In the last two decades we have witnessed considerable efforts directed towards making electronic healthcare records comparable and interoperable through advances in record architectures and (bio)medical terminologies and coding systems. Deep semantic issues in general, and ontology in particular, have received some interest from the research communities. However, with the exception of work on so-called ‘controlled vocabularies’, ontology has thus far played little role in work on standardization. The prime focus has been rather the rapid population of terminologies (...) at the level of fine detail. In this paper, we argue that more efforts are needed on the side of both research and standardization to ensure that the coding systems used in electronic healthcare records enjoy a semantics that is coherent with the semantics of the record. We propose realist ontology as a method to bring about this coherence by means of a robust system of top-level ontological categories. (shrink)

The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing. Objective: This study examines the role of wireless, electronic, medical records and com- munications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, (...) especially when principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)

PURPOSE—A substantial fraction of the observations made by clinicians and entered into patient records are expressed by means of negation or by using terms which contain negative qualifiers (as in “absence of pulse” or “surgical procedure not performed”). This seems at first sight to present problems for ontologies, terminologies and data repositories that adhere to a realist view and thus reject any reference to putative non-existing entities. Basic Formal Ontology (BFO) and Referent Tracking (RT) are examples of such (...) paradigms. The purpose of the research here described was to test a proposal to capture negative findings in electronic health record systems based on BFO and RT. METHODS—We analysed a series of negative findings encountered in 748 sentences taken from 41 patient charts. We classified the phenomena described in terms of the various top-level categories and relations defined in BFO, taking into account the role of negation in the corresponding descriptions. We also studied terms from SNOMED-CT containing one or other form of negation. We then explored ways to represent the described phenomena by means of the types of representational units available to realist ontologies such as BFO. RESULTS—We introduced a new family of ‘lacks’ relations into the OBO Relation Ontology. The relation lacks_part, for example, defined in terms of the positive relation part_of, holds between a particular p and a universal U when p has no instance of U as part. Since p and U both exist, assertions involving ‘lacks_part’ and its cognates meet the requirements of positivity. CONCLUSION—By expanding the OBO Relation Ontology, we were able to accommodate nearly all occurrences of negative findings in the sample studied. (shrink)

Electronic Health Records (EHRs) are organized around two kinds of statements: those reporting observations made, and those reporting acts performed. In neither case does the record involve any direct reference to what such statements are actually about. They record not: what is happening on the side of the patient, but rather: what is said about what is happening. While the need for a unique patient identifier is generally recognized, we argue that we should now move to (...) an EHR regime in which all clinically salient particulars – from the concrete disorder on the side of the patient and the body parts in which it occurs to the concrete treatments given – should be uniquely identified. This will allow us to achieve interoperability among different systems of records at the level where it really matters: in regard to what is happening in the real world. It will also allow us to keep track of particular disorders and of the effects of particular treatments in a precise and unambiguous way. We discuss the ontological and epistemological aspects of our claim and describe a scenario for implementation within EHR systems. (shrink)

The goal of referent tracking is to create an ever-growing pool of data relating to the entities existing in concrete spatiotemporal reality. In the context of Electronic Healthcare Records (EHRs) the relevant concrete entities are not only particular patients but also their parts, diseases, therapies, lesions, and so forth, insofar as these are salient to diagnosis and treatment. Within a referent tracking system, all such entities are referred to directly and explicitly, something which cannot be achieved when familiar (...) concept-based systems are used in what is called “clinical coding”. In this paper we describe the components of a referent tracking system in an informal way and we outline the procedures that would have to be followed by healthcare personnel in using such a system. We argue that the referent tracking paradigm can be introduced with only minor – though nevertheless ontologically important – technical changes to existing EHR infrastructures, but that it will require a radically different mindset on the part of those involved in clinical coding and terminology development from that which has prevailed hitherto. (shrink)

Referent Tracking (RT) advocates the use of instance unique identifiers to refer to the entities comprising the subject matter of patient health records. RT promises many benefits to those who use health record data to improve patient care. To further the adoption of the paradigm we provide an illustration of how data from an EHR application needs to be decomposed in order to make it accord with the tenets of RT. We describe the ontological principles on which (...) this decomposition is based in order to allow integration efforts to be applied in similar ways to other EHR applications. We find that an ordinary statement from an EHR contains a surprising amount of “hidden” data that are only revealed by its decomposition according to these principles. (shrink)

There is growing interest in the use of technology to enhance the tracking and quality of clinical information available for patients in disaster settings. This paper describes the design and evaluation of the Wireless Internet Information System for Medical Response in Disasters (WIISARD).

My aim in this paper is to give a philosophical analysis of the relationship between contingently available technology and the knowledge that it makes possible. My concern is with what specific subjects can know in practice, given their particular conditions, especially available technology, rather than what can be known “in principle” by a hypothetical entity like Laplace’s Demon. The argument has two parts. In the first, I’ll construct a novel account of epistemic possibility that incorporates two pragmatic conditions: responsibility and (...) practicability. For example, whether subjects can gain knowledge depends in some circumstances on whether they have the capability of gathering relevant evidence. In turn, the possibility of undertaking such investigative activities depends in part on factors like ethical constraints, economical realities, and available technology. In the second part of the paper, I’ll introduce “technological possibility” to analyze the set of actions made possible by available technology. To help motivate the problem and later test my proposal, I’ll focus on a specific historical case, one of the earliest uses of digital electronic computers in a scientific investigation. I conclude that the epistemic possibility of gaining access to scientific knowledge about certain subjects depends (in some cases) on the technological possibility for making responsible investigations. (shrink)

