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1. HLTHINFO 730 – lecture 6 Slide #1
HLTHINFO 730
Healthcare Decision Support Systems
Lecture 6: Decision Trees
Lecturer: Prof Jim Warren

2. HLTHINFO 730 – lecture 6 Slide #2
Decision Trees
• Essentially flowcharts
– A natural order of ‘micro decisions’ (Boolean –
yes/no decisions) to reach a conclusion
– In simplest form all you need is
• A start (marked with an oval)
• A cascade of Boolean decisions (each with exactly
outbound branches)
• A set of decision nodes (marked with ovals) and
representing all the ‘leaves’ of the decision tree (no
outbound branches)

3. HLTHINFO 730 – lecture 6 Slide #3
Example
• Consider this fragment of the ‘Prostate Cancer Workup (Evaluation)’
decision tree from
http://www.nccn.org/patients/patient_gls/_english/_prostate/contents.asp#
The page also shows supporting text:
“Additional testing is recommended for men
expected to live 5 or more years or who have
symptoms from the cancer. For example, if
the tumor is T1 or T2, a bone scan is
recommended if the PSA level is greater than
20 or if the Gleason score is greater than 8. A
bone scan is also recommended if the man
has any symptoms, or the cancer is growing
outside the prostate (T3 or T4). A CT or MRI
of the pelvis is recommended when the tumor
is T1 or T2 and there is a 7% or greater
chance of lymph node spread based on the
Partin tables, or the tumor is growing outside
the prostate (T3 or T4).”

4. HLTHINFO 730 – lecture 6 Slide #4
KE problems for flowchart
• The natural language may pack a lot in
– E.g., “any one of the following”
– Even harder if they say “two or more of the following” which
implies they mean to compute some score and then ask if it’s
>=2
• Incompleteness
– There are logically possible (and, worse, physically possible)
cases that aren’t handled
• The ‘for example’ in the text is a worry
• Inconsistency
– Are we trying to reach one decision (which test) or a set of
decisions
• 1) whether to do a bone scan
• 2) whether to do a ‘CT or MRI’

5. HLTHINFO 730 – lecture 6 Slide #5
Let’s try it anyway
• What’s said for ‘staging workup’ looks like this
T1 or T2
T3 or T4 PSA>20
Symptoms
T3 or T4
LNS
S3 S2
BS
BS
BS
S2
S3
N Y
Legend
S2 = step 2: ‘CT or MRI of pelvis
BS = Bone scan
S3 = step 3: ‘All others: no
additional testing’
LNS = ‘7% or greater chance of
lymph node spread based on
the Partin tables’
Please don’t decide your father’s
Prostate follow-up from this!
It’s unverified, and I don’t think a
tumour can be ‘T1 or T2’ and
ALSO ‘T3 or T4’ (but that’s what
it says!)

6. HLTHINFO 730 – lecture 6 Slide #6
Decision Tables
• As you can see from the Prostate example, a
flowchart can get huge
– We can pack more into a smaller space if we
relinquish some control on indicating the order of
microdecisions
• A decision table has
– One row per ‘rule’
– One column per decision variable
– An additional column for the decision to take when
that rule evaluates to true

7. HLTHINFO 730 – lecture 6 Slide #7
Decision Table example
From van Bemmel & Musen, Ch 15
d=
doesn’t
matter
(True or
False)

8. HLTHINFO 730 – lecture 6 Slide #8
Flowcharts v. Tables
• Decision table is not as natural as a flowchart
– But we’ve seen, a ‘real’ (complete and consistent) flowchart ends
up very large (or representing a very small decision)
• Decision table gets us close to production rule
representation
– Good as design specification to take to an expert system shell
• Completeness is more evident with a flowchart
• Decision table could allow for multiple rules to
simultaneously evaluate to true
– Messy on a flowchart (need multiple charts, or terminals that
include every possible combination of decision outcomes)
• Applying either in practice requires KE in a broad sense
– E.g., may need to reformulate the goals of the guideline

9. HLTHINFO 730 – lecture 6 Slide #9
On to production rule systems
• In a production rule system we have decision-table-like
rule, but also the decision outcomes can feed back to the
decision variables
• Evaluating some special decision rule (or rules) is then
the goal for the decision process
– The other rules are intermediary, and might be part of the
explanation of how externally-derived decision variables were
used to reach a goal decision
• The inference engine of the expert system shell chooses
how to reach the goal
– i.e., with backward chaining, or forward chaining
– Possibly with some direction from a User Interface (UI) manager
component (e.g., we might group sets of variables for input into
forms as a web page)

10. HLTHINFO 730 – lecture 6 Slide #10
Boolean Algebra
• To formulate flow chart decisions and
(especially) decision table rows, can help to
have mastered Boolean Algebra
• Basic operators
– NOT – if A was true, NOT A is false
– AND – A AND B is only true if both A and B are true
– OR – A OR B is true if either A, or B, or both are true
(aka inclusive or)
• This is not the place for a course on Boolean
algebra, but a few ideas will help…

