Clinical guidelines as plans: An ontological theory

Clinical guidelines are special types of plans realized by collective agents. We provide an ontological theory of such plans that is designed to support the construction of a framework in which guideline-based information systems can be employed in the management of workflow in health care organizations. The framework we propose allows us to represent in formal terms how clinical guidelines are realized through the actions of are realized through the actions of individuals organized into teams. We provide various levels of implementation representing different levels of conformity on the part of health care organizations. Implementations built in conformity with our framework are marked by two dimensions of flexibility that are designed to make them more likely to be accepted by health care professionals than standard guideline-based management systems. They do justice to the fact 1) that responsibilities within a health care organization are widely shared, and 2) that health care professionals may on different occasions be non-compliant with guidelines for a variety of well justified reasons. The advantage of the framework lies in its built-in flexibility, its sensitivity to clinical context, and its ability to use inference tools based on a robust ontology. One disadvantage lies in its complicated implementation

Workflow Management for Multiple Sclerosis Patients: IT and Organization

Patients with Multiple Sclerosis (MS) visit various healthcare providers during the course of their disease. It was suggested that IT might help to\ud orchestrate their care provision. We have applied the USE IT-tool to get insight in the relevant problems, solutions and constraints of the MS-care and the MS care providers both in the organizational and the information technological area. There is hardly a chain of healthcare, but rather, a network in which informal communication plays an important role. This informal network worked reasonably effective, but inefficient and slow. The patient himself plays a keyrole in information exchange between care-providers. Many providers were unaware of the services that other healthcare providers could give in general or did provide to a specific patient. MS patients-count is only small for most care providers. None of the interviewed patients mentioned a lack of contacts between careproviders as a problem. They thought that lack of\ud experience caused their major problems: insufficient and inadequate care. To improve care, we proposed a solution that combines a “short MS-protocol”, the\ud introduction of a central coordinator of care and a Patient Relation Management (PRM) System. This is a simple web-based application that is based on agreement by the caregivers that supports routing, tracking and tracing of a MS patient and supplies the caregivers with professional guidelines, as written down in the protocol. It is likely that we would have suggested a far more complicated ICT solution if we had only analyzed the MS-care process as such, without specific consideration of the USE IT dimensions

Supporting Special-Purpose Health Care Models via Web Interfaces

The potential of the Web, via both the Internet and intranets, to facilitate development of clinical information systems has been evident for some time. Most Web-based clinical workstations interfaces, however, provide merely a loose collection of access channels. There are numerous examples of systems for access to either patient data or clinical guidelines, but only isolated cases where clinical decision support is presented integrally with the process of patient care, in particular, in the form of active alerts and reminders based on patient data. Moreover, pressures in the health industry are increasing the need for doctors to practice in accordance with ¿best practice¿ guidelines and often to operate under novel health-care arrangements. We present the Care Plan On-Line (CPOL) system, which provides intranet-based support for the SA HealthPlus Coordinated Care model for chronic disease management. We describe the interface design rationale of CPOL and its implementation framework, which is flexible and broadly applicable to support new health care models over intranets or the Internet

NEOREG : design and implementation of an online neonatal registration system to access, follow and analyse data of newborns with congenital cytomegalovirus infection

Today's registration of newborns with congenital cytomegalovirus (cCMV) infection is still performed on paper-based forms in Flanders, Belgium. This process has a large administrative impact. It is imortant that all screening tests are registered to have a complete idea of the impact of cCMV. Although these registrations are usable in computerised data analysis, these data are not available in a format to perform electronic processing. An online Neonatal Registry (NEOREG) System was designed and developed to access, follow and analyse the data of newborns remotely. It allows patients' diagnostic registration and treatment follow-up through a web interface and uses document forms in Portable Document Format (PDF), which incorporate all the elements from the existing forms. Forms are automatically processed to structured EHRs. Modules are included to perform statistical analysis. The design was driven by extendibility, security and usability requirements. The website load time, throughput and execution time of data analysis were evaluated in detail. The NEOREG system is able to replace the existing paper-based CMV records

Personalizing Situated Workflows for Pervasive Healthcare Applications

In this paper, we present an approach where a workflow system is combined with a policy-based framework for the specification and enforcement of policies for healthcare applications. In our approach, workflows are used to capture entitiespsila responsibilities and to assist entities in fulfilling them. The policy-based framework allows us to express authorisation policies to define the rights that entities have in the system, and event-condition-action (ECA) policies that are used to adapt the system to the actual situation. Authorisations will often depend on the context in which patientspsila care takes place, and our policies support predicates that reflect the environment. ECA policies capture events that reflect the current state of the environment and can perform actions to accordingly adapt the workflow execution. We show how the approach can be used for the Edema treatment and how fine-grained authorisation and ECA policies are expressed and used

