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

Development and preliminary evaluation of a clinical guidance programme for the decision about prophylactic oophorectomy in women undergoing a hysterectomy

Objectives: To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation. Subjects: Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology. Setting: Oophorectomy decision consultation at the outpatient or pre-admission clinic. Methods: A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken. Results: The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised format and some were surprised at the specificity of the guidance given. Conclusions: A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient’s own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients’ preferences for inclusion in the decision making process

Guidelines for the use of cell lines in biomedical research

Cell-line misidentification and contamination with microorganisms, such as mycoplasma, together with instability, both genetic and phenotypic, are among the problems that continue to affect cell culture. Many of these problems are avoidable with the necessary foresight, and these Guidelines have been prepared to provide those new to the field and others engaged in teaching and instruction with the information necessary to increase their awareness of the problems and to enable them to deal with them effectively. The Guidelines cover areas such as development, acquisition, authentication, cryopreservation, transfer of cell lines between laboratories, microbial contamination, characterisation, instability and misidentification. Advice is also given on complying with current legal and ethical requirements when deriving cell lines from human and animal tissues, the selection and maintenance of equipment and how to deal with problems that may arise

Municipal wastewater treatment with pond technology : historical review and future outlook

Facing an unprecedented population growth, it is difficult to overstress the assets for wastewater treatment of waste stabilization ponds (WSPs), i.e. high removal efficiency, simplicity, and low cost, which have been recognized by numerous scientists and operators. However, stricter discharge standards, changes in wastewater compounds, high emissions of greenhouse gases, and elevated land prices have led to their replacements in many places. This review aims at delivering a comprehensive overview of the historical development and current state of WSPs, and providing further insights to deal with their limitations in the future. The 21st century is witnessing changes in the way of approaching conventional problems in pond technology, in which WSPs should no longer be considered as a low treatment technology. Advanced models and technologies have been integrated for better design, control, and management. The roles of algae, which have been crucial as solar-powered aeration, will continue being a key solution. Yet, the separation of suspended algae to avoid deterioration of the effluent remains a major challenge in WSPs while in the case of high algal rate pond, further research is needed to maximize algal growth yield, select proper strains, and optimize harvesting methods to put algal biomass production in practice. Significant gaps need to be filled in understanding mechanisms of greenhouse gas emission, climate change mitigation, pond ecosystem services, and the fate and toxicity of emerging contaminants. From these insights, adaptation strategies are developed to deal with new opportunities and future challenges

Questionable care: avoiding ineffective treatment

Overview In some hospitals, far too many people get a treatment they should not get, even when the evidence is clear that it is unnecessary or doesn’t work. Australia urgently needs a system to identify these outlier hospitals and make sure they are not putting patients at risk. To show how such a system could work, this report examines five treatments that should not be used on certain patients. One is treating osteoarthritis of the knee with an arthroscope – putting a tube inside the knee to remove tissue. Another is filling a backbone (vertebrae) with cement to treat fractures. A third is putting patients in a pressurised oxygen chamber when it will not help treat their specific condition. Expert guidance labels most of these five treatments do-not-do, yet in 2010-11 nearly 6000 people – or 16 people a day – received them. These procedures can harm. Some people who had them developed infections or other complications during their hospital visit. Some could have avoided the stress, cost, inconvenience and risk of a hospital stay altogether. Do-not-do treatments happen in all states, cities and rural areas, in public and private hospitals. But the ones we measured only happen in a minority of hospitals, some of which provided do-notdo treatments at 10 or 20 times the average rate. We also examined three procedures that are sometimes appropriate, but should not be offered routinely. Again, a few hospitals have very different treatment patterns from their peers. There are important reasons why clinicians sometimes choose inappropriate treatments. Evidence about treatments can be hard for clinicians to access, evaluate and use. Second, there is little systematic monitoring of where do-not-do treatments happen, leaving clinicians and hospitals in the dark about where problems might exist. Finally, the health system does not manage this problem well. There are rarely major negative consequences for providing ineffective care. In fact, there are incentives that go the other way – hospitals and clinicians get income for giving ineffective care. To fix the problem, the Australian Commission on Safety and Quality in Health Care should publish a list of do-not-do treatments. It should then identify public and private hospitals that provide these treatments more often than usual. There could be a good reason for a do-not-do treatment, but if some hospitals provide them consistently it is a real concern. These outlier hospitals should be asked to improve. If they do not, a clinical review by the state health department should check whether the hospital is providing the right care. If it is not, and if it still fails to improve, there should be consequences for the hospital’s management and funding. The approach in this report can easily be used for many more treatments, using evidence and data that governments already have. Governments should use the approach demonstrated in this report to make sure that far fewer people get the wrong treatment

Archives Conservation Discussion Group 2011: Digitization and Its Effect on Conservation Treatment Decisions: How Has Wide-Spread Digitizing of Collections Changed Our Approach to Treatment?

In line with this year’s AIC theme: ETHOS, LOGOS, PATHOS: ethical principles and critical thinking in conservation, The Archives Conservation Discussion Group 2011 examined the impact of providing digital collections in museums and libraries, and their conservation implications. Presentations and a subsequent discussion covered topics such as: How conservators are balancing ethical concerns, especially as dictated by the AIC Code of Ethics, with increased demand from digital projects. How conservators are keeping pace with large-scale or fast-paced digitizing projects, while maintaining standards. And the impact of limiting access to original materials by providing digital surrogates and its effect on treatment decisions

Prevention of Skin Breakdown In the Pediatric Intensive Care Unit

Skin breakdown occurs when one or more layers of the skin have been disrupted (McLane et al., 2004; National Pressure Ulcer Advisory Panel, 2007). While some literature uses the terms skin breakdown and pressure ulcer interchangeably, these are actually two distinct conditions and pressure ulcers are encompassed in the definition of skin breakdown (Kuller, 2001; Lund, 1999; Suddaby et al., 2006). The consequences of skin breakdown in the pediatric population can include increased cost of treatment, infection, increased morbidity and mortality as well as psychological consequences from resulting alopecia or scarring (Schindler, 2010; Willock & Maylor, 2004). Development of skin breakdown has also been associated with increased morbidity, increased length of stay, and higher costs of care (McCord et al., 2004). Prevention of skin breakdown can be accomplished by the use of barriers and specialty surfaces. Barrier protection is achieved by the use of preparations, such as zinc oxide, petrolatum-containing compounds, and alcohol-free barrier films, and also by the application of transparent film and hydrogel dressings (Atherton, 2004; Atherton, 2005; Baharestani, 2007; Campbell et al., 2000; Lund et al., 2001). Surfaces can be useful in the prevention of skin breakdown by aiding in the distribution of pressure and decreasing moisture, and can also be used to aid in temperature control for some patients (Norton, Coutts, & Sibbald, 2011). The PICO format question used to guide this project is: For patients in Pediatric Intensive Care Units, is barrier protection or use of specialty surfaces more effective at preventing skin breakdown