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

A modular, open-source information extraction framework for identifying clinical concepts and processes of care in clinical narratives

In this thesis, a synthesis is presented of the knowledge models required by clinical informa- tion systems that provide decision support for longitudinal processes of care. Qualitative research techniques and thematic analysis are novelly applied to a systematic review of the literature on the challenges in implementing such systems, leading to the development of an original conceptual framework. The thesis demonstrates how these process-oriented systems make use of a knowledge base derived from workflow models and clinical guidelines, and argues that one of the major barriers to implementation is the need to extract explicit and implicit information from diverse resources in order to construct the knowledge base. Moreover, concepts in both the knowledge base and in the electronic health record (EHR) must be mapped to a common ontological model. However, the majority of clinical guideline information remains in text form, and much of the useful clinical information residing in the EHR resides in the free text fields of progress notes and laboratory reports. In this thesis, it is shown how natural language processing and information extraction techniques provide a means to identify and formalise the knowledge components required by the knowledge base. Original contributions are made in the development of lexico-syntactic patterns and the use of external domain knowledge resources to tackle a variety of information extraction tasks in the clinical domain, such as recognition of clinical concepts, events, temporal relations, term disambiguation and abbreviation expansion. Methods are developed for adapting existing tools and resources in the biomedical domain to the processing of clinical texts, and approaches to improving the scalability of these tools are proposed and evalu- ated. These tools and techniques are then combined in the creation of a novel approach to identifying processes of care in the clinical narrative. It is demonstrated that resolution of coreferential and anaphoric relations as narratively and temporally ordered chains provides a means to extract linked narrative events and processes of care from clinical notes. Coreference performance in discharge summaries and progress notes is largely dependent on correct identification of protagonist chains (patient, clinician, family relation), pronominal resolution, and string matching that takes account of experiencer, temporal, spatial, and anatomical context; whereas for laboratory reports additional, external domain knowledge is required. The types of external knowledge and their effects on system performance are identified and evaluated. Results are compared against existing systems for solving these tasks and are found to improve on them, or to approach the performance of recently reported, state-of-the- art systems. Software artefacts developed in this research have been made available as open-source components within the General Architecture for Text Engineering framework

The electronic patient record: a linguistic ethnographic study in general practice

PhDElectronic Patient Records (EPRs) are in widespread use in UK general practice. Although often taken-for-granted by clinicians, managers, administrators and patients, there is limited understanding of how EPRs shape care processes and healthcare interactions in this setting. The EPR is ubiquitous in practice, but its social impact remains under-researched. In this thesis I present a novel approach to examining the role of the EPR, which draws on ethnography and discourse analysis. My work is based on eight months of ethnographic observation in clinical and administrative areas of two general practices. This included observation of clinical consultations, with videorecording of the interpersonal interaction and contemporaneous screen capture of the EPR. This opens up the ‘EPR-in-use’ to detailed scrutiny. In my analysis, which draws particularly on the theoretical work of Goffman and Bakhtin, I pay close attention to the detail of local action and interaction, whilst maintaining sensitivity to the wider context of the general practice organisation. This makes an original contribution to the emerging field of linguistic ethnography. My analysis shows that the EPR contributes to shaping and regimenting interactions and care practices in profound ways, both within the consultation and more widely in general practice organisations. It creates new opportunities, but also creates new demands and tensions. In particular, it sharpens the tension between different ways of framing the patient – the patient as ‘individual’ and the patient as ‘one of a population’ – the latter a more institutional version of the patient. This creates what I have called a ‘dilemma of attention’ for clinicians engaged in patient care. I show ways in which the EPR contributes to the bureaucratisation of care, the construction and circulation of authority within and beyond the consultation, and the production of new notions of patienthood and professional habitus in contemporary general practice

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

Interpretative framework of chronic disease management to guide textual guideline GEM-encoding.

