Endorsement, Prior Action, and Language: Modeling Trusted Advice in Computerized Clinical Alerts

The safe prescribing of medications via computerized physician order entry routinely relies on clinical alerts. Alert compliance, however, remains surprisingly low, with up to 95% often ignored. Prior approaches, such as improving presentational factors in alert design, had limited success, mainly due to physicians' lack of trust in computerized advice. While designing trustworthy alert is key, actionable design principles to embody elements of trust in alerts remain little explored. To mitigate this gap, we introduce a model to guide the design of trust-based clinical alerts-based on what physicians value when trusting advice from peers in clinical activities. We discuss three key dimensions to craft trusted alerts: using colleagues' endorsement, foregrounding physicians' prior actions, and adopting a suitable language. We exemplify our approach with emerging alert designs from our ongoing research with physicians and contribute to the current debate on how to design effective alerts to improve patient safety

Understanding Advice Sharing among Physicians: Towards Trust-Based Clinical Alerts

Safe prescribing of medications relies on drug safety alerts, but up to 96% of such warnings are ignored by physicians. Prior research has proposed improvements to the design of alerts, but with limited increase in adherence. We propose a different perspective: before re-designing alerts, we focus on improving the trust between physicians and computerized advice by examining why physicians trust their medical colleagues. To understand trusted advice among physicians, we conducted three contextual inquiries in a hospital setting (22 participants), and corroborated our findings with a survey (37 participants). Drivers that guide physicians in trusting peer advice include: timeliness of the advice, collaborative language, empathy, level of specialization and medical hierarchy. Based on these findings, we introduce seven design directions for trust-based alerts: endorsement, transparency, team sensing, collaborative, empathic, conflict mitigating and agency laden. Our work contributes to novel alert design strategies to improve the effectiveness of drug safety advice

Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

This is the final version. Available from NIHR Journals Library via the DOI in this record.Background Pain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed. Aims and objectives Two studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals. Methods For the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team. Results Data from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information. Limitations Grey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate. Conclusions No single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.National Institute for Health Research Health Services and Delivery Research programm

Risk Assessment Framework for Evaluation of Cybersecurity Threats and Vulnerabilities in Medical Devices

Medical devices are vulnerable to cybersecurity exploitation and, while they can provide improvements to clinical care, they can put healthcare organizations and their patients at risk of adverse impacts. Evidence has shown that the proliferation of devices on medical networks present cybersecurity challenges for healthcare organizations due to their lack of built-in cybersecurity controls and the inability for organizations to implement security controls on them. The negative impacts of cybersecurity exploitation in healthcare can include the loss of patient confidentiality, risk to patient safety, negative financial consequences for the organization, and loss of business reputation. Assessing the risk of vulnerabilities and threats to medical devices can inform healthcare organizations toward prioritization of resources to reduce risk most effectively. In this research, we build upon a database-driven approach to risk assessment that is based on the elements of threat, vulnerability, asset, and control (TVA-C). We contribute a novel framework for the cybersecurity risk assessment of medical devices. Using a series of papers, we answer questions related to the risk assessment of networked medical devices. We first conducted a case study empirical analysis that determined the scope of security vulnerabilities in a typical computerized medical environment. We then created a cybersecurity risk framework to identify threats and vulnerabilities to medical devices and produce a quantified risk assessment. These results supported actionable decision making at managerial and operational levels of a typical healthcare organization. Finally, we applied the framework using a data set of medical devices received from a partnering healthcare organization. We compare the assessment results of our framework to a commercial risk assessment vulnerability management system used to analyze the same assets. The study also compares our framework results to the NIST Common Vulnerability Scoring System (CVSS) scores related to identified vulnerabilities reported through the Common Vulnerability and Exposure (CVE) program. As a result of these studies, we recognize several contributions to the area of healthcare cybersecurity. To begin with, we provide the first comprehensive vulnerability assessment of a robotic surgical environment, using a da Vinci surgical robot along with its supporting computing assets. This assessment supports the assertion that networked computer environments are at risk of being compromised in healthcare facilities. Next, our framework, known as MedDevRisk, provides a novel method for risk quantification. In addition, our assessment approach uniquely considers the assets that are of value to a medical organization, going beyond the medical device itself. Finally, our incorporation of risk scenarios into the framework represents a novel approach to medical device risk assessment, which was synthesized from other well-known standards. To our knowledge, our research is the first to apply a quantified assessment framework to the problem area of healthcare cybersecurity and medical networked devices. We would conclude that a reduction in the uncertainty about the riskiness of the cybersecurity status of medical devices can be achieved using this framework

A New Kind of Therapeutic Relationship: Exploring Factors that Influence the Effectiveness of Computer-Delivered Interventions for Alcohol Use Disorders

