System-Agnostic Clinical Decision Support Services: Benefits and Challenges for Scalable Decision Support

System-agnostic clinical decision support (CDS) services provide patient evaluation capabilities that are independent of specific CDS systems and system implementation contexts. While such system-agnostic CDS services hold great potential for facilitating the widespread implementation of CDS systems, little has been described regarding the benefits and challenges of their use. In this manuscript, the authors address this need by describing potential benefits and challenges of using a system-agnostic CDS service. This analysis is based on the authors’ formal assessments of, and practical experiences with, various approaches to developing, implementing, and maintaining CDS capabilities. In particular, the analysis draws on the authors’ experience developing and leveraging a system-agnostic CDS Web service known as SEBASTIAN. A primary potential benefit of using a system-agnostic CDS service is the relative ease and flexibility with which the service can be leveraged to implement CDS capabilities across applications and care settings. Other important potential benefits include facilitation of centralized knowledge management and knowledge sharing; the potential to support multiple underlying knowledge representations and knowledge resources through a common service interface; improved simplicity and componentization; easier testing and validation; and the enabling of distributed CDS system development. Conversely, important potential challenges include the increased effort required to develop knowledge resources capable of being used in many contexts and the critical need to standardize the service interface. Despite these challenges, our experiences to date indicate that the benefits of using a system-agnostic CDS service generally outweigh the challenges of using this approach to implementing and maintaining CDS systems

System-Agnostic Clinical Decision Support Services: Benefits and Challenges for Scalable Decision Support

System-agnostic clinical decision support (CDS) services provide patient evaluation capabilities that are independent of specific CDS systems and system implementation contexts. While such system-agnostic CDS services hold great potential for facilitating the widespread implementation of CDS systems, little has been described regarding the benefits and challenges of their use. In this manuscript, the authors address this need by describing potential benefits and challenges of using a system-agnostic CDS service. This analysis is based on the authors’ formal assessments of, and practical experiences with, various approaches to developing, implementing, and maintaining CDS capabilities. In particular, the analysis draws on the authors’ experience developing and leveraging a system-agnostic CDS Web service known as SEBASTIAN. A primary potential benefit of using a system-agnostic CDS service is the relative ease and flexibility with which the service can be leveraged to implement CDS capabilities across applications and care settings. Other important potential benefits include facilitation of centralized knowledge management and knowledge sharing; the potential to support multiple underlying knowledge representations and knowledge resources through a common service interface; improved simplicity and componentization; easier testing and validation; and the enabling of distributed CDS system development. Conversely, important potential challenges include the increased effort required to develop knowledge resources capable of being used in many contexts and the critical need to standardize the service interface. Despite these challenges, our experiences to date indicate that the benefits of using a system-agnostic CDS service generally outweigh the challenges of using this approach to implementing and maintaining CDS systems

A standards-based ICT framework to enable a service-oriented approach to clinical decision support

This research provides evidence that standards based Clinical Decision Support (CDS) at the point of care is an essential ingredient of electronic healthcare service delivery. A Service Oriented Architecture (SOA) based solution is explored, that serves as a task management system to coordinate complex distributed and disparate IT systems, processes and resources (human and computer) to provide standards based CDS. This research offers a solution to the challenges in implementing computerised CDS such as integration with heterogeneous legacy systems. Reuse of components and services to reduce costs and save time. The benefits of a sharable CDS service that can be reused by different healthcare practitioners to provide collaborative patient care is demonstrated. This solution provides orchestration among different services by extracting data from sources like patient databases, clinical knowledge bases and evidence-based clinical guidelines (CGs) in order to facilitate multiple CDS requests coming from different healthcare settings. This architecture aims to aid users at different levels of Healthcare Delivery Organizations (HCOs) to maintain a CDS repository, along with monitoring and managing services, thus enabling transparency. The research employs the Design Science research methodology (DSRM) combined with The Open Group Architecture Framework (TOGAF), an open source group initiative for Enterprise Architecture Framework (EAF). DSRM’s iterative capability addresses the rapidly evolving nature of workflows in healthcare. This SOA based solution uses standards-based open source technologies and platforms, the latest healthcare standards by HL7 and OMG, Decision Support Service (DSS) and Retrieve, Update Locate Service (RLUS) standard. Combining business process management (BPM) technologies, business rules with SOA ensures the HCO’s capability to manage its processes. This architectural solution is evaluated by successfully implementing evidence based CGs at the point of care in areas such as; a) Diagnostics (Chronic Obstructive Disease), b) Urgent Referral (Lung Cancer), c) Genome testing and integration with CDS in screening (Lynch’s syndrome). In addition to medical care, the CDS solution can benefit organizational processes for collaborative care delivery by connecting patients, physicians and other associated members. This framework facilitates integration of different types of CDS ideal for the different healthcare processes, enabling sharable CDS capabilities within and across organizations

