Patent Publication Number: US-2012030156-A1

Title: Computer-implemented method, clinical decision support system, and computer-readable non-transitory storage medium for creating a care plan

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This patent application claims the priority benefit under 35 U.S.C. §119(e) of U.S. Provisional Application No. 61/368,331, filed on Jul. 28, 2010, the contents of which are herein incorporated by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The invention relates to care plans for remote patient management systems, in particular to creating a care plan to achieve an interventional goal. 
     2. Description of the Related Art 
     Behavioral change is an important aspect in the management of chronic conditions like Heart Failure, Chronic obstructive pulmonary disease, or diabetes. Behavioral determinants are the starting point of behavioral interventions to achieve the behavioral change. 
     Patient non-compliance decreases the efficacy of pharmacological and non-pharmacological therapy and exposes the patient to clinical destabilization, which can lead to exacerbating disease symptoms. Evidence from clinical trials and validated insights show that the most commonly identified cause of disease worsening, e.g. HF decompensation, is non-compliance with medication, low sodium diet, fluid restriction and physical activity. Non-compliance is the precipitating factor of exacerbation, leading to poor clinical outcomes. 
     SUMMARY OF THE INVENTION 
     Structured approaches to identify the determinants that should be addressed in behavioral interventions are described in text books and educational material for medical professionals. However: 
     a) applying this knowledge in practice is a complex task: there are no systems offering a list of possible determinants to the professional, e.g., the relevant personal characteristics of the patients and their relation to specific behavioral goals; there are no systems offering a list of possible interventions for modifying (a set of) determinants; 
     b) the risk overseeing or not taking into account specific characteristics of a patient is quite high and could result in selecting the wrong determinates and consequently applying a less effective intervention; and 
     c) medical professionals have not enough time to keep up to date with newest evidence becoming available regularly. 
     Therefore, success is often based on the level of experience of the care professional. Embodiments of the invention may address these difficulties and others with a clinical decision support system which provides the care professional with an up-to-date overview of determinants relevant for reaching behavioral goals based on evidence from clinical trials and consumer studies. Various embodiments of the invention may: 
     a) provide the determinants specific for a patient, based that patient&#39;s health at the right moment in time to allow the professional to make the right decision; 
     b) educe the (administrative) effort needed to apply a structural determinant selection process; 
     c) optimize the workflow or the care professional; Provide a structured way to professionals to identify the determinants (examples of determinants are knowledge, attitude, perceived barriers, self efficacy); 
     d) tag literature for evidence and use that information for weighing determinants; 
     e) make an explicit link between determinant and chance of success in reaching goals; 
     f) merge different therapy goals with associated determinants into a single advice in which determinants to address; 
     g) instantiate of a set of determinants for a patient based on historical data (function, trend, not latest value); 
     h) create audit trails of the current practice to provided evidence for process improvement; and 
     i) dentify improvements based on historical data. 
     Embodiments may achieve some or all of these goals by: 
     a) providing a structured way to professionals to identify the determinants; 
     b) tagging of literature for evidence and use that info for weighing determinants 
     c) making an explicit link between determinant and chance of success in reaching goals; 
     d) merging different therapy goals with associated determinants into a single advice on which determinants to address; 
     e) instantiation of a set of determinants for a patient based on historical data (function, trend, not latest value); 
     f) create audit trails of the current practice to provided evidence for process improvement; and 
     g) effect analyzer: identifying improvements based on historical data. 
     A ‘remote patient management system’ as used herein is a system for remotely administering a care plan. A ‘care plan’ as used herein is a day-to-day plan for managing a disease or health condition. A ‘content element’ as used herein is content which may be provided to a patient and which may be integrated into a care plan for the patient. For instance a remote patient management system may present content elements for educating, motivating, or assessing a patient. Examples of these content elements include, but are not limited to: text messages, audio messages, or video messages, educational games, educational video games, questionnaires, surveys, quizzes, interactive videos. The term content element encompasses both multimedia presented to a patient and to media with which the patient interacts. 
     Content elements may be provided either by a hospital or an outpatient clinic or a disease management organization or a remote patient management system. 
     A ‘home infrastructure device’ as used herein is a device adapted for delivering the content elements to the patient. The home infrastructure device comprises at least one diagnostic medical device for measuring a value of a patient&#39;s vital sign. 
     The term ‘vital sign’ as used herein refers to are any physical property of the patient which may be measured. Examples of vital signs include, but are not limited to: weight, blood sugar level, blood pressure, pulse/heart rate, SpO2, and bio-impedance. 
     A ‘display’ as used herein is an electronic device adapted for graphically displaying text, images, multimedia clips, video, and other audio-visual content. Examples of a display include, but are not limited to: a computer monitor, the screen of a cellular telephone, and a television. 