Objective: There are benefits and risks of giving patients more granular control of their personal health information in electronic health record (EHR) systems. When designing EHR systems and policies, informaticists and system developers must balance these benefits and risks. Ethical considerations should be an explicit part of this balancing. Our objective was to develop a structured ethics framework to accomplish this. -/- Methods: We reviewed existing literature on the ethical and policy issues, developed an ethics framework called a “Points (...) to Consider” (P2C) document, and convened a national expert panel to review and critique the P2C. -/- Results: We developed the P2C to aid informaticists designing an advanced query tool for an electronic health record (EHR) system in Indianapolis. The P2C consists of six questions (“Points”) that frame important ethical issues, apply accepted principles of bioethics and Fair Information Practices, comment on how questions might be answered, and address implications for patient care. -/- Discussion: The P2C is intended to clarify whatis at stake when designers try to accommodate potentially competing ethical commitments and logistical realities. The P2C was developed to guide informaticists who were designing a query tool in an existing EHR that would permit patient granular control. While consideration of ethical issues is coming to the forefront of medical informatics design and development practices, more reflection is needed to facilitate optimal collaboration between designers and ethicists. This report contributes to that discussion. (shrink)

We present a novel methodology for calculating the improvements obtained in successive versions of biomedical ontologies. The theory takes into account changes both in reality itself and in our understanding of this reality. The successful application of the theory rests on the willingness of ontology authors to document changes they make by following a number of simple rules. The theory provides a pathway by which ontology authoring can become a science rather than an art, following principles analogous to those that (...) have fostered the growth of modern evidence-based medicine. Although in this paper we focus on ontologies, the methodology can be generalized to other sorts of terminology-based artifacts, including Electronic Patient Records. (shrink)

The translational research community, in general, and the Clinical and Translational Science Awards (CTSA) community, in particular, share the vision of repurposing EHRs for research that will improve the quality of clinical practice. Many members of these communities are also aware that electronic health records (EHRs) suffer limitations of data becoming poorly structured, biased, and unusable out of original context. This creates obstacles to the continuity of care, utility, quality improvement, and translational research. Analogous limitations to sharing objective (...) data in other areas of the natural sciences have been successfully overcome by developing and using common ontologies. This White Paper presents the authors’ rationale for the use of ontologies with computable semantics for the improvement of clinical data quality and EHR usability formulated for researchers with a stake in clinical and translational science and who are advocates for the use of information technology in medicine but at the same time are concerned by current major shortfalls. This White Paper outlines pitfalls, opportunities, and solutions and recommends increased investment in research and development of ontologies with computable semantics for a new generation of EHRs. (shrink)

The paradigm of referent tracking is based on a realist presupposition which rejects so-called negative entities (congenital absent nipple, and the like) as spurious. How, then, can a referent tracking-based Electronic Health Record deal with what are standardly called ‘negative findings’? To answer this question we carried out an analysis of some 748 sentences drawn from patient charts and containing some form of negation. Our analysis shows that to deal with these sentences we need to introduce a new (...) ontological relationship between a particular and a universal, which holds when no instance of the universal has a specific qualified ontological relation with the particular. This relation is found to be able to accommodate nearly all occurrences of negative findings in the examined sample, in ways which involve no reference to negative entities. (shrink)

Semantic interoperability requires the use of standards, not only for Electronic Health Record (EHR) data to be transferred and structurally mapped into a receiving repository, but also for the clinical content of the EHR to be interpreted in conformity with the original meanings intended by its authors. Accurate and complete clinical documentation, faithful to the patient’s situation, and interoperability between systems, require widespread and dependable access to published and maintained collections of coherent and quality-assured semantic resources, including models (...) such as archetypes and templates that would (1) provide clinical context, (2) be mapped to interoperability standards for EHR data, (3) be linked to well specified, multi-lingual terminology value sets, and (4) be derived from high quality ontologies. Wide-scale engagement with professional bodies, globally, is needed to develop these clinical information standards. (shrink)

Despite the recent advances in information and communication technology that have increased our ability to store and circulate information, the task remains of ensuring that the right sorts of information reach the right sorts of people. In what follows we defend the thesis that efforts to develop efficient means for sharing information across healthcare systems and organizations would benefit from a careful analysis of human action in healthcare organizations, and that the communication of healthcare information and knowledge needs to rest (...) on a sound ontology of social interaction. We illustrate this thesis in relation to the HL7 RIM, which is one centrally important tool for communication in the healthcare domain. (shrink)

The automatic integration of rapidly expanding information resources in the life sciences is one of the most challenging goals facing biomedical research today. Controlled vocabularies, terminologies, and coding systems play an important role in realizing this goal, by making it possible to draw together information from heterogeneous sources – for example pertaining to genes and proteins, drugs and diseases – secure in the knowledge that the same terms will also represent the same entities on all occasions of use. In the (...) naming of genes, proteins, and other molecular structures, considerable efforts are under way to reduce the effects of the different naming conventions which have been spawned by different groups of researchers. Electronic patient records, too, increasingly involve the use of standardized terminologies, and tremendous efforts are currently being devoted to the creation of terminology resources that can meet the needs of a future era of personalized medicine, in which genomic and clinical data can be aligned in such a way that the corresponding information systems become interoperable. (shrink)