Impact of Information and Communication Technologies on Remote Testing. Forced Spirometry as a Use Case

[cat] INTRODUCCIÓ El desplegament de nous models de salut basats en la coordinació entre nivells assistencials constitueixen una prioritat a nivell europeu davant la necessitat de gestionar les disfuncions generades per l’elevat impacte sanitari i social de les malalties cròniques. La transferència de la complexitat des de l’atenció sanitària especialitzada, en general de base hospitalària, a professionals d’Atenció Primària constitueix un dels elements centrals del canvi en el model de salut. Això implica el redisseny de processos clínics i la preparació del personal sanitari pel nou entorn. L’ús eficient del potencial que ofereixen les Tecnologies de la Informació i la Comunicació (TIC), com a element facilitador de la col•laboració entre nivells assistencials i d’una major accessi­bilitat del pacient, té un rol important en el desplegament i l’articulació dels Serveis d’Atenció Integrada (SAI) que configuren el nou model de salut. En aquest context, la transferència de les intervencions diagnòstiques especialitzades a l’atenció primària constitueix un àrea molt rellevant en el procés de canvi. L’hipòtesi central de la present tesi doctoral és que la transferència de determinades proves diagnòstiques a l’atenció primària genera eficiències a nivell del sistema de salut. Els diferents estudis realitzats en la tesi es centren en l’espirometria forçada (EF), seleccionada, per les seves característiques, com una prova de concepte. Els objectius generals són explorar aquells fac­tors que s’han identificat com a claus en la modulació del procés de la transferència de l’EF, així com definir estratègies per a la seva escalabilitat regional. La tesi s’estructura en base a 3 objectius específics: OBJECTIU 1 - ANÀLISI DE LA TRANSFERÈNCIA DE LA EF A ATENCIÓ PRIMÀRIA I A OFICINES DE FARMÀCIA. En el primer estudi “Telemedicine enhances Quality of Forced Spirometry in Primary Care” es va demostrar l’eficàcia en el temps (12 m) d’un servei centralitzat pel control de qualitat de l’EF efectuada per professionals no especialitzats de tres regions espanyoles. Es va demostrar que la col•laboració remota entre professionals de primària i especialistes de funció pulmonar tenen un efecte positiu sostingut sobre la qualitat de l’EF realitzada per personal no expert. Es va observar una diferència significativa entre el grup d’intervenció (71.5% EF d’alta qualitat) i el grup control (59.5% EF d’alta qualitat) durant els 12 mesos de l’estudi (p<0.001). La investigació va generar informació valuosa per planejar de forma adient l’escalabilitat del programa a nivell regional. Els resultats d’aquest estudi, junt amb altres apartats de la tesi i d’altres investigacions en curs, facilitaran el redisseny del rol de les proves diagnòstiques en la gestió dels pacients crònics en un entorn d’atenció integrada. Els estudis 2 (Early detection of COPD in customers of urban community pharmacies: a pilot­study) i 3 (Spirometry in community-pharmacies: a novel strategy to reduce COPD underdiag­nosis) de la tesi responen de forma afirmativa a la següent pregunta: Poden les oficines de farmàcia tenir un rol rellevant en un programa de detecció de casos de MPOC? Els resultats són clarament indicatius del potencial de les oficines de farmàcia com a agent sanitari en estreta col•laboració amb Atenció Primària. Cal senyalar que amdos estudis sola­ment aporten informació sobre factibilitat. L’anàlisi d’eficiència es planeja com a una activitat més enllà d’aquesta tesi doctoral, en el marc del projecte EU Synergy-COPD i del Pla Director de Malalties de l’Aparell Respiratori (PDMAR) del Departament de Salut de la Generalitat de Catalunya. OBJECTIU 2 – AVALUACIÓ DE REQUERIMENTS PER A L’ESCALABILITAT REGIONAL A NIVELL DE CATALUNYA En els estudis 4 (Encuesta de utilización de la función pulmonar en los hospitales públicos de Cataluña en 2009) y 5 (Estudio de la función pulmonar básica en los centros de atención pri­maria de Cataluña. Atención Primaria) s’analitzà la situació i necessitats futures de les proves de funció pulmonar a Catalunya a nivell hospitalari i extra-hospitalari en el marc del PDMAR. Els resultats obtinguts confirmen la necessitat de desplegar l’EF a l’Atenció Primària i d’incrementar l’homogeneïtat territorial en el que respecta a l’accés