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

Guideline-based decision support in medicine : modeling guidelines for the development and application of clinical decision support systems

Guideline-based Decision Support in Medicine Modeling Guidelines for the Development and Application of Clinical Decision Support Systems The number and use of decision support systems that incorporate guidelines with the goal of improving care is rapidly increasing. Although developing systems that are both effective in supporting clinicians and accepted by them has proven to be a difficult task, of the systems that were evaluated by a controlled trial, the majority showed impact. The work, described in this thesis, aims at developing a methodology and framework that facilitates all stages in the guideline development process, ranging from the definition of models that represent guidelines to the implementation of run-time systems that provide decision support, based on the guidelines that were developed during the previous stages. The framework consists of 1) a guideline representation formalism that uses the concepts of primitives, Problem-Solving Methods (PSMs) and ontologies to represent guidelines of various complexity and granularity and different application domains, 2) a guideline authoring environment that enables guideline authors to define guidelines, based on the newly developed guideline representation formalism, and 3) a guideline execution environment that translates defined guidelines into a more efficient symbol-level representation, which can be read in and processed by an execution-time engine. The described methodology and framework were used to develop and validate a number of guidelines and decision support systems in various clinical domains such as Intensive Care, Family Practice, Psychiatry and the areas of Diabetes and Hypertension control

Tackling Dierent Business Process Perspectives

Business Process Management (BPM) has emerged as a discipline to design, control, analyze, and optimize business operations. Conceptual models lie at the core of BPM. In particular, business process models have been taken up by organizations as a means to describe the main activities that are performed to achieve a specific business goal. Process models generally cover different perspectives that underlie separate yet interrelated representations for analyzing and presenting process information. Being primarily driven by process improvement objectives, traditional business process modeling languages focus on capturing the control flow perspective of business processes, that is, the temporal and logical coordination of activities. Such approaches are usually characterized as \u201cactivity-centric\u201d. Nowadays, activity-centric process modeling languages, such as the Business Process Model and Notation (BPMN) standard, are still the most used in practice and benefit from industrial tool support. Nevertheless, evidence shows that such process modeling languages still lack of support for modeling non-control-flow perspectives, such as the temporal, informational, and decision perspectives, among others. This thesis centres on the BPMN standard and addresses the modeling the temporal, informational, and decision perspectives of process models, with particular attention to processes enacted in healthcare domains. Despite being partially interrelated, the main contributions of this thesis may be partitioned according to the modeling perspective they concern. The temporal perspective deals with the specification, management, and formal verification of temporal constraints. In this thesis, we address the specification and run-time management of temporal constraints in BPMN, by taking advantage of process modularity and of event handling mechanisms included in the standard. Then, we propose three different mappings from BPMN to formal models, to validate the behavior of the proposed process models and to check whether they are dynamically controllable. The informational perspective represents the information entities consumed, produced or manipulated by a process. This thesis focuses on the conceptual connection between processes and data, borrowing concepts from the database domain to enable the representation of which part of a database schema is accessed by a certain process activity. This novel conceptual view is then employed to detect potential data inconsistencies arising when the same data are accessed erroneously by different process activities. The decision perspective encompasses the modeling of the decision-making related to a process, considering where decisions are made in the process and how decision outcomes affect process execution. In this thesis, we investigate the use of the Decision Model and Notation (DMN) standard in conjunction with BPMN starting from a pattern-based approach to ease the derivation of DMN decision models from the data represented in BPMN processes. Besides, we propose a methodology that focuses on the integrated use of BPMN and DMN for modeling decision-intensive care pathways in a real-world application domain

A unified system for clinical guideline management and execution

There are several approaches to Computer-Interpretable Guidelines (CIG) representation and execution that offer the possibility of acquiring, executing and editing CPGs. Many CIG approaches aim to represent Clinical Practice Guidelines (CPGs) by computationally formalising the knowledge that they enclose, in order to be suitable for the integration in Clinical Decision Support Systems (CDSS). However, the current approaches for this purpose lack in providing a unified workflow for management and execution of CIGs. Besides characterising these limitations and identifying improvements to include in future tools, this work describes the unified architecture for CIG management and execution, a unified approach that allows the CIG acquisition, editing and execution.This work has been supported by COMPETE: POCI-01-0145-FEDER-0070 43 and FCT – Funda ̧c ̃aopara a Ciˆencia e Tecnologia within the Project Scope UID/CEC/ 00319/2013

Development and implementation of clinical guidelines : an artificial intelligence perspective

Clinical practice guidelines in paper format are still the preferred form of delivery of medical knowledge and recommendations to healthcare professionals. Their current support and development process have well identified limitations to which the healthcare community has been continuously searching solutions. Artificial intelligence may create the conditions and provide the tools to address many, if not all, of these limitations.. This paper presents a comprehensive and up to date review of computer-interpretable guideline approaches, namely Arden Syntax, GLIF, PROforma, Asbru, GLARE and SAGE. It also provides an assessment of how well these approaches respond to the challenges posed by paper-based guidelines and addresses topics of Artificial intelligence that could provide a solution to the shortcomings of clinical guidelines. Among the topics addressed by this paper are expert systems, case-based reasoning, medical ontologies and reasoning under uncertainty, with a special focus on methodologies for assessing quality of information when managing incomplete information. Finally, an analysis is made of the fundamental requirements of a guideline model and the importance that standard terminologies and models for clinical data have in the semantic and syntactic interoperability between a guideline execution engine and the software tools used in clinical settings. It is also proposed a line of research that includes the development of an ontology for clinical practice guidelines and a decision model for a guideline-based expert system that manages non-compliance with clinical guidelines and uncertainty.This work is funded by national funds through the FCT – Fundação para a Ciência e a Tecnologia (Portuguese Foundation for Science and Technology) within project PEst-OE/EEI/UI0752/2011"

Information Systems and Healthcare XXXIV: Clinical Knowledge Management Systems—Literature Review and Research Issues for Information Systems

Knowledge Management (KM) has emerged as a possible solution to many of the challenges facing U.S. and international healthcare systems. These challenges include concerns regarding the safety and quality of patient care, critical inefficiency, disparate technologies and information standards, rapidly rising costs and clinical information overload. In this paper, we focus on clinical knowledge management systems (CKMS) research. The objectives of the paper are to evaluate the current state of knowledge management systems diffusion in the clinical setting, assess the present status and focus of CKMS research efforts, and identify research gaps and opportunities for future work across the medical informatics and information systems disciplines. The study analyzes the literature along two dimensions: (1) the knowledge management processes of creation, capture, transfer, and application, and (2) the clinical processes of diagnosis, treatment, monitoring and prognosis. The study reveals that the vast majority of CKMS research has been conducted by the medical and health informatics communities. Information systems (IS) researchers have played a limited role in past CKMS research. Overall, the results indicate that there is considerable potential for IS researchers to contribute their expertise to the improvement of clinical process through technology-based KM approaches