Computerization of workflows, guidelines and care pathways: a review of implementation challenges for process-oriented health information systems

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways. A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes. One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed. We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings

Improving health care services through enhanced Health Information System: Human capacity development Model

AbstractBackground: Quality of health care depends on how the health system is able to reduce errors through evidence-based decisions. Demand for data on patient care has increased over the years to improve the health care system, including planning and policy issues in several countries across the globe. However, there are challenges and opportunities in the process of recording, managing, analyzing, interpreting, and reporting data and/or information. Accordingly, several studies showed that an appropriate capacity development program is expected to improve data recording, data quality and use by professionals, planners, policymakers, and stakeholders.Objective: This project aims to assess existing capacity-building efforts and formulate a new and better capacity-building model for the lower-level health facility staff of Addis ababa City administration, 2018-2020.Methods: PRISM and SWOT analysis method were employed to assess existing HIS gaps and opportunities. The assessment was carried out in the health centers located in selected three sub-cities of Addis Ababa City Administration. We employed phase to phase approach to design an innovative human capacity development model, namely, desk review, data collection, data synthesis, design, and validation.Results: The project designed interventions that were implemented simultaneously and one supporting the other. The capacity-building model includes a renewed approach to training; structured mentorship approach; practically oriented supportive supervision; ‘experience sharing program’ for helping those in a poor environment gain experience through experience sharing; quality improvement initiatives; and implementation science studies to tackle problems that may not be solved with activities listed earlier.Conclusion and recommendation: The new capacity-building approach helped to improve individual knowledge, interpersonal relationship, strategic thinking, system management, and accountability, all of which lead to sustained and improved HIS. Improvement in HIS is often a collective effort of several forces, but the human element plays a decisive role. [Ethiop. J. Health Dev. 2021; 35(SI-1):42-49]Keywords: Human Capacity Development Model, Health Information Systems, Quality of health care, data quality, Information us

iManageMyHealth and iSupportMyPatients: mobile decision support and health management apps for cancer patients and their doctors

Clinical decision support systems can play a crucial role in healthcare delivery as they promise to improve health outcomes and patient safety, reduce medical errors and costs and contribute to patient satisfaction. Used in an optimal way, they increase the quality of healthcare by proposing the right information and intervention to the right person at the right time in the healthcare delivery process. This paper reports on a specific approach to integrated clinical decision support and patient guidance in the cancer domain as proposed by the H2020 iManageCancer project. This project aims at facilitating efficient self-management and management of cancer according to the latest available clinical knowledge and the local healthcare delivery model, supporting patients and their healthcare providers in making informed decisions on treatment choices and in managing the side effects of their therapy. The iManageCancer platform is a comprehensive platform of interconnected mobile tools to empower cancer patients and to support them in the management of their disease in collaboration with their doctors. The backbone of the iManageCancer platform comprises a personal health record and the central decision support unit (CDSU). The latter offers dedicated services to the end users in combination with the apps iManageMyHealth and iSupportMyPatients. The CDSU itself is composed of the so-called Care Flow Engine (CFE) and the model repository framework (MRF). The CFE executes personalised and workflow oriented formal disease management diagrams (Care Flows). In decision points of such a Care Flow, rules that operate on actual health information of the patient decide on the treatment path that the system follows. Alternatively, the system can also invoke a predictive model of the MRF to proceed with the best treatment path in the diagram. Care Flow diagrams are designed by clinical experts with a specific graphical tool that also deploys these diagrams as executable workflows in the CFE following the Business Process Model and Notation (BPMN) standard. They are exposed as services that patients or their doctors can use in their apps in order to manage certain aspects of the cancer disease like pain, fatigue or the monitoring of chemotherapies at home. The mHealth platform for cancer patients is currently being assessed in clinical pilots in Italy and Germany and in several end-user workshops

