To link to this article: DOI:10.1016/j.eurger.2015.02.011
http://dx.doi.org/10.1016/j.eurger.2015.02.011
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http://oatao.univ-toulouse.fr/
Eprints ID: 14090
To cite this version:
Kamsu-Foguem, Bernard and Tiako, Pierre and Mutafungwa, Edward and
Foguem, Clovis Knowledge-based modelling applied to synucleinopathies.
European Geriatric Medicine. ISSN
1878-7649
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Technology
applied
to
geriatric
medicine
Knowledge-based
modelling
applied
to
synucleinopathies
B.
Kamsu-Foguem
a,*
,
P.F.
Tiako
b,
E.
Mutafungwa
c,
C.
Foguem
daLaboratoryofProductionEngineering(LGP),EA1905,ENIT-INPT,UniversityofToulouse,47,avenued’Azereix,BP1629,65016Tarbescedex,France bCenterforITResearch,LangstonUniversity,OK73050,USA
cAaltoUniversitySchoolofElectricalEngineering,PL13000,00076Aalto,Espoo,Finland d
CenterforFoodandTastesciences(CSGA)–UMR6265CNRS–UMR1324INRA–UniversityofBurgundy,9E,boulevardJeanne-d’Arc,21000Dijon,France
1. Introduction
Thecurrentmedicaldemographyanditsunevendistribution, particularlyin somemedical disciplines,arecreatingsignificant challengesinensuringcontinuityof care.Thishasresultedina pressingneedformedicalfacilitiesinplaceswheretheshortageof specialistsisacute.Telemedicineisatoolthatenablesequalaccess tomedicalexpertiseregardlessofplaceofcare[1].Thispractice allows physicians of regional institutions to ensure access to competencefor differentmedical investigationsorcasesand to
benefit from the expertise of their colleagues from different
specializations (radiology, surgery, psychiatry or neurology)
[2].Indeed,telemedicinehasalloweddoctorshospitalsandclinics
tohavea network for accessingremoteresources and
comple-mentaryskills[3].Otherbenefitsoftelemedicineincludepatients whoarelesstiredandstressedandfamilieswhonolongerhaveto travellongdistancestovisittheirdoctors[4].Medicalpractitioners
now have in their offices or in their local hospitals capacity
identicaltothoseatmajorhospitals.Theseadvancesarepotential
safeguard measures to ensure the protection of some local
hospitals. In summary, telemedicine provides impact in three
keydimensions[5]:
medical impact through improved medical diagnosis and
treatment,aswellas,theincreasedcompetenceofpractitioners participatinginthenetwork;
territorialimpactbymaintainingskillsandspecializedservices inhospitalsandclinicsinmediumandsmallercities,especially inruralareas;
medico-economicimpactthrough reductioninthenumber of
unnecessarytransfersand theincreaseinthenumberof vital transferswithausefulgainforpatientswhilecontrollingcosts. Theeraoftechnologicalnetworksinmedicineisinevitableto
improve the quality, safety, and continuity of care, while
promotingequalaccesstohighqualitylocalcarebypromoting coordinationandcooperationofallstakeholders.Atthe
techno-logical level, further progress can be made in the field of
telemedicineifthemainobstaclesareovercome[6].Bydeploying
this technology in all remote hospitals or care centers, one
improvesconnectivitybysettingapplicationofqualitystandards andbuildingarelationshipoftrust.Telemedicineefficiencyshould
allow equitable management of patients. It allows sharing of
Keywords: Telemedicine Ontologicalknowledge Collaboration Semanticmodelling Geriatrics ABSTRACT
Theadoptionoftelemedicinetechnologieshasenabledcollaborativeprogramsinvolvingavarietyof links among distributed medical structures and health officials and professionals. The use for telemedicinefortransmissionofmedicaldataandthepossibilityforseveraldistantphysicianstoshare theirknowledge on given medical cases provides clear benefits,but also raises severalunsolved conceptualandtechnicalchallenges.Theseamlessexchangeandaccessofmedicalinformationbetween medicalstructures,healthprofessionals,andpatientsisaprerequisitefortheharmoniousdevelopment ofthisnewmedicalpractice.Thispaper proposesanewapproachofsemanticinteroperabilityfor enabling mutual understanding of terminologies and concepts used. The proposed semantic interoperabilityapproachisbasedonconceptualgraphtosupportcollaborativeactivitiesbydescribing howdifferent healthspecialists can applyappropriatestrategies to eliminate differential medical diagnosis.Intelligentanalysisstrategiesareusedtonarrowdownandpinpointmedicaldisorders.The modelproposedisfullyverifiedbyacasestudyinthecontextofelderlypatientsandspecificallydealing withsynucleinopathies,agroupofneurodegenerativediseasesthatincludeParkinson’sdisease(PD), dementiawithLewybodies(DLB),pureautonomicfailure(PAF)andmultiplesystematrophy(MSA).
