Safer clinical systems : interim report, August 2010

Safer Clinical Systems is the Health Foundation’s new five year programme of work to test and demonstrate ways to improve healthcare systems and processes, to develop safer systems that improve patient safety. It builds on learning from the Safer Patients Initiative (SPI) and models of system improvement from both healthcare and other industries. Learning from the SPI highlighted the need to take a clinical systems approach to improving safety. SPI highlighted that many hospitals struggle to implement improvement in clinical areas due to inherent problems with support mechanisms. Clinical processes and systems, rather than individuals, are often the contributors to breakdown in patient safety. The Safer Clinical Systems programme aimed to measure the reliability of clinical processes, identify defects within those processes, and identify the systems that result in those defects. Methods to improve system reliability were then to be tested and re-developed in order to reduce the risk of harm being caused to patients. Such system-level awareness should lead to improvements in other patient care pathways. The relationship between system reliability and actual harm is challenging to identify and measure. Specific, well-defined, small-scale processes have been used in other programmes, and system reliability has been shown to have a direct causal relationship with harm (e.g. care bundle compliance in an intensive care unit can reduce the incidence of ventilator-associated pneumonia). However, it has become evident that harm can be caused by a variety of factors over time; when working in broader, more complex and dynamic systems, change in outcome can be difficult to attribute to specific improvements and difficulties are also associated with relating evidence to resulting harm. The overall aim of Phase 1 of the Safer Clinical Systems programme was to demonstrate proof-of-concept that using a systems-based approach could contribute to improved patient safety. In Phase 1, experienced NHS teams from four locations worked together with expert advisers to co-design the Safer Clinical Systems programme

Digital service analysis and design : the role of process modelling

Digital libraries are evolving from content-centric systems to person-centric systems. Emergent services are interactive and multidimensional, associated systems multi-tiered and distributed. A holistic perspective is essential to their effective analysis and design, for beyond technical considerations, there are complex social, economic, organisational, and ergonomic requirements and relationships to consider. Such a perspective cannot be gained without direct user involvement, yet evidence suggests that development teams may be failing to effectively engage with users, relying on requirements derived from anecdotal evidence or prior experience. In such instances, there is a risk that services might be well designed, but functionally useless. This paper highlights the role of process modelling in gaining such perspective. Process modelling challenges, approaches, and success factors are considered, discussed with reference to a recent evaluation of usability and usefulness of a UK National Health Service (NHS) digital library. Reflecting on lessons learnt, recommendations are made regarding appropriate process modelling approach and application

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 participatory design approach for the development of support environments in eGovernment services to citizens

The introduction of eGovernment services and applications leads to major changes in the structure and operation of public administrations. In this paper we describe the work in progress in an Italian project called “SPO.T.” aimed at the analysis, development, deployment and evaluation of tools and environments to support the people who plan, deliver, use and evaluate user-centred provision of One-Stop-Shop services to citizens. The “SPO.T.” project has focused on two requirements: 1. the support tools and environments must facilitate the active involvement of all stakeholders in the definition and evolution of eGovernment applications and services, and it is argued that through participatory design changes of structure, process and culture can be delivered effectively; 2. they must embody a set of architecturally coherent resources which reflect the new roles and relationships of public administration and which are sufficiently generic to be relevant to a wide range of local contexts across the community

Evolving a software development methodology for commercial ICTD projects

This article discusses the evolution of a “DistRibuted Agile Methodology Addressing Technical Ictd in Commercial Settings” (DRAMATICS) that was developed in a global software corporation to support ICTD projects from initial team setup through ICT system design, development, and prototyping, to scaling up and transitioning, to sustainable commercial models. We developed the methodology using an iterative Action Research approach in a series of commercial ICTD projects over a period of more than six years. Our learning is reflected in distinctive methodology features that support the development of contextually adapted ICT systems, collaboration with local partners, involvement of end users in design, and the transition from research prototypes to scalable, long-term solutions. We offer DRAMATICS as an approach that others can appropriate and adapt to their particular project contexts. We report on the methodology evolution and provide evidence of its effectiveness in the projects where it has been used

How to design and evaluate interventions to improve outcomes for patients with multimorbidity

Multimorbidity is a major challenge for patients and healthcare providers. The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions. Here we present a consensus view from a group of international researchers working to improve care for people with multimorbidity to guide future studies of interventions. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems

Development and validation of a pragmatic natural language processing approach to identifying falls in older adults in the emergency department

BACKGROUND: Falls among older adults are both a common reason for presentation to the emergency department, and a major source of morbidity and mortality. It is critical to identify fall patients quickly and reliably during, and immediately after, emergency department encounters in order to deliver appropriate care and referrals. Unfortunately, falls are difficult to identify without manual chart review, a time intensive process infeasible for many applications including surveillance and quality reporting. Here we describe a pragmatic NLP approach to automating fall identification. METHODS: In this single center retrospective review, 500 emergency department provider notes from older adult patients (age 65 and older) were randomly selected for analysis. A simple, rules-based NLP algorithm for fall identification was developed and evaluated on a development set of 1084 notes, then compared with identification by consensus of trained abstractors blinded to NLP results. RESULTS: The NLP pipeline demonstrated a recall (sensitivity) of 95.8%, specificity of 97.4%, precision of 92.0%, and F1 score of 0.939 for identifying fall events within emergency physician visit notes, as compared to gold standard manual abstraction by human coders. CONCLUSIONS: Our pragmatic NLP algorithm was able to identify falls in ED notes with excellent precision and recall, comparable to that of more labor-intensive manual abstraction. This finding offers promise not just for improving research methods, but as a potential for identifying patients for targeted interventions, quality measure development and epidemiologic surveillance

Designing a Mobile Device for Pre-hospital Care

Peer reviewedPreprin

Knowledge dependencies in fuzzy information systems evaluation

Experience and research within the field of Information Systems Evaluation (ISE), has traditionally centered on providing tools and techniques for investment justification and appraisal, based upon explicit knowledge which encodes financial and other direct situational factors (such as accounting, costing and risk metrics). However, such approaches tend not to include additional causal interdependencies that are based upon tacit knowledge and are inherent within such a decision-making task. The authors show the results of applying a cognitive mapping approach, in the guise of a Fuzzy Cognitive Mapping (FCM) simulation, i.e. Fuzzy Information Systems Evaluation (F-ISE), in order to highlight the usefulness of applying such a technique. The authors highlight those contingent and necessary knowledge dependencies, in an exploratory sense, which relate to the investment appraisal decision-making task, in terms of the interplay between tacit and explicit knowledge, in this regard