Healthcare Integrated Approach as a Dynamic Process leading Innovation and Inclusive growth: Conceptual Framework based on Care Puglia (Italy)

Background Societal challenges introduced by Horizon 2020 and global challenges around health and environment expressed by seventeen sustainable development goals seek a mission-oriented agenda. Healthcare evaluation require a portfolio of projects with bottom-up experimentation. Current economic evaluations do not include a social component within the analysis. This study describes an integrated care model involving several stakeholders across healthcare sectors primary, secondary, tertiary, private and community sectors. The new integrated care framework has the aim encompass social welfare. Methods The existing evidence about the economic impact of integrated care available in the thin scientific literature is inconclusive. A European programme called Strategic Intelligence Monitor on Personal Health Systems Phase 3 presented 24 projects of integrated care service. Those studies were set in fourteen different European countries at exception of Israel and USA. Those projects included telehealth, telecare and independent solutions for older patients with chronic conditions. Those studies mainly identified drivers and barriers of the organizational models to integrate healthcare and social care, they stress the role of Information and Communication technology in facilitating the integration of healthcare and social care. Results Care Puglia based on Assisted Diagnostic & Therapeutic Pathway (PDTA) developed a chronic care clinical network in the southern region of Italy. This study is going to implement a Situational Awareness Team (SAT) with the ability to fuse different types of information generating a real-time sense-check and understanding barriers to change while unfolding the properties of the model. The new framework is going to focus on the Socio-Economic aspect of the Integrated Care system fostering Management Performance, Cost-Effectiveness Analysis and Sustainability Plan. A well-informed local health authority system counts of better transparency upon local governance. The mainstay of this new integrated approach to healthcare is engaging the process of building organisations to becoming learning organisations. Integrated care results being a dynamic approach to the assessment of health policies to replace the more static cost-benefit approach. This pillar is about a smart thinking allowing innovation and inclusive growth

Resource constraints in health care - case studies on technical, allocative and economic efficiency

The scarcity of resources and the need to produce more with less is an ever-present reality for managers of health care organisations. Trends in healthcare costs are a widely acknowledged concern among policy-makers worldwide. Many factors will contribute to the evolution of future health care systems. They include changing demand and demand patterns, developments of medical technology, citizens' expectations of readily available high-quality services, the availability and capacity of health care resources, the purchasing power of citizens, and financing mechanisms. In the study, six cases – representing the operative and conservatory area of special care, an open care system, a major regional diagnostic support function, elderly care systems and a regional health care system – are analyzed. The main contributions of operations management to resource constraint problem are related to, but not limited to, how capacity of resources can be measured and managed. This study provides insight and a model for how resource constraints can be identified in all health care service production processes as well as in patient episodes. Applying technical, allocative and economic efficiency analysis provides tools for identifying and reducing the impact of resource constraints. Reducing the impact or eliminating bottlenecks increases the total capacity of a process or system with interdependent resources. The benefits of the analysis increase as its scope analysis is extended to include the regional service network. Efficiency improvement efforts should focus on constrained resources, as a system's capacity can only be increased by increasing the capacity of these resources. Capacity is almost exclusively limited by personnel resources, but the capacity of personnel is rarely sufficiently analyzed. This is due to insufficient management tools and results in an inability to manage operations according to its constrained resources. Once resource constraints have been identified and quantified, the means for increasing capacity of bottlenecks are subject to improvements of technical and/or allocative efficiency. Here the benefits and potential of OM are significant. The study shows that there may be significant room for improvement of both technical and allocative efficiency in many areas of health care. Excessive focus is placed on the efficient management of non-constrained resources for which information is more readily available. This is likely to result in optimisation of non-constrained resources, which may be synonymous to sub-optimisation. Maximizing the use of non-constrained resources may impose new resource constraints. Economic efficiency depends on technical and allocative efficiency. Thus, improvements of technical and allocative efficiency are highly likely to render improvements of economic efficiency. On the regional level, economic efficiency improvement potential is likely to be subject to significant resource reallocation efforts. This study highlights the importance of maintaining a throughput- or process-oriented management mindset as opposed to mere focus on costs. Nevertheless, the importance of a more comprehensive state of analysis, which combines process and financial information, is strongly advocated

The relationship between empathy and Self-Management Support in general practice consultations in areas of high and low socio-economic deprivation

Aim: Empathy is widely regarded as an important attribute of healthcare professionals, and has been linked to higher patient satisfaction, enablement, and some health outcomes. The ‘mechanism of action’ of clinical empathy is not well understood. An ‘effect model’ of empathic communication in the clinical encounter has been proposed by Neumann et al (2009). In this model, clinician empathy is seen as having a positive effect in encouraging patients to tell more about their symptoms and concerns (for example, by picking up on emotional cues and responding in an encouraging way). This can result in ‘affective-oriented effects’ (such as the patient feeling listened to and understood) or ‘cognitive/action-oriented effects’ which include the clinician collecting more detailed information (medical and psychosocial), gaining a more accurate perception of the problem (and possible diagnosis) and enhanced understanding and responses to the patients’ individual needs. Such responses may include Self-Management Support of various kinds, which help enable the patients to better manage their condition(s), leading to improved outcomes. Recent Government policy in Scotland has focused on Self-Management Support and Anticipatory Care as key priorities in primary care, in response to the rise in chronic disease and health inequalities. However, the amount and type of Self-Management Support and Anticipatory Care that occurs in routine consultations in primary care is not known, nor their relationship with empathy and patient enablement. Thus the ‘effect model’ of empathy as proposed by Neumann, which postulates a relationship between empathy, Self-Management Support, and outcomes in the consultation remains largely theoretical. The aim of this thesis was to examine the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations. Due to the wide health inequalities that exist in Scotland, and the continuing operation of the ‘inverse care law’, a comparison was made between consultations in areas of high or low socio-economic deprivation to establish whether the relationships varied by deprivation. The thesis had the following research objectives; • To assess the nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups • To determine whether patients’ perceptions of GP empathy is related to Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation groups • To explore the effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups • To assess patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups Methods: The research objectives were investigated by a secondary analysis of data collected between 2006-2008 by Mercer and colleagues in the Section of General Practice and Primary Care at the University of Glasgow. These data were collected as part of a research project in general practice in areas of high and low deprivation funded by the Chief Scientist Office of the Scottish Government. The research produced database, includes 659 videoed baseline consultations, with patient rated experience measures, including the Consultation and Relational Empathy (CARE) Measure, the Patient Enablement Instrument (PEI) and outcomes (self-reported symptom change and well-being) at 1 month post-consultation available on 499 patients. An observer-rated method of assessing Self-Management Support and Anticipatory Care was sought from the literature to answer objectives 1-3. However, there were a lack of validated observer-rated tools available that were specifically designed to measure these constructs. As such, the Davis Observation Code was identified as a validated system of coding primary care consultations across a broad range of consultation components which included items deemed to relate to Self-Management Support and Anticipatory Care. The process of selecting the Davis coding system, and the rejection of alternative coding systems is discussed in detail in Chapter 5. The Davis coding system was also considered feasible given the large size of the database. Self-Management Support and Anticipatory Care were then measured by using combinations of seven codes deemed relevant to Self-Management Support within the consultation setting. Four additional codes were added to the Davis system, in order to include tasks relevant to UK general practice consultations. These additional codes were not part of Self-Management Support or Anticipatory Care but were added to achieve a complete coding system of activities within the consultations. The Verona coding system measured emotional cues, concerns and health provider responses that were observed within the consultations. As such, this system was used to answer objective 4. The choice of this system reflected a desire to use an observer-rated measure to help ‘validate’ the patient-rated empathy measure (the CARE Measure) in terms of the first part of the Neumann et al (2009) model, i.e. eliciting concerns and symptoms, separate from the cognitive/action oriented effects relating to Self-Management Support. Results: Reliability of the objective coding systems Preliminary work was carried out on both coding systems in order to establish reliability in the application of the codes. This was a lengthy process, involving several cycles of coding by two coders (the author and one of her supervisors) but resulted in acceptably high levels of inter-rater reliability (kappa > 0.7 for the Davis coding system, and > 0.9 for the Verona coding system). Objective 1: The nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups In both the high and low deprivation groups, time was predominantly allocated to gaining information about the patient’s complaint, conducting physical examinations and planning treatment. There was no difference observed in the amount of Self-Management Support overall in the consultations between high and low deprivation areas. However, there