a les proves de funció pul­monar per a pacients i professionals. Es confirma la necessitat del programa de transferència de l’EF plantejat en la tesi doctoral. En un segon grup d’estudis en el Objectiu 2 de la tesi, efectuats en el marc del PDMAR, s‘analitzaren les necessitats i estratègies pel que fa a l’entrenament dels professionals no es­pecialitzats tant en l’àmbit català, estudi 6 (Disseny d’un programa de formació basic para aconseguir espirometries de qualitat), com a nivell europeu, estudi 7 (HERMES Spirometry: the European Spirometry Driving Licence). OBJECTIU 3 – CONTRIBUCIONS TECNOLÒGIQUES A L’ESCALABILITAT L’estudi 8 (Requerimientos técnicos de los espirómetros en la estrategia para garantizar el acceso a una espirometría de calidad) va aportar un element essencial per assegurar l’interoperabilitat de les dades de l’EF al assegurar l’estandardització de la transferència d’informació utilitzant el protocol HL7 v3 i CDA (Clinical Document Architecture) amb estàndard R2. Efectuat amb el suport de l’Oficina d’Estàndards i Interoperabilitat del Departament de Salut de la Generalitat de Catalunya dins el Pla de Digitalizació de la Imatge Mèdica. L’estàndard de transferència de l’EF ha estat ja adoptat per alguns fabricants d’equips de medició i és un requeriment per als concursos públics a nivell regional. A més, a l’estudi 9 (Clinical Decision Support System to Enhance Quality Control of Forced Spi­rometry) es va generar i validar un algoritme per el control automàtic de la qualitat de l’EF. Els resultats de la validació amb 778 corbes espiromètriques varen indicar que la sensibilitat i especificitat de l’algoritme era del 96.1 i 94.9%, respectivament. La validació de l’algoritme aportà un segon element tecnològic necessari per a l’escalabilitat del programa de transfer­ència de l’EF a Atenció Primària i a les oficines de farmàcia. L’algoritme ha estat integrat a la plataforma TIC de gestió de malalts crònics. La validació del procés clínic s’efectuarà dins del projecte EU Synergy-COPD i el pla d’escalabilitat a Catalunya es materialitzarà a curt termini en el marc del PDMAR. CONCLUSIONS 1. Es demostra el potencial de transferibilitat de l’EF a Atenció Primària amb el suport d’una aplicació web de treball col•laboratiu que va facilitar un augment significatiu i sostenible de la qualitat de les proves efectuades per personal no especialitzat (manuscrit 1). 2. Es verificà la factibilitat del rol de les oficines de farmàcia per a la detecció de casos de MPOC en un programa coordinat amb Atenció Primària. Les oficines de Farmàcia podrien tenir un rol complementari a l’Atenció Primària en el diagnòstic de MPOC oculta. El desenvolupament i validació del programa es completarà una vegada finalitzada la present tesi doctoral (manuscrits 2 i 3). 3. L’elaboració del mapa de proves de funció pulmonar a Catalunya va permetre la identifi­cació dels requeriments per a l’escalabilitat regional del programa de transferència de l’EF en el marc d’un model de atenció integrada (manuscrits 4 i 5). 4. Es va verificar el rol essencial de les estratègies d’entrenament dels professionals no espe­cialitzats com a component essencial d’un programa de transferència d’EF de qualitat a l’ Atenció Primària (manuscrits 6 i 7). 5. Es van efectuar dos contribucions tecnològiques rellevants per assegurar la interoperabilitat de l’EF a nivell del sistema de salut: l’elaboració del CDA (manuscrit 8) i el desenvolupament i validació d’un algoritme per l’avaluació automàtica de la qualitat de l’EF (manuscrit 9).[eng] INTRODUCTION The deployment of new health care models based on the coordination between different levels is a priority at European level to manage the dysfunctions generated by health and social impact of chronic diseases. The transfer of complexity from specialized health care in general hospital-based, to primary care professionals is one of the central elements of change in the health model. This involves the redesign of clinical processes and preparing the workforce for the new environment. The potential of Information and Communications Technology (ICT) as a facilitator element of collaboration between levels of care and greater patient accessibility, have an important role in the deployment and coordination of Integrated Care Services (ICS) that configure the new health model. In this context, the transfer of specialized