Ontology Modeling for Nursing Care Plans and Clinical Practice Guidelines by Muzammil A. Din Submitted in partial fulfillment of the requirements for the degree of Master of Health Informatics at Dalhousie University Halifax, Nova Scotia March 2009 © Copyright by Muzammil A. Din, 2009 Library and Bibliotheque et 1*1 Archives Canada Archives Canada Published Heritage Direction du Branch Patrimoine de I'edition 395 Wellington Street 395, rue Wellington Ottawa ON K1A0N4 Ottawa ON K1A0N4 Canada Canada Your file Votre reference ISBN: 978-0-494-50254-9 Our file Notre reference ISBN: 978-0-494-50254-9 NOTICE: AVIS: The author has granted a non­ L'auteur a accorde une licence non exclusive exclusive license allowing Library permettant a la Bibliotheque et Archives and Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par telecommunication ou par Plntemet, prefer, telecommunication or on the Internet, distribuer et vendre des theses partout dans loan, distribute and sell theses le monde, a des fins commerciales ou autres, worldwide, for commercial or non­ sur support microforme, papier, electronique commercial purposes, in microform, et/ou autres formats. paper, electronic and/or any other formats. The author retains copyright L'auteur conserve la propriete du droit d'auteur ownership and moral rights in et des droits moraux qui protege cette these. this thesis. Neither the thesis Ni la these ni des extraits substantiels de nor substantial extracts from it celle-ci ne doivent etre imprimes ou autrement may be printed or otherwise reproduits sans son autorisation. reproduced without the author's permission. In compliance with the Canadian Conformement a la loi canadienne Privacy Act some supporting sur la protection de la vie privee, forms may have been removed quelques formulaires secondaires from this thesis. ont ete enleves de cette these. While these forms may be included Bien que ces formulaires in the document page count, aient inclus dans la pagination, their removal does not represent il n'y aura aucun contenu manquant. any loss of content from the thesis. Canada DALHOUSIE UNIVERSITY To comply with the Canadian Privacy Act the National Library of Canada has requested that the following pages be removed from this copy of the thesis: Preliminary Pages Examiners Signature Page (pii) Dalhousie Library Copyright Agreement (piii) Appendices . - Copyright Releases (if applicable) To my parents: AbdurRahman & Nusrat TABLE OF CONTENTS LIST OF TABLES viii LIST OF FIGURES ix ABSTRACT xi LIST OF ABBREVIATIONS USED xii ACKNOWLEDGEMENTS xiv CHAPTER 1 INTRODUCTION 1 1.1 Problem Statement 2 1.2 Research Objectives 3 1.3 Research Challenges 4 1.4 Solution Approach 5 1.5 Thesis Contributions 6 1.6 Thesis Organization 6 CHAPTER 2 BACKGROUND 8 2.1 Nursing Care Plans 8 2.1.1 The Nursing Process 8 2.1.2 Nursing Care Plan 10 2.1.3 Types of Nursing Care Plans 10 2.1.4 Structure of a Nursing Care Plan 11 2.1.5 Individualized Care Planning 15 2.1.6 Advantages of using Standard Nursing Care Plans 17 2.2 Nursing Clinical Practice Guidelines 18 2.2.1 Role of Nursing CPGs 18 2.2.2 Relationship between NCPs, NCPGs, and CPGs 19 2.3 Computerization of Nursing Care Plans and NCPGs 20 2.3.1 Computerization of Nursing Care Plans 20 2.3.2 Computerization of Clinical Practice Guidelines 22 2.4 Task Network Models 26 2.5 The Semantic Web and Ontologies 27 2.6 Review of Ontology Engineering Methodologies 27 2.6.1 The Cyc Methodology 28 2.6.2 The Enterprise Ontology Methodology 30 2.6.3 The TOVE Project Methodology 32 v 2.6.4 The KACTUS Methodology 35 2.6.5 The SENSUS Methodology 36 2.6.6 METHONTOLOGY Methodology 36 2.7 Summary 41 CHAPTER 3 RESEARCH METHODOLOGY 42 3.1 Selection of a Methodology 42 3.2 Our Ontology Modeling Methodology 44 3.3 Summary 47 CHAPTER 4 NCP ONTOLOGY ENGINEERING 48 4.1 Ontology Specification and Knowledge Identification 48 4.2 Ontology Modeling 51 4.2.1 Knowledge Abstraction (Phase 1) 52 4.2.2 Ontology Conceptualization (Phase 2) 53 4.2.3 Ontology Implementation (Phase 3) 56 4.3 Modeling tasks 57 4.3.1 Representation and Activation of a NCP 60 4.3.2 Representation and Activation of a NCPG 61 4.3.3 Task Model 61 4.3.4 Mechanism of Execution 62 4.3.5 Execution Rules 71 4.4 Ontology Screenshots and Metrics 71 4.5 Summary 73 CHAPTERS EVALUATION 74 5.1 Evaluation for Representational accuracy 74 5.1.1 NCPG for the management of Ocular Conditions 76 5.1.2 NCPG for the the prevention and treatment of Pressure Ulcers 77 5.1.3 NCPG for the management of Heart Failure 78 5.1.4 Discharge guidelines for a child with a Stoma 79 5.1.5 Adult