Biomedical terminologies are focused on what is general, Electronic Health Records (EHRs) on what is particular, and it is commonly assumed that the step from the one to the other is unproblematic. We argue that this is not so, and that, if the EHR of the future is to fulfill its promise, then the foundations of both EHR architectures and biomedical terminologies need to be reconceived. We accordingly describe a new framework for the treatment of both generals and (...) particulars in biomedical information systems that is designed: 1) to provide new opportunities for the sharing and management of data within and between healthcare institutions, 2) to facilitate interoperability among different terminology and record systems, and thereby 3) to allow new kinds of reasoning with biomedical data. (shrink)

Ontological principles are needed in order to bridge the gap between medical and biological information in a robust and computable fashion. This is essential in order to draw inferences across the levels of granularity which span medicine and biology, an example of which include the understanding of the roles of tumor markers in the development and progress of carcinoma. Such information integration is also important for the integration of genomics information with the information contained in the electronic patient (...) records in such a way that real time conclusions can be drawn. In this paper we describe a large multi-granular datasource built by using ontological principles and focusing on the case of colon carcinoma. (shrink)

Referent tracking (RT) is a new paradigm, based on unique identification, for representing and keeping track of particulars. It was first introduced to support the entry and retrieval of data in electronic health records (EHRs). Its purpose is to avoid the ambiguity that arises when statements in an EHR refer to disorders or other entities on the side of the patient exclusively by means of compound descriptions utilizing general terms such as ‘pimple on nose’ or ‘small left (...) breast tumor’. In this paper, we describe the theoretical foundations of this paradigm and show how it is being applied to the solution of analogous problems of ambiguous identification in the fields of digital rights management, corporate memories and decision algorithms. (shrink)

Personal Health Monitoring (PHM) uses electronic devices which monitor and record health-related data outside a hospital, usually within the home. This paper examines the ethical issues raised by PHM. Eight themes describing the ethical implications of PHM are identified through a review of 68 academic articles concerning PHM. The identified themes include privacy, autonomy, obtrusiveness and visibility, stigma and identity, medicalisation, social isolation, delivery of care, and safety and technological need. The issues around each of these are discussed. The (...) system / lifeworld perspective of Habermas is applied to develop an understanding of the role of PHMs as mediators of communication between the institutional and the domestic environment. Furthermore, links are established between the ethical issues to demonstrate that the ethics of PHM involves a complex network of ethical interactions. The paper extends the discussion of the critical effect PHMs have on the patient’s identity and concludes that a holistic understanding of the ethical issues surrounding PHMs will help both researchers and practitioners in developing effective PHM implementations. (shrink)

Medicine is often thought of as a science of the body, but it is also a science of data. In some contexts, it can even be asserted that data drive health. This article focuses on a key piece of data technology central to contemporary practices of medicine: the medical record. By situating the medical record in the perspective of its history, we inquire into how the kinds of data that are kept at sites of clinical encounter often depend on informational (...) requirements that originate well outside of the clinic, in particular in health insurance records systems. Although this dependency of today's electronic medical records on billing requirements is widely lamented by clinical providers, its history remains little studied. Following the archaeology of medicine developed by Michel Foucault in The Birth of the Clinic and expanding his methodology in light of more recent contributions to the field of media archaeology, this article excavates some of the underexplored technological conditions that help constitute today's electronic medical record. If in some contexts, it is true that data drive health, then an archaeology of medical records helps reveal how health insurance records often impact clinical care and, by extension, health and disease. (shrink)

Despite the recent advances in information and communication technology that have increased our ability to store and circulate information, the task of ensuring that the right sorts of information gets to the right sorts of people remains. We argue that the many efforts underway to develop efficient means for sharing information across healthcare systems and organizations would benefit from a careful analysis of human action in healthcare organizations. This in turn requires that the management of information and knowledge within healthcare (...) organizations be combined with models of resources and processes of patient care that are based on a general ontology of social interaction. The Health Level 7 (HL7) is one of several ANSI-accredited Standards Developing Organizations operating in the healthcare arena. HL7 has advanced a widely used messaging standard that enables healthcare applications to exchange clinical and administrative data in digital form. HL7 focuses on the interface requirements of the entire healthcare system and not exclusively on the requirements of one area of healthcare such as pharmacy, medical devices, imaging or insurance transactions. This has inspired the development of a powerful abstract model of patient care called the Reference Information Model (RIM). The present paper begins with an overview of the core classes of the HL7 (Version 3) RIM and a brief discussion of its “actcentered” view of healthcare. Central to this account is what is called the life cycle of events. A clinical action may progress from defined, through planned and ordered, to executed. These modalities of an action are represented as the mood of the act. We then outline the basis of an ontology of organizations, starting from the theory of speech Acts, and apply this ontology to the HL7 RIM. Special attention is given to the sorts of preconditions that must be satisfied for the successful performance of a speech act and to the sorts of entities to which speech acts give rise (e.g. obligations, claims, commitments, etc.). Finally we draw conclusions for the efficient communication and management of medical information and knowledge within and between healthcare organizations, paying special attention to the role that medical documents play in such organizations. (shrink)

BACKGROUND: Little is known about how hospitalized patients share decisions with physicians. METHODS: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. RESULTS: Most patients were white (61%) and half were (...) female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. CONCLUSIONS: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. PRACTICE IMPLICATIONS: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy. (shrink)