diagnostic interventions to primary care is a highly relevant area in the change process. The central hypothesis of this thesis is the transfer of functional testing from specialized to primary care within a coordinated care scenario will improve the efficiency of delivery of care and will generate cross-fertilization between levels of care. The general hypothesis is that extensive deployment of different, well-articulated ICS-ICTs covering the entire spectrum of severity of chronic patients generates efficiencies at a system level. This PhD thesis focuses on functional testing and specifically addresses forced spirometry as a use case. This PhD thesis aims to identify the key factors that seem to modulate success of the transfer of forced spirometry (FS) testing to primary care and to other non-specialized professionals and to explore the deployment of services with potential for scalability. The thesis is structured around four specific objectives: OBJECTIVE 1 – TRANSFERABILITY OF FS TO PRIMARY CARE AND PHARMACY OFFICES The first objective is to assess the deployment of the transfer of FS in two scenarios, each with different purposes. The first manuscript analyzes the sustainability of a service to ensure high-quality forced spirometry in primary care. The two other manuscripts under Objective 1 examine the potential of transferability to pharmacy offices, to generate a COPD case-finding program. In the first study "Telemedicine Enhances Quality of Forced Spirometry in Primary Care" efficacy was demonstrated over time (12 m) for quality control of the FS performed by non specialist in five Spanish regions. It was shown that remote collaboration between primary care and specialists has a sustained positive effect on the quality of the FS performed by non-expert personnel. A significant difference between the intervention group (71.5% high quality FS) and the control group (59.5% high quality FS) during the 12 months of the study (p <0.001) was observed. The research generated valuable information to plan properly scalability of the program at regional level, and facilitate the redesign of the role of diagnostic tests in the management of chronic patients in an environment of integrated care. Studies 2 “Early detection of COPD in customers of urban community pharmacies: a pilot-study” and 3 “Spirometry in community-pharmacies: a novel strategy to reduce COPD underdiagnosis”. Results clearly indicate the potential of the community pharmacy as a health partner in close collaboration with primary care. Note that both studies only provide information about feasibility. The efficiency analysis is planned as an activity beyond this thesis, under the EU Project Synergy-COPD and the Master Plan for Respiratory Diseases (PDMAR) of the Department of Health of the Generalitat de Catalunya. OBJECTIVE 2 - ASSESSMENT OF REQUIREMENTS FOR SCALABILITY AT REGIONAL LEVEL Within objective 2, we performed two clusters of studies. The first two (manuscripts 4 and 5) “Survey about the use of Lung Function Testing in Public Hospitals in Catalonia in 2009” and “Estudio de la función pulmonar básica en los centros de atención primaria de Cataluña” analyze the status and needs of FS testing in Catalonia. The second cluster includes two studies (manuscripts 6 and 7) “Design of a basic training program to get quality spirometry” and “HERMES Spirometry: the European Spirometry Driving Licence” with specific proposals for training programs for deployment in Catalonia and at a European level. All these studies were performed directly under the auspices of the Catalan Master Plan of Respiratory Diseases. OBJETIVE 3 - TECHNOLOGICAL CONTRIBUTIONS In this PhD thesis, two areas were identified in which specific technological contributions were needed to ensure the success of the deployment. Firstly, “Technical Requirements of Spirometers in the Strategy for Guaranteeing the Access to Quality Spirometry” the design and production of a FS-CDA for structured data transfer using the protocol HL7 and Clinical Document Architecture (CDA) with the R2 standard supporting interoperability across healthcare tiers (manuscript 8) and, secondly, “Improving quality control of forced spirometry: a new algorithm for automatic evaluation” the development of an automatic tool (algorithm) for remote FS quality control (manuscript 9). The results of the