were significant differences in the nature, type and frequency of certain aspects of Self-Management Support, with significantly more Anticipatory Care in the consultations in the high deprivation areas. The results also showed that patients in the high deprivation group tended to experience a more direct biomedical focused consultation that featured practical tasks such as physical examinations and discussion of substance misuse. In the low deprivation group, a biopsychosocial approach was more common, which involved more time spent within the consultation discussing treatment effects, compliance or discussing how previous interventions had impacted on the patient’s health. For both groups, little time was allocated to gathering family information or counselling, answering patient questions or discussing health knowledge. Objective 2: Patients’ perception of GP empathy and relationship with Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation areas. The relationship between empathy and Self-Management Support was explored using the Consultation and Relational Empathy Measure (CARE) and the Davis observation code respectively. Potential confounding variables were taken into account. Patients' perceptions of their GP's empathy were significantly associated with Self-Management Support in the low deprivation group, but not the high deprivation group. Anticipatory Care was not associated with patients' perceptions of their GP's empathy in either high or low deprivation groups. Objective 3: Effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups The effects of Self-Management Support on patient enablement and health outcomes were explored. Patient Enablement was not related to the amount of Self-Management Support or Anticipatory Care in the consultations in either high or low deprivation settings, nor were Davis codes associated with enablement in the high deprivation group. However, enablement was positively and significantly associated with discussions around patient questions in the low deprivation group. The amount of time spent on procedures (such as taking blood) had a negative association with enablement in the low deprivation group. Changes in health outcome in terms of symptom severity at 1 month post-consultation were not related to overall Self-Management Support in the consultation in either high or low deprivation settings. However, Anticipatory Care in the consultation was related positively with symptom improvement in the low deprivation group but not high deprivation group. Changes in health outcome in terms of well-being improvement at 1 month post-consultation were not related to overall Self-Management Support or Anticipatory Care in the consultation in either high or low deprivation settings. Objective 4: Patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups Patient perception of GP empathy within the consultation, as measured by the CARE Measure, was compared with the type and frequency of patients’ emotional cues and concerns and GP responses using the Verona coding system. Because of the lengthy process that this coding system entails, coding was undertaken on a sub-group of the full data set. 112 consultations were coded, from the highest and lowest empathy GPs, (based on GPs’ mean CARE Measure scores) in the dataset, in both high and low deprivation areas. The results showed that in areas of high deprivation, patients who consulted GPs with high empathy (high CARE measure scores) expressed more emotional cues and concerns and the GPs had more encouraging responses, compared with consultations with practitioners with low patient ratings of empathy. These associations between Verona codes and GP empathy were not observed in consultations in low deprivation areas. These findings suggest that the way in which patients judge their GPs to be empathic or not differ according to deprivation level. Conclusions The thesis findings are based on one of the largest databases of general practice consultation content linked to health outcomes in the world. New findings on the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations have been identified. Objective measurement of Self-Management Support showed similar amounts of Self-Management Support overall in consultations in high or low deprivation areas, though more Anticipatory Care (involving more health promotion) was observed in the high deprivation group, possibly as a reactive response to the higher levels of unhealthy behaviours (such as smoking and substance misuse) in deprived areas. However, the amount of Self-Management Support shown in consultations in both deprivation areas was generally low. In agreement with theoretical cognitive/action-oriented effects of the Neumann model, perceived GP empathy was positively related to the amount of Self-Management Support in the consultations in the low deprivation areas. However, this was not found in the high deprivation consultations, suggesting that patients judge their GPs empathy on different criteria depending on their deprivation levels and that affect-oriented effects may be more important in consultations in deprived areas. Symptom improvement was related to the amount of Anticipatory Care in the low deprivation group, which would again fit with the cognitive/action-oriented effects of the Neumann model. However, in the high deprivation group such an association was not found. Collectively, the results of this thesis indicate that the relationships between perceived GP empathy, Self-Management Support (including Anticipatory Care), patient enablement, and health outcomes are complex and differ depending on the deprivation level of the patient. The findings provide some support for the utility of the ‘effect model’ of empathy but mainly in the low deprivation setting. These findings have implications for how consultations are best conducted in high or low deprivation areas, and possibly for medical student and GP training in communication and consultation skills

User-centered visual analysis using a hybrid reasoning architecture for intensive care units

One problem pertaining to Intensive Care Unit information systems is that, in some cases, a very dense display of data can result. To ensure the overview and readability of the increasing volumes of data, some special features are required (e.g., data prioritization, clustering, and selection mechanisms) with the application of analytical methods (e.g., temporal data abstraction, principal component analysis, and detection of events). This paper addresses the problem of improving the integration of the visual and analytical methods applied to medical monitoring systems. We present a knowledge- and machine learning-based approach to support the knowledge discovery process with appropriate analytical and visual methods. Its potential benefit to the development of user interfaces for intelligent monitors that can assist with the detection and explanation of new, potentially threatening medical events. The proposed hybrid reasoning architecture provides an interactive graphical user interface to adjust the parameters of the analytical methods based on the users' task at hand. The action sequences performed on the graphical user interface by the user are consolidated in a dynamic knowledge base with specific hybrid reasoning that integrates symbolic and connectionist approaches. These sequences of expert knowledge acquisition can be very efficient for making easier knowledge emergence during a similar experience and positively impact the monitoring of critical situations. The provided graphical user interface incorporating a user-centered visual analysis is exploited to facilitate the natural and effective representation of clinical information for patient care

Designing community care systems with AUML

This paper describes an approach to developing an appropriate agent environment appropriate for use in community care applications. Key to its success is that software designers collaborate with environment builders to provide the levels of cooperation and support required within an integrated agent–oriented community system. Agent-oriented Unified Modeling Language (AUML) is a practical approach to the analysis, design, implementation and management of such an agent-based system, whilst providing the power and expressiveness necessary to support the specification, design and organization of a health care service. The background of an agent-based community care application to support the elderly is described. Our approach to building agent–oriented software development solutions emphasizes the importance of AUML as a fundamental initial step in producing more general agent–based architectures. This approach aims to present an effective methodology for an agent software development process using a service oriented approach, by addressing the agent decomposition, abstraction, and organization characteristics, whilst reducing its complexity by exploiting AUML’s productivity potential. </p

The client-oriented model of cultural competence in healthcare organizations

The paper aims to propose a new model of cultural competence in health organizations based on the paradigm of client orientation. Starting from a literature review, this study takes inspiration from dimensions that characterize the cultural competence of health organizations, and re-articulates them in more detail by applying a client orientation view. The resulting framework is articulated into six dimensions (formal references; procedures and practices; cultural competences of human resources; cultural orientation toward client; partnership with community; and self-assessment) that define the ability of a health organization to achieve its mission, acknowledging, understanding, and valorizing cultural differences of internal clients (staff) and external clients (consumers). This study makes an effort to address the paucity of studies linking approaches to managing cultural diversity in health organizations with cultural competence within the framework of client orientation