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From John Green <john.travis.gr...@gmail.com>
Subject Re: Sundry
Date Thu, 31 Oct 2013 16:05:41 GMT
A follow up point to the previous email:

Yes Tim: middleware. This is moving beyond just documentation toward
diagnosis and action, which I suppose is a hidden assumption here - maybe
the cTakes community doesnt care at this point, based on history or
physical exam/labs. However, a common quote in medicine is that a good
clinician can diagnose 90% of the time based on history alone. This may be
an overstatement, however, it underscores its importance. I think OPQRST
shouldn't be overlooked as a simple paradigm for as starting point.

Now, some of this may be integrated into cTakes already. I must admit, I am
still in my infancy with understanding cTakes, UIMA, etc.

JG



On Thu, Oct 31, 2013 at 12:00 PM, John Green <john.travis.green@gmail.com>wrote:

> Pei and Tim - Good questions.
>
> The bottom line is that OPQRST is the algorithm that every clinician uses
> to characterize the history of a sign, symptom or constellation of
> symptoms. Each letter has multiple meanings, but generally they're grouped.
> O for onset, was it quick or slow in onset, P for palliative or provoking
> phenomenon, that is, does tylenol make it better? Does it feel better when
> you lean forward? Is it worse with standing? Q is the quality, generally,
> though I could give more examples of each Ill keep it brief from here, R is
> generally region or radiation of the pain and or sign, S is the severity,
> and T is the time course, is it intermittent? When it happens, how long
> does it last for? I could send documents used to teach new clinicians to
> better comprehend for anyone interested.
>
> OPQRST, while most residents would assume it is only for teaching new
> clinicians, as Tim said, is a useful tool at all levels. Great clinicians,
> and I work with some great senior folks, use this everyday. The idea that
> it is only for teaching is founded on two things: one, that it doubles as a
> structured mnemonic for characterizing signs and symptoms and two, that
> everyone so far ingrains this into their clinical skill set, unless they
> are geared toward teaching, they, after the basic level, never think about
> it again! Caveat: many good clinicians will tell you to keep it algorithmic
> so that you're systematic and do not overlook details.
>
> What is it's application to ML? Obviously the furthest desired end-state
> for NLP like cTakes would be understanding a clinical encounter to such a
> nuanced level that detailed diagnoses could be considered along with
> treatment plans. While I only know what I've read in Artificial
> Intelligence: A Modern Approach and picked up from friends over the years
> who were good knowledgeable in this field, I feel that OPQRST would be a
> huge benefit toward beginning to outline the problem of more rigorous ML
> characterization of the clinical narrative.
>
> The utility of OPQRST may not still be entirely clear to those who have
> never been presented with a clinical encounter. Let me try one more stab:
> Take the classic example of chest pain. A man comes to the ER with chest
> pain. Is the onset quick? Yes doc, it was all of a sudden. This might
> support a diagnosis of, say, MI, aortic dissection, pulmonary embolism, but
> less likely someone would call GERD sudden. Palliative or provoking
> features? Well, when I take 8 antacids it gets better (GERD), or, When I
> take my wifes nitroglycerine it got better for a little while (angina), or,
> when I took my wifes nitroglycerine it did nothing (pericarditis?).
> Quality: Is it stabbing? Ya doc, its stabbing (less likely MI). Is it
> crushing? Like an elephant on your chest? Ya doc, that's it. (more likely
> MI), and so on.
>
> Now of course, cTakes could be used for a real life encounter like this
> (middleware) at some point, but likely it would be taking a history and
> proposing a diagnosis (middleware again Tim, yes). But the point is, the
> first steps toward knowing what were dealing with at the historical level
> is centered around OPQRST, and it just occurred to me to ask what we
> thought about the feasibility of something like that.
>
> In retrospect, it may be too tough, but at some point it would need done,
> just as much as a clinician must learn it.
>
> One final point: problem lists. These are absolutely essential to any
> clinician in making a diagnosis. Again, often times, they dont think about
> it, but they use them. When writing the above it occurred to me: much of a
> problem list definition may already be contained to varying degrees in
> existing cTakes databases. It would be an interesting and worthwhile paper,
> I think, to see how well cTakes compiled problem lists matched Medical
> Students, Residents, and Attending physician's problem lists. If anyone is
> interested in this line of thought, I would be interested in collaborating.
> It would be very easy, and the data may actually already exist to compare.
> Forgive me if its already been done, but, if it hasnt, then it would go a
> long way toward proving cTakes efficacy in regards to high-order processes.
> And if it hasnt been done and someone does it at a later date, please, send
> me an email to the paper!
>
> JG
>
>
> On Wed, Oct 30, 2013 at 10:08 AM, Tim Miller <
> timothy.miller@childrens.harvard.edu> wrote:
>
>> Thanks for bumping this Pei, it reminds me I meant to respond to it.
>>
>> The OPQRST does sound like a great ML project. At a glance I might think
>> a sequence model over sentences (like a CRF) would be a good model.
>> But I'm wondering what the end use case is? Is it for teaching OPQRST to
>> new clinicians? Or maybe as a sort of middleware for other projects where
>> it might be a useful feature? Without a physician's intuition I sometimes
>> suffer from a failure of imagination on these things.
>>
>> Tim
>>
>>
>>
>> On 10/30/2013 09:59 AM, Chen, Pei wrote:
>>
>>> Hi John,
>>> I was away for a little bit and finally got a chance to catch up on
>>> emails...
>>>
>>>  2) I work for the DoD and have latched on to several IRB approved
>>>> projects
>>>> within that community where Ill be using cTakes, though minimally at
>>>> first.
>>>> This is just a statement, a bug in the ear of the community of what
>>>> people
>>>> are up to.
>>>>
>>> This is really news!  Looking forward to hearing more...
>>>
>>>  has anyone considered (and maybe the components already do this in some
>>>> way I
>>>> haven't explored yet - time is ever limited) adding an OPQRST
>>>> classifier?
>>>>
>>> I'm not too familiar on how OPQRST would be determined from the
>>> patient's record.
>>> Just curious, how is it currently determined manually now?  Is it a
>>> single score determined by a formula/rule(s)?
>>> Seems like another good use case for cTAKES output-- clinically focused.
>>> --Pei
>>>
>>
>>
>

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