7 ms·

I’d rather have the pdf than a custom tool. Especially considering the tool will be unique to the practice or emr. And likely expensive to maintain. PDFs suck

I’d rather have the pdf than a custom tool. Especially considering the tool will be unique to the practice or emr. And likely expensive to maintain. PDFs suck in many ways but are durable and portable. If I work with two oncologists, I use the same pdf. The author means well but his solution will likely be worse because only he will understand it. And there’s a million edge cases.

akoboldfrying 2y ago
The author is proposing that the DAG representation be in addition to the PDF: >The organizations drafting guidelines should release them in structured, machine-interpretable formats in addition to the downloadable PDFs. My opinion: Ideally the PDF could be generated from the underlying DAG -- that would give you confidence that everything in the PDF has been captured in the DAG.
- maxerickson 2y ago
  You could generate the document from the graph and then attach it as data.
  - JumpCrisscross 2y ago
    > could generate the document from the graph and then attach it as data Much easier for doctors to draft PDFs than graphs.
    - seb1204 2y ago
      I have not drafted a PDF myself and I doubt doctors will. They work in a text writer or spreadsheet application and then export or print to PDF would be my guess. An interactive interface could spit out the PDF with the decision three in the end. This solution would still mean the decision tree source is in some software package.
crazygringo 2y ago
Exactly. The PDF's work. They won't break. You can see all the information with your own eyes. You can send them by e-mail. A wizard-type system hides most of the information from you, it might have bugs you aren't aware of, if you want to glance at an alternative path you can't, it's going to be locked into registered users, the system can go down. I think much more intelligent computer systems are the future in health care, but I doubt the way to start is with yet another custom tool designed specifically for cancer guidelines and nothing else.
- crabmusket 2y ago
  > it's going to be locked into registered users, the system can go down I didn't see anything in the screenshots presented that wouldn't be doable in a single HTML file containing the data, styles and scripts? This is a countercultural idea but it fits so many use cases; it's a tragedy we don't do this more often. The two options are either PDF or SaaS.
- ajsnigrutin 2y ago
  > The PDF's work. They won't break. Not just that, PDFs are one of the few formats, where i'm willing to bet my own money, that they'll still work in 10 or 20 years. Even basic html has changed, layouts look different depending on many factors, and even the <blink>-ing doesn't work anymore.
  - seb1204 2y ago
    A case specific PDF could be created and stored in the patient's electronic records. Such PDF could just highlight the decision three path.
  - inferiorhuman 2y ago
    Sure, PDF/A is an ISO-standardized subset of the larger PDF spec designed expressly for archival purposes. You could do that with HTML but then how would you get your crypto mining AI chat bot powered by WASM to work?
slaucon 2y ago
Hey author here! Appreciate the feedback! Agreed on importance of portability and durability. I'm not trying to build this out or sell it as a tool to providers. Just wanted to demo what you could do with structured guidelines. I don't think there's any reason this would have to be unique to a practice or emr. As sister comments mentioned, I think the ideal case here would be if the guideline institutions released the structured representations of the guidelines along with the PDF versions. They could use a tool to draft them that could export in both formats. Oncologists could use the PDFs still, and systems could lean into the structured data.
- Dalewyn 2y ago
  >Agreed on importance of portability and durability. I think "importance" is understating it, because permanent consistency is practically the only reason we all (still) use PDFs in quite literally every professional environment as a lowest common denominator industrial standard. PDFs will always render the same, whether on paper or a screen of any size connected to a computer of any configuration. PDFs will almost always open and work given Adobe Reader, which these days is simply embedded in Chrome. PDFs will almost certainly Just Work(tm), and Just Working(tm) is a god damn virtue in the professional world because time is money and nobody wants to be embarrassed handing out unusable documents.
  - abtinf 2y ago
    PDFs generally will look close enough to the original intent that they will almost always be usable, but will not always render the same. If nothing else, there are seemingly endless font issues.
    - lstamour 2y ago
      In this day and age that seems increasingly like a solved problem to most end users, often a client-side issue or using a very old method of generating a PDF? Modern PDF supports font embedding of various kinds (legality is left as an exercise to the PDF author) and supports 14 standard font faces which can be specified for compatibility, though more often document authors probably assume a system font is available or embed one. There are still problems with the format as it foremost focuses on document display rather than document structure or intent, and accessibility support in documents is often rare to non-existent outside of government use cases or maybe Word and the like. A lot of usability improvements come from clients that make an attempt to parse the PDF to make the format appear smarter. macOS Preview can figure out where columns begin and end for natural text selection, Acrobat routinely generates an accessible version of a document after opening it, including some table detection. Honestly creative interpretation of PDF documents is possibly one of the best use cases of AI that I’ve ever heard of. While a lot about PDF has changed over the years the basic standard was created to optimize for printing. It’s as if we started with GIF and added support to build interactive websites from GIFs. At its core, a PDF is just a representation of shapes on a page, and we added metadata that would hopefully identify glyphs, accessible alternative content, and smarter text/line selection, but it can fall apart if the PDF author is careless, malicious or didn’t expect certain content. It probably inherits all the weirdness of Unicode and then some, for example.
KPGv2 2y ago
You say this, but on the other hand, the author alleges that the places that use these custom tools achieve better outcomes. You didn't address this point one way or the other. Do you think this is a completely fabricated non-explanation? It's not like the link says "the worst places use these custom tools."
ahardison 2y ago
Totally valid concerns. If you have time, I would like to show you my solution to get your thoughts as I believe I have found ways to mitigate all of your concerns. Currently I am using STCC (Schmitt-Thompson Clinical Content). I Have sent you some of the PDF's we use for testing.
zahlman 2y ago
It would, I imagine, be much easier to generate a PDF from the tool's internal flowchart representation than the other way around.
Spooky23 2y ago
I think there’s value if it can scale down. Community oncologists have limited technology resources as compared to a national cancer center. If we can make their lives easier, it can only be a good thing. That said, I like published documents like PDFs - systems usually make it hard to conii ok are the June release from the September release.
layer8 2y ago
I agree. However, since the PDF format supports structured data, one could in principle have it both ways, within a single file.
- queuebert 2y ago
  ^ This. See, e.g., https://lab6.com/ https://lab6.com/ for some interesting tricks with the PDF format.