validation with 778 spirometric curves indicated that the sensitivity and specificity of the algorithm was of 96.1 and 94.9%, respectively. The validation of the algorithm provided a second technology element necessary for scalability transfer program of FS to primary care and community pharmacies. The algorithm has been integrated in the ICT management platform for chronic patients. The clinical validation process will be within the EU project Synergy-COPD and scalability in Catalonia plan will materialize in the short term under the PDMAR. CONCLUSIONS 1. The potential for transferability of Forced Spirometry testing to Primary Care was demonstrated by the effectiveness of the web-based collaborative tool that showed sustainable enhancement of high-quality testing performed by non-specialized professionals (manuscript 1). 2. The feasibility of having pharmacy offices play a complementary role to primary care in early diagnosis of chronic respiratory disorders has been proven. Moreover, the potential of pharmacy offices in a future COPD case-finding program has been identified and will be developed beyond this PhD thesis (manuscripts 2 & 3). 3. The lung function testing map in Catalonia was drawn up and requirements for the deployment of high-quality FS within a coordinated care scenario were identified (manuscripts 4 & 5). 4. Conventional and novel coaching strategies to be further developed and integrated into the ICT-supported platform were analyzed (manuscripts 6 & 7) 5. Technological contributions to health system interoperability aimed at facilitating adoption of a high quality FS service supported by ICT were developed and validated, namely: Clinical Document Architecture and an algorithm for automatic assessment of FS quality.[spa] INTRODUCCIÓN El despliegue de nuevos modelos de salud basados en la coordinación entre niveles asisten­ciales constituye una prioridad a nivel Europeo ante la necesidad de gestionar las disfunciones generadas por elevado impacto sanitario y social de las enfermedades crónicas. La transferencia de complejidad desde la atención sanitaria especializada, en general de base hospitalaria, a profesionales de Atención Primaria, constituye uno de los elementos centrales del cambio en el modelo de salud. Ello implica el rediseño de procesos clínicos y la preparación del personal sanitario para el nuevo entorno. El uso eficiente del potencial que ofrecen las Tecnologías de la Información y la Comunicación (TIC), como elemento facilitador de la colaboración entre niveles asistenciales y de una mayor accesibilidad del paciente, tiene un papel importante en el despliegue y articulación de los Servicios de Atención Integrada (SAI) que configuran el nuevo modelo de salud. En este con­texto, la transferencia de las intervenciones diagnósticas especializadas a la atención primaria constituye un área muy relevante en el proceso de cambio. La hipótesis central de la presente tesis doctoral es que la transferencia de determinadas pruebas diagnósticas a la atención primaria genera eficiencias a nivel del sistema de salud. Los dife­rentes estudios realizados en la tesis se centran en la espirometría forzada (EF), seleccionada, por sus características, como una prueba de concepto. Los objetivos generales son explorar aquellos factores que se han identificado como claves en la modulación del proceso de la transferencia de la EF, así como definir estrategias para su escalabilidad regional. La tesis se estructura en base a 3 objetivos específicos: OBJETIVO 1 - ANÁLISIS DE LA TRANSFERENCIA DE LA EF A ATENCIÓN PRIMARIA Y A OFICINAS DE FARMACIA. En el primer estudio “Telemedicine enhances Quality of Forced Spirometry in Primary Care” se demostró la eficacia en el tiempo (12 m) de un servicio centralizado para control de calidad de la EF efectuada por profesionales no especializados de tres regiones españolas. Se demostró que la colaboración remota entre profesionales de primaria y especialistas de función pulmonar tiene un efecto positivo sostenido sobre la calidad de la EF realizada por personal no experto. Se observó una diferencia significativa entre el grupo intervención (71.5% EF de alta calidad) y el grupo control (59.5% EF de alta calidad) durante los 12 meses del estudio (p<0.001). La investigación generó información valiosa para planear de forma adecuada la escalabilidad del programa a nivel