(Computers and Medicine) Steven Evans (auth.)-The PACE System_ An Expert Consulting System for Nursi - Computers and Medicine Helmuth F Orthner Series

(Computers and Medicine) Steven Evans (auth.)-The PACE System_ An Expert Consulting System for Nursi

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Unformatted text preview: Computers and Medicine Helmuth F. Orthner, Series Editor Springer Science+Business Media, LLC Computers and Medicine Information Systems for Patient Care Bruce I. Blum (Editor) Computer-Assisted Medical Decision Making, Volume 1 James A. Reggia and Stanley Tuhrim (Editors) Computer-Assisted Medical Decision Making, Volume 2 James A. Reggia and Stanley Tuhrim (Editors) Expert Critiquing Systems Perry L. Miller Use and Impact of Computers in Clinical Medicine James G. Anderson and Stephen J. Jay (Editors) Selected Topics in Medical Artificial Intelligence Perry L. Miller (Editor) Implementing Health Care Information Systems Helmuth F. Orthner and Bruce I. Blum (Editors) Nursing and Computers: A n Anthology Virginia K. Saba, Karen A. Rieder, and Dorothy B. Pocklington (Editors) A Clinical Information System for Oncology John P. Enterline, Raymond E. Lendhard, Jr., and Bruce I. Blum (Editors) H E L P : A Dynamic Hospital Information System Gilad J. Kuperman, Reed M. Gardner, and T. Allan Pryor Decision Support Systems in Critical Care M. Michael Shabot and Reed M. Gardner (Editors) Information Retrieval: A Health Care Perspective William R. Hersh Mental Health Computing Marvin J. Miller, Kenric W. Hammond, and Matthew G. Hile The P A C E System: A n Expert Consulting System for Nursing Steven Evans Steven Evans The P A C E System A n Expert Consulting System for Nursing With 30 Illustrations Springer Steven Evans Director Oncor M e d Genetic Risk Assessment 2027 Dodge Street, Suite 402 Omaha, N E 68102, U S A Series Editor Helmuth F . Orthner Medical Informatics Department University of U t a h School of Medicine 59 N o r t h Medical Drive Salt L a k e City, U T 84132, U S A Library of Congress Cataloging-in-Publication Data Evans, Steven. Use P A C E system: an expert consulting system for nursing / Steven Evans. p. cm.—(Computers and medicine) Includes bibliographical references and index. ISBN 978-1-4612-1900-2 (eBook) ISBN 978-1-4612-7331-8 DOI 10.1007/978-1-4612-1900-2 1. Nursing—Data processing—Research—Case studies. 2. Expert systems (Computer science)—Research—Case studies. 3. Artificial intelligence—Medical applications—Research—-Case studies. I. Title. II. Series: Computers and medicine (New York, N.Y.) RT50.5.E28 19% 610.73 '0285' 633—dc20 96-12477 Printed on acid-free paper. © 1997 Springer Science+Busmess Media New York Originally published by Springer-Verlag New York, Inc. in 1997 Softcover reprint of the hardcover 1st edition 1997 A ll rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher Springer Science-EBusiness Media, L L C , except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production managed by Chernow Editorial Services, Inc., and supervised by Karen Phillips; manufacturing supervised by Jacqui Ashri. Typeset by Best-set Typesetter Ltd., Hong Kong. 987654321 ISBN 978-1-4612-7331-8 Dedicated to my father and my mother Foreword In this volume, Steven Evans reports on a quarter century of work-work that resulted in a commercial product known as the PACE System. An advanced clinical management system, PACE links all care delivery settings and reaches across multiple episodes. It offers capabilities critical to managed care, including care planning and clinical pathways, the critical pathway analyzer and clinical repository central to outcomes-based care, and more. The pages that follow describe the PACE project, focusing on its knowledge base and semantic network. They offer insights into system implementation and address the synthesis of principles within the PACE System. From this project in nursing informatics, Steven Evans relates both successes and failures, sharing the strategies and techniques to adopt and pitfalls to avoid in a project that followed five years of preliminary theoretical work. With clarity and candor, he gives us the benefit of two decades of project development, first in academia and then in the commercial sector. Over the course of the project, many tens of millions of dollars and close to 500 person-years of effort were invested. Building on the strong conceptual base developed at Creigton University's School of Nursing, the project has seen exponential growth in its clinical capabilities since entering the commercial sector in 1989. As an advocate of nursing informatics, I have had the great good luck to follow Steven Evans' work on this project from early on. Despite the frustrations and complications that inevitably surround a large-scale group effort, he held true to his concept, building on each success and learning from every failure. Like other visionary health informaticians, including Larry Weed, he has been proven right by time. Steven Evans was among the first to recognize the contribution that cognitive science could make to healthcare computing. Today we are seeing this discipline gain recognition as informaticians seek to understand information-seeking behaviors in a changing information environment. vii viii Foreword Through his intellectual boldness and professional dedication, Steven Evans has succeeded. What was 25 years ago difficult, if not impossible for many of us to conceptualize, is now a reality we can see for ourselves-and that we can use to improve patient care. I join with Steven Evans in thanking those many professionals who helped move his theories into practice. He has counted mightily on their support. Yet I know the one central truth: without Steven Evans, there would be no PACE System. He has been its true believer, the one who held true to his vision when it would have been easier to relinquish it. For this commitment, we owe him our admiration and our attention to the pages that follow. Let us read and learn. Today more than ever, our world needs the benefits visions made real can bring. Marion J. Ball Series Preface This monograph series intends to provide medical information scientists, health care administrators, physicians, nurses, other health care providers, and computer science professionals with successful examples and experiences of computer applications in health care settings. Through the exposition of these computer applications, we attempt