Category Archives: Clinical Decision Support

The Knowledge Last Mile Problem

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File:Ancients repository of knowledge.jpg

Colonel Jack O’Neill, the intrepid leader of the Stargate SG-1 taskforce of the eponymous popular Sci-Fi TV show, in his time took some remarkably astute decisions, oftentimes in situations of great stress, saving our galaxy from being overrun by nasty alien races more than a few times. Now, O’Neill is a great generalist and thinks fast on his feet but he never was a paragon of erudition nor does he have any such pretensions. Indeed, he harbors a robust disdain for anything resembling scholarly pursuit. However we all know, in intergalactic matters our gut-level decisions are not always enough. From time to time we have to invoke a higher body of knowledge. When the Replicators were on the verge of exterminating humans and no weapon in possession of humans and their alien allies seemed to be having any lasting impact on the ferocious onslaught, it was clear a new kind of weapon was desperately needed if the Replicators were to be thwarted. Fortunately for the earthlings, Colonel O’Neill very recently, had downloaded into his brain the entire knowledge repository of an incredibly advanced race, the Ancients. Armed with this knowledge he could quickly devise a weapon capable of annihilating the Replicators. Needless to say, once again the Milky Way Galaxy was saved.

Note that O’Neill did not learn from the Ancients. Instead his mind just imbibed the knowledge. He ‘acquired’ countless skills, including those needed to deal with the Replicator emergency, without having to go through the arduous process of learning. I shudder to think what would have happened if O’Neill had had to read countless PDFs and WebPages before he was suitably equipped.

In short, the Ancients had developed the perfect technology to bridge the last mile knowledge gap, the gap between existing knowledge and its translation into practice, the gap that every human institution that works with knowledge has struggled with. No matter the amount of conclusive findings clinical research throws up, if the clinicians do not integrate them into their care-delivery is it worth anything?

Since beginning there has been the gap, the gap between research findings and how it is applied in practice.


The good intentioned knowledge producing people and institutions reduced it by making it easier for people to access the results of the research. This was done by using journals, monographs, textbooks and such, and later on making much of it available for little or no cost by the medium of internet.


But soon the realization dawned upon the knowledge producers and providers that just providing easier access to the research results is never going to be enough. The outputs of research efforts need to be sifted through to allow only the reliable information to impact practice. What came to be known as Evidence Based Medicine was driven by such meta-analysis. Besides vetting research for quality, the research results have to be articulated in actionable terms, which, in the field of medicine, came be known as clinical guidelines. The users of the knowledge, such as the clinicians, do not usually have time and inclination to undertake such analyses and translations. So it seemed to make sense that pre-processing the research results into meta-research and guidelines before it is made available will lead to improved application of the research into practice.

These efforts did result in narrowing the gap but not remarkably. The original enthusiasm for guidelines and meta-research seems to have lost steam.


What if a clinician’s mind had access to a knowledge repository just like the Ancients’, and had the ability to simply suck in on demand, the most appropriate pieces of knowledge? That would surely eliminate the gap.

A clinician with access to such a knowledge repository would be able to manage almost any condition using the best evidence and recommended practices. For such a scenario to unfold will take a very long time because we do not yet possess that level of ability to tinker with minds. However, we do possess reasonable knowledge of computers. After all we created them. Can we then think of a way in which all human wisdom, expressed into actions, be made available in a shared knowledge repository. The computer of the clinician can then access this knowledge on demand to get precise advice about what next needs to be done about the patient on hand. The wisdom in such a repository could be deposited, over course of time, by clinicians themselves to be shared with other clinicians. The clinicians would enhance the knowledge to work for themselves but will also be able to share it to be able to make significant difference to others.

What will be the form of knowledge contained in such a knowledge repository? Remember, the knowledge should be able to modify behavior of a computer system to be able to advise the clinicians about individual patients. Software has been used for a long time as the standard way of altering the behavior of computers. However, software is created by programmers with special skills using sophisticated development tools. If the knowledge repository has to acquire the necessary knowledge that evolves with the understanding of the experts and clinicians, it will need to be modifiable by people with clinical expertise who normally do not possess software development skills.