Introduction Current treatments for pain have limited benefits and worrying side effects. Some studies suggest that pain is reduced when clinicians deliver positive messages. However, the effects of positive messages are heterogeneous and have not been subject to meta-analysis. We aimed to estimate the efficacy of positive messages for pain reduction. -/- Methods We included randomized trials of the effects of positive messages in a subset of the studies included in a recent systematic review of context factors for treating pain. (...) Several electronic databases were searched. Reference lists of relevant studies were also searched. Two authors independently undertook study selection, data extraction, risk of bias assessment, and analyses. Our primary outcome measures were differences in patient- or observer-reported pain between groups who were given positive messages and those who were not. -/- Results Of the 16 randomized trials (1703 patients) that met the inclusion criteria, 12 trials had sufficient data for meta-analysis. The pooled standardized effect size was −0.31 (95% confidence interval [CI] −0.61 to −0.01, p = 0.04, I2 = 82%). The effect size remained positive but not statistically significant after we excluded studies considered to have a high risk of bias (standard effect size −0.17, 95% CI −0.54 to 0.19, P = 0.36, I2 = 84%). -/- Conclusion Care of patients with chronic or acute pain may be enhanced when clinicians deliver positive messages about possible clinical outcomes. However, we have identified several limitations of the present study that suggest caution when interpreting the results. We recommend further high-quality studies to confirm (or falsify) our result. -/- FUNDING -/- Alexander Mebius research has been funded through the ERC grant "Philosophy of Pharmacology: Safety, Statistical Standards, and Evidence Amalgamation" (GA: 639276). (shrink)

Objective: This study aimed to determine the diagnostic value of median nerve cross-sectional area (MNCSA; mm2), which can be measured using ultrasonography (US), compared with electrophysiological parameters in patients with mild and moderate carpal tunnel syndrome (CTS). Methods: The study included 72 wrists of 25 patients with CTS diagnosis and 23 healthy controls. Median and ulnar sensory and motor nerve conduction study results and MNCSA values determined by US, of all subjects were recorded. Electrophysiological and US data of the (...) class='Hi'>patient and control groups were compared, and a correlation between MNCSA and velocity and latency of sensory and motor conduction of median nerves was investigated. Moreover, Receiver operating characteristic ROC curve analysis was performed to determine the cut-off value for diagnosing CTS with MNCSA. Differences between the mean MNCSA values, median nerve sensory conduction velocity (SCV), and motor distal latency (MDL) were statistically significant between the groups. Results: Differences between the mean MNCSA values of grade 1 CTS patients with very mild CTS and those of the healthy controls were statistically significant. There was a moderate and significant negative correlation between MNCSA and SCV values and a low and significant positive correlation between MNCSA and MDL values. In addition, there was a moderate and significant positive correlation between MNCSA values and grades. A cut-off value of 10.25 mm2, which was obtained by the ROC analysis, enabled the differentiation of patients and controls with a sensitivity of 80% and specificity of 76%. Conclusion: We suggest that MNCSA, which is calculated using US, has high sensitivity and specificity values and is used as a firstline diagnostic tool with electromyography. (shrink)

Coronary artery vasospasm (CAVS) is a clinical entity that can cause angina, but also unstable angina pectoris, acute myocardial infarction, fatal arrhythmias, and sudden death. Although it is a condition that is usually controlled with medical treatment, more aggressive treatments may rarely be required. In this case, the patient with a known diagnosis of CAVS had multiple arrests despite optimal medical treatment. We observed that fatal arrhythmias persisted in the Implantable Cardioverter Defibrillator (ICD) records, even though we implanted (...) a stent and gave the patient maximal medical treatment. We performed sympathectomy as a last resort and we did not detect any recurrence in the 6-month follow-up of the patient. ICD implantation and sympathectomy should always be considered in resistant CAVS cases. (shrink)

Objective: Inflammation is one of several etiopathological mechanisms contributing to bipolar disorder. Neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and platelet-lymphocyte ratio (PLR) are relatively cheap hematological parameters recommended to measure the level of inflammation. In this study, the NLR, MLR, and PLR values of the same patients during manic and euthymic periods were compared to a healthy control group. -/- Methods: This retrospective study was conducted on inpatients with bipolar disorder manic episodes at the University Faculty of Medicine psychiatry clinic. (...) Ninety-nine patients with manic episodes of bipolar disorder and age and gender-matched 101 volunteers without prior psychiatric illness were included in the study. Neutrophil, lymphocyte, monocyte, and platelet counts during the disease period were recorded, and NLR, MLR, and PLR values were calculated from these values. Similar hematological parameters of the same patients in the euthymic period after discharge were compared. -/- Results: Patients with manic episodes were shown to have significantly higher neutrophil, platelet, NLR, MLR, and PLR levels than the control group (p<0.001). Monocyte count was significantly lower in manic episode patients compared to controls (p<0.001). Neutrophil and monocyte counts were significantly lower during the euthymic period compared to the control group, while NLR, MLR, and PLR levels were higher (p<0.001). -/- Conclusions: The fact that NLR, MLR, and PLR are higher in BD patients compared to the healthy control group in both manic and euthymic periods indicates that they can be used as trait biomarkers. (shrink)