regional. Los resultados de este estudio, junto con otros apartados de la tesis y otras investigaciones en curso, facilitarán el rediseño del papel de las pruebas diagnósticas en la gestión de los pacientes crónicos en un entorno de atención integrada. Los estudios 2 (Early detection of COPD in customers of urban community pharmacies: a pilot­study) y 3 (Spirometry in community-pharmacies: a novel strategy to reduce COPD underdiag­nosis) de la tesis responden de forma afirmativa a la siguiente pregunta: Pueden las oficinas de farmacia tener un papel relevante en un programa de detección de casos de EPOC? Los resultados son claramente indicativos del potencial de las oficinas de farmacia como agente sanitario en estrecha colaboración con Atención Primaria. Cabe señalar que ambos estudios solo aportan información sobre factibilidad. El análisis de eficiencia se planea como una actividad más allá de esta tesis doctoral, en el marco del proyecto EU Synergy-COPD y del Plan Director de Enfermedades de Aparato Respiratorio (PDMAR) del Departamento de Salud de la Generalitat de Catalunya. OBJETIVO 2 – EVALUACIÓN DE REQUERIMIENTOS PARA LA ESCALABILIDAD REGIONAL A NIVEL DE CATALUNYA En los estudios 4 (Encuesta de utilización de la función pulmonar en los hospitales públicos de Cataluña en 2009) y 5 (Estudio de la función pulmonar básica en los centros de atención primaria de Cataluña. Atención Primaria) se analizó la situación y necesidades futuras de las pruebas de función pulmonar en Catalunya a nivel hospitalario y extra-hospitalario en el marco del PDMAR. Los resultados obtenidos confirman la necesidad de desplegar la EF en Atención Primaria y de incrementar la homogeneidad territorial en lo que respecta al acceso a las pruebas de función pulmonar para pacientes y profesionales. Se confirma la necesidad del programa de transferencia de la EF planteado en la tesis doctoral. En un segundo grupo de estudios en el Objetivo 2 de la tesis, efectuados en el marco del PDMAR, se analizaron las necesidades y estrategias en lo que respecta al entrenamiento de profesionales no especializados tanto en el ámbito catalán, estudio 6 (Diseño de un programa de formación básico para conseguir espirometrías de calidad), como a nivel Europeo, estudio 7 (HERMES Spirometry: the European Spirometry Driving Licence). OBJETIVO 3 – CONTRIBUCIONES TECNOLÓGICAS A LA ESCALABILIDAD El estudio 8 (Requerimientos técnicos de los espirómetros en la estrategia para garantizar el ac­ceso a una espirometría de calidad) aportó un elemento esencial para asegurar la interopera­bilidad de los datos de EF al asegurar la estandarización de la transferencia de información uti­lizando el protocolo HL7 v3 y CDA (Clinical Document Architecture) con estándar R2. Efectuado con el soporte de la Oficina de Estándares e Interoperabilidad del Departament de Salut de la Generalitat de Catalunya dentro del Plan de Digitalización de la Imagen Médica. El estándar de transferencia de la EF ha sido ya adoptado por algunos fabricantes de equipos de medición y es un requerimiento para los concursos públicos a nivel regional. Además, en el estudio 9 (Clinical Decision Support System to Enhance Quality Control of Forced Spirometry) se generó y validó un algoritmo para el control automático de la calidad de la EF. Los resultados de la validación con 778 curvas espirométricas indicaron que la sensibilidad y especificidad del algoritmo era del 96.1 y 94.9%, respectivamente. La validación del algoritmo aportó un segundo elemento tecnológico necesario para la escalabilidad del programa de transferencia de la EF a Atención Primaria y a oficinas de farmacia. El algoritmo ha sido inte­grado a la plataforma TIC de gestión de pacientes crónicos. La validación del proceso clínico se efectuará dentro del proyecto EU Synergy-COPD y el plan de escalabilidad en Catalunya se materializará a corto plazo en el marco del PDMAR. CONCLUSIONES 1. Se demostró el potencial de transferibilidad de la EF a Atención Primaria con el soporte de una aplicación web de trabajo colaborativo que facilitó un aumento significativo y sostenible de la calidad de las pruebas efectuadas por personal no especializado (manuscrito 1). 2. Se verificó la factibilidad del rol de las oficinas de farmacia para la detección de casos de EPOC en un programa coordinado con Atención Primaria. Las oficinas de Farmacia podrían tener un