This is where knowledge form like Proteus comes in. The Proteus knowledge is executable and yet modifiable by clinicians. We are in the process of building early mechanisms to allow clinicians to deposit such knowledge in a publicly available repository, which will allow clinicians to integrate, on demand, any part of knowledge they need to modify behavior of the Proteus Engine, a software module which interprets the knowledge and provides advice to the clinicians about individual patients based on the data from those patients.


Proteus Open Source Now!

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This is to announce the availability of source code for tools related to clinical decision support guidelines model, Proteus under an open source license (EPL). The open source development will proceed under the new Proteus Intelligent Processes (PIP) project.

With this announcement, we are also opening up the project for general participation. The code and related information can be found at  The home for Proteus will remain at Introductory information about the rule authoring system GreEd is available at

This also coincides with the release of the version 2.7 (beta), which has several new features to make knowledge authoring more exciting and easy.  Take the new application for a spin by downloading it from

What’s New

I list some of the new features in Version 2.7 below:

Protean (Clinical Workflow Authoring Tool)

  • Sharing executable knowledge
  • Unlimited undo and redo
  • Promotion and demotion
  • Move an item from one location to another
  • Search your library of components

GreEd (Rule Authoring Tool)

  • Undo and Redo
  • Default Inference
  • Semantic Guidance and constraints
  • New operators for your expressions, like [N of M] and [Between]
  • Date Fields and Operations

Read more about the new features here:

This is a major milestone for Proteus which was made possible by contributions from many wonderful people. Much of the development for this version was done in the Semantic Data Capture Initiative project of Henry Ford Health System, my employer. Besides Henry Ford, Lister Hill Center of National Library of Medicine played a critical role at the nascent stage of Proteus. Several ideas related to metadata usage and rule authoring were developed at City of Hope National Medical Center.

We will be scheduling a web seminar to provide a quick introduction to Proteus, GreEd and the PIP project and demonstrate the tools. Please let me know if you are interested in participating.

I will be at the upcoming AMIA annual symposium, in San Francisco and will be happy to meet you if you are planning to attend.

We welcome your participation and feedback.

Feel free to contact me.


Get to know GreEd Better

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In one of my previous posts, I had promised that I will be sharing with you more information about GreEd.  I did one better; I posted several pages about GreEd. You can find these here:

The same pages can also be accessed from the top menu of this blog.

Stay tuned, we will be adding some flash demos and tutorials for GreEd in near future. I will also keep you informed about development of GreEd.

P.S. Do not worry about mispronouncing GreEd, it is pronounced same as the good old human foible – greed. Either way, we wouldn’t be too offended.


Proteus and GreEd to Go Live in Henry Ford Health System

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The Henry Ford Health System is one of the largest health care providers of USA. It has also been at the forefront of many cutting edge innovations in healthcare. One such Henry Ford effort has been in progress, silently and away from the limelight, for the the last two years.  However, soon it will lead to deployment of Proteus – the unique clinical decision support technology and GreEd – the clinical/business rules management system to implement clinical guidelines to allow physicians to save time and yet make better decisions about their patients.

This effort is called Semantic Data Capture Initiative project. I have just added a new page on this blog to give you some idea of what this project is about.

The Semantic Data Capture Initiative page provides you with an overview of the project. I will keep posting updates from this project here. Stay tuned.


Triumph of Open Source? : Lessons from VistA

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An interesting article in Washington Monthly highlights how VistA achieved its popularity was referred to on the AMIA Clinical Information System LISTSERV by Scot Silverstein.

To my mind, the key elements of VistA’s success are:

  • Participation of clinicians at every stage of its development including their writing of pieces of code and modules
  • Continuous, ongoing evolution and innovation
  • High degree of adaptability to different needs, not in small measure due to its being open source
  • Starting small and growing outwards, organically, rather than with a grand plan in a top-down approach

The bottom line is, Clinical Information Systems belong to clinicians. The sooner the Information Technology finds a way to hand it over to them the better it will be for the clinicians and for healthcare.