     A ‘computer-readable storage medium’ as used herein is any storage medium which may store instructions which are executable by a processor of a computing device. The computer-readable storage medium may be a computer-readable non-transitory storage medium. The computer-readable storage medium may also be a tangible computer readable medium. In some embodiments, a computer-readable storage medium may also be able to store data which is able to be accessed by the processor of the computing device. An example of a computer-readable storage medium include, but are not limited to: a floppy disk, a magnetic hard disk drive, a solid state hard disk, flash memory, a USB thumb drive, Random Access Memory (RAM) memory, Read Only Memory (ROM) memory, an optical disk, a magneto-optical disk, and the register file of the processor. Examples of optical disks include Compact Disks (CD) and Digital Versatile Disks (DVD), for example CD-ROM, CD-RW, CD-R, DVD-ROM, DVD-RW, or DVD-R disks. The term computer readable-storage medium also refers to various types of recording media capable of being accessed by the computer device via a network or communication link. For example data may be retrieved over a modem, over the internet, or over a local area network. 
     Computer memory is an example of a computer-readable non-transitory storage medium. Computer memory is any memory which is directly accessible to a processor. Examples of computer memory include, but are not limited to: RAM memory, registers, and register files. 
     Computer storage is an example of a computer-readable non-transitory storage medium. Computer storage is any non-volatile computer-readable storage medium. Examples of computer storage include, but are not limited to: a hard disk drive, a USB thumb drive, a floppy drive, a smart card, a DVD, a CD-ROM, and a solid state hard drive. In some embodiments computer storage may also be computer memory or vice versa. 
     A ‘processor’ as used herein is an electronic component which is able to execute a program or machine executable instruction. References to the computing device comprising “a processor” should be interpreted as possibly containing more than one processor. The term computing device should also be interpreted to possibly refer to a collection or network of computing devices each comprising a processor. Many programs have their instructions performed by multiple processors that may be within the same computing device or which may even distributed across multiple computing device. 
     A ‘data base’ as used herein encompasses a data stored in a computer memory or computer storage that is stored in a organized fashion such that data of interest may be accessed using an indexing system or search function. Examples of data bases include, but are not limited to: a text file containing data, a folder in a file system containing a collection of data files, a spreadsheet containing data, and a relational database. 
     The invention provides for a computer-implemented method for creating a care plan for a patient. The method comprises the step of receiving an intervention goal. An ‘intervention goal’ as used herein is a goal of a medical intervention. An intervention goal may be for instance to reduce weight or to reduce sodium intake. The method further comprises the step of creating a behavioral determinants list using the intervention goal. A behavioral determinant is a psychological factor which affects the behavior of a patient. The intervention goal may be entered into a computer interface or a graphical user interface by a healthcare professional in some embodiments. In other embodiments the intervention goal is generated automatically from input by a remote patient management system. 
     Once the intervention goal is received the behavioral determinants list may be generated automatically. For instance for a particular intervention goal there may be a cross reference or listing in a database which references specific behavioral determinants which may then be used to create the behavioral determinants list. The method further comprises the step of assigning a ranking to each behavioral determinant in the list of behavioral determinants using patient data descriptive of the patient. The ranking may be numerical, a set of descriptive labels, or a graphical ranking which indicates which of the behavioral determinants in the list of the behavioral determinants is most relevant to a particular patient. 
     ‘Patient data’ as used herein may have several different meanings Patient data may be part or comprise a patient&#39;s medical record. Patient data may also be data derived or obtained from a remote patient management system. Patient data may also be information which is supplied or entered by a healthcare professional in response to queries on a display or graphical user interface. 
     The method further comprises the step of receiving a subset of the behavioral determinant list. The subset is determined by using the ranking of each behavioral determinant in the list of behavioral determinants. In this step a subset of the behavioral determinants list is selected. This may be done automatically for instance using the ranking. If the subset is generated automatically then the rankings may be used to select determinants over a particular threshold or to select a predetermined number of determinants with the highest ranking. In some embodiments the ranking is simply displayed on a display or graphical user interface and the healthcare professional selects which of the behavioral determinants is a member of the subset. In still yet other embodiments a proposed subset of behavioral determinants is displayed for the healthcare professional. In this embodiment the subset is first displayed and then the healthcare professional may simply accept the subset or may edit it using a graphical user interface. 
     The method further comprises the step of creating the care plan using the subset. The care plan may for instance be compiled using a template or rules for creating a care plan. This computer-implemented method is advantageous because a personalized care plan is created for a patient which follows a rigorous method of determining behavioral determinants. 
     In another embodiment the care plan is created by generating a list of behavioral models using the subset of behavioral determinants. This may for instance be achieved by having a database of behavioral models. The behavioral models could be referenced to various behavioral determinants. The healthcare professional may then select a behavioral model which he or she believes to be appropriate for the particular patient. The care plan is further created by receiving a selection of at least one selected behavioral model from the list of behavioral models. The care plan is further created by compiling the care plan using a care plan template determined by the at least one selected behavioral model. The care plan template may for instance be a timeline with symbolic links representing multimedia or training content. During the compilation of the care plan the symbolic links to multimedia content may be resolved and content may be integrated into the care plan template. A care plant template are used herein encompasses a timeline or plan for creating a care plan. 