* Correspondingauthor.Tel.:+33624302337;fax:+33562442708. E-mailaddress:Bernard.Kamsu-Foguem@enit.fr(B.Kamsu-Foguem).
qualityimageviewingstations(adapteddiagnostic),flexibleusage ofresources(possibilityofWebaccess),and,toensurethat the
benefitsof suchtelemedicine canbemutual, provides
opportu-nities for technology transfer and improved efficiency in the
healthcare sectors of partners institutions.The development of telemedicineisbasedonstrengtheningourinnovationcapabilities andrequiressustainedcooperationthatcutsacrossthefieldsof health, industry, research, and defence [7]. A tele-consultation
session canshow thevarious documents available:image of a
patientorphysician,radiographicimages,andotherclinicaldata. Insomecircumstances,remotebiotechnologytoolscanbeusedto performenricheddiagnosticsbymoleculartechniques,targeting ofpathogens,andidentificationofsensitivitiestodrugsinorderto enhancetreatment[8].
Therestofthepaperisstructuredasfollows.Section2exposes
thematerialandmethodswiththeconceptualgraphoperations
usedtoimplementthemodellingofexpertrulesincollaborative decision-makingprocesses.Section3presentstheresultswithan
illustrative case for the telemedicine management within the
geriatricsfieldispresented.Finally,section4providesadiscussion andsection5concludesanddiscusseslessonslearnedandfuture challenges.
2. Materialandmethods
2.1. Knowledgeformalizationwithconceptualgraphs
Theconceptualgraph(CG)formalismisaknowledge
represen-tationlanguage, which hasa well-definedsyntaxand a formal
semantics that allows one to reason from its representations
[9].Theconceptualgraphformalismisconsideredasacompromise
representation between a formal language and a graphical
language, because it is visual and has a range of reasoning
processes[10].Conceptualgraphscanbeusedinmanycomputer
science areas, including text analysis, web semantics, and
intelligentsystems[11].
A simple conceptual graph is a finite, connected, directed, bipartitegraph consistingofconceptnodes (denotedas boxes),
which are connected toconceptual relation nodes (denoted as
circles). In the alternative linear notation, concept nodes are writtenwithin []-brackets while conceptualrelation nodes are denotedwithin()-brackets.Theconceptssetandtherelationsset aredisjoint.
A concept is composed of a type and a marker [<type>: <marker>],forexample[Disease:IdiopathicParkinson’sdisease]. Thetypeofconceptrepresentstheoccurrenceofobjectclass.They aregroupedin a hierarchicalstructure calleda conceptslattice
showing their inherit relationships. The marker specifies the
meaningofaconceptbyspecifyinganoccurrenceofthetypeof concept.
Aconceptualrelationbindstwoormoreconceptsaccordingto thefollowingdiagram:
C1 ½ ðrelation0snameÞ C 2 ½ meaningthat00C 1 isrelatedtoC2 ð bythisspecificrelation00Þ
Intheanalysisoftelemedicinemanagement,themostcommon relationsaredependencyrelations,specifically,causal, condition-al,temporal,andBooleanconnectives,suchasAND,alternating-OR
and exclusive-ORrelations. An exampleof conceptual graph is
showninFig.1:amedicalactivityistheagentofatelemedicine serviceandits durationis influencedbythediagnosticcriteria.
The semantics of the core and extended CGs is defined by a
formal mapping to and from a common abstract syntax and
model-theoreticfoundationforafamilyoflogic-basednotations (ISO/IEC24707)[12].
Aderivationisafinitesequenceoftheseelementaryoperations thathaveaformalsemanticsbasedonalogicalinterpretation.As aresult,themeaningofgraphoperationsisdeterminedinlightof the derivation to be applied, based on a logical interpretation whichgivesfulleffecttothevisualreasoning[13].Thederivation hasoneofthreeconceivablepropertiesonthelogicalrelationship betweenastartinggraphuandtheresultinggraph
v
[14]: 2.1.1. EquivalenceCopyandsimplifyareequivalencerules,whichgenerateagraph
v
thatislogicallyequivalenttotheoriginal:theknowledgeofu isincludedinv
andtheknowledgeofv
isincludedinu(logical meaninguv
andv
u).2.1.2. Specialization
Joinandrestrictarespecializationrules,whichgenerateagraph
v
thatimplies theoriginal:v
contains morespecificknowledge thanu(logicalmeaningv
u).2.1.3. Generalization
Detachandunrestrictaregeneralizationrules,whichgeneratea graph vthat is implied by theoriginal:
v
contains less precise knowledgethanv
(logicalmeaninguv
).Ontological knowledge provides a formal description of the
studied system [15] with associated experiences and lessons
learned[16,17].