to show what is effective and efficient and hope to provide some guidance on the acquisition or design of medical information systems so that costly mistakes can be avoided. The health care industry is currently being pushed and pulled from all directions-from clinicians, to increase quality of care; from business, to lower cost and improve financial stability; from legal and regulatory agencies, to provide detailed documentation; and from academe, to provide data for research and improved opportunities for education. Medical information systems sit in the middle of all these demands. The generally accepted (popular) notion is that these systems can satisfy all demands and solve all the problems. Obviously, this notion is naive and is an overstatement of the capabilities of current information technology. Eventually, however, medical information systems will have sufficient functionality to satisfy most information needs of health care providers. We realize that computer-based information systems can provide more timely and legible information than traditional paper-based systems. Most of us know that automated information systems provide, on average, more accurate information because data capture is mote complete and automatic (e.g., directly from devices). Medical information systems can monitor the process of health care and improve quality of patient care by providing decision support for diagnosis or therapy, clinical reminders for follow-up care, warnings about adverse drug interactions, alerts to questionable treatment or deviations from clinical protocols, and more. Because medical information systems are functionally very rich, must respond quickly to user interactions and queries, and require a high level of security, these systems can be classified as very complex and, from a developer's perspective, also as "risky." ix x Series Preface Information technology is advancing at an accelerated pace. Instead of waiting for 3 years for a new generation of computer hardware, we are now confronted with new computing hardware every 18 months. The forthcoming changes in the telecommunications industry will be revolutionary. Certainly before the end of this century new digital communications technologies, such as the Integrated Services Digital Network (ISDN) and very high-speed local area networks using efficient cell switching protocols (e.g., ATM) will not only change the architecture of our information systems but also the way we work and manage health care institutions. The software industry constantly tries to provide tools and productive development environments for the design, implementation, and maintenance of information systems. Still, the development of information systems in medicine is, to a large extent, an art, and the tools we use are often self-made and crude. One area that needs desperate attention is the interaction of health care providers with the computer. Although the user interface needs improvement and the emerging graphical user interfaces may form the basis for such improvements, the most important criterion is to provide relevant and accurate information without drowning the physician in too much (irrelevant) data. To develop an effective clinical system requires an understanding of what is to be done and how to do it and an understanding of how to integrate information systems into an operational health care environment. Such knowledge is rarely found in anyone individual; all systems described in this monograph series are the work of teams. The size of these teams is usually small, and the composition is heterogeneous (i.e., health professionals, computer and communications scientists and engineers, biostatisticians, epidemiologists, etc). The team members are usually dedicated to working together over long periods of time, sometimes spanning decades. Clinical information systems are dynamic systems; their functionality constantly changes because of external pressures and administrative changes in health care institutions. Good clinical information systems will and should change the operational mode of patient care, which, in turn, should affect the functional requirements of the information systems. This interplay requires that medical information systems be based on architectures that allow them to be adapted rapidly and with minimal expense. It also requires a willingness by management of the health care institution to adjust its operational procedures and most of all, to provide end-user education in the use of information technology. Although medical information systems should be functionally integrated, these systems should be modular so that incremental upgrades, additions, and deletions of modules can be done to match the pattern of capital resources and investments available to an institution. We are building medical information systems just as automobiles were built early in this century (191Os) (i.e., in an ad hoc manner that disregarded even existing standards). Although technical standards addressing computer and communications technologies are necessary, they are insufficient. xi Series Preface We still need to develop conventions and agreements, and perhaps a few regulations, that address the principal use of medical information in computer and communication systems. Standardization allows the mass production of low-cost parts that can be used to build more complex structures. What are these parts exactly in medical information systems? We need to identify them, classify them, describe them, publish their specifications, and, most important, use them in real health care settings. We must be sure that these parts are useful and cost-effective even before we standardize them. Clinical research, health services research, and medical education will benefit greatly when controlled vocabularies are used more widely in the practice of medicine. For practical reasons, the medical profession has developed numerous classifications, nomenclatures, dictionary codes, and thesauri (e.g., lCD, CPT, DSM-III, SNOMED, COSTAR dictionary codes, BAlK thesaurus terms, and MESH terms). The collection of these terms represents a considerable amount of clinical activity, a large portion of the health care business, and access to our recorded knowledge. These terms and codes form the glue that links the practice of medicine with the business of medicine. They also link the practice of medicine with the literature of medicine, with further links to