An approach to safety analysis of clinical workflows

A clinical workflow considers the information and processes that are involved in providing a clinical service. They are safety critical since even minor faults have the potential to propagate and consequently cause harm to a patient, or even for a patient's life to be lost. Experiencing these kinds of failures has a destructive impact on all the involved parties. Due to the large number of processes and tasks included in the delivery of a clinical service, it can be difficult to determine the individuals or the processes that are responsible for adverse events, since such an analysis is typically complex and slow to do manually. Using automated tools to carry out an analysis can help in determining the root causes of potential adverse events and consequently help in avoiding preventable errors through either the alteration of existing workflows, or the design of a new workflow. This paper describes a technical approach to safety analysis of clinical workflows, utilising a safety analysis tool (Hierarchically-Performed Hazard Origin and Propagation Studies (HiP-HOPS)) that is already in use in the field of mechanical systems. The paper then demonstrates the applicability of the approach to clinical workflows by applying it to analyse the workflow in a radiology department. We conclude that the approach is applicable to this area of healthcare and provides a mechanism both for the systematic identification of adverse events and for the introduction of possible safeguards in clinical workflows

A Consent-based Workflow System for Healthcare Systems

In this paper, we describe a new framework for healthcare systems where patients are able to control the disclosure of their medical data. In our framework, the patient's consent has a pivotal role in granting or removing access rights to subjects accessing patient's medical data. Depending on the context in which the access is being executed, different consent policies can be applied. Context is expressed in terms of workflows. The execution of a task in a given workflow carries the necessary information to infer whether the consent can be implicitly retrieved or should be explicitly requested from a patient. However, patients are always able to enforce their own decisions and withdraw consent if necessary. Additionally, the use of workflows enables us to apply the need-to-know principle. Even when the patient's consent is obtained, a subject should access medical data only if it is required by the actual situation. For example, if the subject is assigned to the execution of a medical diagnosis workflow requiring access to the patient's medical record. We also provide a complex medical case study to highlight the design principles behind our framework. Finally, the implementation of the framework is outlined

Performance Measures Using Electronic Health Records: Five Case Studies

Presents the experiences of five provider organizations in developing, testing, and implementing four types of electronic quality-of-care indicators based on EHR data. Discusses challenges, and compares results with those from traditional indicators

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems

Importance: The indication (reason for use) for a medication is rarely included on prescriptions despite repeated recommendations to do so. One barrier has been the way existing electronic prescribing systems have been designed. Objective: To evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing systems, the efficiency, error rate, and satisfaction with a new computerized provider order entry prototype for the outpatient setting that allows clinicians to initiate prescribing using the indication. Design, Setting, and Participants: This quality improvement study used usability tests requiring internal medicine physicians, residents, and physician assistants to enter prescriptions electronically, including indication, for 8 clinical scenarios. The tool order assignments were randomized and prescribers were asked to use the prototype for 4 of the scenarios and their usual system for the other 4. Time on task, number of clicks, and order details were captured. User satisfaction was measured using posttask ratings and a validated system usability scale. The study participants practiced in 2 health systems\u27 outpatient practices. Usability tests were conducted between April and October of 2017. Main Outcomes and Measures: Usability (efficiency, error rate, and satisfaction) of indications-based computerized provider order entry prototype vs the electronic prescribing interface of 2 electronic health record vendors. Results: Thirty-two participants (17 attending physicians, 13 residents, and 2 physician assistants) used the prototype to complete 256 usability test scenarios. The mean (SD) time on task was 1.78 (1.17) minutes. For the 20 participants who used vendor 1\u27s system, it took a mean (SD) of 3.37 (1.90) minutes to complete a prescription, and for the 12 participants using vendor 2\u27s system, it took a mean (SD) of 2.93 (1.52) minutes. Across all scenarios, when comparing number of clicks, for those participants using the prototype and vendor 1, there was a statistically significant difference from the mean (SD) number of clicks needed (18.39 [12.62] vs 46.50 [27.29]; difference, 28.11; 95% CI, 21.47-34.75; P \u3c .001). For those using the prototype and vendor 2, there was also a statistically significant difference in number of clicks (20.10 [11.52] vs 38.25 [19.77]; difference, 18.14; 95% CI, 11.59-24.70; P \u3c .001). A blinded review of the order details revealed medication errors (eg, drug-allergy interactions) in 38 of 128 prescribing sessions using a vendor system vs 7 of 128 with the prototype. Conclusions and Relevance: Reengineering prescribing to start with the drug indication allowed indications to be captured in an easy and useful way, which may be associated with saved time and effort, reduced medication errors, and increased clinician satisfaction