Computerization of workflows, guidelines and care pathways: a review of implementation challenges for process-oriented health information systems

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways. A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes. One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed. We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings

Implementation conditions for diet and physical activity interventions and policies : an umbrella review

BACKGROUND: This umbrella review aimed at identifying evidence-based conditions important for successful implementation of interventions and policies promoting a healthy diet, physical activity (PA), and a reduction in sedentary behaviors (SB). In particular, we examined if the implementation conditions identified were intervention-specific or policy-specific. This study was undertaken as part of the DEterminants of DIet and Physical Activity (DEDIPAC) Knowledge Hub, a joint action as part of the European Joint Programming Initiative a Healthy Diet for a Healthy Life. METHODS: A systematic review of reviews and stakeholder documents was conducted. Data from nine scientific literature databases were analyzed (95 documents met the inclusion criteria). Additionally, published documentation of eight major stakeholders (e.g., World Health Organization) were systematically searched (17 documents met the inclusion criteria). The RE-AIM framework was used to categorize elicited conditions. Across the implementation conditions 25 % were identified in at least four documents and were subsequently classified as having obtained sufficient support. RESULTS: We identified 312 potential conditions relevant for successful implementation; 83 of these received sufficient support. Using the RE-AIM framework eight implementation conditions that obtained support referred to the reach in the target population; five addressed efficacy of implementation processes; 24 concerned adoption by the target staff, setting, or institutions; 43 referred to consistency, costs, and adaptations made in the implementation process; three addressed maintenance of effects over time. The vast majority of implementation conditions (87.9 %; 73 of 83) were supported by documents referring to both interventions and policies. There were seven policy-specific implementation conditions, which focused on increasing complexities of coexisting policies/legal instruments and their consequences for implementation, as well as politicians' collaboration in implementation. CONCLUSIONS: The use of the proposed list of 83 conditions for successful implementation may enhance the implementation of interventions and policies which pursue identification of the most successful actions aimed at improving diet, PA and reducing SB

Telehealth methods to deliver multifactorial dietary interventions in adults with chronic disease: A systematic review protocol

Background: The long-term management of chronic diseases requires adoption of complex dietary recommendations, which can be facilitated by regular coaching to support sustained behaviour change. Telehealth interventions can overcome patient-centred barriers to accessing face-to-face programs and provide feasible delivery methods, ubiquitous and accessible regardless of geographic location. The protocol for this systematic review explains the methods that will be utilised to answer the review question of whether telehealth interventions are effective at promoting change in dietary intake and improving diet quality in people with chronic disease. Methods/design: A structured search of Medline, EMBASE, CINAHL, and PsychINFO, from their inception, will be conducted. We will consider randomised controlled trials which evaluate complex dietary interventions in adults with chronic disease. Studies must provide diet education in an intervention longer than 4 weeks in duration, and at least half of the intervention contact must be delivered via telehealth. Comparisons will be made against usual care or a non-telehealth intervention. The primary outcome of interest is dietary change with secondary outcomes relating to clinical markers pre-specified in the methodology. The process for selecting studies, extracting data, and resolving conflicts will follow a set protocol. Two authors will independently appraise the studies and extract the data, using specified methods. Meta-analyses will be conducted where appropriate, with parameters for determining statistical heterogeneity pre-specified. The GRADE tool will be used for determining the quality of evidence for analysed outcomes. Discussion: To date, there has been a considerable variability in the strategies used to deliver dietary education, and the overall effectiveness of telehealth dietary interventions for facilitating dietary change has not been reviewed systematically in adults with chronic disease. A systematic synthesis of telehealth strategies will inform the development of evidence-based telehealth programs that can be tailored to deliver dietary interventions specific to chronic disease conditions. Systematic review registration: PROSPERO CRD42015026398

Decentralised Clinical Guidelines Modelling with Lightweight Coordination Calculus