medical research and education. Because information systems are more efficient in retrieving information when controlled vocabularies are used in large databases, the attempt to unify and build bridges between these coding systems is a great example of unifying the field of medicine and health care by providing and using medical informatics tools. The Unified Medical Language System (UMLS) project of the National Library of Medicine, NIH, in Bethesda, Maryland, is an example of such effort. The purpose of this series is to capture the experience of medical informatics teams that have successfully implemented and operated medical information systems. We hope the individual books in this series will contribute to the evolution of medical informatics as a recognized professional discipline. We are at the threshold where there is not just the need but already the momentum and interest in the health care and computer science communities to identify and recognize the new discipline called Medical Informatics. Salt Lake City, Utah HELMUTH F. ORTHNER Acknowledgments Like PACE, this book was possible through the support in part by a grant from the W.K. Kellogg Foundation of Battle Creek, Michigan. The author is also greatly indebted to Dr. Helmut Orthner, Springer series editor, for his invaluable recommendations and encouragement, without which this book would never have survived. What clarity of expression there is owes its debt to both the Springer-Verlag and Chernow editors. Finally, both PACE and this volume owe their existence to the family support every contributor needs; just as this author is indebted to his Evans family, Deirdre, Bette, Micah, Jeremy, and Frances, too. xiii Contents Foreword vii Series Preface ix Acknowledgments 1. Introduction to the PACE Project xiii 1 2. PACE-Then and Now* 26 3. Initial Knowledge Base Development 62 4. Acquiring, Maintaining, and Managing a Knowledge Base 74 5. System Implementation 93 6. Issues in Semantic Network Development and Utilization 102 Synthesis of Principles and Lessons Learned 137 Appendix A. Taxonomy for the Health Sciences 145 Appendix B. Glossary for the Taxonomy for the Health Sciences 160 Index 165 7. * Coauthored with Patricia L. Tikkanen, RN, MSN xv CHAPTER 1 Introduction to the PACE Project Purpose and Organization of the Book First Goal: Requirements for Project Survival The first goal of this book is to utilize the case study of the development of the PACE (Patient Care Expert) system to describe and explain fundamental requirements that enabled a 20-year, large-scale project not only to survive but also to achieve its overall mission in the face of significant challenges (Evans, 1988b). The challenges facing a major initiative differ crucially from those confronting a focused and cohesive limited project. Contrast the task of obtaining lunch for oneself with the goal of preparing lunch for several battalions of an army. For yourself, you can find a convenience store, buy a ready-made sandwich and a drink, eat the lunch, and discard the packaging as you leave. Feeding several battalions requires obtaining massive amounts of ingredients, storing them, identifying recipes commensurate with huge quantities, preparing the different components of the meal in parallel with numerous personnel, distributing the food in a short time to large numbers, deploying support facilities to pick up (and store) the leftovers, completing the cleanup, and so on. Clearly there are challenges in the latter case that do not arise in the former. Such are the issues in a large-scale project like the one we shall describe in this volume. Readers involved in such larger efforts will find this volume helpful in the planning, initiation, and ongoing management of these enterprises. From the first goal presented above, it may be somewhat apparent why this book is applicable not only to nursing but to many other similar domains as well. Although some of the challenges facing the project were to a degree unique to nursing, most are endemic to any undertaking that is extensive and substantial in scope. Major efforts usually entail large groups, a large scale, and the long term. If the project requires a group effort, then inherent in this need is the division of knowledge and effort among the members of the group. From this division arises the need for integration and communication to mitigate 1 2 Purpose and Organization of the Book the effects of division and separate activities. A large-scale project calls for the allocation of significant resources. Inherent in such resource allocation is the need for ongoing support and the continuous management of resources. In a long-term project, changes are likely to occur in the technology, the philosophy, and the environment in which the project is immersed. With a longer term come changes in personnel, the need to renew focus and project continuity, and normal loss of momentum, which can impede any effort. Since the foregoing attributes apply to any domain, whether nursing or another, this book has widespread applicability. There is great potential in gaining insights into the approaches that were successful, understanding the pitfalls and mistakes from which lessons may be extracted, and recognizing solutions that may be applicable in the future. Since this specific undertaking did achieve worthwhile results in nursing, those with a special interest in nursing will also have particular interest in the details of this effort (Evans, 1988a). Second Goal: PACE Strategies and Approaches The second major goal of this book is to more fully elaborate on the specific approaches and solutions we devised to successfully accomplish the project. We describe the strategies that worked and those that did not, explaining why success was or was not achieved and giving our reasons for choosing one path over another. Thus others may benefit from the enormous experience acquired and lessons learned over two decades. We shall discuss in greater depth the various specific problems confronted, the selection and use of methodological approaches, the challenge of massive knowledge acquisition, codification, and maintenance, and the distribution of a practical system applicable to the working professional. These issues and underlying solution strategies remain as active and applicable today as they were during the 20 years needed to fashion them, although inform...
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