2.2. Exploitationofconceptualgraphsrepresentationinreasoning
AformalknowledgemodelledbyCGsinexperiencefeedback
processescanbeaveryusefultoolforconveyingaccuratemeaning
to a collaborative workenvironment involving domainexperts
[18].Foragivenapplication,severalviewpointsofexpertisemay beengagedincombination.Forexample,someinvestigationsto improve the availability of a geriatric health care system can involveexpertknowledgeintele-expertiseandassociatedremote practices.
During theknowledge modelling phase of the telemedicine
rules,theuseofCGpropertieswillhelptoenrichthetelemedicine knowledgebaseinordertoeasetheiraccess,sharingandreuseby themembersofthetelemedicinemanagementintheirindividual andcollectivetasks.Furthermore,experiencegainedandlessons learnedfrominitialproblemsolvingdevelopmentswillbeapplied as soon as possiblein similar situations in othercollaborative telemedicine activities with temporal modelling considerations [19].
In conceptualstructures, the operations of visual reasoning
with semantic mapping form the bridge from perception to
differentformsofconceptualoperations,rangingfrom specializa-tionandgeneralizationtounification[20].Whentheconceptual
graphs operations are used in the visual reasoning, semantic
comparisonsaredeployedateverystep,andtheonlydifference betweendeductionandanalogiesisthenatureoftheorientations onthereasoning[21].Particularly,oneconceptualgraphissimilar toanotherifthereisasemanticmapping(graphhomomorphism) fromthefirstgraphtothesecondone.Inthiscontext,the case-basedreasoningcanbeengagedtosearchsomeunknownfeatures ofanewcasefromitsknownfeaturesandpreviouscasesstoredin thecasesbase.In analogicalreasoning,theconceptualstructure thatdescribesknownfeaturesofthenewcaseiscomparedwith thematchingfeaturesoftheconceptualstructuresassociatedto
previous cases [22]. The assessment takes into account the
determineddegreeofsimilarityandclassifiedalternativeoptions forothercases.Thecasethatprovidesthegreatestcorrespondence
maybeundertakenasthetopbasisofindicationforapproximating theunknownfeaturesofthenewcase.
3. Results
WeillustratetheproposedapproachusingCGswiththecase studyofsynucleinopathiesmostlyneurologicorgeriatricdiseases. Theaccommodationoftheagingpopulationisamajorconcernin healthcareandforfamilies[23].Thecostofmedicalinterventions fortheelderly,whoareoftenfrailandwithrecurringepisodesof chronicdiseases,isincreasing[24].Supportforthesevulnerable people,whoareoftenisolated,requiresthedeploymentofflexible
and effective systems to prevent hospitalizations sometimes
experiencedbyelderlyasatraumaticeventandenabletheelderly
to maintain their living place if possible [25]. Could new
technologiesprovidesomesolutions?Theexpectedbenefitsare
summarized by economic gain or improvement in the care of
elderlypatientsortheirqualityoflife.Alsoarehealthcareteams theyreadytoembracethesenewtechnologies?
3.1. Clinicaloutlineofthesynucleinopathies
Thisapplicationisinthecontextofdecisionsupportinhealth andrelatesparticularlytoneuroscienceandespecially synuclei-nopathies,agroupofneurodegenerativediseasescharacterizedby
fibrillary aggregates of alpha-synuclein protein (the major
componentsofLewybodies,dystrophic(Lewy)neuritis,andthe Papp-Lantosfilaments)inthecytoplasmofselectivepopulationsof
neurons and glia. These disorders include mainly Parkinson’s
disease(PD),dementiawithLewybodies(DLB),multiplesystem
atrophy (MSA), and also pure autonomic failure (PAF) and
Hallervorden-Spatz syndrome (HHS) [26]. Clinically, they are
characterized by a chronic and progressive decline in motor
(mainly Parkinsonism), cognitive, behavioral, and autonomic
functions, dependingon thedistributionofthelesions[27]. Al-though there are validated clinical and pathological consensus
criteria for PD, DLB, and MSA, because of clinical overlap,
differentialdiagnosisissometimesverydifficult[28].Moreover, early diagnosis of these diseases is also difficult [29]. Several approachesandnewbiomarkersarebeinginvestigatedtofacilitate
the early ante-mortem diagnosis, as the common hallmark of
synucleinopathies is the finding of alpha-synuclein protein on
brain biopsy.Amongthesepotentialnewbiomarkers,there are
myocardialmetaiodobenzyl guanidine(MIBG)scintigraphy[30],
functional cerebral imageries (reduced dopamine transporter
activity in some part of the brain), olfaction’s tests threshold revealinghyposmiaandolfactorypathwaypathology[31].Others
newdiagnosiscorefeaturesasRapidEyeMovementsleep(REM
sleep), behavior disorder, severe neuroleptic sensitivity, some clinical signs, symptoms and biological elements are assessing thestructureofthesefeaturesagainstthecriteriasetoutinthe guideline.However,therediagnosisaccuracyisnotoptimal,but inmostofcases,theycontributetoeliminatedifferentialdiagnosis. Itwillbeusefultoinvestigatednewsapproachesadaptedtothese newneedswithpossibilitytoimprovediagnosiscriteria.
