A Fit between Clinical Workflow and Health Care Information Systems: Not waiting for Godot but making the journey

Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6]

Points of Failure: A Systematic Review of information-flow using Medication Use Cases

Background: Medication errors pose a significant problem in the clinical environment, causing adverse events which impact patient safety. Problem: The introduction of electronic information and clinical systems have reduced medication errors but have also been identified as creating new types of errors. Method: Using the previously developed Hermon model, this research aimed to identify and understand medication errors due to clinical information-flow in the Australian General Practice (primary care) setting. The research used existing general practice medication error report cases from the Threat to Patient Safety (TAPS) Study to map against the Hermon model, and validated this mapping through consultations with general practitioners. Findings: The findings informed the refinement of the Hermon Model, and assisted in identifying medication errors points of information-flow failure in general practice information-flow. Impact: This study has significance to improve patient safety and inform the development of general practice desktop systems through identification and understanding of information-flow points of failure which result in medication errors

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

Cause of and factors associated with stillbirth: a systematic review of classification systems.

Introduction An estimated 2.6 million stillbirths occur worldwide each year. A standardised classification system setting out possible cause of death and contributing factors is useful to help obtain comparative data across different settings. We undertook a systematic review of stillbirth classification systems to highlight their strengths and weaknesses for practitioners and policymakers Material and methods We conducted a systematic search and review of the literature undertaken to identify classification systems used to aggregate information for stillbirth and perinatal deaths. Narrative synthesis used to compare range and depth of information required to apply the systems, the different categories provided cause of and factors contributing to stillbirth. Results: A total of 118 documents were screened; 31 classification systems were included, of which 6 were designed specifically for stillbirth, 14 for perinatal death, 3 systems include neonatal and 2 include infant deaths. The majority (27/31) were developed in and first tested using data obtained from high-income settings. All systems require information from clinical records. One-third of the classification systems (11/31) include information obtained from histology or autopsy. The percentage where cause of death remained unknown ranged from 0.39% using the Nordic-Baltic classification to 46.4% using the Keeling system. Conclusion Over time, classification systems have become more complex. The success of application is dependent on the availability of detailed clinical information and laboratory investigations. Systems which adopt a layered approach allow for classification of cause of death to a broad as well as to a more detailed level

Design and Evaluation of Image Guidance Systems for RARP

INTRODUCTION: There is a strong appetite amongst laparoscopic surgeons for image guidance during the procedure. It seems intuitively obvious that providing the surgeon with additional information on the location of unseen anatomy can only improve patient outcomes. This is not necessarily the case however. If the system gives information that is not relevant to the procedure it becomes a distraction. Similarly, if the system has large alignment errors the information may be dangerously wrong. One danger is that image guidance systems can be developed on an ad-hoc basis based not on targeted clinical goals but on the technical expertise and research goals of the scientists and engineers involved. Such a system may or may not benefit the patient. However, there is a real danger, as discussed by [1], that such systems will be introduced into surgical practice without proper assessment. We present our minimalist image guidance system for robot assisted radical prostatectomy together with a design and evaluation framework built upwards from the desired clinical outcomes

Scanning the horizon: emerging hospital-wide technologies and their impact on critical care

This commentary represents a selective survey of developments relevant to critical care. Selected themes include advances in point-of-care diagnostic testing, glucose control, novel microbiological diagnostics and infection control measures, and developments in information technology that have implications for intensive care. The latter encompasses an early example of an artificially intelligent clinical decision support mechanism, the introduction of a national health care information technology programme (UK NPfIT) and its implications, and exotic threats to patient safety due to emergent behaviour in complex information systems

Success Factors of European Syndromic Surveillance Systems: A Worked Example of Applying Qualitative Comparative Analysis

Introduction: Syndromic surveillance aims at augmenting traditional public health surveillance with timely information. To gain a head start, it mainly analyses existing data such as from web searches or patient records. Despite the setup of many syndromic surveillance systems, there is still much doubt about the benefit of the approach. There are diverse interactions between performance indicators such as timeliness and various system characteristics. This makes the performance assessment of syndromic surveillance systems a complex endeavour. We assessed if the comparison of several syndromic surveillance systems through Qualitative Comparative Analysis helps to evaluate performance and identify key success factors. Materials and Methods: We compiled case-based, mixed data on performance and characteristics of 19 syndromic surveillance systems in Europe from scientific and grey literature and from site visits. We identified success factors by applying crisp-set Qualitative Comparative Analysis. We focused on two main areas of syndromic surveillance application: seasonal influenza surveillance and situational awareness during different types of potentially health threatening events. Results: We found that syndromic surveillance systems might detect the onset or peak of seasonal influenza earlier if they analyse non-clinical data sources. Timely situational awareness during different types of events is supported by an automated syndromic surveillance system capable of analysing multiple syndromes. To our surprise, the analysis of multiple data sources was no key success factor for situational awareness. Conclusions: We suggest to consider these key success factors when designing or further developing syndromic surveillance systems. Qualitative Comparative Analysis helped interpreting complex, mixed data on small-N cases and resulted in concrete and practically relevant findings

Action Research For Information Systems

This tutorial provides an introduction and “how-to” overview of the action research methodology within the context of information technology and qualitative information systems research. The introductory material will deal with conflicting definitions of action research and the appropriate application of this technique in particular information technology settings. The how-to overview will focus on the participatory and clinical forms of action research. The practical overview will conclude with a discussion of criteria for evaluating the effectiveness of action research and the relationship between action research and consulting

The role of copying and pasting in electronic clinical documentation

Thesis (S.M.)--Harvard-MIT Division of Health Sciences and Technology, 2009.Includes bibliographical references (leaves 21-22).Clinical documentation by physicians and nurses has struggled to evolve with advancing technology and societal requirements. Originally designed as a physician's personal notes for a patient, the modern medical record functions as a patient record, communication tool between providers, and instrument for financial reimbursement. Technology has played a pivotal part in advancing the role of the medical record. Advantages and disadvantages inherent in the introduction of each new technology have prompted much debate, but none more than the introduction of electronic documentation systems within electronic medical records. Electronic systems provide clear advantages of information exchange as well as decision and diagnostic support. They have also proven quite controversial, particularly in the initial implementation stages. One aspect of electronic documentation, electronic copying and pasting, provides a tool for the clinician that is not clearly beneficial or detrimental, with proponents on each side. In this paper we explore the social, economic, and legal issues surrounding electronic copying and pasting in clinical documentation, review the literature on this subject, and propose a model for future research in this topic to help shape how clinicians use and process patient information from multiple sources.by Michael Jernigan.S.M