Health Telematics (AIM) Final Report


	Updated: Feb 1, 97
DILEMMA

Logic Engineering in General Practice, Oncology and Shared Care

Project Code: A2005

Project value: 4337 KECU

EC contribution: 2347 KECU

No of partners: 8

No of countries: 6

Duration: 36 months

Contact:
Prof John Fox
Imperial Cancer Research Fund
Advanced Computation Laboratory
PO Box 123
Lincoln's Inn Fields
London WC2A 3PX, U.K.
Tel.: +44-71-269.36.27
Fax: +44-71-269.31.86
E-mail: jf@acl.icnet.uk

Overview

The DILEMMA project has addressed clinical, technical and methodological questions in the design and implementation of aids for medical decision making and patient management. Technically, the project has focused on the use of logic programming and knowledge-based methods for constructing a generic technology to support clinical decision making, and for assisting in the scheduling and execution of clinical tasks in protocol-based care. DILEMMA has succeeded in integrating its generic decision support technology and electronic health care record with existing clinical information systems in a number of clinical domains.

Objectives

The DILEMMA project has developed systems to support medical decision making and patient management. The main aims of the project were to establish clinical requirements for advanced clinical decision support systems; to develop tools, methodologies and architectures with which to construct such systems; and to develop protocol-based applications in three main clinical settings:

general medical practice, to provide support for a range of clinical tasks, including prescribing and guideline-based management of common conditions like asthma and otalgia;
hospital-based cancer care, paying particular attention to the use of oncology protocols;
shared care of cancer and cardiology patients outside the hospital by primary care physicians, nurses, and paramedics, in consultation with hospital-based specialists.

Results, exploitation, demonstration.

Clinical Scenario

The following scenario illustrates the types of services developed by DILEMMA to support clinical users. It has been taken from one of the main clinical areas covered by the project: hospital oncology. Comparable services were also developed in the fields of primary care, and cardiology and oncology shared care.

A clinical oncologist is on routine rounds seeing patients in a specialist hospital ward. Although the doctor is quite experienced, state-of-the-art chemotherapy and radiotherapy are complex matters. There are many different cancers and many different therapies: frequent and precise adjustments may be required (e.g. to drugs or dosages), and medical care is complicated by rapid research developments and changes in preferred practice. Oncologists make many different kinds of decision, including decisions about diagnosis and tumour assessment, decisions about tests and investigations, and decisions about treatments and how to plan and execute them over time. However, the doctor can routinely access a range of information retrieval, data management and decision support services via her terminal which is interfaced with the hospital's information system. In this way she can access and update a patient's clinical history and treatment record; order investigations and other actions from remote hospital departments; consult a large library of electronic publications (medical reference material, drug databases etc); and, by taking advantage of the decision support system integrated with the hospital information system, gain assistance in making clinical decisions. The system can supply the clinician with help on any aspect of clinical decision making in oncology management, providing up-to-date support in one of the most important though complex and challenging of medical specialities.

Impact

Problems involved with the dissemination and consistent reproduction of best standards of care, soundly based on scientific evidence, arise increasingly throughout medicine. A substantial proportion of future medical practice will depend greatly on improved collaboration between the primary and secondary healthcare sectors, and effective sharing of data and expertise by different healthcare professionals. The creation and dissemination of clinical guidelines is finding increasing favour with clinicians and governments as a way to help clinical professionals keep pace with the avalanche of new clinical knowledge. Use of clinical guidelines in everyday healthcare has been shown to result in significant improvements in the care process and outcomes.

DILEMMA has built on conventional primary and secondary sector clinical informatics systems by providing clinicians with protocol-based decision support. The project has applied decision support telematics in two areas where there is significant concern for the quality and efficiency of healthcare provision throughout Europe: primary care and shared care. DILEMMA technology has aimed to extend the capabilities of existing conventional clinical information systems by adding value in such areas as patient data entry and retrieval, hypermedia database access, diagnosis, care planning, prescribing and follow-up.

Technology And Demonstrator Applications

DILEMMA technology extended the capabilities of existing conventional clinical information systems by adding value in such areas as patient data entry and retrieval, hypermedia database access, diagnosis, care planning, prescribing and follow-up. The development of clinical applications in DILEMMA was underpinned by a methodology for establishing clinical and functional requirements for decision support systems, and by a generic business model which formalises protocol-based care.

Technically the project focused on knowledge-based methods and the use of logic programming for constructing a generic technology to support clinical decision making. The decision technology supported the scheduling and execution of clinical tasks in protocol-based patient care. The decision functions have been used in diagnosis, investigation and therapy selection applications, and in a primary care prescribing advice system. The DILEMMA decision model and associated technology were successfully demonstrated in some six clinical application areas taken from oncology, cardiology and primary on care.

DILEMMA technology was integrated with an operational French oncology hospital information system and with a leading UK general practice management system. It also formed the basis of an oncology shared care telematics network, under development in France, linking specialist hospital oncologists, GPs and home care nurses.

DILEMMA technology included:

An electronic patient record, developed to accommodate protocol-based care plans.
A protocol-oriented system for supporting clinical decision making and the management of care plans
Specific clinical applications (i) hospital oncology, ii) primary care and iii) cardiology shared care. These applications were linked to the decision and protocol support functions which access patient data stored in the electronic patient record.

Protocol-based decision support, a major concern of the project, has become widely recognised as important to the future of health care and is likely to develop into a major commercial opportunity for DILEMMA partners and licensees of DILEMMA technology.

Dissemination And Exploitation

The primary results of the project were software products to support quality and consistency of care in oncology, cardiology and primary care, by means of improved patient data management and more effective application of state-of-the-art therapeutic knowledge in clinical care. The technology was, however, designed to be generic and was therefore applicable to a wide range of clinical specialities. The DILEMMA Protocol Model and technology were attracting particular interest from user organisations. A national project to develop a comprehensive set of cancer protocols, established by The French Federation of Cancer Centres and co-ordinated by our French partner, used the DILEMMA model.

Links have been established between members of the consortium and software companies, in the UK and France in particular, who will participate in future development and commercialisation of the technologies. Participation in the Fourth Framework will be important in providing clinical sites at which to validate commercial products (the lead partners in DILEMMA have established the PROMPT project and are developing clinical workstation technologies for the ACTION project cluster).

1) Industrial Impact.

There is likely to be a substantial market among healthcare suppliers for efficient and cost-effective telematics products which can extend the scope of primary and shared care and enable these sectors to co-operate more extensively with the hospital sector. Primary care and shared care are much less costly than hospital care, and applications for these sectors have been a major focus throughout DILEMMA.

Commercialisation of the electronic patient record, is being carried out by the Institut Bergonié, and the decision support and protocol management technologies are being commercialised by the Imperial Cancer Research Fund. The existence of a market for a clinical trials management system for the pharmaceuticals sector, based on DILEMMA technologies, has also been established and is providing the basis of a clinical trials product within a 4th Framework project, MACRO.

2) Health/Social Impact

Rationale. European clinicians in many healthcare sectors experience difficulty in applying the best current medical knowledge in everyday decision-making. Clinical decision support systems could improve both the quality of care and efficiency of resource use.

Social challenge. The ageing European population, growing pressures on health service resources, and public concern for the quality of patient care and patient life are leading to growing roles for primary care and for shared care delivered in a community setting. These changes are creating new demands for the distribution and availability of expert knowledge of best clinical practice.

3) Obstacles and difficulties.

Certain aims proved to be more difficult to fulfil than had been originally envisaged, resulting in some slippage and a need to redefine a limited number of activities. One sub-activity was curtailed during year 2 of the project. The project consortium however met its main overall goals in developing decision support systems for primary care, shared care, and in oncology and cardiology. DILEMMA's achievements have indeed been taken up in a number of European projects.

List of Deliverables

Year 1

A software tool set for clinical decision support system (5/R/R)
An authoring tool for clinical protocols (8/P/R)
Requirements for decision support in cancer shared care (12/S/R)
Methodology for the definition of clinical DSS requirements (12/R/R)

Year 2

Integration of DSS with primary health care informatics (3/P/R)
Integration of decision support systems with HIS (6/P/R)
Regional cancer care model (6/R/R)
Evaluation of a primary health care decision support system (12/R/R)

Year 3

Transfer of technology to cardiology (6/P/R)
European transferability issues for shared care DSS telematics (6/P/R)
Advanced capabilities in decision support technology (7/R/R)
Evaluation of a primary health care decision support system (12/R/R)
An integrated technology for clinical decision support (12/R/R)
Extended demonstration of a cardiology shared care demonstrator (12/R/R)

List of Participants

Mr Stephen Todd Hewlett Packard Ltd. Medical Products Group Filton Road, Stoke Gifford Bristol BS12 6QZ, U.K. Tel.: +44-272-22.87.98 Fax: +44-272-79.05.54	Dr. Jean -Louis Renaud-Salis Fondation Bergonie rue de Saint-Genes F-33076 Bordeaux, France Tel.: +33-56-92.43.00 Fax: +33-56-91.68.29
Mr. Ian Herbert NHS Information Management Centre Calthorpe Road Edgbaston Birmingham B15 1RP, U.K. Tel.: +44-392-783.15 ext. 388 Fax: +44-392-42.47.13	Prof. Dr. Claus Koehler Deutsches Krebsforschungszentrum Im Neuenheimer Feld 280 D-6900 Heidelberg 1, Germany Tel.: +49-6221-42.23.53 Fax: +49-6221-41.14.09
Prof. Toomas Timpka MDA Group Linkoping University Dept. of Computer and Information Science S-58183 Linköping, Sweden Tel.: +46-13-28.14.71 Fax: +46-13-14.22.31	Dr. Pedro Barahona UNINOVA - CRIA Artifical Intelligence Center Campus da FCT/UNL Quinta da Torre P-2825 Monte Da Caparica, Portugal Tel.: +351-1-295.32.20 Fax: +351-1-295.56.41
Prof. Richard Grol Catholic University of Nijmegen Faculty of Medical Science Academisch Ziekenhuis Geert Grooteplein NL-6525 GA Nijmegen, The Netherlands Tel.: +31-80-61.89.34 Fax: +31-80-54.07.04
- Royal Brompton Hospital, London - Société Pragm, Lyon - German Cancer Research Centre, Heidelberg



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