Background: Despite the at least decades long record of philosophical recognition and interest, the intricacy of the deceptively familiar appearing concepts of ‘disease’, ‘disorder’, ‘disability’, etc., has only recently begun showing itself with clarity in the popular discourse wherein its newly emerging prominence stems from the liberties and restrictions contingent upon it. Whether a person is deemed to be afflicted by a disease or a disorder governs their ability to access health care, be it free at the point of use (...) or provided by an insurer; it also influences the treatment of individuals by the judicial system and employers; it even affects one’s own perception of self. -/- Aims: All existing philosophical definitions of disease struggle with coherency, causing much confusion and strife, and leading to inconsistencies in real-world practice. Hence, there is a real need for an alternative. -/- Materials & Methods: In the present article I analyse the variety of contemporary views of disease, showing them all to be inadequate and lacking in firm philosophical foundations, and failing to meet the desideratum of patient driven care. -/- Results: Illuminated by the insights emanating from the said analysis, I introduce a novel approach with firm ethical foundations, which foundations are rooted in sentience, that is the subjective experience of sentient beings. -/- Discussion: I argue that the notion of disease is at best superfluous, and likely even harmful in the provision of compassionate and patient-centred care. -/- Conclusion: Using a series of presently contentious cases illustrate the power of the proposed framework which is capable of providing actionable and humane solutions to problems that leave the current theories confounded. (shrink)

In contemporary paternalism literature, persuasion is commonly not considered paternalistic. Moreover, paternalism is typically understood to be problematic either because it is seen as coercive, or because of the insult of the paternalist considering herself superior. In this paper, I argue that doctors who persuade patients act paternalistically. Specifically, I argue that trying to persuade a patient (here understood as aiming for the patient to consent to a certain treatment, although he prefers not to) should be differentiated from (...) trying to convince him (here understood as aiming for the patient to want the treatment) and recommending (the doctor merely providing her professional opinion). These three forms of influence are illustrated by summaries of video-recorded hospital encounters. While convincing and recommending are generally not paternalistic, I argue that persuasion is what I call communicative paternalism and that it is problematic for two reasons. First, the patient’s preferences are dismissed as unimportant. Second, the patient might wind up undergoing treatment against his preferences. This does not mean that persuasion always should be avoided, but it should not be undertaken lightly, and doctors should be aware of the fine line between non-paternalism and paternalism. The fact that my analysis of paternalism differs from traditional accounts does not imply that I deem these to be wrong, but rather that paternalism should be considered as a more multi-faceted concept than previous accounts allow for. (shrink)

Purpose of Review Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is identified from Wuhan, China, and has spread almost worldwide. Recently, the newly identified SARS-CoV-2 has been confirmed to kill millions of people worldwide and is dangerous to society health, survival, and livelihood. The people with cardiovascular problems are noticed as most common patients of coronavirus disease 2019 (COVID-19). There is a greater risk of mortality and morbidity in these patients than other patients of COVID-19. In the heart, expressed angiotensin-converting enzyme (...) 2 (ACE2) and response effect of hyperactivity with angiotensin II associated to the renin-angiotensin mechanism are key factors of hypertension, atherosclerosis, and congestive heart failure. -/- Recent Findings Mortality rates have been observed about 10.5% cases in patients with cardiovascular disease; however, a mortality rate of 52% was recorded in patients with heart failure, while 12% recovered ultimately. The occupancy of intense injury controlled by troponin elevation was a noteworthy factor in relation to mortality. Among 187 patients infected with SARS-CoV-2, about 35% were diagnosed with cardiovascular disease (CVD) history and 28% with raised troponin. Troponin elevation was identified more frequently (55%) in patients with cardiovascular diseases. Mortality rate in patients without cardiovascular diseases and normal troponin was 7.6%, normal troponin and cardiovascular disease with 13.3%, augmented troponin and without cardiovascular disease 37.5%, however 69.4% among cardiovascular disease and advanced troponin. -/- Summary The study reflected a significant association of case fatality rate (CFR) to COVID-19 patients with cardiovascular diseases which supposed to be the most common dangerous risk factor and health challenge during the current pandemic situation. (shrink)

The advance of scientific approaches to life has recorded a plethora of successes as well as failures. Man being at the center of its experiment is tossed toe and fro by the result of its inquiry. Predictions are that in the nearest time, humanity might be living absolutely under the directives of Technology based on Artificial intelligence. At present, Technology based on Artificial Intelligence is quickly finding its way into various areas of life including health and social services. This spread (...) and or interplay connotes the relinquishing of health responsibilities from man to sensor technology as well as dependency on the data and result of this technology. This effort questions this unethical dependency as well as raises moral issues associated with the use of Technology base on artificial intelligence on psychiatric patient. It dabbles into medical values such as; autonomy of the patient cum consent, Kantian universal principle and its implication to implementing the universal usage of technology in mental health care services, and so on. The work of Patricia A. Arean (2016) titled Mobile Technology for Mental Health Assessment gave an in-depth analysis of the available approaches, doting advantages of sensor technology on psychiatric patient. The paper applied the analytic, descriptive and prescriptive method of philosophy to achieve its objective. To this end, it is in the view of this work imperative for the mental-medical community to consider reflectively these issues and the philosophic recommendations provided herein. (shrink)

We present a novel model of individual people, online posts, and media platforms to explain the online spread of epistemically toxic content such as fake news and suggest possible responses. We argue that a combination of technical features, such as the algorithmically curated feed structure, and social features, such as the absence of stable social-epistemic norms of posting and sharing in social media, is largely responsible for the unchecked spread of epistemically toxic content online. Sharing constitutes a distinctive communicative act, (...) governed by a dedicated norm and motivated to a large extent by social identity maintenance. But confusion about this norm and its lack of inherent epistemic checks lead readers to misunderstand posts, attribute excess or insufficient credibility to posts, and allow posters to evade epistemic accountability—all contributing to the spread of epistemically toxic content online. This spread can be effectively addressed if people and platforms add significantly more context to shared posts and platforms nudge people to develop and follow recognized epistemic norms of posting and sharing. (shrink)

As health systems around the world turn towards highly distributed, specialized and cooperative structures to increase quality and safety of care as well as efficiency and efficacy of delivery processes, there is a growing need for supporting communication and collaboration of all parties involved with advanced ICT solutions. The Electronic Health Record (EHR) provides the information platform which is maturing towards the eHealth core application. To meet the requirements for sustainable, semantically interoperable, and trustworthy EHR solutions, different standards and (...) different national strategies have been established. The workshop summarizes the requirements for such advanced EHR systems and their underlying architecture, presents different strategies and solutions advocated by corresponding protagonists, discusses pros and cons as well as harmonization and migration strategies for those approaches. It particularly highlights a turn towards ontology-driven architectures. (shrink)

David Chalmers thinks his iPhone exemplifies the extended mind thesis by meeting the criteria ‎that he and Andy Clark established in their well-known 1998 paper. Andy Clark agrees. We take ‎this proposal seriously, evaluating the case of the GPS-enabled smartphone as a potential mind ‎extender. We argue that the “trust and glue” criteria enumerated by Clark and Chalmers are ‎incompatible with both the epistemic responsibilities that accompany everyday activities and the ‎practices of trust that enable users to discharge them. Prospects (...) for revision of the original ‎criteria are dim. We therefore call for a rejection of the trust criterion and a reevaluation of the ‎extended mind thesis.‎. (shrink)

Electronic health records (EHRs) serve as repositories of documented data collected in a health care encounter. An EHR records information about who receives, who provides the health care and about the place where the encounter happens. We also observe additional elements relating to social relations in which the healthcare consumer is involved. To provide a consensus representation of common data and to enhance interoperability between different EHR repositories we have created a solution grounded in formal ontology. Here, (...) we present how an ontology for the obstetric and neonatal domain deals with these general elements documented in health care encounters. Our goal is to promote the interoperability of information among EHRs created in different specialties. To develop our ontology, we used two main approaches: one based on ontological realism, the other based on the principles of the OBO Foundry, including reuse of reference ontologies. (shrink)

Leading prescriptions for addressing the spread of fake news, misinformation, and other forms of epistemically toxic content online target either the platform or platform users as a single site for intervention. Neither approach attends to the intense feedback between people, posts, and platforms. Leading prescriptions boil down to the suggestion that we make social media more like traditional media, whether by making platforms take active roles as gatekeepers, or by exhorting individuals to behave more like media professionals. Both approaches are (...) impracticable and wrong. (shrink)

People increasingly form beliefs based on information gained from automatically filtered Internet ‎sources such as search engines. However, the workings of such sources are often opaque, preventing ‎subjects from knowing whether the information provided is biased or incomplete. Users’ reliance on ‎Internet technologies whose modes of operation are concealed from them raises serious concerns about ‎the justificatory status of the beliefs they end up forming. Yet it is unclear how to address these concerns ‎within standard theories of knowledge and justification. (...) To shed light on the problem, we introduce a ‎novel conceptual framework that clarifies the relations between justified belief, epistemic responsibility, ‎action, and the technological resources available to a subject. We argue that justified belief is subject to ‎certain epistemic responsibilities that accompany the subject’s particular decision-taking circumstances, ‎and that one typical responsibility is to ascertain, so far as one can, whether the information upon which ‎the judgment will rest is biased or incomplete. What this responsibility comprises is partly determined by ‎the inquiry-enabling technologies available to the subject. We argue that a subject’s beliefs that are ‎formed based on Internet-filtered information are less justified than they would be if she either knew how ‎filtering worked or relied on additional sources, and that the subject may have the epistemic ‎responsibility to take measures to enhance the justificatory status of such beliefs.‎. (shrink)

Information providing and gathering increasingly involve technologies like search ‎engines, which actively shape their epistemic surroundings. Yet, a satisfying account ‎of the epistemic responsibilities associated with them does not exist. We analyze ‎automatically generated search suggestions from the perspective of social ‎epistemology to illustrate how epistemic responsibilities associated with a ‎technology can be derived and assigned. Drawing on our previously developed ‎theoretical framework that connects responsible epistemic behavior to ‎practicability, we address two questions: first, given the different technological ‎possibilities available (...) to searchers, the search technology, and search providers, ‎who should bear which responsibilities? Second, given the technology’s ‎epistemically relevant features and potential harms, how should search terms be ‎autocompleted? Our analysis reveals that epistemic responsibility lies mostly with ‎search providers, which should eliminate three categories of autosuggestions: those ‎that result from organized attacks, those that perpetuate damaging stereotypes, and ‎those that associate negative characteristics with specific individuals.‎. (shrink)

Background: Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT, hereafter abbreviated SCT) is acomprehensive medical terminology used for standardizing the storage, retrieval, and exchange of electronic healthdata. Some efforts have been made to capture the contents of SCT as Web Ontology Language (OWL), but theseefforts have been hampered by the size and complexity of SCT. Method: Our proposal here is to develop an upper-level ontology and to use it as the basis for defining the termsin SCT in a way that (...) will support quality assurance of SCT, for example, by allowing consistency checks ofdefinitions and the identification and elimination of redundancies in the SCT vocabulary. Our proposed upper-levelSCT ontology (SCTO) is based on the Ontology for General Medical Science (OGMS). Results: The SCTO is implemented in OWL 2, to support automatic inference and consistency checking. Theapproach will allow integration of SCT data with data annotated using Open Biomedical Ontologies (OBO) Foundryontologies, since the use of OGMS will ensure consistency with the Basic Formal Ontology, which is the top-levelontology of the OBO Foundry. Currently, the SCTO contains 304 classes, 28 properties, 2400 axioms, and 1555annotations. It is publicly available through the bioportal athttp://bioportal.bioontology.org/ontologies/SCTO/. Conclusion: The resulting ontology can enhance the semantics of clinical decision support systems and semanticinteroperability among distributed electronic health records. In addition, the populated ontology can be used forthe automation of mobile health applications. (shrink)