Background: Clinical protocols and guidelines have been considered as a major means to ensure that cost-effective services are provided at the point of care. Recently, the computerisation of clinical guidelines has attracted extensive research interest. Many languages and frameworks have been developed. Thus far, however,an enactment mechanism to facilitate decentralised guideline execution has been a largely neglected line of research. It is our contention that decentralisation is essential to maintain a high-performance system in pervasive health care scenarios. In this paper, we propose the use of Lightweight Coordination Calculus (LCC) as a feasible solution. LCC is a light-weight and executable process calculus that has been used successfully in multi-agent systems, peer-to-peer (p2p) computer networks, etc. In light of an envisaged pervasive health care scenario, LCC, which represents clinical protocols and guidelines as message-based interaction models, allows information exchange among software agents distributed across different departments and/or hospitals. Results: We outlined the syntax and semantics of LCC; proposed a list of refined criteria against which the appropriateness of candidate clinical guideline modelling languages are evaluated; and presented two LCC interaction models of real life clinical guidelines. Conclusions: We demonstrated that LCC is particularly useful in modelling clinical guidelines. It specifies the exact partition of a workflow of events or tasks that should be observed by multiple "players" as well as the interactions among these "players". LCC presents the strength of both process calculi and Horn clauses pair of which can provide a close resemblance of logic programming and the flexibility of practical implementation

Obstetric Nurses’ Perceived Barriers to Immediate Skin to Skin Contact after Cesarean Birth

Despite the strong evidence supporting immediate skin to skin contact (SSC) after birth, research suggests that patients who undergo cesarean births do not have the same opportunities for SSC as patients who undergo vaginal births. There are limited studies regarding provider attitudes surrounding the practice of immediate SSC after cesarean birth. The aim of this research was to understand obstetric nurses’ perceived barriers to immediate SSC after cesarean section. An exploratory qualitative design was used for the project. The semi-structured, open-ended interviews were conducted via video conferencing. Conventional content analysis methods were used to analyze the data, which yielded the primary overarching theme of “performing safe and effective skin to skin contact after cesarean birth”. The participants identified both barriers and facilitators to SSC after cesarean. It was evident from the interviews that nurses strongly believe in the benefits of SSC after cesarean and try to implement it as often as possible, but various factors prevented SSC in the OR from occurring on a regular basis. This research can be used as a starting point for refining the practice of SSC after cesarean births

Organizing the U.S. Health Care Delivery System for High Performance

Analyzes the fragmentation of the healthcare delivery system and makes policy recommendations -- including payment reform, regulatory changes, and infrastructure -- for creating mechanisms to coordinate care across providers and settings

Evaluation of a standard provision versus an autonomy promotive exercise referral programme: rationale and study design

Background The National Institute of Clinical Excellence in the UK has recommended that the effectiveness of ongoing exercise referral schemes to promote physical activity should be examined in research trials. Recent empirical evidence in health care and physical activity promotion contexts provides a foundation for testing the utility of a Self Determination Theory (SDT) -based exercise referral consultation. Methods/Design Design: An exploratory cluster randomised controlled trial comparing standard provision exercise on prescription with a Self Determination Theory-based (SDT) exercise on prescription intervention. Participants: 347 people referred to the Birmingham Exercise on Prescription scheme between November 2007 and July 2008. The 13 exercise on prescription sites in Birmingham were randomised to current practice (n=7) or to the SDT-based intervention (n=6). Outcomes measured at 3 and 6-months: Minutes of moderate or vigorous physical activity per week assessed using the 7-day Physical Activity Recall; physical health: blood pressure and weight; health status measured using the Dartmouth CO-OP charts; anxiety and depression measured by the Hospital Anxiety and Depression Scale and vitality measured by the subjective vitality score; motivation and processes of change: perceptions of autonomy support from the advisor, satisfaction of the needs for competence, autonomy, and relatedness via physical activity, and motivational regulations for exercise. Discussion This trial will determine whether an exercise referral programme based on Self Determination Theory increases physical activity and other health outcomes compared to a standard programme and will test the underlying SDT-based process model (perceived autonomy support, need satisfaction, motivation regulations, outcomes) via structural equation modelling. Trial registration The trial is registered as Current Controlled trials ISRCTN07682833

The COVID-19 pandemic: resilient organisational response to a low-chance, high-impact event

The global healthcare sector is currently in the midst of the COVID-19 pandemic, a ‘low-chance, high-impact’ event which will require healthcare systems, and the organisations within them, to maintain organisational resilience in order to respond effectively. However, contrary to the instinctive reaction to tighten control, the quality of response depends on healthcare systems’ capacity to loosen control and, subsequently, enhance improvisation. Three factors critical to enhancing an organisation’s capacity for improvisation are highlighted; increasing autonomy, maintaining structure and creating a shared understanding. By drawing on the case of Christchurch Hospital’s response to a major earthquake, this paper demonstrates the vital role that improvisation can play within a clinical setting, when responding to a low-chance, high-impact event. This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained