines. METHODS This section describes how contemporary software such as Java, server software, web-services, XML, is used to implement CDSSs based on Arden Syntax. Special emphasis is given to clinical decision support (CDS) that employs practice guidelines as its clinical knowledge base. RESULTS Two guideline-based applications using Arden Syntax for medical knowledge representation and processing were developed. The first is a software platform for implementing practice guidelines from dermatology. This application employs fuzzy set theory and logic to represent linguistic and propositional uncertainty in medical data, knowledge, and conclusions. The second application implements a reminder system based on clinically published standard operating procedures in obstetrics to prevent deviations from state-of-the-art care. A to-do list with necessary actions specifically tailored to the gestational week/labor/delivery is generated. DISCUSSION Today, with the latest versions of Arden Syntax and the application of contemporary software development methods, Arden Syntax has become a powerful and versatile medical knowledge representation and processing language, well suited to implement a large range of CDSSs, including clinical-practice-guideline-based CDSSs. Moreover, such CDS is provided and can be shared as a service by different medical institutions, redefining the sharing of medical knowledge. Arden Syntax is also highly flexible and provides developers the freedom to use up-to-date software design and programming patterns for external patient data access.

[1]  Prakash M. Nadkarni,et al.  Metadata-driven software systems in biomedicine : , 2011 .

[2]  G Hripcsak,et al.  Writing Arden Syntax Medical Logic Modules. , 1994, Computers in biology and medicine.

[3]  Klaus-Peter Adlassnig,et al.  Medical Knowledge Packages and their Integration into Health-Care Information Systems and the World Wide Web , 2008, MIE.

[4]  Guilherme Del Fiol,et al.  Clinical Information System Services and Capabilities Desired for Scalable, Standards-Based, Service-oriented Decision Support: Consensus Assessment of the Health Level 7 Clinical Decision Support Work Group , 2012, AMIA.

[5]  Omolola Ogunyemi,et al.  Description and Status Update on GELLO: a Proposed Standardized Object-Oriented Expression Language for Clinical Decision Support , 2004, MedInfo.

[6]  Klaus-Peter Adlassnig,et al.  An Arden-Syntax-Based Clinical Decision Support Framework for Medical Guidelines - Lyme Borreliosis as an Example , 2014, eHealth.

[7]  Stanley M. Huff,et al.  Ontologies, vocabularies, and data models , 2007 .

[8]  Aziz A. Boxwala,et al.  Sharable Representation of Clinical Guidelines in GLIF: Relationship to the Arden Syntax , 2001, J. Biomed. Informatics.

[9]  Adam Wright,et al.  A four-phase model of the evolution of clinical decision support architectures , 2008, Int. J. Medical Informatics.

[10]  Enrico Coiera Guide to health informatics , 2015 .

[11]  Yuval Shahar,et al.  Medizinische Leitlinien und Protokolle: das Asgaard/Asbru-Projekt , 1997, Künstliche Intell..

[12]  Suzanne Bakken,et al.  Improving the Human Readability of Arden Syntax Medical Logic Modules Using a Concept-oriented Terminology and Object-oriented Programming Expressions , 2006, Computers, informatics, nursing : CIN.

[13]  H. Christen,et al.  Lyme disease--current state of knowledge. , 2009, Deutsches Arzteblatt international.

[14]  Thomas Vetterlein,et al.  Fuzzy Arden Syntax: A fuzzy programming language for medicine , 2010, Artif. Intell. Medicine.

[15]  E. Shortliffe,et al.  Biomedical informatics : computer applications in health care and biomedicine , 2001 .

[16]  Elizabeth V. Murphy Clinical Decision Support: Effectiveness in Improving Quality Processes and Clinical Outcomes and Factors That May Influence Success , 2014, The Yale journal of biology and medicine.

[17]  Robert A. Greenes,et al.  Research Paper: The GuideLine Interchange Format: A Model for Representing Guidelines , 1998, J. Am. Medical Informatics Assoc..

[18]  John Fox,et al.  Application of Information Technology: The Syntax and Semantics of the PROforma Guideline Modeling Language , 2003, J. Am. Medical Informatics Assoc..

[19]  Adam Wright,et al.  SANDS: A service-oriented architecture for clinical decision support in a National Health Information Network , 2008, J. Biomed. Informatics.

[20]  Mor Peleg,et al.  Guidelines and Workflow Models , 2014 .

[21]  Katherine A. Sward,et al.  Executing medical logic modules expressed in ArdenML using Drools , 2012, J. Am. Medical Informatics Assoc..

[22]  Ferdinand T. Velasco,et al.  Improving Outcomes with Clinical Decision Support: An Implementer's Guide , 2012 .

[23]  Matthias Samwald,et al.  The Arden Syntax standard for clinical decision support: Experiences and directions , 2012, J. Biomed. Informatics.

[24]  V. Fingerle,et al.  EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis , 2010, European journal of neurology.

[25]  Klaus-Peter Adlassnig,et al.  Service-Oriented Fuzzy-Arden-Syntax-Based Clinical Decision Support , 2014 .

[26]  Krystyna Milian,et al.  Automated generation of patient-tailored electronic care pathways by translating computer-interpretable guidelines into hierarchical task networks , 2013, Artif. Intell. Medicine.

[27]  Mor Peleg,et al.  Computer-interpretable clinical guidelines: A methodological review , 2013, J. Biomed. Informatics.

[28]  B. Kosko Fuzziness vs. probability , 1990 .

[29]  Jon Duckett Beginning HTML, XHTML, CSS, and JavaScript , 2009 .

[30]  Elizabeth S. Chen,et al.  Using Arden Syntax to Identify Registry-Eligible Very Low Birth Weight Neonates from the Electronic Health Record , 2014, AMIA.

[31]  E. Aberer Lyme borreliosis – an update , 2007, Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG.