health advisor project

Health Advisor ProjectHealth Advisor Project

Carlo MazolenyCarlo MazolenyRavi Shankar, Ph.D.Ravi Shankar, Ph.D.

Florida Atlantic UniversityFlorida Atlantic University

May 2009May 2009

Health Advisor ProjectHealth Advisor ProjectBACKGROUNDBACKGROUND

OVERVIEWOVERVIEWCASE BACKGROUNDCASE BACKGROUND

THE GAIA METHODOLOGYTHE GAIA METHODOLOGYCASE ANALYSIS PHASECASE ANALYSIS PHASECASE DESIGN PHASECASE DESIGN PHASE

FUTURE DEVELOPMENTSFUTURE DEVELOPMENTSQUESTIONSQUESTIONS

BACKGROUNDBACKGROUNDThe Healthcare SystemThe Healthcare System

Health Care Statistics

Healthcare is one of the top social and economic problems facing Americans today.

• Healthcare expenditures in the United States exceed $2 trillion a year. In comparison, the federal budget is $3 trillion a year.

• The amount people pay for health insurance increased 30 percent from 2001 to 2005, while income for the same period of time only increased 3 percent, as reported by the Robert Wood Johnson Foundation.

• Nearly 50 million Americans do not have health insurance, while another 25 million are underinsured.

• The typical family health insurance plan costs $12,000 a year or more. • In a study completed by the Commonwealth Fund, 45 percent of the adults in the

survey reported that they had a hard time paying their bills, even with health insurance, and had been contacted by a collection agency or had to change their way of life in an effort to pay their medical bills.

• Approximately 50 percent of personal bankruptcies are due to medical expenses. • According to a Kaiser Family Foundation poll, 28 percent of middle income

families (annual family income between $30,000 and $75,000) stated that they were currently having a serious problem paying for healthcare or health

insurance

http://www.healthcareproblems.org/




BACKGROUNDBACKGROUNDThe Healthcare SystemThe Healthcare System

Health Care Statistics (Continue..)

Most Americans would agree that health care reform needs to happen.

The United States is fast becoming one of the worst health care systems in the world even though they have one of the highest rates for health care

expenditures.

One of the biggest and most costly aspects of health care is the treatment of chronic diseases. It will be hard to make insurance affordable without changing

how chronic disease is treated.

Many of the problems with health care that are affecting Americans today, come from lack of access to preventative care.





The Health Advisor OverviewThe Health Advisor Overview

CASE BACKGROUNDCASE BACKGROUNDPARKINSON’S DISEASEPARKINSON’S DISEASE

Parkinson's disease occurs when certain nerve cells, or neurons, in an area of the brain known as the substantia nigra die or become impaired. Normally, these neurons produce an important brain chemical known as dopamine. Dopamine is a chemical messenger responsible for transmitting signals between the substantia nigra and the next "relay station" of the brain, the corpus striatum, to produce smooth, purposeful muscle activity. Loss of dopamine causes the nerve cells of the striatum

to fire out of control, leaving patients unable to direct or control their movements in a normal manner.

CASE BACKGROUNDCASE BACKGROUNDPARKINSON’S DISEASEPARKINSON’S DISEASE

Possible Causes Possible Causes One theory holds that free radicals - unstable and potentially damaging molecules generated by normal chemical reactions in the body - may contribute to nerve cell death thereby leading to Parkinson's disease. Free radicals are unstable because they lack one electron; in an attempt to replace this missing electron, free radicals react with neighboring molecules (especially metals such as iron), in a process called oxidation. Oxidation is thought to cause damage to tissues, including neurons. Normally, free radical damage is kept under control by antioxidants, chemicals that protect cells from this damage. Evidence that oxidative mechanisms may cause or contribute to Parkinson's disease includes the finding that patients with the disease have increased brain levels of iron, especially in the substantia nigra, and decreased levels of ferritin, which serves as a protective mechanism by forming a ring around the iron, and isolating it.

Some scientists have suggested that Parkinson's disease may occur when either an external or an internal toxin selectively destroys dopaminergic neurons. An environmental risk factor such as exposure to pesticides or a toxin in the food supply is an example of the kind of external trigger that could hypothetically cause Parkinson's disease. The theory is based on the fact that there are a number of toxins, such as 1-methyl-4-phenyl-1,2,3,6,-tetrahydropyridine (MPTP) and neuroleptic drugs, known to induce parkinsonian symptoms in humans. So far, however, no research has provided conclusive proof that a toxin is the cause of the disease.

A relatively new theory explores the role of genetic factors in the development of Parkinson's disease. Fifteen to twenty percent of Parkinson's patients have a close relative who has experienced parkinsonian symptoms (such as a tremor).

CASE BACKGROUNDCASE BACKGROUNDPARKINSON’S DISEASE (continued..)PARKINSON’S DISEASE (continued..)CLINICAL MOTOR AND NONMOTOR FEATURESCLINICAL MOTOR AND NONMOTOR FEATURES

Resting tremor: An involuntary, rhythmic, shaking movement produced when muscles repeatedly contract and relax

70% of patients“Pill-rolling” tremor in handsCan involve lips, chin, jaw, legs

Bradykinesia: Slowed ability to start and continue movements, and impaired ability to adjust the body's position. Can be a symptom of Parkinson's disease, or a side effect of medications

80% to 90% of patientsMost disabling symptom of PD

Rigidity: or cogwheel rigidity basically refers to the tone of muscles. Sometimes rigidity is experienced as a sense of stiffness or even tightness in muscles

>90% of patients“Cogwheel” (fluctuating) or “lead pipe” (continuous)

Postural instability: is the state when one can not keep his body in stable or balance position

Indicative of advanced-stage PDFrequent cause of falls

Motor Features

CASE BACKGROUNDCASE BACKGROUNDPARKINSON’S DISEASE (continued..)PARKINSON’S DISEASE (continued..)CLINICAL MOTOR AND NONMOTOR FEATURESCLINICAL MOTOR AND NONMOTOR FEATURES

Nonmotor Features

Psychiatric disorders •Depression in up to 40% of patients•Anxiety in ~30% of patients

Cognitive disorders •Mild cognitive impairment(memory processing, perception and problem solving) •Dementia in 15% to 40% of patients

Sleep abnormalities •>70% of patients•REM sleep behavior disorder•Insomnia•Daytime somnolence

Autonomic dysfunction •Constipation•Dysphagia (difficulty in swallowing)•Hypersalivation•Orthostatic hypotension (also known as postural hypotension, and, colloquially, as head rush or a dizzy spell)

Sensory •Olfactory dysfunction (anosmia)

Miscellaneous •Fatigue and weight loss

CASE BACKGROUNDCASE BACKGROUNDPARKINSON’S DISEASE (continued..)PARKINSON’S DISEASE (continued..)

CLINICAL MOTOR AND NONMOTOR RATING SCALESCLINICAL MOTOR AND NONMOTOR RATING SCALES

PD Rating Scales: Motor SymptomsHoehn and Yahr scale: commonly used system for describing how the symptoms of Parkinson's disease progress. The scale allocates stages from 0 to 5 to indicate the relative level of disability.

0 (no signs of disease) to 5 (wheelchair-bound)Valuable for broadly classifying disease severityStage one: Symptoms on one side of the body only. Stage two: Symptoms on both sides of the body. No impairment of balance. Stage three: Balance impairment. Mild to moderate disease. Physically independent. Stage four: Severe disability, but still able to walk or stand unassisted. Stage five: Wheelchair-bound or bedridden unless assisted.

UPDRS: (Unified Parkinson's Disease Rating Scale) is a rating scale used to follow the longitudinal course of Parkinson's disease.

Widely employed for assessing disability70% of physicians incorporate into clinical practiceComprehensive assessment of motor symptomsIt is made up of the following sections:Mentation, behavior, and mood; Activities of daily living; Motor; Complications of therapy;

MDS-UPDRS: clinimetric testing program for the Movement Disorder Society (MDS)-sponsored revision of the Unified Parkinson's Disease Rating Scale (UPDRS)

Modified UPDRS to integrate nonmotor symptomsCurrently being validated


CLINICAL MOTOR AND NONMOTOR RATING SCALESCLINICAL MOTOR AND NONMOTOR RATING SCALES

PD Rating Scales: HRQOL

Measure No.

itemsDescription of items addressed

PDQ-39 39 Mobility, ADL, emotional well-being, stigma, social support, cognition, communication, physical discomfort

PDQ-8 8 Same as PDQ-39

PDQUALIF 33 Social function, self-image, sexuality, sleep patterns, outlook, physical function, independence, urinary function, plus 1 item of global HRQOL

PDQL 37 Parkinsonian symptoms, systemic symptoms, emotional function, social function

PIMS 10 Self-image, family/community relationships, work, leisure, travel, safety, financial security, sexuality


EFFECTIVE TREATMENT STRATEGYEFFECTIVE TREATMENT STRATEGY

The primary goal of current pharmacologic therapy for PD is to replenish depleted stores of dopamine.

• levodopa with dopa-decarboxylase inhibitors (DDIs) (eg, carbidopa, benserazide) and catechol-O-methyltransferase (COMT) (eg, entacapone, tolcapone) inhibitors.

• dopamine agonists.

• MAO-B inhibitors.

L-DOPA (3,4-dihydroxy-L-phenylalanine) is a naturally occurring amino acid found in food and made from L-Tyrosine in the human body

Dopamine receptor agonists were originally developed as adjunct therapy to levodopa to treat motor fluctuations, but the more recently introduced nonergot agonists are approved for initial monotherapy as well and are often administered as part of a treatment strategy designed to delay initiation of levodopa therapy.

Monoamine oxidase-B inhibitors (eg, selegiline, rasagiline) block the breakdown of dopamine to dihydroxyphenylacetic acid in the brain, resulting in an increased supply of dopamine. As a result, inhibition of MAO-B can increase the dopaminergic response without requiring an increase in levodopa dosage. Treatment with MAO-B inhibitors has also been employed by some neurologists as a potential disease-modifying strategy. In prospective, double-blind, controlled trials, treatment with first-generation MAO-B inhibitor selegiline delayed the progression of disability in patients who had not received previous treatment for PD. However, selegiline is metabolized to amphetamine and methamphetamine metabolites, which may induce sleep disturbances and hallucinations in susceptible patients.


Treatment Summary Treatment Summary

Early Diagnosing of PD is challenging

Recognition of subtle, nonmotor signs crucial

Effective management of PD

should involve individualized, patient-focused perspective

Minimize disability

Improve HRQOL

Achieve treatment success

THE GAIA METHODOLOGYTHE GAIA METHODOLOGYANALYSIS AND DESIGN FOR AN AGENT-BASED SYSTEMANALYSIS AND DESIGN FOR AN AGENT-BASED SYSTEM

ANALYSIS PHASEANALYSIS PHASE

ORGANIZATION

SUB-ORGANIATION - A SUB-ORGANIATION - B

THE ENVIRONMENT MODEL“All the entities and resources that the MAS can exploit, control or consume”

ROLES MODELIdentifies the key roles in the system

(The role of an agent defines what it is expected to do in the organization)

INTERACTION MODELInteractions are clearly identified and localized in

the definition of the role itself, and they help characterize the overall structure of the

organization and the position of the agent in it.

RESPONSIBILITIESDetermine functionality.

PERMISSIONSThey identify the resources that can legitimately be used to carry out the role. Intuitively, they say what can be spent while carrying out the role.They state the resource limits within which the role executor must operate. Intuitively, they say what can't be spent while carrying out the role.“The information or knowledge the agent has”

ACTIVITIES“Are computations

associated with the role that may be carried out by

the agent without interacting with other

agents.”

PROTOCOLS “Define the waythat a role can

interact with other roles”

PROTOCOL DEFINITIONS”A protocol can be viewed as an

institutionalized pattern of interaction””A single protocol definition will typically give rise to a

number of message interchanges”A protocol definition consists of the following attributes:_ Protocol Name: brief textual description of the nature of the interaction (e.g., information request., .schedule activity. and .assign task.)_ initiator: the role(s) responsible for starting the interaction._ Partner: the role(s) with which the initiator interacts._ inputs: information used by the role initiator while enacting the protocol._ outputs: information supplied by/to the protocol Partner during the course of the interaction._ Description: brief textual description of any Description the protocol initiator performsduring the course of the interaction.

SAFETY PROPERTIES

“Intuitively states that

nothing bad happens”

LIVENESS PROPERTIES

“Intuitively state that something

good happens”

THE GAIA METHODOLOGYTHE GAIA METHODOLOGYANALYSIS AND DESIGN FOR AN AGENT-BASED SYSTEMANALYSIS AND DESIGN FOR AN AGENT-BASED SYSTEM

ANALYSIS PHASEANALYSIS PHASE

ORGANIZATIONAL RULESIdentify the constraints that the actual organization, once defined, will have to respect.

ARCHITECTURAL DESIGN PHASEARCHITECTURAL DESIGN PHASE

ORGANIZATIONAL STRUCTURE”The overall architecture of the organization”

Involves considering: (i) the organizational efficiency, (ii) the real-world organization (if any) in whichthe MAS is situated, and (iii) the need to enforce the organizational rules.

DETAILED DESIGN PHASEDETAILED DESIGN PHASE

AGENT MODELidentifies the agent classes that will make up the

system and the agent instances that will be instantiated from these classes

SERVICES MODELidentifies the main services – intended as coherent

blocks of activity in which agents will engage – that are required to realize the agent’s roles, and their properties

CASE ANALYSIS PHASECASE ANALYSIS PHASETHE PARKINSON’S DISEASE CASETHE PARKINSON’S DISEASE CASE

THE ORGANIZATION (The Health Advisor does not have to be divided into Sub-organizations)

THE ENVIRONMENT (All the entities and resources that the MAS can exploit, control or consume)

•Diagnosis Information (Illness)•Patient Personal Information (Name, Age, Ethnic, Health Insurance)•Patient’s answers to Rating Scale and Health Related quality of Life (HRQOL) questionnaire•Web database of illness information•Web database of Treatment information for all illnesses•Web database of Health Insurance•Web database of Health Care Providers (Hospitals, Clinics, Doctors, Locations, and cost/treatment)•Web database of Health Care Providers’ History and Statistical Records•Knowledge of particular illness (Parkinson’s) features•Knowledge of particular illness (Parkinson’s) development rating scales•Patient’s History Database


ROLES MODEL (What is each entity expected to do in the organization)

Role Schema: Patient

Description Person with illness

Protocols and Activities Inputs via user interface the Diagnosis, personal information, Health Insurance, and answers to rating scale and HRQOL questionnaire

Permissions Use doctor’s diagnosisAnswer rating scale and HRQOL questionnaireUse Health Advisor System’s recommendations

Responsibilities

Liveness Input personal information (Name, Age, Ethnic, etc.)Answer rating scale and HRQOL questionnaire

Safety Input accurate information


ROLES MODEL (Continued..) Role Schema: User Interface

Description Screens where patient communicate with computer

Protocols and Activities Display screen for Input of Patient’s personal info and health InsuranceDisplay screen for rating scale and HRQOL questionnaireReceive the DiagnosisReceive personal information and Health Insurance NameReceive answers to rating scale and HRQOL questionnaireStore information in patient’s history databaseSend information to diagnosis description finderSend information to MonitorReceive report from report generatorDisplay recommendations report

Permissions Read Patient’s inputUpdate patient’s history database

Responsibilities

Liveness Receive patient’s inputStore data in patient’s history databaseSend information to diagnosis description finderSend information to MonitorReceive report from Report GeneratorDisplay report

Safety If incorrect input, prompt patient for correct input


ROLES MODEL (Continued..)

Role Schema: Diagnosis description finder

Description Search the Web for description of illness

Protocols and Activities Search in Web database of illness information for description of illness and pass information to Treatment Finder

Permissions Get diagnosis from user interface Search Web database of illness informationChange patient’s history database

Responsibilities

Liveness Receive diagnosis from user interfaceFind description of illnessUpdate patient’s history databasesend diagnosis description and patient personal info to Treatment FinderUsing Diagnosis and monitor’s assessment to decide whether to search for another description or not.

Safety If illness not found, ask patient through user interface for correct diagnosis


ROLES MODEL (Continued..)

Similar schemas will be created for the following Roles:

•Treatment Finder•Health Care Provider Finder•Cost per Health Care Provider Finder•Risk per Health Care Provider Finder•Report Generator•Patient Monitor


INTERACTIONS MODEL (Message Interchanges)

Protocol Name: Input patient Info

Initiator Patient

Partner User Interface

Inputs Name, Age, Ethnic, Health Insurance, and Diagnosis

Outputs Prompt messages for correct inputPatient’s information, Health Insurance, and Diagnosis

Description Get patient’s personal information, Health Insurance and Diagnosis

Protocol Name: Answer Rating Scale and HRQOL questionnaire

Initiator Patient

Partner User Interface

Inputs Name, Age, Ethnic, Health Insurance, and Diagnosis

Outputs Prompt messages for correct inputPatient’s answers to questionnaire

Description Get answers to Rating Scale and HRQOL questionnaire


INTERACTIONS MODEL (Continued..)

Similar schemas will be created for the following Interactions:

•Send diagnosis description to Treatment finder•Store Patient’s info in patient’s history database•Send diagnosis description to Treatment finder•Send progress assessment to Treatment finder•Store progress assessment in Patient’s History Database•Send progress assessment to Report Generator•Send list of treatments to Health Care Provider finder•Send Health Care Providers list to Cost finder•Send Health Care Providers list to Risk finder•Send Health Care Providers list in location order to the Report Generator•Send Health Care Providers list in cost order to the Report Generator•Send answers of questionnaire to Monitor


INTERACTIONS MODEL (Continued..)

Protocol Name: Send answers of questionnaire to Monitor

Initiator User Interface

Partner Monitor

Inputs patient’s answers to rating scale and HRQOL questionnaire

Outputs patient’s answers to rating scale and HRQOL questionnaire read by monitor

Description The User Interface prompts patient for answers to questionnaire, then sends the patient’s answers to rating scale and HRQOL questionnaire to the monitor

ORGANIZATIONAL STRUCTURE

Peer to Peer ?

CASE DESIGN PHASECASE DESIGN PHASETHE PARKINSON’S DISEASE CASETHE PARKINSON’S DISEASE CASE

AGENT MODELAgent Name: Dictionary Agent

Agent’s roles: Diagnosis description finder

Agent’s Operations: (+) Receive Diagnosis from User Interface(-) Search in Web database of Illness information for description(-) send description of diagnosis to Treatment Agent(A) Using Diagnosis and monitor’s assessment decide whether to search for another description or not.

Agent Name: Treatment Agent

Agent’s roles: Treatment finder

Agent’s Operations: (+) Receive Diagnosis description from Dictionary Agent(+) Receive patient’s progress assessment from Monitor(+) Get Health Insurance from Patient’s History Database(-) Search in Web database of treatments for Illness for possible treatments(-) send possible Treatments to Health Care Provider Agent(A) Using Diagnosis, Monitor’s assessment, Patient History, and time range decide whether to search for another set of treatments or not.


AGENT MODEL (Continued..)

Agent Name: Health Care Provider Agent

Agent’s roles: Health Care Provider finder

Agent’s Operations: (+) Receive list of possible treatments from Treatment Agent(+) Receive patient’s progress assessment from Monitor(+) Get Health Insurance from Patient’s History Database(-) Search in Web database of Health Care Providers for all available Health Care Providers for each treatment.(-) send available Health Care Providers and Health Insurance to Cost Agent(-) send available Health Care Providers and Health Insurance to Risk Agent(A) Using Monitor’s assessment, list of possible treatments, and time range decide whether to search for another Health Care Provider for each treatment or not.


AGENT MODEL (Continued..)

Agent Name: Risk Agent

Agent’s roles: Risk per Health Care Provider Finder

Agent’s Operations: (+) Receive list of available Health Care Providers for each possible treatment from Health Care Provider Agent(+) Get Health Insurance from Patient’s History Database(-) Search in Web database of Health Care Providers’ statistical records for risk associated with all Health Care Providers for each treatment.(-)send results in risk order to Report Generator(A) Using different statistical measurements from database decide the risk level for each Health Care Provider for each treatment.

Agent Name: Cost Agent

Agent’s roles: Cost per Health Care Provider Finder

Agent’s Operations: (+) Receive list of available Health Care Providers for each possible treatment from Health Care Provider Agent(+) Get Health Insurance from Patient’s History Database(-) Search in Web database of Health Insurance for cost of treatment for each Health Care Provider using Health Insurance.(-) send results in cost order to Report Generator(A) Using Monitor’s assessment, list of possible treatments, and Health Insurance plan to negotiate best possible cost.


SERVICES MODELService Name: User Interface

Service’s roles: User Interface

Service’s Operations: (+) Receive Diagnosis, Personal information, and Health Insurance from Patient(+) Receive Answers to Questionnaire from Patient(-) Store Diagnosis, Personal information, and Health Insurance in Patient’s History Database(-)Store Answers to Scale Rating and HRQOL Questionnaire in Patient’s History Database(-) Send Diagnosis information to Dictionary Agent(-) Send Diagnosis, Personal information, Health Insurance, and Answers to Scale Rating and HRQOL Questionnaire to Report Generation service

Service Name: Report Generation

Service’s roles: Report Generator

Service’s Operations: (+) Get Diagnosis, Personal information, Health Insurance, and Answers to Scale Rating and HRQOL Questionnaire from User Interface service(+) Receive Health care provider list in location order from Health care provider Agent(+) Receive Health care provider list in cost order from Cost Agent(+) Receive Health care provider list in risk order from Risk Agent(-) Organize Health care provider by location, by risk, by cost(-) Send report to User Interface service


SERVICES MODEL (Continued..)

Service Name: Monitoring

Service’s roles: Monitor

Service’s Operations: (+) Get Diagnosis, Personal information, Health Insurance, and Answers to Scale Rating and HRQOL Questionnaire from User Interface service(+) Get History from Patient’s History Database(-) Make patient’s progress assessment(-) Store patient’s progress assessment in Patients History database(-) Send patient’s progress assessment to Treatment Agent(-) Send patient’s progress assessment to Report Generation service

FUTURE DEVELOPMENTSFUTURE DEVELOPMENTSTHE HEALTH ADVISORTHE HEALTH ADVISOR

A FEW MORE REVISIONS NEEDED TO MAKE SURE IT IS A COHERENT SYSTEM

IMPLEMENTATION (Possibly in Java)

QUESTIONSQUESTIONS

THE HEALTH ADVISORTHE HEALTH ADVISOR

health advisor project

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