InParkinson’sdisease(PD)forexample,non-motorsymptoms are (described in Table 1): olfactory dysfunction, depression, constipation, pain,genitourinary problems,sleepdisorders, and
cognitive impairments. These are often long ignored, and are
common [32]. They sometimes precede motor symptoms and
should be thoroughly investigated because they lead to a
Binar
y
-
Relation
Before DuringTempor
al-relation
Usual-rela
tio
n
Spatial-rela
tion
Log
ical-rela
tion
Agent
Characterization Object Implication Influence
Concept
Diagnosis TreatmentMedical Activity
Diagno
stic
Criteria
Sign Symptom Test result
Tele
medicin
e
Teleconsultation Teleexpertise Telemonitoring Teleassistance
Durati
on
Compete
ncy
Direction
Tool
Objec
t
Telemedicine
Medical Activity agent Usual-relation Duration
Diagnostic Criteria influence Outside
Inside
Teleexpertise
Diagnosis: Idiopathic Parkinson'sdisease agent characterization Duration
Test Result influence
Specializatio
n
Generalization
Patient
significantburden on the quality of life and have a significant contributiontothemorbidity ormortalityrates ofPD. Besides,
functional imaging using dopaminergic tracers with either
PositronEmissionTomography(PET)orSinglePositronEmission
Tomography(SPECT)canidentifydopaminedeficienciesbutmay
notreliablydifferentiatebetweenParkinson’sdiseaseandother akineticrigiddisorders.Inaddition,evenapathological examina-tioncannotclassifyclinicalsyndromeswithcertainty.Despitethe diagnosticcriteria, a diagnosis of certainty is oftendifficult to
establish because it requires a formal demonstration of the
characteristicfeaturesofthepresumptivedisease. Clinicopatho-logicalstudieshaveshownthattheaccuracyofaclinicaldiagnosis ofPD isless than 80%.More selecteddiagnosticcriteria would increasetheproportionoftruePDcasesidentifiedtomorethan 90%[33].
Misdiagnosisofasynucleinopathyasanotheroneistherefore
potentially extremely dangerous for these patients because of
thetherapeuticsimplications.Forexample,inpatientswithPDor
withdementia with Lewy bodies (DLB), typical neuroleptic or
antipsychoticdrugscouldleadtoneurolepticmalignantsyndrome (NMS),alife-threateningneurologicaldisordermostoftendueto adversereactionsofthesedrugs.NMStypicallyconsistsofmuscle rigidity,fever,autonomicinstability,andcognitivechangessuch
as delirium, and is associated with elevated plasma creatine
phosphokinase.
Morerecentstudiesadvocatethatlanguage,especially seman-tics,maybeanareaofcognitioncapableofdistinguishing
early-onset synucleinopathy patients from healthy controls and
discriminating between various types of synucleinopathies
[34].Particularly,languagedisturbancesin dementiahavebeen
factually attributed to the degradation of stored knowledge,
whereasitisfrequentlyassumedthatlanguagedeficitsinstroke aphasiamirror modality-specificimpairment ofaccesstointact
conceptual knowledge [35]. These deficits can be an acquired
disorderoflanguagecomprehension,production,and/orsymbolic
knowledge.In addition tomemory and language impairments,
assessment in other cognitive domains can also highlight the
influenceof semanticknowledge,for instance,ondecoding the
physico-chemical properties of an odorant [36]. Understanding thesemantics of cognitiveimpairmentsin synucleinopathiesis thusessentialforanumberofarguments.Identifyingsimilarities
and differences between synucleinopathies is the first step in
evolving tests that are differentially sensitive to the distinct conditions,thusprovidingappropriatescreeningteststosupport clinicaldiagnosis.Understandingthequalityofimpairmentsalso providessignificantinformationforpatients andcarers, helping physicians to elaborate better coping skills and care strategies. Besides,comparingthepropertiesofcognitiveimpairmentbetween
patient groups had often contributed to an improvement in a
semanticanalysisoftheprocessunderlyingexecutivecontrolfor understandingthenormalorganizationofcognitivefunctions[33]. 3.2. Visualmodellingofanalysisproceduresinsynucleinopathies
Wecanthink aboutthecontributionofartificialintelligence toolsasameansofanalysistosupportmedicaltestsfortheearly diagnosisanddifferentiationofthesepathologies.Particularlyin this context, operations of conceptualgraphscan be crucial to reasoningonknowledgewithvisualexplanations.Thisknowledge can provide evidence and analysis relevant to the activities of diagnosesanditisveryimportantformedicalresearchingeriatrics orneurosciences.Tothatend,weplantoincludetheengagement of reasoningtechniquesto determineby sequential association rules[37]themostsignificantrulestoassistintheestablishment of themost appropriate diagnosisand to eliminate differential diagnoses. Shared practice rules face the challenge of creating
a solid foundation to support the cognitive development of
collectiveintelligence.Theserulescanbeannotatedusingdomain
ontologies andevaluated byotherusers,who mightconsidera
form of suggestion using intelligent components based on the
annotationsassociatedwithasynucleinopathy.Forexample,given acollaborative actiononasynucleinopathy,decisionsregarding
Table1
Descriptionofnon-motorsymptomsassociatedwithIdiopathicParkinson’sdiseaseadaptedfrom[42].
Non-motorsymptomsassociatedtoIdiopathicParkinson’sdisease Supposedbraindamage Psychological,psychiatricand
cognitivesymptoms
Depression,anxiety,panicattacks,feelinghopeless Locuscoeruleus(norepinephrine),inferiorraphe nucleus(serotonin),amygdala
Apathy,anhedonia,inattention,vegetativesymptomsof depression
Uncertain Psychosis,inappropriatebehaviorandotheradversebehavioral
effectsdisorders,obsessive-compulsivedisorders,delirium
Limbiccortex,amygdala Parkinsonismdementia,confusion,hallucinations(iatrogenic
factor)
Temporallobe,hippocampus,locuscoeruleus, amygdala,nucleusbasalisofMeynert(acetylcholine) Sleepdisturbances Sleep-onsetinsomnia,trueinsomnia,nighttimehallucinations,
rapideyemovementsleepbehaviordisorder,daytime sleepiness,sleepattacks
Subcorticalnucleus(pedunculopontineand subcoerulusnucleus),hypothalamus Sleepfragmentation,sleepapnea(central(CSA),obstructive
(OSA),andcomplexormixedsleepapnea),restlesslegs syndrome(RLS)
Uncertain
Dysautonomicsymptoms Bladder-sphincterdysfunctions(urinaryfrequencyandurinary incontinence,dysuria),excessiveperspiration,abnormalsexual behavior(impotence,hypersexuality),xeropthalmia
Dorsalnucleusofvagusnerve
Orthostatichypotension,post-prandialhypotension Vagusnerve,stellateganglion(orcervicothoracic ganglionorinferiorcervicalganglion)
Gastrointestinalsymptoms Drooling,ageusia(tasteloss),swallowingdisorders,dysphagia, gastroesophagealreflux,vomiting,nausea,constipation,fecal incontinence
Dorsalnucleusofvagusnerve(adrenaline)
Sensorysymptoms Olfactorydisturbance Olfactorybulb
Pain,paresthesias Uncertain
Others Fatigue,seborrhea(skinandgreasyhair),excessive perspiration,weightgain,weightloss
thisactioncanbeautomaticallysuggestedbasedonthe annota-tions,providingthemosteffectivedecisionssemanticallyrelated
to this action. In addition, an adaptation rule is a form of
experientiallearning[38],insofarasitisstudiedintermsofhowto
respondtoamismatchbetweentheexpectedsituationand the
resultsobserved. This leadsto a learning semantic requiring a differenttypeofconceptualorganizationconsistentwithahigher levelofabstractiontoobtainabetterunderstandingoftheeffects ontherulesandknowledgemanipulated.
We consider now the conceptual graph describing the
collaborative expertise (as shown in Fig. 2). In this graph, the differentspecialistscanapplyappropriatestrategiestoidentify, localize,and(wherepossible)correcttheerrorsintheknowledge modelling.Theconceptualgraphspecifiestheuseofintelligent
analysis strategies to narrow down and pinpoint medical
disorders. Through the medical knowledge base, such crucial
expertdescriptionscanbesharedandreusedbythespecialistsin theirindividualandcollectivetasks.Asaresult,bymeansofthe disordersstrategies,fromwhichspecialistslearn,theyareableto
transfer the acquired knowledge and lessons learned easily to
another similar context, with the goal of preventing disease
consequencesorreducingthemtoaminimum.Theywillbeableto
determine whether a context is problematic, whether the
diagnosisor information flow is incorrect, or if theanalysis of thediseasecontextisdefective.
