The aim of DILEMMA is to develop decision support systems (DSS) for use by medical professionals in a variety of clinical settings.
Three main clinical application areas have been targeted by the project. These are:
- General medical practice, where support will be provided for a range of clinical tasks, including cancer care;
- Hospital-based cancer care, with 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.
Work on DSS in the domains of general practice and hospitals was undertaken during the Exploratory Phase of AIM by the LEMMA project. Applications in the domain of shared care will link together and build on these earlier developments. They will demonstrate the medical benefits to be gained by combining decisions support with telematics technologies.
Developmental work in DILEMMA will address the following issues:
- The integration of knowledge-based systems with conventional clinical management and information systems in current use in general practice, hospitals and home care;
- Technical convergence and compatibility with emerging national and European standards in terminology, knowledge representation and data and process modelling;
- The linkage of decision support to other quality techniques including resource management and audit;
- Techniques for supporting the organisation of large modular, share-able, adaptable and maintainable medical knowledge bases.
In DILEMMA we will be aiming to deliver a complete and proven technology, including tools, methods and architectures, for building decision support applications. DILEMMA's ability to address decision support needs in several different, though interconnected fields is made possible by the use of a common underlying decision support technology whose portability and versatility was established during the preceding project. Parallel application trials in different countries, health care sectors and specialities will serve to refine and verify this capability. Clinical sites for initial user trials of all planned applications are available within the consortium.
DILEMMA project activities have been subdivided into four main areas: technologies, primary care, oncology/ shared care and decision support requirements.
In the area of technologies, ICRF London will supply a set of decision support applications development tools to the clinical applications sites in Oxford, Bordeaux, and Linkoeping to be iteratively refined through practical trial over the lifetime of the project. ICRF London will be responsible for integrating different elements of decision support technology contributed by the members of the consortium. UNINOVA will co-ordinate a range of research and development activities designed to extend the decision support capability of the existing technology.
In the area of primary car, the DILEMMA toolset will be used to specify and configure a decision support capability for general medical practice. This will incorporate an interface to existing practice management systems. This exercise will be carried out firstly at Health Centres in Oxford and Mjoelby, and secondly at a group of trial sites in South West France. These systems will offer decision support based on primary care guidelines, assistance with prescribing and hypermedia information services. The French sites will participate in the further development of decision support facilities for shared care.
Work in the oncology/shared care sector will begin at Bordeaux by integrating an oncology protocol-base DSS to an existing hospital information system. An oncology knowledge base authoring tool will be evaluated by oncologists who will use it to construct a library of physician and nursing protocols. Telematic links will be established between the hospital-based DSS and corresponding systems installed in general practices and home care nursing organisations, enabling trial of distributed forms of decision support to support shared care. This work will exploit an existing telematic facility (the Bluestone system, developed by Pragm), connecting the patient's home to the home care centre. On this basis, with the co-operation of local sponsoring bodies, we envisage developing a prototype Regional Care Network in South West France for telematic shared care of cancer.
A second group of partners, Hewlett Packard Ltd and the Royal Brompton Hospital, will investigate and conduct practical trials on the use of the same techniques to support shared care of cardiology patients by general practitioners. This work should provide an important confirmation of the breadth of medical applicability of the DILEMMA technology.
The German Cancer Research Centre will conduct an in-depth study of institutional, legal and technical factors affecting the feasibility of common European approaches to shared care telematics, using cancer as a trial study area.
The area of decision support requirements will be addressed by the MDA group with the NHS Information Management Centre. They will study the integration of their existing health care process analysis and modelling expertise as components of a generic decision support technology. This expertise, including methods for empirical investigation of decision support needs in clinical practice through the documentation of clinical dilemmas, and for constructing general models of health care processes and activities, will also be made available as a consultancy service to the applications designers in the project.
The centre for Quality Assurance Research in Family Practice at the Universities of Nijmegen and Limburg is researching into decision support based on computerised guidelines for primary care for a Dutch national project. It will provide a close exchange of methods and results between this project and DILEMMA.
DILEMMA will add value to existing conventional primary and secondary clinical informatics systems. DILEMMA involves the application of advanced decision support telematics to two areas where there is significant concern for the quality and efficiency of health care provision throughout Europe: primary care and shared care. In primary care, DILEMMA will extend the technology of offering highly cost-effective aids to clinical performance in economically sensitive areas such as prescribing and referral. The use of telematics to develop shared care and home care patients is coming to be recognised as a means of reducing pressure on secondary health resources and of improving patient care and patient quality of life. The adopted technical approach incorporating knowledge-based systems will provide a medium for the distribution of best practice and consensus expertise. The generic approach deployed promises the maximum scope for transfer of results between clinical sectors and settings.
DILEMMA will make contributions to a number of AIM tasks, in particular:
T271 Telematics for primary health care;
T291 Systems and tools for distant functional evaluation of handicaps and monitoring and support of home care;
T321 Clinical Integration of KBS with databases and HIS;
T242 Architectures for medical knowledge based systems;
T241 Knowledge Capture.
Other AIM projects with common interests and concerns where some technical co-operation and convergence could be achieved include:
A2012 GALEN in terminology modelling for KBS;
A2014 GEHR in patient record models;
A2019 KAVAS in knowledge acquisition tools;
A2027 OPADE in computerised prescribing;
A2028 OPENLABS in telematics protocols.
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