Computer-delivered interventions (CDI) for alcohol use comprise a relatively new treatment for individuals struggling with problematic drinking. While CDIs for alcohol misuse have proliferated over the last decade, much remains unknown about factors that influence their effectiveness. This study evaluated the performance of Overcoming Addictions (OA), a CDI based on the principles of SMART Recovery (SR). Subjects were drawn from a sample of 189 participants enrolled in a randomized clinical trial (RCT) that compared three and six-month outcomes for two interventions for problematic alcohol use: control participants were enrolled in SR meetings (face to face and/or online); experimental participants also had access to OA. Primary analyses of between group differences were conducted to detect an additive effect of OA. Further, this study explored variables thought to mediate the effectiveness of OA, and CDIs for problematic alcohol use more generally. Within the experimental group, analyses were conducted to examine whether participants amount of experience navigating the Internet accounted for any variance associated with positive outcomes; also, the study examined the mediating effect of two other closely related variables: participants\u27 sense of how easy the website was to use, and whether participants were satisfied with the amount of content on the website. Primary analysis indicated that both the control and experimental groups showed significant improvement across outcome variables, although no additional benefit of OA was detected. Finally, no evidence was found to support the hypotheses for the identified variables thought to mediate the effectiveness of OA. Implications of this null finding are discussed

The social life of placebos: proximate and evolutionary mechanisms of biocultural interactions in Asante medical encounters

The Social Life of Placebos is an interdisciplinary study of the evolution of placebogenic responses – beneficial ones activated by psychosocial triggers -- and their elicitation in Asante medical contexts. Based on an extensive literature review in social, cultural, and medical studies and over 26 months of intensive research in rural Ghana, West Africa, it examines the therapeutic efficacy of Asante medical encounters by analyzing rites of care-giving within an evolutionary framework. Section 1 investigates why evolutionary processes appear to have made human physiology susceptible to psychosocial manipulation, what the health consequences of that susceptibility are in modern environments, and how culturally specific expectations and healing rituals might dampen or amplify that susceptibility. Because of key transitions in human evolution, the fitness consequences of sociality have increased rapidly and created the conditions whereby endogenous mechanisms have become responsive to sociocultural conditions. This explanation helps us better understand why culturally specific rituals can elicit powerful beneficial (placebo) and adverse (nocebo) physiological responses. Using a mixed methodology of physiological data and ethnographic case studies collected from hundreds of Asante medical encounters, Section 2 illuminates evolutionary and proximate processes in Asante contexts of care-giving and healing rituals in detailed chapters on pain, emotion, and stress. It examines the social and cultural resources and techniques that Asante health practitioners rely on for pain management in contexts where no pain medication is available. It analyzes the biocultural interactions that can take place when healers modify patient perceptions, emotions, and expectations. The dissertation concludes with biometric evidence that Asante indigenous ritual healing ceremonies actually promote significant entrainment and relaxation effects

Clinical Utility of Applying PGx and Deprescribing-Based Decision Support in Polypharmacy

Polypharmacy is a necessary and important aspect of drug treatment; however, it becomes a challenge when the medication risks outweigh the benefits for an individual patient. Drug–drug interactions and the introduction of prescribing cascades are common features of polypharmacy, which can lead to ineffectiveness and increased risk of adverse drug reactions (ADR). Genes encoding CYP450 isozymes and other drug-related biomarkers have attracted considerable attention as targets for pharmacogenetic (PGx) testing due to their impact on drug metabolism and response. This Special Issue is devoted to explore the status and initiatives taken to circumvent ineffectiveness and to improve medication safety for polypharmacy patients. Specific areas include drug–drug interactions and consequences thereof in therapeutic management, including PK- and PD-profiling; the application of PGx-based guidance and/or decision tools for drug–gene and drug–drug gene interactions; medication reviews; development and application of deprescribing tools; and drivers and barriers to overcome for successful implementation in the healthcare system

Social Media And Credibility Indicator: The Effects Of Bandwagon And Identity Cues Within Online Health And Risk Contexts

Three studies were conducted to investigate how social media affordances influence individuals’ source credibility perceptions in risk situations. The MAIN model (Sundar, 2008), warranting theory (Walther & Parks, 2002), and signaling theory (Donath, 1999) served as the theoretical framework to examine the effects of bandwagon cues and identity cues embedded in retweets and users’ profile pages for health and risk online information processing. Study One examines whether bandwagon heuristics triggered by retweets would influence individuals’ source credibility judgments. Study Two investigates how bandwagon heuristics interact with different identity heuristics in credibility heuristics on an individual level. Study Three explores bandwagon heuristics at the organizational level. Three post-test only experiments with self-report online surveys were conducted to investigate the hypothesis and research questions. Results indicate that different online heuristic cues impact the judgments of competence, goodwill, and trustworthiness at different levels. Authority strongly influenced source credibility perceptions. A reverse-bandwagon effect was observed in influencing source credibility judgments. Theoretical and practical implications are discussed