We can also use this experienced knowledge for dedicated
analysisofthespecificstudieddisease(e.g.,Parkinson’sdiseasein
Fig. 3). Thus, in order to assess, interpret, and verify the
reasonableness of the modeled knowledge,one would have to
ensurethatthevarioustypesoftargetedsituationsareconsistent byusingtheprojectionoperationofCGs.Furthermore,theanalysis shouldnotbeviewedastheproblemofoneexpertisemorethan anotherbutasaglobalproblem,whichallinvolvedmembersofthe collaborativeorganizationwouldaddress.
Weputforwardanontologicalmodelandconceptualstructure looselybasedonthevisualapproachusedtosupportteambased telemedicine collaboration. In the considered medical context,
healthcare involves a variety of specializedexperts in different
fields who are often geographically separated. They appreciate
collaborativeactionstofixaparticularcomplexproblemforwhich theirbackgroundandtrainingmakethemqualified.Inthiscase
study, telemedicine actually helps in the diagnostic decision
process,sinceityieldsimprovementintermsofthecostand/or
time neededto arriveat a decision. Research and progresson
telemedicinecouldbevaluable;especiallyweareactuallytesting itinarealtelemedicineenvironment.
4. Discussion
The mainstream eHealth interoperability enhancement
effortsintheECandkeystandardsdevelopmentorganizations
areroughlyclassifiedinto:legalinteroperability,organizational interoperability,technical interoperability,andsemantic inter-operability.Whilepaperobjectivestargetchallengesofsemantic
interoperability, the discussions therein also provide heavy
coverageonissuesoftechnicalinteroperability(ontelemedicine infrastructure)andtosomeextentonorganization interopera-bility.Furthermore,thereareongoingactivitiestodevelopand/ orharmonizeeHealthinteroperabilitystandards(ledbythelikes ofContinuaHealthAlliance,IHE,IEEE/ISO,ITUeHSCG,IHTSDO, etc.). There is a need forfurther research regarding organiza-tionalchange,incentives,liabilityissues,end-usersHIT compe-tencesandskills,structureandworkprocessissuesinvolvedin realizingthebenefitsfromhealthinformationtechnologies(HIT) [39].
Under the coordination of the health information systems
strategydelegation,aworkinggroupoftheFrenchNationalSteering
Committee of Telemedicine has developed a series of concrete
recommendationsfortheoperationalimplementationoftechnical systemsunderlyingthetelemedicineprojectsandactivities[40]:
to promote the implementation of a comprehensive and
coherent infrastructure to include the implementation of
telemedicineprojectsinacoherenturbanization;
Context: elderlypatient
description
Parkinson Synucleinopathies Component
2 1 2 1 Implication 2 Component
DementiawithLewybodies
Multiple system atrophy Component
1
2
2
Analysis: suggestives features
description
Olfactory Dysfunction 1 OR 2
OR
1 2
Cardiovascular dysfunction: {repeated falls, fainting} Language impairments Depression OR 1 2 OR 1 2 1
Analysis: supportivefeatures
description
Neurolepticsensitivity 1 OR 2
OR
1 2
L-dopa treatment ’s efficiency
Sleeps Disorders (REM) OR 1 2 OR 1 2
Analysis: Core features
description
Features of Motor Decline 1 OR 2
OR
1 2
Inadequate Behavioural Attitude; hallucinations
Autonomic Dysfunction Cognitive Impairment
OR 1 2 OR 1 2 Before 1 2 Before 1 Characterization
2 1 Oculomotor disorder (palsy) OR 2 1 Brain-imagingscans
to conduct a risk assessment relating to the security of informationsystemsthatmayaffectthesuccessful accomplish-mentoftheactivityconcerned;
todevelopaglobalandconsistentmanagementofthetechnical devicestoensurethattheirdiversityreallyisenriching; toprovidetraining,suitablesupportandanadaptedassistance:
supervisedstudyperiodsandtutoringservices;
to establish a conventional setting corresponding to the
contracts for the provision of updated technical services in conductingongoingdialoguewithtechnologicalthirdparties.
In practice, this mainly means the capacity to ensure an
effectivemanagementofpersonaldata,whileensuringcompliance withdata protection principlesand security of data exchanges
between different organizations that are concerned by the
telemedicine procedures. Secondly, it is important to prevent
risks threateningthe safety of operational devices. To do this,
operators need to carefully and constantly apply effective
methodologiesandfurtheradvancesinexplorationand develop-menttechniquestoincreasethelikelihoodofdetectingahazard affectingthesafetyofconsidereddevices.Someeventsmaycause
undesired operation (namely service interruption, fraudulent
interferenceonthepartofa thirdpartyorcomputervirusesor inappropriatetimingoftasksandimpairedsignalsordata)andwe shouldmonitorthesignificantoperationalrisksoftheimplement ofthetelemedicineprocedures,inorder,interalia,toidentifyatan
early stage unforeseen adverse effects and to have a look at
possiblesolutions(palliative,curativeandpreventiveoptions). Furthermore,itisimportanttoimproveasfaraspossiblecase managementatallcomponentsoftheproposedimplementationof thetechnicalaspectsoftelemedicinedevicesinaglobalframework basedonformalproceduresandfoundedonbestpractices.Inthis
context, it would ensure a sufficient level of comprehension,
accession and assimilation by the medical actors and health
professionalsusingtelemedicinedevicesforthefullregistrationof
the remote services in the everyday professional practices.