     In another embodiment the method further comprises receiving remote patient management system data. The step of receiving an intervention goal is performed by evaluating the remote patient management system data using a rule. In this embodiment the method is triggered by data which is received from a remote patient management system. For instance the patient&#39;s weight may be above a threshold or the patient may have gained or lost too much weight within a specified time. The remote patient management system data as used herein is data descriptive of (the health, behavior, knowledge, feelings, or other characteristics of) a patient which is generated by a remote patient management system. The remote patient management system data may be physical measurements or vital sign measurements of a patient in some embodiments. In other embodiments the remote patient management system data is a response to quizzes or questionnaires. In some embodiments the remote patient management system data is also a combination of vital sign or physical measurements from a patient and responses to a questionnaire. 
     In another embodiment the remote patient management system data comprises measurements of at least one vital sign from a patient. 
     In another embodiment the remote patient management system data comprises responses to a questionnaire. For instance a questionnaire may be used to ask a patient if he or she has performed some action or to query the patient about his or her opinion of their current health. For instance a questionnaire could enquire about the type of foods that a patient had recently eaten. As another example the remote patient management system could also ask the patient to give the amount of pain experienced by a numerical scale to estimate the effectiveness of treating chronic pain. 
     In another embodiment the method further comprises the step of displaying the behavioral determinant list graphically on a display before receiving the subset. The method further comprises displaying a graphical user interface at the same time as the behavioral determinant list which is adapted for triggering the display of medical evidence pertaining to each behavioral determinant. Essentially in this embodiment the medical evidence or data which is used to assign a ranking to each of the behavioral determinants is made available to the healthcare professional. This is advantageous because the healthcare professional is then able to use this data as part of his or her decision. The healthcare professional can evaluate the evidence for each of the behavioral determinants and determine if this evidence is relevant to this particular patient or not. 
     In another embodiment the method further comprises the step of displaying the ranked subset of determinants graphically on a display. The subset of behavioral determinants may be displayed graphically such that the ranking of the various behavioral determinants is clear to a healthcare professional. The subset is received from a graphical user interface of the display. This embodiment is advantageous because the ranking of each behavioral determinant is displayed to the healthcare professional and the healthcare professional is able to select which of the behavioral determinants are placed into the subset using a graphical user interface. 
     In another embodiment the patient data at least partially comprises remote patient management system data. The method further comprises requesting the remote patient management system data from a remote patient management system and the method further comprises receiving the remote patient management system data from the remote patient management system. In this embodiment it may be that there is not enough data to create the list of behavioral determinants. It may also be that if there is additional data or information from the patient, the number of behavioral determinants which are listed may be reduced. In this embodiment a remote patient management system is queried for data. The data which is returned by the query is then used to at least partially create the behavioral determinants list. 
     In another embodiment the method further comprises determining the type of remote patient management system data in order to reduce the length of the behavioral determinants list. For instance a preliminary behavioral determinants list could be constructed. The behavioral determinants list may have a listing for each behavioral determinant which lists data which is indicative of that particular behavioral determinant. This data can then be cross-referenced against the possible data which can be acquired by a remote patient management system. The remote patient management system can then be queried for this data. The method further comprises reducing the length of the behavioral determinants in accordance with the remote patient management system data. That is to say that the response to the query for remote patient management system data may provide data which eliminates some behavioral determinants on the list of behavioral determinants. 
     In another aspect the invention provides for a clinical decision support system comprising a processor and a computer-readable non-transitory storage medium. The computer-readable non-transitory storage medium contains instructions that cause the processor to perform the step of receiving an intervention goal. The instructions further cause the processor to perform the step of creating a behavioral determinants list using the intervention goal. The instructions further cause the processor to perform the step of assigning a ranking to each behavioral determinant in the list of behavioral determinants using patient data descriptive of the patient. The instructions further cause the processor to perform the step of receiving a subset of the behavioral determinants list. The subset may be determined by using the ranking of each behavioral determinant in the list of behavioral determinants. The instructions further cause the processor to perform the step of creating the care plan using the subset. 
     In another embodiment the care plan is created by the processor generating a list of behavioral models using the group of behavioral determinants. The care plan is further created by the processor receiving a selection of at least one selected behavioral model from the list of behavioral models. The care plan is further created by compiling the care plan using the care plan template determined by the at least one selected behavioral model. 
     In another embodiment the clinical decision support system further comprises a medical records database comprising at least a portion of the patient data. The processor further performs the step of requesting the patient data from the medical record database. The instructions further cause the processor to perform the step of receiving the patient data from the medical record database. 
     In another embodiment the clinical decision support system further comprises a historical evidence generator. The historical evidence generator comprises computer executable code for statistically analyzing the medical record database for correlations between the intervention goal and behavioral determinants. The clinical decision support system further comprises an evidence database. The historical evidence generator further comprises computer executable code for entering correlations between the intervention goal and behavioral determinants into the evidence database. The processor further performs the step comprising extracting the behavioral determinants list from the evidence database. This embodiment is particularly advantageous because historical or medical data is data mined or statistically analyzed to correlate the intervention goals with behavioral determinants. 
     The clinical decision support system comprises a tagger module comprising computer executable code for extracting correlations between the intervention goals and behavioral determinants from publications. This is advantageous because data from publications may be entered into the evidence database. 
     In another embodiment the tagger module uses natural language processing to extract correlations between intervention goals and behavioral determinants from publications. In this embodiment a document or a publication may be parsed in such a way that the correlations between the intervention goals and the behavioral determinants can be determined automatically. In some embodiments the correlations may be determined automatically but may be first approved by a healthcare professional before they are entered into the evidence database. 
     In another aspect the invention provides for a computer-readable non-transitory storage medium containing instructions that when executed by a processor of a clinical decision support system cause the processor to perform the step of receiving an intervention goal. Instructions further cause the processor to create a behavioral determinant list using the intervention goal. Instructions further cause the processor to assign a ranking to each behavioral determinant in the list of behavioral determinants using data descriptive of the patient. The instructions further cause the processor to receive a subset of the behavioral determinant list. The subset may be determined by using the ranking of each behavioral determinant in the list of behavioral determinants. The instructions further cause the processor to perform the step of creating the care plan using the subset. 
     In another embodiment the care plan is created by generating a list of behavioral models using the group of behavioral determinants. The care plan is further created by receiving a selection of at least one selected behavioral model from the list of behavioral models. The care plan is further created by compiling the care plan using a care plan template determined by the at least one selected behavioral model. 
     In another embodiment the instructions further cause the processor to perform the step of receiving remote patient management system data. The instructions further cause the processor to perform the step of evaluating the remote patient management system data using a rule to generate an intervention goal. 
     In another embodiment the instructions further cause the processor to perform the step of displaying the behavioral determinant list graphically on a display before receiving the subset. The instructions further cause the processor to perform the step of displaying a graphical user interface at the same time as the behavioral determinant list. The graphical user interface is adapted for triggering the display of medical evidence pertaining to each behavioral determinant. 
     In another embodiment the instructions further cause the processor to perform the step of displaying the ranked subset of determinants graphically on a display. The subset is received from a graphical user interface on the display 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWING 
       In the following preferred embodiments of the invention will be described, by way of example only, and with reference to the drawings in which: 
         FIG. 1  illustrates an embodiment of a method according to the invention; 
         FIG. 2  illustrates a further embodiment of a method according to the invention; 
         FIG. 3  shows a table of examples of behavioral models addressing specific behavioral determinants; 
         FIG. 4  shows a further embodiment of a method according to an embodiment of the invention; 
         FIG. 5  illustrates a further embodiment of a method according to the invention; 
         FIG. 6  shows a display of the determinants as may be displayed on a graphical user interface according to an embodiment of the invention; 
         FIG. 7  shows a further of the determinants as may be displayed on a graphical user interface according to a further embodiment of the invention; 
         FIG. 8  shows a further of the determinants as may be displayed on a graphical user interface according to a further embodiment of the invention; 
         FIG. 9  shows a functional diagram of a clinical decision support system according to an embodiment of the invention; and 
         FIG. 10  shows a functional diagram of a clinical decision support system according to a further embodiment of the invention. 
     
    
    
     DETAILED DESCRIPTION OF THE EMBODIMENTS 
     Like numbered elements in these Figures are either equivalent elements or perform the same function. Elements which have been discussed previously will not necessarily be discussed in later Figures if the function is equivalent. 
       FIG. 1  illustrates an embodiment of a method according to the invention. The method shown in  FIG. 1  may be implemented in some embodiments as a computer-implemented method. In some embodiments the method shown in  FIG. 1  may also be performed by instructions on a computer-readable non-transitory storage medium. In step  100  an intervention goal is received. In step  102  a behavioral determinants list is created using or in accordance with the intervention goal. In step  104  a ranking is assigned to each behavioral determinant using patient data. In step  106  a subset of the behavioral determinant list is received. In some embodiments the subset is generated automatically using the ranking. In other embodiments the behavioral determinant list is received from a healthcare professional. In step  108  a care plan is created using the subset. 
       FIG. 2  shows a further embodiment of a method according to the invention. As with  FIG. 1 ,  FIG. 2  may be implemented as a computer-implemented method. The method shown in  FIG. 2  may also be implemented by instructions contained on a computer-readable non-transitory storage medium. In step  200  remote patient management system data is received. In step  202  an intervention goal is generated by evaluating the remote patient management system data with a rule. The remote patient management system data is data acquired or received by a remote patient management system. The remote patient management system data may comprise vital sign or other physical measurements of the patient or it may contain responses to surveys presented to the patient. 
     In step  204  the intervention goal is received. In step  206  a behavioral determinants list is created using the intervention goal. In step  208  a ranking is assigned to each behavioral determinant using patient data. In step  210  the behavioral determinant list is displayed along with a graphical user interface which is adapted for triggering the display of medical evidence pertaining to each behavioral determinant. A healthcare professional can use the graphical user interface to explore the medical evidence which was used to generate the behavioral determinant list. In step  212  the subset of the behavioral determinant list is received. The healthcare professional may simply select which of the behavioral determinants to include in the subset. In this case the subset is received from the graphical user interface. 
     In step  214  a list of behavioral models is generated using or in accordance with the subset of behavioral determinants. In step  216  a selection of at least one behavioral model is received. Finally in step  218  a care plan is compiled using a care plan template. A care plan template is simply a set of rules or instructions on how to create a care plan that is personalized for a particular patient. The care plan template may typically include a timeline along with symbolic links to multimedia or other media or content information which may be integrated into the care plan. 
       FIG. 3  illustrates an association between a coaching intervention and compliance mediated by patient engagement and the determinants of compliance. Step  300  is a coaching intervention. The coaching intervention  300  leads to compliance  306  which is a sustained behavior change in the patient. The compliance  306  is achieved by first engaging  302  the patient. Once engagement  302  has been achieved there are a number of determinants of compliance. Block  304  represents behavioral determinants of compliance. Within block  304  is a list  305  of possible determinants that may affect a patient&#39;s compliance  306 . 
       FIG. 4  shows a table of examples of behavioral models addressing specific behavioral determinants. In column  400  four different behavioral change models are listed. In column  402  determinants that are associated with that particular model are listed. During operation of the system a healthcare professional is presented with a list of determinants. By matching these selected determinants to the determinants in column  402  behavioral change models  400  which may be appropriate can be selected. 
       FIG. 5  shows a further embodiment of a method according to an embodiment of the invention. As with the method shown in  FIGS. 1 and 2  the method shown in  FIG. 5  may also be implemented as a computer-implemented method. The method shown in  FIG. 5  could also be implemented by instructions on a computer-readable non-transitory storage medium. In step  500  the method begins. In step  501 , which is also labeled step  1  in the text, the clinician enters intervention goals for a specific patient. In this example the intervention goal is explicitly entered by a healthcare professional. The intervention goal may be entered by a user interface for a computing system such as a graphical user interface or a keyboard. 
     In step  502 , which is labeled in the text as step  2 , the system analyzes the goal and shows the most relevant behavioral determinants to address the goals specified in step  1  also labeled step  501 . In some embodiments the healthcare professional can explore the available medical evidence. In step  503 , which is also labeled step  3  in the text, the system can instantiate the general picture with a specific situation of the patient. The healthcare professional can explore this overview to form a good overview of the system&#39;s proposal for a care plan. 
     In step  504 , which is also labeled step  4  in the text, the healthcare professional can select from the patient specific overview the most relevant determinants for a particular patient to focus on in a subsequent intervention essentially to focus on during the use of a care plan. In step  505 , which is also labeled step  5 , the healthcare professional creates a care plan by having the clinical decision support system compile a care plan. Subsequently in step  506  the method ends. 
     In this embodiment, the healthcare professional first enters the intervention goals into the system (possibly by referring to the intervention goals for a specific patient). Second, the system responds with an overview of behavioral determinants that are relevant to address to the goals specified in Step  1 . 
     These determinants may be ordered with respect to relevance for these specific goals, where the relevance is decided based on: 
     a. Evidence from literature; and/or 
     b. Historical information. 
     For example, relevance could be indicated by numbers in an ordered list, but the system could also provide more visual representations by e.g. relative sizes of bubbles or in the form of Tag Clouds. 
       FIG. 6  shows a display  600  of the determinants  602 ,  604 ,  606  such as may be displayed on a graphical user interface to illustrate the relative importance of various determinants for addressing a particular intervention goal. In the determinants shown in  FIG. 6  they are divided into three different groups. The determinants labeled  602  are determinants for intervention goal  1 . The determinants labeled  604  are the determinants for intervention goal  2 . The determinants labeled  606  are the determinants for intervention goal  3 . The size of each determinant  602 ,  604 ,  606  shows the relative importance of each determinant towards achieving each intervention goal. 
       FIG. 6  shows the determinants (e.g., knowledge, self efficacy, attitude) that have been identified by the system as important for the indicated goals. The size of the bubbles indicates the relevance of the determinant: the bigger the bubble the more important is to address this determinant. Such structured presentation will help the professional to make more conscious choices on possible interventions to effect a behavioral change in the patient to increase compliance with the therapy. 
       FIG. 7  shows the determinants  602 ,  604 ,  606  on a display  700 .  FIG. 7  illustrates how a graphical user interface with a display  700  may be used to display evidence relating to a particular determinant. Dialogue box  702  shows two items of evidence  704 . In the example shown in  FIG. 7  the dialogue box  702  simply has a list of available evidence  704 . The healthcare professional can inspect either piece of this evidence by clicking on that evidence. 
     To get an insight on how the system came to the proposed set of determinants and their relative relevance, the care professional can select a determinant. The system then shows the evidence used, as indicated in  FIG. 7 . The user could then browse in more detail on how specific evidence contributes to that determinant and for which goal, and into that evidence to build his or her own opinion on the system&#39;s analyses. 
     The previous analysis gave the importance of the determinant for general patient population from evidence. In the next step the professional can “instantiate” the determinants landscape for a specific patient, making the determinants&#39; importance patient-specific. Namely, the actual situation of a patient is taken into account to re-evaluate the relevance for each determinant with respect to the identified goals. This results in an adapted picture of determinants for that specific patient in relation to the general population. An example is shown in  FIG. 8 , which depicts importance of the determinants for this patient. 
       FIG. 8  shows a display  800  of determinants  602 ,  604 ,  606  that are similar to the determinants shown in  FIGS. 6 and 7 . However, in  FIG. 8  the boundary  802  of many of the determinants has been adjusted for a particular patient. For a given determinant the boundary  802  shows the new relative importance of the determinant for that particular patient. Several dialogue boxes  804 ,  806  are also shown in  FIG. 8 . 
     In  FIG. 8  a smaller bubble represents the relevance of the particular determinant for the patient, while the bigger bubble represents the general population (in specific cases the personal bubble could also be bigger than the general one). It can also be indicated why the situation is different for this patient. The reasons for the differences between the general population and a patient specific are indicated such that the care professional gets can quickly make decision where to focus on. 
     The system could also indicate the determinants for which too little information is available to make a proper judgment what the effect is for a specific patient. E.g. in case there is evidence that “female patients with a high self-efficacy have high medication compliance” and the gender of the patient is not know (in the system), the system can trigger assessment of that aspect. Dialogue box  804  is a query to provide the gender of the patient as the gender is important to determining the self-efficacy of a particular patient. This can be done by asking the care professional to enter additional data into the Patient Information database, or to generate questionnaires that can be forwarded to the patient via e.g. Remote Patient Monitoring systems. 
       FIG. 9  shows a functional diagram of a clinical decision support system according to an embodiment of the invention. Block  900  represents an intervention goal or intervention goals being input into the system. It is understood that references to an intervention goal herein are also relevant to multiple intervention goals. This may represent either the automatic determination or by a manual input of an intervention goal. The intervention goal is input by block  900  into block  902 . Block  902  is an extractor which queries a goal determinant database  904  for a list of determinants  906 . The block  906  represents the list of determinants output by the extractor  902 . The list of determinants  906  may be output to a browser window  908  or a graphical user interface, resulting in representations as indicated in  FIGS. 6 and 7 . A web browser display is an example of a graphical user interface. 
     A list of determinants  906  are then input into a patient instantiator  910 . The patient instantiator reads patient data from a patient database  918 . The patient instantiator then uses the patient data to output a modified set of determinants  912 . The modified set of determinants  912  are then output to a browser  914  or other graphical user interface, resulting in representations as indicated in  FIG. 8 . The patient list of determinants  912  may then be used according to an embodiment of the invention to create a care plan. The data output by the browser  914  may also be output to a patient logger  916  which logs the list of modified determinants  912  in the patient information database  918 . In some embodiments a patient logger  916  may be a remote patient management system. The data in the patient database  918  may be provided to block  900  as a trigger for automatically triggering the generation of an intervention goal. Data in the patient database  918  may also be data mined or statistically analyzed by a historical evidence generator  920 . 
     The historical evidence generator  920  generates evidence  922  which is essentially the correlation between a particular intervention goal and the modified determinants  912 . A tagging module  924  may then be used to enter the correlation between the evidence  922  and the modified determinants  912  into the goal determinant database  904 . These new entries into the goal determinant database  904  may then be used by the extractor  902 . 
     The system may comprise a Goal-Determinant database  904  storing abstract representations of Goals, Determinants, the effectual relation between them (indicating how important the determinant is for reaching the goal), maybe the sub-population for which these relation has been evaluated, and evidence for this relationship (in terms of scientific papers, evaluations of historical data) and the value of that evidence (contra, low, mid, high) with respect to that relationship. 
     The system may further comprise a database  918  storing patient information. This concerns information about the medical condition of the patient and other patient characteristics. It also concerns historical information about the therapy/intervention goals that have been prescribed, determinants that were addressed for reaching those goals; the determinants which have been assessed for that patient, and evaluation of the extent to which intervention goals were reached. 