Holistic System Design for Distributed National eHealth Services

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Dia-Continua: An Information System for Type 1 Diabetes Consultation. (Interoperability, Privacy, and Information Quality on a FHIR-Based Information System for Type 1 Diabetes Consultations based on Patient-Generated Health Data)

Patient-generated health data (PGHD) is required to monitor chronic conditions like Type 1 Diabetes (T1D). This data includes information from medical devices like insulin pumps and continuous glucose monitors and lifestyle insights from commercial wearables devices such as smartwatches. To improve the quality of medical consultations, we need a unified information system that can integrate PGHD. Designing such a system will pose several challenges. The system should be able to navigate through fragmented information and the complexities of various data formats, proprietary interfaces, and storage methods while ensuring robust security, privacy, and adherence to data ownership principles. It should also enable controlled data sharing with healthcare providers (HCPs) and external entities such as national registries and informal caregivers. This dissertation details designing, developing, and testing an information system for individuals with T1D. The project involved integrative research in health informatics, collaboration with international projects, and collaboration with experienced users and HCPs to address three research questions. These questions focused on interoperability, the security and privacy of the information collected, and the quality of the information presented during consultations. The result is Dia-Continua, a Fast Healthcare Interoperability Resources (FHIR)-based information system with a microservices architecture orchestrated through Kubernetes on an Infrastructure as a Service (IaaS) platform. The system integrates data from various diabetes management devices, questionnaires, and PGHD. Furthermore, using SMART on FHIR for authorization and authentication enables data sharing and reuse with national registries and informal caregivers. Eleven interviews with HCPs evaluated Dia-Continua's new functionalities and information quality. Despite the limitations due to proprietary device systems, the system was assessed positively by HCPs, highlighting the need for a system like Dia-Continua that includes physical activity, sleep, and stress in medical consultations. Dia-Continua is a significant step for a patient-centred model for consultations in T1D. Future work should expand the system's model to other chronic diseases.Utviklingen av medisinske konsultasjoner for kroniske tilstander, spesifikt Type 1 Diabetes (T1D), avhenger i stor grad av pasientgenererte helsedata (PGHD). Disse dataene inkluderer informasjon fra medisinsk utstyr slik som insulinpumper, CGM, samt livsstils data fra kommersielt utstyr som sensorer på smartklokker og smarte ringer. Et helhetlig informasjonssystem som kan integrere PGHD er nødvendig for å forbedre informasjonskvalitet under medisinske konsultasjoner. Imidlertid bør et slikt system være i stand til å la brukeren navigere gjennom fragmentert informasjon og komplekse heterogene dataformater, proprietære grensesnitt og lagringsmetoder, samtidig som systemet sikrer robust sikkerhet, personvern og ivaretakelse av prinsipper for eierskap til data. Systemet bør også muliggjøre kontrollert deling av data med helsepersonell og eksterne aktører slik som nasjonale registre (Noklus) og pasientens omsorgspersoner. Denne avhandlingen beskriver design, utvikling, testing og evaluering av et nytt informasjonssystem for T1D basert på pasientens egne data. Prosjektet har involvert ulike samarbeidspartnere og profesjoner, samt samarbeid med internasjonale prosjekter, erfarne brukere og HP for å adressere de tre forskningsspørsmålene i prosjektet. Ett av resultatene er systemet Dia-Continua, et Fast Healthcare Interoperability Resources (FHIR)-basert informasjonssystem med en Microservice arkitektur orkestrert gjennom Kubernetes på en infrastruktur som en tjenesteplattform (Azure). Systemet integrerer data fra ulike diabetesenheter, spørreskjemaer og andre sensorer. Videre, ved å bruke «SMART on FHIR» for autorisasjon og autentisering, muliggjøres deling og gjenbruk av data med nasjonale registre og uformelle omsorgspersoner. Elleve intervjuer med helsepersonell ble gjort for å evaluere Dia-Continua sine nye funksjonaliteter, samt dets informasjonskvalitet. Til tross for begrensningene på grunn av proprietære standarder, ble systemet positivt mottatt av HP. Informantene understreket behovet for et system som Dia-Continua som inkluderer fysisk aktivitet, søvn og stress i medisinske konsultasjoner. Dia-Continua er et betydelig skritt fram mot en pasientsentrert modell for konsultasjoner i T1D. Fremtidig arbeid bør utvide systemets modell til andre kroniske sykdommer

A Task-based Support Architecture for Developing Point-of-care Clinical Decision Support Systems for the Emergency Department

