Practice-centred e-health system design for cross-boundary clinical decision support

The idea of cross-boundary clinical decision support has the potential to transform the design of future work environments for e-health through a connected healthcare system that allows for harnessing of information and peer opinion across geographical boundaries for better decision-making. The trouble, however, is that the use of healthcare information in decision-making usually occurs within the context of a complex structure of clinical work practices that is often shaped by a wide range of factors, including organisational culture, local work contexts, socially constructed traditions of actions, experiences and patients’ circumstances. They vary across geographical boundaries, and have remained largely unaccounted for in the design of current e-health systems. As a result, achieving the visions of e-health, particularly in relation to cross-boundary clinical decision support, requires a rethinking of key clinical and organisational processes in a manner that accommodates work practice as a fundamental part of how clinicians work and make decisions in the real-world. This thesis investigates the concept of work practice as a design requirement for cross-boundary clinical decision support systems in e-health. It is argued that the task of enabling informed decision support across geographical boundaries in e-health can be enhanced through an understanding, and a formal characterisation, of work practices in various healthcare work contexts, and a specification of how practice can be used, managed and transformed to suit various clinical problem situations and patients’ needs. This research takes a clinical practice-centred approach to inform e-health system design, and draws on the concept of work practice and cultural-historical theory in social science as well as situation awareness in order to describe the local traditions of actions that guide clinicians’ work in the real world. It contributes a coherent conceptual architecture comprising a practice-centred awareness model for cross-boundary awareness, a frame-based technique, named PracticeFrame, for formalising and representing work practice for system design, and ContextMorph, for adaptively transforming a suggestion across work boundaries to suit a user’s local work context and practices. An in-depth user-informed requirements capture was used to gain an understanding of clinical work practices for designing e-health system for cross-boundary decision support. A proof of concept prototype, named CaDHealth, which is based on the Brahms work practice modelling tool and includes a work practice visualisation model, named the practice display, was developed and used to conduct user-based evaluation. The evaluation revealed that incorporating practice-centred awareness enhances usefulness, acceptance and user adoption of e-health systems for cross-boundary clinical decision support