     The system may further have an evidence tagger  924 , a component in the system that evaluates evidence information, e.g. scientific papers and adds that to the Goal/Determinant database with all the information necessary to use it in the context of evaluating the relevance of the determinant with respect to the goal. This could be a manual process, where the system supports the entry of the required information by targeted input processes. Alternatively, this could be an ‘automated’ process where that system automatically analyses possible goal-determinant relations and the necessary information from published material. This could be a semi-automated process where the system first does autonomous analyses of the text and guides a nurse through the tagging process confirming relations found and/or asks for directed additions. 
     The system may further comprise an extractor  902 . Given a set of goals, the extractor  902  retrieves from the Goal-Determinant database all relevant information to create the Determinant view. The extractor merges these sets of determinants into a single set of ranked determinants based on: relative relevance of the original goals from which the determinant was derived; relevance of the determinant in relation with the other determinants for the goal is was retrieved for; level of evidences related to that determinant; and based on the merged set, an overview picture of the determinants could be presented to the user as shown in  FIG. 6  by a browser. This browser is also able to show the background information behind the determinants and ranking, such as the evidence. 
     The system may further comprise a Patient Instantiator  910 . From the result of the Goal Extractor  902  and using information about the patient from the patient information database, the Patient Instantiator  910  evaluates:
         1. whether the evidence actually holds for that patient. E.g., in case there is evidence that “female patients with a high self-efficacy have high medication compliance” (while similar evidence for male persons is not available), and the patient is male, the relevance of “self-efficacy” is calculated disregarding this specific evidence;   2. whether the determinant is satisfied for the patient, e.g. when self-efficacy is already very high for the patient, it becomes less important to focus any intervention on improving that determinant;   3. when significant effort has been focused on the determinant in the past, without any improvement, the determinants will become less relevant for that patient; and   4. merging/relating/rating the determinants in this way results in an advice to the care professional on which determinants to focus the therapy to have the highest probability of success.       

     Based on the merged set, an overview picture of the determinants could be presented to the user as shown in  FIG. 8  by some kind of browser. This browser is also able to show the background information behind the determinants and ranking, like the evidence, relevant patient information, etc. The browser also allows the selection of determinant to select as a base for care plan creation. This selection is logged by the patient logger. 
     The systems may further comprise a Patient Logger  916  which gathers information about the patient and stores that in the patient information database. This is not only about medical information, but also the history of intervention goals set of a patient, the determinants selected to address these goals, the therapy selected based on these determinants, the effects of the therapy in terms of changes in the determinants for the patients and/or progression towards the goals set. 
     The system may further comprise a Historical Evidence Generator which analyses information stored in the Patient Information database with respect to relations between goals set and determinants selected. Output of this process could be used again as input for the total system for improving the whole process. 
       FIG. 10  shows a block diagram which illustrates the functionality of a clinical decision support system according to an embodiment of the invention. The clinical support decision system  1000  comprises a processor  1002 , computer storage  1004  and computer memory  1006 . Both the computer storage  1004  and the computer memory  1006  are examples of computer-readable non-transitory storage medium. The clinical support decision system is shown as being connected to a remote patient management system  1008 . The clinical support decision system  1000  is also shown as being connected to a display  1010  which has a graphical user interface  1012 . 
     The remote patient management system  1008  comprises an application hosting device  1014  which comprises a processor  1016  and a computer memory  1018 . Stored within the computer memory  1018  is a care plan  1020  for execution by the application hosting device  1014  and remote patient management system data  1022 . The remote patient management system data  1022  is data acquired by the application hosting device  1014  and which may be sent back to the clinical decision support system  1000  if it is queried. The remote patient management system also comprises in this example various diagnostic instruments  1024 ,  1028 ,  1032  for making physical measurements of vital signs on a patient  1026 . In this example there is a scale  1024  for measuring the weight of the patient  1024 , a blood pressure cuff  1028  for measuring the blood pressure of the patient  1026  and a urine test strip reader  1030  for measuring a urine sample  1032  from the patient  1026 . All three of these diagnostic instruments  1024 ,  1028 ,  1032  are shown as being networked or connected to the application hosting device  1014 . Also shown in this example is the application hosting device connected to a user interface  1034  or feedback device. The user interface  1034  in this example has a display  1036  which is currently displaying a survey. The response to the survey  1036  or measurements from the diagnostic instruments  1024 ,  1028 ,  1030  may each or in combination be used to generate the remote patient management system data  1022 . 
     Within the memory within the computer storage  1004  is stored a care plan template database  1038  which contains care plans which may be selected using behavioral models. Also within the computer storage  1004  is a media library  1040  which may be linked to a care plan template during the compilation of a care plan. Also shown in the computer storage is a remote patient management system data  1042  which has been transmitted to the clinical support decision system  1000  by the application hosting device  1014 . Also shown in the computer storage  1004  is a care plan  1044  which has been compiled by the clinical support decision system  1000 . 
     The computer storage  1004  also contains a behavioral model database  1046 , an evidence database  1048 , and a medical record database  1050 . The behavioral model database  1046  contains behavioral models which may be selected using behavioral determinants and the behavioral model is then used to select a care plan template from the care plan template database  1038 . The evidence database  1048  contains correlations between patient information and determinants. This corresponds to the evidence  922  in  FIG. 9 . There is a medical record database  1050  which contains patient data  1052  about the patient  1026 . The computer memory  1006  is shown as containing patient data  1052  extracted from the medical record database  1050 . 
     The computer memory also contains a program module  1054  for executing instructions which implement an embodiment of the method according to the invention. The computer memory further contains a behavioral determinant list making module  1056  for generating the behavioral determinant list  1058  from a goal which has been input. The computer memory also contains a ranking module  1060  which are machine executable instructions for ranking the behavioral determinant list  1058  using the patient data  1052 . The output of the ranking module  1060  is shown as a ranked behavioral determinant list  1062  which is also in the computer memory  1006 . A subset of the behavioral determinant list  1064  which has been received is shown as being stored in the memory also  1006 . Within the computer memory is also a care plan compilation module  1068  which contains machine executable instructions for compiling a care plan  1044  using the care plan template database  1038  and the media library  1040 . Also within the computer memory is a historical evidence database generator  1070  which corresponds to the historical evidence generator  920  of  FIG. 9 . The computer memory also contains a tagger module  1072  which corresponds to the tagger  924  of  FIG. 9 . 
     The graphical user interface  1012  displays a list of behavioral determinants  1074 . Adjacent to the list of behavioral determinants  1074  is a set of bar graphs  1076  which show the importance of each of the behavioral determinants  1074  to the patient  1026  that were determined using the patient data  1052 . The graphical user interface  1012  then contains a set of check boxes  1078  adjacent to the list of behavioral determinants  1074  for selecting a subset of the list of behavioral determinants. Once the continue button  1018  on the graphical user interface  1012  is clicked by the healthcare professional the clinical support decision system  1000  receives the subset of the list of behavioral determinants. 
     While the invention has been illustrated and described in detail in the drawings and foregoing description, such illustration and description are to be considered illustrative or exemplary and not restrictive; the invention is not limited to the disclosed embodiments. 
     Other variations to the disclosed embodiments can be understood and effected by those skilled in the art in practicing the claimed invention, from a study of the drawings, the disclosure, and the appended claims. In the claims, the word “comprising” does not exclude other elements or steps, and the indefinite article “a” or “an” does not exclude a plurality. A single processor or other unit may fulfill the functions of several items recited in the claims. The mere fact that certain measures are recited in mutually different dependent claims does not indicate that a combination of these measured cannot be used to advantage. A computer program may be stored/distributed on a suitable medium, such as an optical storage medium or a solid-state medium supplied together with or as part of other hardware, but may also be distributed in other forms, such as via the Internet or other wired or wireless telecommunication systems. Any reference signs in the claims should not be construed as limiting the scope. 
     LIST OF REFERENCE NUMERALS 
     
         
           200  first item 
           300  second item 
           600  display of determinants 
           602  determinant for intervention goal  1   
           604  determinant for intervention goal  2   
           606  determinant for intervention goal  3   
           700  display of determinants 
           702  dialogue box showing evidence 
           704  evidence 
           800  display of determinants 
           802  adjusted size of determinant 
           804  dialogue box 
           806  dialogue box 
           900  intervention goal input 
           902  extractor 
           904  goal determinant database 
           906  list of determinants 
           908  browser window 
           910  patient instantiator 
           912  modified set of determinants 
           914  browser window 
           916  patient logger 
           918  patient information database 
           920  evidence generator 
           922  evidence 
           924  tagging module 
           1000  clinical support decision system 
           1002  processor 
           1004  computer storage 
           1006  computer memory 
           1008  remote patient management system 
           1010  display 
           1012  graphical user interface 
           1014  application hosting device 
           1016  processor 
           1018  computer memory 
           1020  care plan 
           1022  remote patient management system data 
           1024  scale 
           1026  patient 
           1028  blood pressure cuff 
           1030  urine test strip reader 
           1032  urine sample 
           1034  user interface or feedback device 
           1036  display with a survey 
           1038  care plan template database 
           1040  media library 
           1042  remote patient management system data 
           1044  care plan 
           1046  behavioral model database 
           1048  evidence database 
           1050  medical record database 
           1052  patient data 
           1054  program module 
           1056  behavioral determinant list making module 
           1058  behavioral determinant list 
           1060  ranking module 
           1062  ranked behavioral determinant list 
           1064  subset of behavioral determinant list 
           1066  list of selected behavioral models 
           1068  care plan compellation module 
           1070  historical evidence database generator 
           1072  tagger module 
           1074  list of behavioral determinants 
           1076  bar graphs showing adjusted importance 
           1078  check boxes 
           1080  continue button