Asthma Care Guidelines for Nurses-Promoting Control of Asthma 80 5.1.6 Deficient Knowledge-Diabetic Ketoacidosis (NCP) 81 5.1.7 Risk for Infection-TB-(Spread/Reactivation) (NCP) 81 5.1.8 Impaired Swallowing (NCP) 82 5.1.9 Anxiety (NCP) 82 5.1.10 Decreased Cardiac Output (NCP) 83 5.1.11 Sample of Instantiated NCPG 84 VI 5.2 Evaluation against Peleg et al's guideline formalism dimensions 87 5.2.1 Organization of Guideline Plan Components (Dimension 1) 87 5.2.2 Specification of Goals/Intentions (Dimension 2) 89 5.2.3 Model of Guideline Actions (Dimension 3) 89 5.2.4 Decision Models (Dimension 4) 90 5.2.5 Expression Languages Used to Specify Decision Criteria (Dimension 5) 91 5.2.6 Data Interpretations/Abstractions (Dimension 6) 91 5.2.7 Representation of a Medical Concept Model (Dimension 7) 91 5.2.8 Patient Information Model (Dimension 8) 91 5.3 Evaluation for adherence with standard Design Principles 92 5.4 Summary 94 CHAPTER 6 CONCLUSION 95 6.1 Limitations 95 6.2 Future Directions 95 6.3 Conclusion 96 REFERENCES 98 vii LIST OF TABLES Table 2-1 Examples of medical and nursing diagnoses 13 Table 3-1 Technological Support Tools of the various methodologies. 42 Table 3-2 Comparison of Ontology Engineering Methodologies 43 Table 4-1 Knowledge Sources for NCPGs 49 Table 4-2 Knowledge Sources for NCPs 50 Table 4-3 Glossary of terms 54 Table 4-4 Concept Dictionary 55 Table 4-5 Description of binary relations 56 Table 5-1 Nursing Clinical Practice Guidelines for Instantiation 74 Table 5-2 Nursing Care Plans for Instantiation 75 Table 5-3 Classes, Individuals and Properties of an actual NCPG 84 Table 5-4 Compliance with Gomez-Perez's ontology design principles 92 Table 5-5 Compliance with Bodenreider's design principles 93 viii LIST OF FIGURES Figure 2-1 The Nursing Process 9 Figure 2-2 The interrelated steps of the nursing process 9 Figure 2-3 Nursing Diagnoses grouped under Medical Diagnoses 16 Figure 2-4 Customized Nursing Care Plans 17 Figure 2-5 Relationship between NCPs, NCPGs and CPGs 20 Figure 2-6 Phases of the CYC methodology 30 Figure 2-7 Steps of the Enterprise methodology 31 Figure 2-8 Phases of the TOVE methodology 33 Figure 2-9 Overview of the KACTUS Ontology reuse concept 35 Figure 2-10 Ontology Conceptualization Phases of METHONTOLOGY...40 Figure 3-1 Ontological Principles for Medical Ontologies 44 Figure 3-2 Our Ontology Modeling Process 46 Figure 4-1 Core Elements found in the NCPs 53 Figure 4-2 Core Elements found in the NCPGs 53 Figure 4-3 Concept Classification Trees 55 Figure 4-4 Binary Relation Diagram 55 Figure 4-5 Schematic Representation of a Recommendation or Intervention 59 Figure 4-6 Examples of a Task and an Activity 59 Figure 4-7 Example of Procedure comprised of Activities and Tasks. ..60 Figure 4-8 Simplified Representation of a NCP 60 Figure 4-9 Simplified Representation of a NCPG 61 Figure 4-10 Task Model 62 Figure 4-11 Task State transitions 63 Figure 4-12 Linking Tasks 63 Figure 4-13 The NCP/NCPG Model representing two tasks 64 Figure 4-14 The NCP/NCPG Model with First task active 65 ix Figure 4-15 The NCP/NCPG Model with First task completed 65 Figure 4-16 The NCP/NCPG Model with Second task is failure 66 Figure 4-17 The NCP/NCPG Model with sequential tasks 67 Figure 4-18 Activated NCP/NCPG Snapshot 68 Figure 4-19 Merging different NCP/NCPGs 68 Figure 4-20 Issue with Task Reusability 69 Figure 4-21 Solution of'Task reuse' problem 70 Figure 4-22 Our NCP & NCPG Ontology Metrics ...71 Figure 4-23 Classes of our NCP & NCPG Ontology 72 Figure 4-24 Object and Date properties of our NCP & NCPG Ontology 72 Figure 5-1 Categorisation of Tasks 89 Figure 5-2 Representing Dates and Durations 90 x ABSTRACT Nurses play a vital role in providing patient care. Nursing Care Plans and Clinical Practice Guidelines promote an evidence-based standardized form of patient care, but their current form does not allow patient-centered care. Our solution is to computerize them in terms of fine-grained activity-specific components—the systematic composition of multiple activity specific components yields a patient-centered 'Care Plan'. In this research, we investigated and modeled the structure and function of Nursing Care Plans and Guidelines as a generic high-level model. Taking a Semantic Web approach, we adapted the METHONTOLOGY methodology for ontology engineering to develop an OWL-based ontology. Using it we instantiated a set of Nursing Care Plans and Guidelines that can now be executed using reasoning methods and data inputs, to generate individualized care plans comprising of step-by-step instructions.