11. HLTHINFO 730 – lecture 6 Slide #11
Notation
• Alas there are a lot of ways the operators are written
– NOT A might appear as A, ~A, A′ or ¬A
– A AND B might appear as A.B, A·B, A^B or simply AB
– A OR B might appear as A+B or AvB
• We can use parentheses like in normal algebra
– C(A+B) means the expression is True if and only if C is true AND
either B is true OR C is true (or both)
– It’s equivalent to CA + CB (C-AND-A or C-AND-B, evaluate AND
before OR)
– So AND is a bit like multiplication, whereas OR is a bit like
addition
• 1 + 1 ≥ 1 1 + 0 ≥ 1 (inclusive OR)
• 1 x 1 ≥ 1 1 x 0 ≥ 1 (logical AND)

12. HLTHINFO 730 – lecture 6 Slide #12
Think!
• If you just keep your head and focus on
the meaning in the clinical domain, you
can usually find the Boolean expression
you need
– Be sure to be precise
• “NOT (x>43)” is “x is NOT GREATER than 43” is
“x<=43” (get your equals in the right place!)
(with this advice, I won’t teach you De Morgan’s
Law, truth tables, or Karnaugh maps, but feel
free to look them up – they all Google well)

13. HLTHINFO 730 – lecture 6 Slide #13
Venn diagrams
• Visual representations of membership in sets
– Can be very useful to decide what Boolean
expression you need
– Say A is the set of everything with two legs and B the
set of everything
that flies
• A^B would be true for a parrot
• A would be true for a human,
B would be false
• B would be true for a mosquito,
A would be false
Human
Parrot
Mossie
A: 2 legs B: can fly

14. HLTHINFO 730 – lecture 6 Slide #14
Decision Tree Induction
• An alternative to knowledge engineering a
decision tree is to turn the task over to a
machine learning algorithm
– The decision tree can be ‘induced’ (or inducted) from
a sufficiently large set of example
• The ID3 algorithm is the classic for inducing a
decision tree using Information Theory
– If I have 50 examples where the patients survived and
50 where they didn’t I have total (1.0) entropy and
zero information
– Given a set of potential decision attributes I can try to
create more order (less entropy, more information) in
the data

15. HLTHINFO 730 – lecture 6 Slide #15
Example: Induced Decision Tree
From Chen et al, Complete Blood Count as a Surrogate CD4 Marker for HIV Monitoring in
Resource-limited Settings, 10th Conf on Retroviruses and Opportunistic Infection, 2003.
Of course they go and use
ovals for listing the decision
variables, put the test criteria
on the arcs and put ‘leaf’
decisions in rectangles –
notations vary; get used to it!

16. HLTHINFO 730 – lecture 6 Slide #16
Using Entropy measures in ID3
• For a decision node S with pp positive example (e.g.,
surviving patients) and pn negataive example
– Entropy(S) = - pplog2 pp – pnlog2 pn
• So with 15 survivors out of 25 patients
– Entropy(S) = - (15/25) log2 (15/25) - (10/25) log2 (10/25) = 0.970
• I want to select a Boolean attribute A that splits S such
that the two subsets are as ordered as possible, usually
written…

17. HLTHINFO 730 – lecture 6 Slide #17
ID3 continued
• So if I have 20 available Boolean decision variables
– I try splitting my cases, S, according to each, until I find the
variable that gives the most Gain
– I repeat this on each sub-tree until either every node if perfect
(all survivors, or all deaths) or I run out of attributes
• If my variables aren’t Boolean, then I have more work to
do
– Actually, the Gain equation works fine if the attribute is multi-
valued (Day of Week would be OK, I just have a 7-way split in
my tree)
– For continuous values I have to ‘discretize’ – make one or more
split points
• e.g., SBP<140? – now I’ve made continuous-valued blood pressure
into a Boolean
• Can be done based on knowledge (e.g., clinical significance), or
handed to an algorithm to search for the max Gain
See http://dms.irb.hr/tutorial/tut_dtrees.php

18. HLTHINFO 730 – lecture 6 Slide #18
Tools
• You don’t find ‘pure’ ID3 too much
– Other algorithms in a similar spirit to search for are
C4.5 and Adaboost
• Tools
– Matlab implements decision tree induction
– Weka toolkit (from Waikato Uni) has a variety of Java
tools for machine learning
– Try Pierre Geurts’ online decision tree induction
applet, e.g., for ‘animal descriptions’ from
http://www.montefiore.ulg.ac.be/~geurts/dtapplet/dtexplication.html#online

19. HLTHINFO 730 – lecture 6 Slide #19
I de-selected
‘backbone’
from the
available
decision
attributes, hit
New Tree,
then Build,
and hit
Zoom+ a
couple times
(note that the
attribute
order in the
database
effects how
the decision
nodes end up
phrased)

20. HLTHINFO 730 – lecture 6 Slide #20
Summary
• Decision trees are a basic design-level knowledge
representation technique for ‘logical’ (rule based,
Boolean-predicate-driven) decisions
• Decision tables let you compactly compile a host of
decisions on a fixed set of decision variables
– These take you very close to the representation needed to
encode production rules for an inference engine
• Rule induction from data provides an alternative to
conventional Knowledge Engineering
– Computer figures out rules that fit past decisions instead of you
pursuing experts to ask them what rules they use