Therefore, it is essential to establish with technological third parties,intheframeworkpartnershipagreementssignedbetween
themandtheProjectManager,requirementlevelsconsistentwith theneedsidentifiedintheagreementswithbusinessstakeholders.
5. Conclusion
In this paper, we have shown that the use of knowledge
modelling and formal semantic techniques provide additional
supporttotelemedicinetasksbyimprovingtheuser understand-ingofthediseasesbeingtreated.Wemadeacasestudywiththe knowledgemodellingofsynucleinopathiesinelderly.Theresults ofthisstudygaverisetoa seriesofrecommendations,whichin turnwillformthefoundationofthecollaborativeactionplanin
response to telemedicine management. Particularly, non-motor
symptoms play an essential part in appropriate diagnosis of
synucleinopathies and a very insightful and knowledgeable
analysisoftheirsystemictemporaldevelopmentschemesshould
more consequently be taken into consideration within the
elaborationofdiagnosticprogrammesinthefieldofhealthpolicy.
However, while the motor-based disease (or even cognitive
disorder) diagnosis system is described in some detail, the
elementsoftheconsiderednon-motorsymptomsevaluationare
sketchy,in particular withregard toprocessand management.
Such facilities are currently an early stage and for instance, olfactorytests,whichweresupposedtobeautomated,hadtobe executedmanuallyinordertoensurecorrectnessof processing and reports on diagnosticevaluations. Aswell, these processes oftenareheldoveracoupleofhours,requiringtimeinvestments frompatients andhealth professionals.Thisdoes notallowthe medicalactorsresponsiblefortheregularoutpatientconsultations tovalidatesomemedical investigationsanddiagnosisfor acute
illness and preventive health care. We will achieve these
investigations through the close collaboration of ambulatory
carewithinterestedphysiciansandmedicalreferencecenters.It iscurrentlyassociatedwithamovementtoincludeafocusonthe healthofelderlypersonstohelptoverifythatequalityinaccessto healthcareismadeareality.Undercollaborativeactivitiesmadein telemedicine, medical organizationsarepooling their resources andstructurestoimplementasustainableandeffectiveinclusion
Context: elderlypatient description
Parkinson implication 1 2
description Bradykinesia Motorsymptoms description
Resting tremor
OR 2 1 OR 2 1 description Hypertony before2 1 description
Mood disorders: depression Nonmotor symptoms
description
Loss of sense of smell
OR 2 1 OR 2 1 description
Autonomic Dysfunction description
Olfactory Test Supportingfeatures
description Abnormal SPECT/PET OR 2 1 OR 2 1 description before2 1
Brain-imaging scan
OR 2 1 description L-dopa efficiency OR 2 1 description Postural instability OR 2 1 description REM
programmedesigned toguarantee maximumpossible coverage andequalconditionsasregardsaccessandtreatmentforpatients, regardlessoftheirageorplaceofresidence.
Relying on the modelling of expert knowledge through
conceptual graphs operations, we proposed an approach that
positivelyimpactsthetelemedicinemanagementplans:
abetteraccesstoavailablebestpracticesandmethodologiesas wellassupporttrainingandtheexchangeofinformationonnew practicaldevelopmentsrelatedtocriticalmedicalactivities. aframeworkofpracticalknowledgeandgoodpracticetoensure
modellingofneededinformation,qualitytutoringandtobring stakeholderstogetheratorganizationandgloballevels. apossibleconceptualmodellingwithreasoningmechanismsfor
theanalysisandexchangeofgoodpracticesonaccesstoservices.
To that end, good modelling practice on access to traces of
reasoningshouldbepromoted.
If the significant potentials of telemedicine to assist in the managementguidanceandoutpatientcarearetoberealized,then
research strategies need to be undertaken to improve disease
diagnosis and monitoring. However, the modalities of suchan
approach should be clarified so as to allow greater security,
flexibilityandergonomicfunctionalities[41]inrespondingtothe pragmaticneeds ofmedicalprocedures[42]and efficientuseof experiencedhealthcareproviders[43–51].
Disclosureofinterest
The authors declare that they have no conflicts of interest concerningthisarticle.
