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

Healthcare Process Support: Achievements, Challenges, Current Research

Healthcare organizations are facing the challenge of delivering high-quality services to their patients at affordable costs. To tackle this challenge, the Medical Informatics community targets at formalisms for developing decision-support systems (DSSs) based on clinical guidelines. At the same time, business process management (BPM) enables IT support for healthcare processes, e.g., based on workflow technology. By integrating aspects from these two fields, promising perspectives for achieving better healthcare process support arise. The perspectives and limitations of IT support for healthcare processes provided the focus of three Workshops on Process-oriented Information Systems (ProHealth). These were held in conjunction with the International Conference on Business Process Management in 2007-2009. The ProHealth workshops provided a forum wherein challenges, paradigms, and tools for optimized process support in healthcare were debated. Following the success of these workshops, this special issue on process support in healthcare provides extended papers by research groups who contributed multiple times to the ProHealth workshop series. These works address issues pertaining to healthcare process modeling, process-aware healthcare information system, workflow management in healthcare, IT support for guideline implementation and medical decision support, flexibility in healthcare processes, process interoperability in healthcare and healthcare standards, clinical semantics of healthcare processes, healthcare process patterns, best practices for designing healthcare processes, and healthcare process validation, verification, and evaluation

A collaborative platform for management of chronic diseases via guideline-driven individualized care plans

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians

Standards for Scalable Clinical Decision Support: Need, Current and Emerging Standards, Gaps, and Proposal for Progress

Despite their potential to significantly improve health care, advanced clinical decision support (CDS) capabilities are not widely available in the clinical setting. An important reason for this limited availability of CDS capabilities is the application-specific and institution-specific nature of most current CDS implementations. Thus, a critical need for enabling CDS capabilities on a much larger scale is the development and adoption of standards that enable current and emerging CDS resources to be more effectively leveraged across multiple applications and care settings. Standards required for such effective scaling of CDS include (i) standard terminologies and information models to represent and communicate about health care data; (ii) standard approaches to representing clinical knowledge in both human-readable and machine-executable formats; and (iii) standard approaches for leveraging these knowledge resources to provide CDS capabilities across various applications and care settings. A number of standards do exist or are under development to meet these needs. However, many gaps and challenges remain, including the excessive complexity of many standards; the limited availability of easily accessible knowledge resources implemented using standard approaches; and the lack of tooling and other practical resources to enable the efficient adoption of existing standards. Thus, the future development and widespread adoption of current CDS standards will depend critically on the availability of tooling, knowledge bases, and other resources that make the adoption of CDS standards not only the right approach to take, but the cost-effective path to follow given the alternative of using a traditional, ad hoc approach to implementing CDS

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

Exploring Quality Improvement for Diabetes Care: A Multiple Case Study of Primary Care Teams in First Nations Communities in Canada

Clinical quality improvement (QI) teams from First Nations communities across Canada participated in an 18-month QI collaborative program called the TransFORmation of IndiGEnous Primary HEAlthcare Delivery (FORGE AHEAD) clinical QI initiative. Community-based participatory research and multiple case study methodologies were utilized to explore the experience of two clinical QI teams from diverse primary care settings in First Nations communities as they engaged in developing and implementing changes in practice to improve the quality of diabetes care. This study provides insight into how clinical QI teams drew upon multiple sources of knowledge and information to inform their QI activities, the importance of strengthening relationships and building partnerships with the community, and the factors that support or hinder QI within First Nations communities in Canada. The knowledge generated may help inform community action and future development and implementation of QI programs in First Nations communities in Canada

Diabetic Retinopathy in Kenya: assessment of services and interventions to improve access

The majority of the estimated 425 million people living with diabetes (PLWD) reside in low and middle-income countries. An estimated 35% of PLWD have diabetic retinopathy (DR) and 10% have vision threatening retinopathy (VTDR) requiring urgent treatment. There is a high unmet need for DR services in many of these countries, which highlights the need to strengthen health systems. The purpose of this PhD is to provide evidence on the factors and interventions for promoting access and utilisation of services for DR. The study setting is Kenya, which has adopted Universal Health Coverage (UHC) as a target for 2030. The specific objectives were: i) To synthesise the literature on the magnitude, needs and priorities for diabetic retinopathy services; ii)To conduct an assessment of the health system for PLWD and diabetic retinopathy in Kenya; iii) To use the evidence from the literature and evidence from the health system assessment as a platform for health system strengthening; and iv) To develop and test an intervention through a randomized clinical trial to improve uptake of eye care services for PLWD in Kenya. Methods: The first objective was achieved through a literature review. For the second objective, a health system assessment for diabetes and DR was conducted, based on the World Health Organization’s framework for health systems building blocks and the tracer condition approach. For the third objective, as part of health system strengthening, national guidelines for DR and a short online course for health care workers were developed. For the fourth objective, using the evidence from the health system assessment, we designed and implemented a two arm (1:1) pragmatic cluster randomized controlled trial to test whether a peer-supporter-led package of interventions can increase uptake of DR screening among members of diabetes support groups who have never had screening. The primary outcome measure was attendance at DR screening in the 14 clusters and 734 participants followed up over six months. Results: A review of the literature on the epidemiology and interventions for diabetes and DR, identified that the key priorities of health systems in reducing the incidence of DR-related blindness are: (1) control of diabetes (2) early detection of DR and (3) appropriate treatment of DR. However, most of the available evidence is from highincome countries. The health system assessment for diabetes and DR in Kenya identified a high unmet need for DR screening, and uptake of screening was the bottleneck to entry to DR services. The barriers were lack of referral and inadequate knowledge of diabetes eye health. The lack of clinical guidelines and inadequate opportunities for continuous professional development limit the availability of DR services. To address this barrier, national clinical guidelines were developed through a process of adaptation from generic guidelines. The scope of the guidelines is screening, diagnosis, treatment and follow-up for DR. In addition, an online training course on the control of DR has been developed using the theories of adult learning and instructional design. The results of the cluster-randomized trial indicate that the peer-led interventions are acceptable and reach the population most vulnerable to DR. One in two of the participants in the intervention arm compared to one in ten in the control arm attended DR screening. We also found that most of the effect occurs early—within the first month of the intervention. Conclusions: This thesis provides evidence about how national DR guidelines and online training programmes for health workers can be developed to strengthen health systems and improve eye services for PLWD. The thesis also provides evidence that the uptake of DR screening by PLWD can be significantly increased through a community based intervention utilising diabetes support groups and peer-supporters. This can lead to earlier diagnosis of DR and the prevention of blindness

The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review

Acknowledgements University of Stirling for providing financial support for open access costs Funding This review was funded by the Chief Scientist Office, grant number GCA/17/26. JC, PC and EAD are employed by the Nursing, Midwifery and Allied Health Professions Research Unit, which is funded by the Chief Scientist Office in Scotland.Peer reviewedPublisher PD