The COVID-19 pandemic prompted immense work on the investigation of the SARS-CoV-2 virus. Rapid, accurate, and consistent interpretation of generated data is thereby of fundamental concern. Ontologies––structured, controlled, vocabularies––are designed to support consistency of interpretation, and thereby to prevent the development of data silos. This paper describes how ontologies are serving this purpose in the COVID-19 research domain, by following principles of the Open Biological and Biomedical Ontology (OBO) Foundry and by reusing existing ontologies such as the Infectious Disease Ontology (...) (IDO) Core, which provides terminological content common to investigations of all infectious diseases. We report here on the development of an IDO extension, the Virus Infectious Disease Ontology (VIDO), a reference ontology covering viral infectious diseases. We motivate term and definition choices, showcase reuse of terms from existing OBO ontologies, illustrate how ontological decisions were motivated by relevant life science research, and connect VIDO to the Coronavirus Infectious Disease Ontology (CIDO). We next use terms from these ontologies to annotate selections from life science research on SARS-CoV-2, highlighting how ontologies employing a common upper-level vocabulary may be seamlessly interwoven. Finally, we outline future work, including bacteria and fungus infectious disease reference ontologies currently under development, then cite uses of VIDO and CIDO in host-pathogen data analytics, electronic health record annotation, and ontology conflict-resolution projects. (shrink)

A recent systematic review of Machine Learning (ML) approaches to health data, containing over 100 studies, found that the most investigated problem was mental health (Yin et al., 2019). Relatedly, recent estimates suggest that between 165,000 and 325,000 health and wellness apps are now commercially available, with over 10,000 of those designed specifically for mental health (Carlo et al., 2019). In light of these trends, the present chapter has three aims: (1) provide an informative overview of some of the recent (...) work taking place at the intersection of text mining and mental health so that we can (2) highlight and analyze several pressing ethical issues that are arising in this rapidly growing field and (3) suggest productive directions for how these issues might be better addressed within future interdisciplinary work to ensure the responsible development of text mining approaches in psychology generally, and in mental health fields, specifically. In Section 1, we review some of the recent literature on text-mining and mental health in the contexts of traditional experimental settings, social media, and research involving electronic health records. Then, in Section 2, we introduce and discuss ethical concerns that arise before, during, and after research is conducted. Finally, in Section 3, we offer several suggestions about how ethical oversight of text-mining research might be improved to be more responsive to the concerns mapped out in Section 2. (shrink)

The last two decades have seen considerable efforts directed towards making Electronic Health Records interoperable through improvements in medical ontologies, terminologies and coding systems. Unfortunately, these efforts have been hampered by a number of influential ideas inherited from the work of Eugen Wüster, the father of terminology standardization and the founder of ISO TC 37. We here survey Wüster’s ideas – which see terminology work as being focused on the classification of concepts in people’s minds – and we (...) argue that they serve still as the basis for a series of influential confusions. We argue further that an ontology based unambiguously, not on concepts, but on the classification of entities in reality can, by removing these confusions, make a vital contribution to ensuring the interoperability of coding systems and healthcare records in the future. (shrink)

It is only by fixing on agreed meanings of terms in biomedical terminologies that we will be in a position to achieve that accumulation and integration of knowledge that is indispensable to progress at the frontiers of biomedicine. Standardly, the goal of fixing meanings is seen as being realized through the alignment of terms on what are called ‘concepts’. Part I addresses three versions of the concept-based approach – by Cimino, by Wüster, and by Campbell and associates – and surveys (...) some of the problems to which they give rise, all of which have to do with a failure to anchor the terms in terminologies to corresponding referents in reality. Part II outlines a new, realist solution to this anchorage problem, which sees terminology construction as being motivated by the goal of alignment not on concepts but on the universals (kinds, types) in reality and thereby also on the corresponding instances (individuals, tokens). We outline the realist approach, and show how on its basis we can provide a benchmark of correctness for terminologies which will at the same time allow a new type of integration of terminologies and electronic health records. We conclude by outlining ways in which the framework thus defined might be exploited for purposes of diagnostic decision-support. (shrink)

It is only by fixing on agreed meanings of terms in biomedical terminologies that we will be in a position to achieve that accumulation and integration of knowledge that is indispensable to progress at the frontiers of biomedicine. Standardly, the goal of fixing meanings is seen as being realized through the alignment of terms on what are called ‘concepts’. Part I addresses three versions of the concept-based approach – by Cimino, by Wüster, and by Campbell and associates – and surveys (...) some of the problems to which they give rise, all of which have to do with a failure to anchor the terms in terminologies to corresponding referents in reality. Part II outlines a new, realist solution to this anchorage problem, which sees terminology construction as being motivated by the goal of alignment not on concepts but on the universals (kinds, types) in reality and thereby also on the corresponding instances (individuals, tokens). We outline the realist approach, and show how on its basis we can provide a benchmark of correctness for terminologies which will at the same time allow a new type of integration of terminologies and electronic health records. We conclude by outlining ways in which the framework thus defined might be exploited for purposes of diagnostic decision-support. (shrink)