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BernardKamsuFoguemHehasaPhDinComputerScienceandEngineeringfromthe UniversityofMontpellier2in2004.Hegotthe‘‘accreditationtosuperviseresearch’’, abbreviatedHDRfromUniversityofToulousein2013.Hiscurrentinterestsarein KnowledgeDiscoveryand DataMining,KnowledgeRepresentation,FormalVisual Reasoning,Ontology-basedSemanticAnalysis,KnowledgeExploitationfor Collabora-tion,DecisionSupportSystemsandIntelligentSystems.Applicationdomainsinclude ContinuousImprovementprocessandHealthInformationSystems.Heisareviewerfor alargenumberofinternationalscientificjournalssuchasComputersinBiologyand Medicine,KnowledgeManagementResearch&Practice,InteractingwithComputers, Sensors,EngineeringApplications ofArtificial Intelligence and Knowledge-Based Systems.Heisamemberofthethematicgroup:e-HealthofInterOP-VLab (Interna-tionalVirtualLaboratoryforEnterpriseInteroperability).
PierreF.TiakoHeistheDirectoroftheCenterforInformationTechnologyResearchat LangstonUniversity(USA)andanassistantprofessorofComputerScienceand Infor-mationSystem.HeworkedasavisitingprofessoratOklahomaStateUniversity(OSU) beforethecurrentposition.PriortoOSU,hetaughtcomputersciencecoursesanddid researchatUniversitiesofNancyandRennes(France),andalsoworkedasanexpert engineeratINRIA,theFrenchnationalinstituteforresearchininformationtechnology. Dr.Tiakohasauthoredmorethan50journalandconferencetechnicalpapersand co-editedfourproceedingsvolumes,resultingfromservicesasprogramchairforseveral internationalconferencesandworkshops.HeholdsaPhDinsoftwareandinformation systemsengineeringfromNationalPolytechnicInstituteofLorraine(France).Dr.Tiakois aseniormemberofIEEEandpastChairmanforIEEEOklahomaCityComputerSociety.
EdwardMutafungwaHeisaresearcherandprojectmanagerattheDepartmentof CommunicationsandNetworking(Comnet)oftheAaltoUniversitySchoolof Elec-tricalEngineering.HereceivedtheB.Eng.degreeinElectronicSystemsEngineering andtheM.Sc.degreeintelecommunicationsandinformationsystemsbothfromthe UniversityofEssex,Colchester,U.K.,in1996and1997,respectively,andtheDr.Sc. Tech.degreeinCommunicationsEngineeringfromtheHelsinkiUniversityof Tech-nology(TKK,nowAaltoUniversitySchoolofElectricalEngineering),Espoo,Finland, in2004.Foroveradecade,hehasalternativelybeenalecturer,researcherand projectmanagerinvariousnational(TEKES,AcademyofFinland)andinternational (EU,Celtic)projectsatComnet,AaltoUniversity.Hisresearchinterestsliewithinthe generalfieldsofbroadbandwirelesscommunications,opticalnetworking,ICTfor development(ICT4D)andpublicsafetycommunications.Intheareaoftelemedicine, hehasbeenstudyingtheuseofmobilebroadbandtechnologies(smallcells)for implementationofpersonaltelehealthsystems andemergencytelemedicinein indoorenvironments.
Clovis FoguemHe isanInternal Medicineand Geriatric medicaldoctorand has undertakenaPhDon‘OlfactionandElderly:studyoftheolfactory(CNI)andtrigeminal (CNV)sensitivitiesinteractionsinageriatricpopulation;constantsandpathological specificities’.He isalsoparticularlyinterestedinneurodegenerativediseases (as ParkinsondiseaseorLewyBodydementia),elderlyepilepsyandwhetherpathogenic inflammatoryorautoimmuneresponses cancontributetothesedisordersinthe elderly.Moreoverheisalsointerestedinmedicalknowledgerepresentationand medicalclinicdesignguidelines.Forhisworkon‘OlfactionandElderly’,DrC.Foguem waslaureateofHealthResearchAwardforemerginghealthresearchersfromthe corporatefoundation‘GroupePasteurMutualite´’in2011.Heisgroundedinmedical researchapplicationsofInformationandCommunicationsTechnology.FormerFaculty ofMedicine’sClinicalInstructor,heisnowHospitalPractitionerinFrance.Heis peer-reviewerofmanyscientistjournalsamongwhich:ClinicalInterventionsinAging; DegenerativeNeurologicalandNeuromuscularDisease;InternationalMedicalCase ReportsJournal;NeuroscienceandNeuroeconomics;ClinicalMedicineInsights; Jour-nalofthePancreas;International ScholarsJournals(ISJ);CancerTherapy; Indian JournalofCriticalCareMedicineand,AfricanJournalofEnvironmentalScienceand Technology.