Transcript Heartcare Use - HEALTH SYSTEMS LAB

Linking lay people to the
professional literature
An application of
natural language processing to
free-text e-mail
Patricia Flatley Brennan, RN, PhD, FAAN
University of Wisconsin- Madison
Supported by Grants from the National Library of Medicine (LM 6249);
Intel Corporation (Advanced Technologies for Health@Home),
1 )
and Wisconsin Alumni Research Foundation (The Kellet Professorship
Plan for the talk
• Provide an update of the final results
of the HeartCare randomized field
experiment
• Apply NLP tools to decode patient
messages
• Describe current work in two areas:
– Community capacity building
– Infrastructure-building
2
The HeartCare Team
• Investigators
– University of Wisconsin-Madison
•
•
•
•
Patti Brennan
Barrett Caldwell (Now Purdue)
Mary Ellen Murray
Dave Gustafson
– Case Western Reserve University
• Shirley Moore
• Sree Sreenath
– Cleveland Clinic Foundation
• Ralph O’Brien
• Undergraduate, Graduate, and Post-Doctoral trainees
3
Meeting the Challenges of
CABG Recovery
• Monitor, Manage, Mend, Motivate
• Demands in the discharge encounter
• Patient-centered, tailored
information
4
HeartCare
Recovery requires communication and
tailored health information
• Peer and professional communication
• Information sequenced over time and
tailored to the patient’s needs
–
–
–
–
Weeks 1-2: Symptom Management
Week 3-6: Resume physical activity
Weeks 6-12: Return to prior function
Weeks 12-26: Adopt healthy behaviors
5
HeartCare Evaluation
• Randomized Field Evaluation
– 6 Months experimental period
– 140 adults recovering from CABG surgery
• Mean age: 63; 35% Female; 19% Non-majority
– Outcome Measures
• Symptom Inventory, Sickness Impact Profile, POMS (Depression),
Family function, Health Behavior change
• Three Groups
– Usual Care
– CHIP, An Audiotape Intervention
– HeartCare: WWW-based recovery support
6
8
9
Does access to
HeartCare improve
recovery from
CABG?
Yes!
11
Sickness Impact Profile (SIP)
35
30
SIP
25
20
CHIP
15
10
5
0
HeartCare
0
1
2
3
4
5
6
Months Since Surgery
12
POMS Depressive Symptom Scale
14
Depression
12
10
8
CHIP
6
HeartCare
4
2
0
0
1
2
3
4
5
6
Months Since Surgery
13
Summary
• Participants in the HeartCare group
recovered faster, with fewer symptoms,
than those using the CHIP intervention.
• Participants use HeartCare intensively
during the early recovery phase.
• E-mail used more often than public forum
• Information reviewed on most encounter
14
What’s needed to make
HeartCare-like interventions Scalable?
•
•
•
•
•
Strategies to understand information
needs
Characterization of the ways lay people
organize health information
Sustainable knowledge management
approaches
Alignment of the CHI investments with
the community’s health information assets
Robust health information infrastructure
15
What’s needed to make
HeartCare-like interventions Scalable?
•
•
•
•
•
Strategies to understand information
needs
Characterization of the ways lay people
organize health information
Sustainable knowledge management
approaches
Alignment of the CHI investments with
the community’s health information assets
Robust health information infrastructure
16
Message to the Nurse
Dear Connie, I've been out of the loop for a few weeks. I had a setback
with the appearance of a blood clot 2 weeks ago and was back in the
hospital for a week. I was released a week ago Friday and now am on
several new medications. With all these new meds, I feel nauseous
almost all the time and frequently dizzy. I have a visiting nurse coming
to see me 3x a week, and she monitors my blood pressure, temperature
and checks my legs for possible clots. But nothing seems to help the
nauseous feeling and I have little appetite. The medication I am now
taking are … I suspect the Lasix may be the culprit, since I had been on
it a LONG time ago and it made me nauseous, but I don't know. Do I
really need to be on all of these now? I take alot of them at the same
time (meal time), but should I change this and stagger them? What
order should I take them, or are there alternatives to this medication for
now? Any advise you could give me before I go back to see my
internist on Tuesday would be helpful, then I could discuss it with him
again. I see the cardiologist on Thursday and hope to be cleared to start
cardiac rehab after that. Right now, however, it is slow going and17
discouraging. Thanks, Bill
Can
existing
UMLS lexical tools
decode
patient information needs?
18
Mapped
terms
that can
launch
searches of
electronic
resources
SPECIALIST lexicon
Dear Connie, I've been
out of the loop for a
few weeks. I had a
setback with the
appearance of a blood
clot 2 weeks ago and
was back in the
hospital for a week. I
was released a week
ago Friday and now am
on several new
19
medications.
Background
• Federal initiatives to meet lay people’s information
needs
• Most common stimulus: query phrases
• But…
– Consumers’ don’t speak UMLS
– Information need arise in colloquial conversations
• However,
– The UMLS and its lexical tools exist-- exploitable?
– Electronic resources applying machine-readable indexing
approaches
20
USUAL APPROACHES
• Human intermediary
• Natural language interpretation
– Awakening from the dream stage
• Terminological strategies
– Query terms
– Indexing Initiative
22
Can NLP tools
built to manage professional vocabularies
help patients?