Objectives: The purpose of this study was to create a task-based support architecture for developing clinical decision support systems (CDSSs) that assist physicians in making decisions at the point-of-care in the emergency department (ED). The backbone of the proposed architecture was established by a task-based emergency workflow model for a patient-physician encounter. Methods: The architecture was designed according to an agent-oriented paradigm. Specifically, we used the O-MaSE (Organization-based Multi-agent System Engineering) method that allows for iterative translation of functional requirements into architectural components (e.g., agents). The agent-oriented paradigm was extended with ontology-driven design to implement ontological models representing knowledge required by specific agents to operate. Results: The task-based architecture allows for the creation of a CDSS that is aligned with the task-based emergency workflow model. It facilitates decoupling of executable components (agents) from embedded domain knowledge (ontological models), thus supporting their interoperability, sharing, and reuse. The generic architecture was implemented as a pilot system, MET3-AE – a CDSS to help with the management of pediatric asthma exacerbation in the ED. The system was evaluated in a hospital ED. Conclusions: The architecture allows for the creation of a CDSS that integrates support for all tasks from the task-based emergency workflow model, and interacts with hospital information systems. Proposed architecture also allows for reusing and sharing system components and knowledge across disease-specific CDSSs

Information Systems and Healthcare XXI: A Dynamic, Client-Centric, Point-Of-Care System for the Novice Nurse

Nurse clinicians need to make complex decisions on a continual basis, while delivering cost-effective treatments. The rapid proliferation of medical and nursing knowledge complicates the decision-making process, particularly for novice nurses. We describe a Clinical Decision Support System (CDSS) for the novice nurse that combines evidence-based nursing knowledge with specific patient information to create a real-time guide through the nursing diagnostic care process. The goal of the paper is to describe how an appropriately designed and evidence-based CDSS can aid the nursing practice. An off-the-shelf handheld computer is utilized to deliver clinical knowledge to the nurse, via wireless link to a central server and a data repository. In describing the software architecture of the system, particular emphasis is paid to the issue of appropriate design by discussing the steps taken to address system extensibility, performance, reliability, and security, which are important factors in the design of a CDSS

User-centered design and evaluation of RxMAGIC: A Prescription Management And General Inventory Control system for free clinic dispensaries

Medication management is a complex and expensive multistage process that covers the prescribing and ordering, order communication, dispensing, administering, and monitoring and use of prescription medications. While challenges in medication management are ubiquitous across all settings, they can be particularly exacerbated in a free clinic that serves a medically vulnerable population. These patients suffer from financial constraints, poor health literacy, multiple chronic conditions, and medication non-adherence. Clinical pharmacists play an integral role in the provision of healthcare services to these patients and could benefit from the use of medication management information technology (MMIT) to provide efficiencies in the tracking, provision, and use of medications. While MMITs exist, they are not designed to support the unique needs of pharmacists in these settings

The Morningside Initiative: Collaborative Development of a Knowledge Repository to Accelerate Adoption of Clinical Decision Support

The Morningside Initiative is a public-private activity that has evolved from an August, 2007, meeting at the Morningside Inn, in Frederick, MD, sponsored by the Telemedicine and Advanced Technology Research Center (TATRC) of the US Army Medical Research Materiel Command. Participants were subject matter experts in clinical decision support (CDS) and included representatives from the Department of Defense, Veterans Health Administration, Kaiser Permanente, Partners Healthcare System, Henry Ford Health System, Arizona State University, and the American Medical Informatics Association (AMIA). The Morningside Initiative was convened in response to the AMIA Roadmap for National Action on Clinical Decision Support and on the basis of other considerations and experiences of the participants. Its formation was the unanimous recommendation of participants at the 2007 meeting which called for creating a shared repository of executable knowledge for diverse health care organizations and practices, as well as health care system vendors. The rationale is based on the recognition that sharing of clinical knowledge needed for CDS across organizations is currently virtually non-existent, and that, given the considerable investment needed for creating, maintaining and updating authoritative knowledge, which only larger organizations have been able to undertake, this is an impediment to widespread adoption and use of CDS. The Morningside Initiative intends to develop and refine (1) an organizational framework, (2) a technical approach, and (3) CDS content acquisition and management processes for sharing CDS knowledge content, tools, and experience that will scale with growing numbers of participants and can be expanded in scope of content and capabilities. Intermountain Healthcare joined the initial set of participants shortly after its formation. The efforts of the Morningside Initiative are intended to serve as the basis for a series of next steps in a national agenda for CDS. It is based on the belief that sharing of knowledge can be highly effective as is the case in other competitive domains such as genomics. Participants in the Morningside Initiative believe that a coordinated effort between the private and public sectors is needed to accomplish this goal and that a small number of highly visible and respected health care organizations in the public and private sector can lead by example. Ultimately, a future collaborative knowledge sharing organization must have a sustainable long-term business model for financial support