akoboldfrying 2y ago

The author is proposing that the DAG representation be in addition to the PDF: >The organizations drafting guidelines should release them in structured, machine-interpretable formats in addition to the downloadable PDFs. My opinion: Ideally the PDF could be generated from the underlying DAG -- that would give you confidence that everything in the PDF has been captured in the DAG.

maxerickson 2y ago
You could generate the document from the graph and then attach it as data.
- JumpCrisscross 2y ago
  > could generate the document from the graph and then attach it as data Much easier for doctors to draft PDFs than graphs.
  - seb1204 2y ago
    I have not drafted a PDF myself and I doubt doctors will. They work in a text writer or spreadsheet application and then export or print to PDF would be my guess. An interactive interface could spit out the PDF with the decision three in the end. This solution would still mean the decision tree source is in some software package.

crazygringo 2y ago

Exactly. The PDF's work. They won't break. You can see all the information with your own eyes. You can send them by e-mail. A wizard-type system hides most of the information from you, it might have bugs you aren't aware of, if you want to glance at an alternative path you can't, it's going to be locked into registered users, the system can go down. I think much more intelligent computer systems are the future in health care, but I doubt the way to start is with yet another custom tool designed specifically for cancer guidelines and nothing else.

crabmusket 2y ago
> it's going to be locked into registered users, the system can go down I didn't see anything in the screenshots presented that wouldn't be doable in a single HTML file containing the data, styles and scripts? This is a countercultural idea but it fits so many use cases; it's a tragedy we don't do this more often. The two options are either PDF or SaaS.
ajsnigrutin 2y ago
> The PDF's work. They won't break. Not just that, PDFs are one of the few formats, where i'm willing to bet my own money, that they'll still work in 10 or 20 years. Even basic html has changed, layouts look different depending on many factors, and even the <blink>-ing doesn't work anymore.
- seb1204 2y ago
  A case specific PDF could be created and stored in the patient's electronic records. Such PDF could just highlight the decision three path.
- inferiorhuman 2y ago
  Sure, PDF/A is an ISO-standardized subset of the larger PDF spec designed expressly for archival purposes. You could do that with HTML but then how would you get your crypto mining AI chat bot powered by WASM to work?