• Source document
– 241 messages sent from patients to nurses in the
HeartCare project
• Pass thru Metamap
–
–
–
–
Parses text of electronic bibliographic databases
Strips capitalization, ignores word order
Assigns candidates from UMLS
Scores the adequacy of the concept match
23
Approach
• Stimulus text acquired
– Sanitizing process
– Human Subjects’ issues
• Preliminary Structuring
– Demarked units
– Title of message ---> Citation Title
– Body of Message ---> Abstract
24
Preliminary Results
• 241 Messages (1976 Utterances)
• 15566 Phrases
• 11,373 Candidate UMLS Concepts found
– (mean 32.91 ; sd 42.7741)
– 9903 phrases had no candidates
• 7143 Mappings found (1.13; s.d.1.79)
25
Observations
• Diagnosis, symptom and findings recognized
• Health service elements not recognized
(appointments, medication renewals)
• No tolerance for mis-spellings
• Idioms choke the system
• Full UMLS may be too rich
– Metamorph
– Post-processing to remove selected components
26
Preliminary Thoughts
• Promising but sparse; PARSING is key
• Efficiency/interpretation tradeoff
• Early work in a highly professional, highly
controlled stimulus had a 70% mapping
• Most messages deal with managing a health
problem in the home
---> Nursing!
27
Vocabularies used in the Test
The Six Nursing Vocabularies
Nursing Plus:
International Classification of Primary Care (ICPC2E)
International Classification of Primary Care- Am English (ICPC2AE)
Micromedex DRUGDEX (MMX01)
National Drug Data File (NDFF01)
Thesaurus of Psychological Terms (PSY2001)
WHO Adverse Drug Reaction Terminology (WHO97)
NursingPLUS + Medical Subject Heading 2003 (MSH_2003)
NursingPLUS + SNOMED International Version 3.5 (SMNI98)
28
Vocabulary performance
on a single message
Nursing
Only
NursingPlus NursingPlus +
MeSH
NursingPlus
+SNOMED
Candidates
Concepts
15
54
85
114
Mapped
Concepts
13
42
57
70
Phrases w/ one
or more
maps
12
43
50
57
Mean concepts/
phrase
1.08
.98
1.14
1.22
Errors
3
23
37
39
29
How did the vocabularies perform?
Nursing
Only
NursingPlus
NursingPlus +
MeSH
NursingPlus +
SNOMED
Candidates
Concepts
1016
3734
5786
7366
Mapped Concepts
948
3094
4439
5078
Phrases w/ one or
more maps
871
2863
3995
4383
1.09 (0.28)
1.08 (0.30)
1.11 (0.35)
1.16 (0.38)
Mean concepts/
phrase
30
Mapping Adequacy
• Findings
– True Positives
– False Positives
– Missing
• Trade-off of recall and precision
• Zeng’s Model of Mapping:
– Lexical
– Semantic
– Mental Model
31
The Contexts of Care
• Living Environments
– Homes
– Communities
• Social Environments
– Families
– Cultural Groups
• Psychological Environments
– Illness representations
– Human Information Processing
• Technological Environments
– Telecommunication
– Consumer Electronics
• Health Service Environment
– Clinical Care Practices
– Financing & Delivery Institutions
32
What’s needed to make
HeartCare-like interventions Scalable?
•
•
•
•
•
Strategies to understand information
needs
Characterization of the ways lay people
organize health information
Sustainable knowledge management
approaches
Alignment of the CHI investments with
the community’s health information assets
Robust health information infrastructure
33
The Dodge-Jefferson
Healthier Communities
Partnership
34
Develop a model to generate
design criteria
for health-related IT solutions
from an understanding of
citizen
health information managment behaviors
and
community resources
35
49 Households in
Central Wisconsin
• Housing type
– 39 Single Family, 9
Apartments, 1 Mobile Home
• Most of those interviewed
live alone
• Over half of the 1 & 2 person
families had one person over
age 65
• Electronics
– Phones: 49
– Cable: 42
– Internet: 26
36
Health of the Household
• Respondents:
– 7 Excellent; 12 Very Good; 10 Good; 3 Fair
• No one indicated Poor
• Respondent’s assessment of household generally matched
• Health Concerns
– Cancer, Cardiovascular disease, Hypertension, Arthritis
• Also: depression, memory problems, nutrition, wellness
• Income adequate
• ? Health Insurance coverage
• ? Health Care Provider
37
Where Do People get
Health Information?
Family
Physician
0
5
10
15
20
25
30
35
Physician
Clinic/Hospital
Public Health Nurse
Library
News
Health Magazines
Internet
Hotlines
Reference Books
Alt Med Sources
Family/Friends
School
Classes
Other
38
Information Managed in the Home:
39
Information Management
in the home
• Information types named
by at least 20 respondents
– Appointment & Contact
Information
– Medication
– Treatment
– Birth/Death records
• Household experiences
– Average 10.2 (sd. 3.3)
information types
– Number and variety
unrelated to age of
respondents or presence
of children
Where do they put all of this information?
40
41
42
43
What’s needed to make
HeartCare-like interventions Scalable?
1. Strategies to understand information
PKI
Approaches
needs
Personal
2. Characterization ofto
the ways lay people
Consumer
Assessment
of
organize health
information
Secure E-Mail
3. Sustainable
knowledge
management
Community
Health
Information
Health
Information
among
approaches
Resources
Exchange
Health
Professionals
4. Alignment of the CHI
investments with
(ARCHIR)
the community’s
health information assets
(P-CHIE)
5. Robust health information infrastructure
Dodge-Jefferson
Community-Partnership
HealthierDigitial
Communities
Partnership
Library
Project
45
Community-Centered Information System
State Health
Dept
Clinic
Pharmacy
Public Library
Consumer Health
Information
Network
Dentist
Furtive
Records
Hospital
trainee
clinician
46
patient
Web Site:
healthsystems.engr.wisc.edu
[email protected]
47