This paper presents the Obstetric and Neonatal Ontology (OntONeo). This ontology has been created to provide a consensus representation of salient electronic health record (EHR) data and to serve interoperability of the associated data and information systems. More generally, it will serve interoperability of clinical and translational data, for example deriving from genomics disciplines and from clinical trials. Interoperability of EHR data is important to ensuring continuity of care during the prenatal and postnatal periods for both mother and child. (...) As a strategy to advance such interoperability we use an approach based on ontological realism and on the ontology development principles of the Open Biomedical Ontologies Foundry, including reuse of reference ontologies wherever possible. We describe the structure and coverage domain of OntONeo and the process of creating and maintaining the ontology. (shrink)

Abstract: This research explores the application of artificial neural networks (ANNs) in predicting cancer using a synthetically generated dataset designed for research purposes. The dataset comprises 10,000 pseudo-patient records, each characterized by gender, age, smoking history, fatigue, and allergy status, along with a binary indicator for the presence or absence of cancer. The 'Gender,' 'Smoking,' 'Fatigue,' and 'Allergy' attributes are binary, while 'Age' spans a range from 18 to 100 years. The study employs a three-layer ANN architecture to (...) develop a predictive model. The achieved accuracy of 97.24% and a low loss value of 0.02 indicate promising performance. Further analysis involves a comprehensive examination of the confusion matrix, precision, recall, and F1 score metrics, along with the ROC curve and AUC score, to provide a detailed understanding of the model's strengths and weaknesses. Additionally, considerations for cross-validation, hyperparameter tuning, and interpretability are discussed. It is emphasized that while the synthetic nature of the dataset allows for controlled experimentation, results should be cautiously interpreted and validated on authentic clinical data before extrapolation to real-world medical scenarios. This research serves as a valuable contribution to the exploration of predictive models for cancer detection, encouraging continued investigation and development in the field. (shrink)

There are a number of existing classifications and staging schemes for carcinomas, one of the most frequently used being the TNM classification. Such classifications represent classes of entities which exist at various anatomical levels of granularity. We argue that in order to apply such representations to the Electronic Health Records one needs sound ontologies which take into consideration the diversity of the domains which are involved in clinical bioinformatics. Here we outline a formal theory for addressing these issues (...) in a way that the ontologies can be used to support inferences relating to entities which exist at different anatomical levels of granularity. Our case study is the colon carcinoma, one of the most common carcinomas prevalent within the European population. (shrink)

Migraine is a complex neurological disorder characterized by recurrent moderate to severe headaches, accompanied by additional symptoms such as nausea, sensitivity to light and sound, and visual disturbances. Accurate and timely diagnosis of migraines is crucial for effective management and treatment. However, the diverse range of symptoms and overlapping characteristics with other headache disorders pose challenges in the diagnostic process. In this research, we propose the development of an expert system for migraine diagnosis using artificial intelligence and the CLIPS (C (...) Language Integrated Production System) framework. The expert system utilizes a rule-based inference engine to analyze patient-reported symptoms and provide reliable diagnoses or probability scores indicating the likelihood of migraine. The knowledge base of the expert system is designed based on expert knowledge obtained from medical professionals specializing in migraines. The collected knowledge is translated into a structured format suitable for the CLIPS inference engine, incorporating rules and facts to represent the diagnostic criteria and associated symptoms. The system prompts users to provide relevant information about their symptoms, medical history, and potential triggers. It applies the defined rules and facts to evaluate the likelihood of migraine and generate accurate diagnoses or probability scores. Preliminary evaluation results demonstrate the potential of the expert system as a valuable tool for diagnosing migraines. A dataset of anonymized patient records with confirmed migraine cases was used to test the system. The diagnoses generated by the expert system were compared against the known diagnoses, and a high level of accuracy was observed, with 90% of cases correctly diagnosed as migraines. These results highlight the effectiveness and reliability of the system in assisting medical professionals in the diagnosis of migraines. The proposed expert system offers several advantages for migraine diagnosis. It leverages the collective knowledge and expertise of experienced migraine specialists, providing a standardized and consistent approach to diagnosis. The system can handle large amounts of patient data and effectively analyse complex relationships between symptoms, risk factors, and diagnostic criteria. Furthermore, it offers real-time feedback and recommendations, supporting medical professionals in their clinical decision-making process. Future work involves refining the expert system based on feedback from medical experts, expanding the knowledge base to encompass a wider range of symptoms and risk factors, and conducting further evaluations to enhance its accuracy and applicability in clinical settings. The development of an expert system for migraine diagnosis has the potential to improve the diagnostic process, leading to more effective management and treatment strategies for individuals suffering from migraines. (shrink)

We are developing the Neurological Disease Ontology (ND) to provide a framework to enable representation of aspects of neurological diseases that are relevant to their treatment and study. ND is a representational tool that addresses the need for unambiguous annotation, storage, and retrieval of data associated with the treatment and study of neurological diseases. ND is being developed in compliance with the Open Biomedical Ontology Foundry principles and builds upon the paradigm established by the Ontology for General Medical Science (OGMS) (...) for the representation of entities in the domain of disease and medical practice. Initial applications of ND will include the annotation and analysis of large data sets and patient records for Alzheimer’s disease, multiple sclerosis, and stroke. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians (...) use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)