slaucon 2y ago

Hey author here! Appreciate the feedback! Agreed on importance of portability and durability. I'm not trying to build this out or sell it as a tool to providers. Just wanted to demo what you could do with structured guidelines. I don't think there's any reason this would have to be unique to a practice or emr. As sister comments mentioned, I think the ideal case here would be if the guideline institutions released the structured representations of the guidelines along with the PDF versions. They could use a tool to draft them that could export in both formats. Oncologists could use the PDFs still, and systems could lean into the structured data.

Dalewyn 2y ago
>Agreed on importance of portability and durability. I think "importance" is understating it, because permanent consistency is practically the only reason we all (still) use PDFs in quite literally every professional environment as a lowest common denominator industrial standard. PDFs will always render the same, whether on paper or a screen of any size connected to a computer of any configuration. PDFs will almost always open and work given Adobe Reader, which these days is simply embedded in Chrome. PDFs will almost certainly Just Work(tm), and Just Working(tm) is a god damn virtue in the professional world because time is money and nobody wants to be embarrassed handing out unusable documents.
- abtinf 2y ago
  PDFs generally will look close enough to the original intent that they will almost always be usable, but will not always render the same. If nothing else, there are seemingly endless font issues.
  - lstamour 2y ago
    In this day and age that seems increasingly like a solved problem to most end users, often a client-side issue or using a very old method of generating a PDF? Modern PDF supports font embedding of various kinds (legality is left as an exercise to the PDF author) and supports 14 standard font faces which can be specified for compatibility, though more often document authors probably assume a system font is available or embed one. There are still problems with the format as it foremost focuses on document display rather than document structure or intent, and accessibility support in documents is often rare to non-existent outside of government use cases or maybe Word and the like. A lot of usability improvements come from clients that make an attempt to parse the PDF to make the format appear smarter. macOS Preview can figure out where columns begin and end for natural text selection, Acrobat routinely generates an accessible version of a document after opening it, including some table detection. Honestly creative interpretation of PDF documents is possibly one of the best use cases of AI that I’ve ever heard of. While a lot about PDF has changed over the years the basic standard was created to optimize for printing. It’s as if we started with GIF and added support to build interactive websites from GIFs. At its core, a PDF is just a representation of shapes on a page, and we added metadata that would hopefully identify glyphs, accessible alternative content, and smarter text/line selection, but it can fall apart if the PDF author is careless, malicious or didn’t expect certain content. It probably inherits all the weirdness of Unicode and then some, for example.

KPGv2 2y ago

You say this, but on the other hand, the author alleges that the places that use these custom tools achieve better outcomes. You didn't address this point one way or the other. Do you think this is a completely fabricated non-explanation? It's not like the link says "the worst places use these custom tools."

ahardison 2y ago

Totally valid concerns. If you have time, I would like to show you my solution to get your thoughts as I believe I have found ways to mitigate all of your concerns. Currently I am using STCC (Schmitt-Thompson Clinical Content). I Have sent you some of the PDF's we use for testing.

zahlman 2y ago

It would, I imagine, be much easier to generate a PDF from the tool's internal flowchart representation than the other way around.

Spooky23 2y ago

I think there’s value if it can scale down. Community oncologists have limited technology resources as compared to a national cancer center. If we can make their lives easier, it can only be a good thing. That said, I like published documents like PDFs - systems usually make it hard to conii ok are the June release from the September release.

layer8 2y ago

I agree. However, since the PDF format supports structured data, one could in principle have it both ways, within a single file.

queuebert 2y ago
^ This. See, e.g., https://lab6.com/ https://lab6.com/ for some interesting tricks with the PDF format.