The aim of this work is to develop an XML-based application for the automated generation of decision rules from a textual guideline encoded using the Guideline Elements Model (GEM). A formalization of guideline-based chronological steps of treatment has been proposed to resolve the semantic ambiguities of the original document. The GEM DTD has been extended in order to standardize both decision variable and action representations in recommendations. Under these assumptions, the 1999 Canadian Recommendations for the management of hypertension have been marked-up as a GEM-encoded instance of the extended DTD. An XML parser has been used to extract the relevant elements as IF and THEN clauses of decision rules. This GEM application generated 104 rules to be compared to the 98 rules manually developed from the same guideline during the ASTI project

A discourse analyses of persons living with psychotic like experiences

A growing number of epidemiology studies have determined significant rates of psychotic experiences throughout general/non-clinical populations. Typically, the term used to classify these phenomena is ‘Psychotic Like Experiences’ described in terms of aberrations, attenuated psychosis or magical ideation. In accordance with Social Constructionist theory, it is expected that there are various interpretations and applications of this knowledge. These range from identification of a psychosis phenotype in order to ascertain those at risk of transition into psychotic illness; to an anti-separation, a normalisation approach whereby the existence of psychotic experiences is portrayed as integral to the human condition, ‘as part of ordinary mental life’. The former is promoted as a route to develop early intervention and prevention health programmes; the latter as part of an anti-stigma and social inclusion agenda. However, there are few qualitative studies into the lives of those living with PLEs beyond the ‘professional, statutory health domain’ and certainly none that attempts to explore the conceptualisations, the social impact and subsequent discourses created by those living with PLEs specifically in Ireland. As part of Social Constructionist theory language and discourse are the primary source that shape the human world where social objects such as psychotic experiences are deliberated. Through the deployment of discourse analysis this thesis sets out to explore discursive devices that arise from texts created by a number of participants living with PLEs in Ireland. Discourse Analysis can help participant groups develop their discourse through consciousness raising including the identification of compromises and contradictions that destabilise social agendas - that of normalisation. The identification of discursive repertoires revealed participant positioning and a number of compromises and dilemmas. Summarily, these were found to be: The continuation 2 of social exclusion through Othering; internalization of a social phenomenon; the individualization of a universal experience; accountability and responsibility and absorption of neo-liberal ideals. I conclude with suggestions to enhance a truth claim, or ‘candidate for knowledge’ through the symbiosis of knowledge, experience and expertise from within the very thing they resist – the meta/grand narratives of psychosis

The implementation and sustainability of pro-poor local economic development initiatives in the King Cetshwayo district municipality.

Doctoral Degree. University of KwaZulu-Natal, Durban.The main aim of the study was to critically explore the implementation and sustainability of pro-poor Local Economic Development in the KCD municipality. The secondary objective of the study was to determine how the implementation and sustainability of LED initiatives are organised, assessed, strategized and reviewed in the KCD. The implementation of economic development policies seemed to be a persistent problem hindering Local Economic Development (LED) in South Africa. Local government is a sphere of government that is closest to local communities and is so placed to identify, drive and implement programmes aimed at addressing unemployment, poverty alleviation and developmental challenges facing local communities in South Africa. The King Cetshwayo District (KCD) is not excluded from these challenges, which include the challenges of stimulating pro-poor LED by creating jobs and promoting the growth of small and medium business enterprises (SMMEs). The need to address poverty and unemployment is one of the most critical issues in this municipality. This research study was founded on the theoretical framework of the World Bank Local Economic Development model that involves several stages of LED strategic planning. A qualitative approach was adopted whereby eight in-depth interviews were conducted to interview municipal officials which included the mayor, the municipal manager and LED officials in two local municipalities in the KCD. The study further conducted 14 focus group discussions with community members which included co-operatives. Thematic analysis through an interpretive approach was used to analyse and present data for this study. The findings have shown that LED in the KCD is conceptualised generally as a form of partnership or coalition undertaken between the key players in a local municipality and involves the development of partnerships between the private sector, government and civil society. Moreover, the Richards Bay Industrial Development Zone (RBIDZ) together with other stakeholders, including the municipality, have put measures in place to assist SMMEs to benefit from the RBIDZ activities. LED initiatives in the uMhlathuze local municipality are intended to stimulate both the enhanced growth of the local economy (pro-growth) and to address concerns of persistent poverty (pro-poor). The study also noted that both local municipalities have adopted the LED strategy but they are not sufficiently guided by the strategy to respond to the people’s needs. Pro-poor LED initiatives allow community members to showcase their skills and their desires and at the same time they can earn a living. Both municipalities are, however, not adequately monitoring and reviewing the LED strategies and initiatives, hence most of the pro-poor LED initiatives in the KCD are not sustainable. From the discussion of the findings the study concluded that LED initiatives that are established in different communities, particularly the KCDM, lack uniqueness and face stiff competition. There is also a lack of skills to manage LED initiatives, a lack of knowledge about the processes and the procedures of implementing and sustaining pro-poor LED initiatives. Moreover, there is inadequate funding to facilitate and implement LED and there is a need to involve the people from the planning stage and a request for more community participation