Evolution of the Arden Syntax: Key Technical Issues from the Standards Development Organization Perspective

BackgroundThe initial version of the Arden Syntax for Medical Logic Systems was created to facilitate explicit representation of medical logic in a form that could be easily composed and interpreted by clinical experts in order to facilitate clinical decision support (CDS). Because of demand from knowledge engineers and programmers to improve functionality related to complex use cases, the Arden Syntax evolved to include features typical of general programming languages but that were specialized to meet the needs of the clinical decision support environment, including integration into a clinical information system architecture.MethodReview of the design history and evolution of the Arden Syntax by workers who participated in this evolution from the perspective of the standards development organization (SDO).ResultsIn order to meet user needs, a variety of features were successively incorporated in Arden Syntax. These can be grouped in several classes of change, including control flow, data structures, operators and external links. These changes included expansion of operators to manipulate lists and strings; a formalism for structured output; iteration constructs; user-defined objects and operators to manipulate them; features to support international use and output in different natural languages; additional control features; fuzzy logic formalisms; and mapping of the entire syntax to XML. The history and rationale of this evolution are summarized.ConclusionIn response to user demand and to reflect its growing role in clinical decision support, the Arden Syntax has evolved to include a number of powerful features. These depart somewhat from the original vision of the syntax as simple and easily understandable but from the SDO perspective increase the utility of this standard for implementation of CDS. Backwards compatibility has been maintained, allowing continued support of the earlier, simpler decision support models.     

Transformation of Arden Syntax's medical logic modules into ArdenML for a business rules management system

IntroductionArden Syntax is a Health Level Seven International (HL7) standard language that is used for representing medical knowledge as logic statements. Arden Syntax Markup Language (ArdenML) is a new representation of Arden Syntax based on XML. Compilers are required to execute medical logic modules (MLMs) in the hospital environment. However, ArdenML may also replace the compiler. The purpose of this study is to demonstrate that MLMs, encoded in ArdenML, can be transformed into a commercial rule engine format through an XSLT stylesheet and made executable in a target system.MethodsThe target rule engine selected was Blaze Advisor. We developed an XSLT stylesheet to transform MLMs in ArdenML into Structured Rules Language (SRL) in Blaze Advisor, through a comparison of syntax between the two languages. The stylesheet was then refined recursively, by building and applying rules collected from the billing and coding guidelines of the Korean health insurance service. Two nurse coders collected and verified the rules and two information technology (IT) specialists encoded the MLMs and built the XSLT stylesheet. Finally, the stylesheet was validated by importing the MLMs into Blaze Advisor and applying them to claims data.ResultsThe language comparison revealed that Blaze Advisor requires the declaration of variables with explicit types. We used both integer and real numbers for numeric types in ArdenML. “IF ∼ THEN” statements and assignment statements in ArdenML become rules in Blaze Advisor. We designed an XSLT stylesheet to solve this issue. In addition, we maintained the order of rule execution in the transformed rules, and added two small programs to support variable declarations and action statements. A total of 1489 rules were reviewed during this study, of which 324 rules were collected. We removed duplicate rules and encoded 241 unique MLMs in ArdenML, which were successfully transformed into SRL and imported to Blaze Advisor via the XSLT stylesheet. When applied to 73,841 outpatients’ insurance claims data, the review result was the same as that of the legacy system.ConclusionWe have demonstrated that ArdenML can replace a compiler for transforming MLMs into commercial rule engine format. While the proposed XSLT stylesheet requires refinement for general use, we anticipate that the development of further XSLT stylesheets will support various rule engines.