Medical Planning. David Glasspool. Advanced Computation Laboratory, Cancer Research UK

Transcription

1 Medical Planning David Glasspool Advanced Computation Laboratory, Cancer Research UK

2 Outline Review The place of planning in healthcare The cognitive psychology of planning New Directions How can IT assist plan execution? How can IT assist plan creation?

3 Part I Review

4 Planning No mention in Schwartz & Griffin book Plenty of work on clinical decisions Little work on clinical planning i.e. Plans in medical thinking Plenty of work on medical plans; Plans are ubiquitous in clinical practice

5 Planning in healthcare Types of clinical plan Protocols Guidelines Integrated care pathways Operations on plans Plan generation Plan modification Plan enactment Use models for plans Clinician guidance Patient guidance Problem solving (individual and joint) Integration of services & treatment

6 Types of plan: 1. Healthcare Strategy

7 Types of plan: 2. Protocol

8 Many people use the plan A Senior clinician plans treatment B Family plan around hospital visits C D Junior clinician performs one particular task Pharmacist checks prescriptions

9 Plan as mediator between agents A D B C Planners : Exercise judgement, set goals, use expertise, modify plans (Generating/Manipulating Plans) Actors : Perform actions, modify to local environment, react to events (Using Plans)

10 Cognitive psychology of planning

11 Central (reasoning, planning) Experimental Psychology Engineering solutions from scratch AI Making sense of empirical evidence Peripheral (sensory/motor)

12 Early work was AI-inspired Planning as problem solving. Miller, Galanter & Pribram (1960): Plans and the structure of behaviour. Plans are hierarchically structured as is our knowledge. Plans are the interconnection between knowledge and behaviour. Newell: GPS; Production systems.

13 Planning as problem-solving and the Tower Tasks Tower of Hanoi / Tower of London Objective: move from start state to goal state. Constraints: Only one disc can be moved at a time. All discs not being moved must be placed on a peg. A larger disc must not be placed on a smaller disc.

14 A B C B A C Preconditions Disk A Clear Disk A on Disk B Disk C Clear Disk A < Disk C Operator Move Disk A to Disk C Postconditions Disk A Clear Disk A on Disk C Disk B Clear Start Goal

15 Naturalistic planning Hayes-Roth & Hayes-Roth (1979). Partial On-line & opportunistic Partly bottom-up Klein: Recognition-primed planning Experts' plans are usually: Simple. Based on stereotyped initial plan, then developed. Satisficing approach Alternative plans are rarely compared

16 Empirical evidence Evidence that working memory and executive processes are heavily involved (Owen 1997). The number of variables and interactions within a plan appear critical, and skilled planners in real-world planning tasks form only relatively simple mental plans (Klein, 1998). The level of detail in which a planner considers the future consequences of planned actions influences their plans (Hirt & Sherman, 1985; Huys, Evers-Kiebooms & d'ydwalle, 1992).

17 Well-learned plans Planning is limited by cognitive resources Experts develop strategies to compensate. Scripts/schemas/MOPs Representation and use of plan knowledge. Understanding situations by reference to stereotyped plans. Potential relevance to much of clinical procedural knowledge ( The art of medicine?)

18 Novice vs. Expert Skill Representation Incompetent Competent Conscious Trainee Graduate Unconscious Complete novice Expert

19 Dual-process models Deliberative processing Automatic processing Deliberative Miller et al. Newell & colleagues Tower tasks Mixed Hayes-Roth & Hayes-Roth Klein & colleagues Automatic Scripts & schemas Contention scheduling

20 Part II New Directions Executing plans Generating/modifying plans

21 Intelligent plan execution What does it mean to execute a plan intelligently? Generalisation: Not having to specify every last detail. Flexibility: Ability to change details to suit circumstances while preserving overall intentions. Resilience: Ability to detect when situation is not developing as expected and either adapt the plan or request re-planning (or other

22 The Norman & Shallice (1980) framework Supervisory Attention (SAS) Deliberative processing, planning & reasoning Contention Scheduling Automatic processing of routine behaviour Action system Motor level action control World

23 Contention scheduling Goal Plan Plan Plan Alternative plans that can achieve the same goal Goal Goal Goal (Possibly ordered) set of subgoals which must be achieved to implement this plan. Plan Plan Plan Alternative plans that can achieve the same goal

24 Goal-oriented sequencing Flexible execution Execution can be allowed to adapt itself to the prevailing circumstances by providing alternative plans for achieving each goal. Automatic recovery from (mild) error. Preference order over plans can allow back-up action. (Alternatively recovery action(s) may be explicitly specified)

25 Assisting plan creation

26 Cognitive demands of planning 1. Hold plan in memory. 2. Identify options at each step. 3. Identify pros and cons. 4. Track constraints & dependencies. 5. Track effect of plan with respect to its goals.

27 A scenario A woman tests positive for a mutation to one of the two known genes predisposing to breast cancer (BRCA1/BRCA2). If no action is taken to mitigate the risk, the chances are high that she will contract a potentially fatal cancer during her lifetime. A genetics counsellor now works with the woman to plan a strategy of intervention.

28 Demo

29 The REACT approach 1. Memory for plan 2. Identification of options 3. Monitoring wrt Goals 4. Identification of pros and cons 5. Identification of conflicts and interactions

30 Evaluation Aims Feasibility, usability, attitudes. Participants 8 cancer genetic counsellors Method Actresses playing patients. with/without REACT. Videotape, questionnaire, interview.

31 Results 7/8 participants at least somewhat negative before sessions. 7/8 participants highly positive after sessions. Appreciated: Dynamic visual display. Arguments were useful bullet-points for discussion. Accurate, detailed, up-to-date information.

32 Conclusions Plenty of work on medical decision making & medical plans, little work on medical planning. Like other experts, clinicians use stereotyped plans to reduce cognitive demands of full planning. Goal-oriented hierarchical partial planning can support intelligent plan execution. REACT supports plan generation/modification by targeting cognitive load.

33 With thanks to Ayelet Oettinger James Smith-Spark John Fox Jon Bury Kirsty Bradbrook Fred Kavalier Pete Yule