A ‘Houston’ for Clinicians

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Imagine an astronaut hurtling through the immense void on his journey towards Mars in a space probe. It is a lonely journey and scary adventure. There are untold unknowns and even the known variables are so many that to keep a constant eye on each one of them is not possible for a single human. The only chance he has of making the adventure a success is by getting constant support from the proverbial ‘Houston’. ‘Houston’ translates into a large of team of scientists and engineers manning an array of sophisticated equipment in constant radio contact with the Mars probe. So not only can our astronaut flip a switch and say, “Houston, we have a problem”, when he senses something out of the ordinary, ‘Houston’ can also proactively inform the space traveler of any important issues that he needs to be aware of. ‘Houston’ might even address some of the issues remotely without distracting the astronaut from whatever else he might be doing.

Turn your gaze earthward now and look at a clinician entering into an exam room to see her patient. Continue reading


The Power of the Checklist

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We know that most successful medical departments exploit the power of the checklists to achieve their results. Some interesting thoughts about this in a blog here:  Checklists aren’t just for pilots. Do watch the video clips and read Atul Gawande’s New Yorker article referred to in the blog. Gawande says:

If a new drug were as effective at saving lives as Peter Pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.

The question we need to ask is how to best integrate checklists in the clinical information systems. The answer to me is obvious: by having a process-oriented approach. I think the current Clinical Systems are based on the table paradigm which do not lend themselves to ordering the sequence of activities that need to be performed. Therefore it stands to reason that the approach that we are pursuing (Proteus), which has a process orientation at its core, is not just for clinical decision support but also for guiding all activities in the clinical world.


A Clinician’s Angst with Computers

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All of us who are in the field of informatics are well advised to pay attention to voices like these: Op-Ed Contributor – The Computer Will See You Now –

So many times have I heard the whines of those who develop applications for the clinicians. The refrain goes something like this, "The doctors are technology averse", "The clinicians are not interested in learning new ways of doing things".


There are innumerable examples of doctors embracing technology when it helped them achieve the goal of delivering better or more efficient care. I remember the days when ultrasound first arrived on the scene. The ultrasound machines in those days were kludgy pieces of equipment. The screens were tiny, with no shades of gray, the text messages displayed were cryptic, the buttons on the console were ill-organized. In short, they were the epitome of user-unfriendly technology. Yet, the clinicians took to them with gusto. Why? Because they gave them that extra edge in looking at soft organs. Obstetricians, whose notoriety as technology-averse is a legion, took the lead in adopting the technology. So, let’s just agree that the clinicians do not like technology is a myth promoted to conceal the failure of the discipline of Information Technology in meeting the needs of the clinicians.

A question that is relevant for us who are working with Proteus in the Semantic Data Capture Initiative (SDCI) is how much will the clinician feel shackled by the pre-defined processes which are created based upon guidelines? Does the clinician really need to enter all the data in exactly the same order as prescribed by the process or the guideline? We have taken an interesting approach to address this. In the web interface we are developing to provide clinical decision support from the Proteus Engine, we will allow the clinicians to enter any data that any of the templates for the guideline/process require, at any time. However, they will only be able to submit the data of each individual clinical context (defined by the knowledge components) only when the executing process reaches that particular point. This allows us to have best of both worlds: constraining data submission based on the needs of the decision support system while allowing the clinician to freedom to type ahead if they feel like it.


What Rules In the World of Clinical Decisions?

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Recently one of the NY Times blog carried this news about Vanderbilt University Medical Center going in for the Ilog business rules management system The Doctor Will B.R.M.S. You Now – Bits Blog – Other health IT sites and the blogosphere picked up this news and were abuzz for a while with the potential of such systems.

From this:


To This:


One has to stop and ask what is so complex about rules for healthcare that expensive systems are needed to support them. Do we really need them? Continue reading