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

Querying a regulatory model for compliant building design audit

The ingredients for an effective automated audit of a building design include a BIM model containing the design information, an electronic regulatory knowledge model, and a practical method of processing these computerised representations. There have been numerous approaches to computer-aided compliance audit in the AEC/FM domain over the last four decades, but none has yet evolved into a practical solution. One reason is that they have all been isolated attempts that lack any form of standardisation. The current research project therefore focuses on using an open standard regulatory knowledge and BIM representations in conjunction with open standard executable compliant design workflows to automate the compliance audit process. This paper provides an overview of different approaches to access information from a regulatory model representation. The paper then describes the use of a purpose-built high-level domain specific query language to extract regulatory information as part of the effort to automate manual design procedures for compliance audit

Taylorism, targets and the pursuit of quantity and quality by call centre management

The paper locates the rise of the call centre within the context of the development of Taylorist methods and technological change in office work in general. Managerial utilisation of targets to impose and measure employees' quantitative and qualitative performance is analysed in four case-study organisations. The paper concludes that call centre work reflects a pardigmic re-configuration of customer servicing operations, and that the continuing application of Taylorist methods appears likely

NETTAB 2012 on “Integrated Bio-Search”

The NETTAB 2012 workshop, held in Como on November 14-16, 2012, was devoted to "Integrated Bio-Search", that is to technologies, methods, architectures, systems and applications for searching, retrieving, integrating and analyzing data, information, and knowledge with the aim of answering complex bio-medical-molecular questions, i.e. some of the most challenging issues in bioinformatics today. It brought together about 80 researchers working in the field of Bioinformatics, Computational Biology, Biology, Computer Science and Engineering. More than 50 scientific contributions, including keynote and tutorial talks, oral communications, posters and software demonstrations, were presented at the workshop. This preface provides a brief overview of the workshop and shortly introduces the peer-reviewed manuscripts that were accepted for publication in this Supplement

Reconceptualisation of Architects’ Intentionality in Computational Form Generation: A Tripartite Model

This paper attempts to create a theoretical framework to reconceptualise architects’ intentionality in computational form generation. Parallel to the increasing complexity of design problems and the increased realm of architects’ responsibility, the last two decades have shown that a vast amount of information can be managed and operated within the design process by using computational methods and associated technologies. This condition led to an expansion of the dominant mode in form computation that largely relies on data-driven forms as outcomes of pure calculations and rationalistic determinism. As an alternative, this study proposes a tripartite model as a basis to understand and assess design intentionality by unfolding and thereby reflecting on designers’ internalised processes. Initially defined in the field of computation, network and communication sciences for management and organisation of information, the proposed model – composed of centralised, partial and distributed approaches – is operational in responding to different forms and degrees of design intentionality within computational processes in architecture

User adoption of a CRM-based information system within a financial services organisation: An empirical analysis

Financial Services firms require processes and systems which can support and maintain customer-related information for the purposes of core business-focussed activity. Specifically within the investment banking sector, the importance and criticality of such customer information underpins the firm’s ability to transact sales, trading and other advisory-based services in an efficient and relevant manner. The design and development of Customer Relationship Management (CRM) systems to address the given external vs. internal customer information touchpoints, therefore provides a vital link between financial services professionals, client data and business processes. In doing so, the input of CRM user requirements is a key step in deriving benefit from such a technology solution. This paper henceforth identifies and details user requirements and experiences of such an information system within a case study company and highlights pertinent issues for the adoption of such systems within the given secto

Generic business process modelling framework for quantitative evaluation

PhD ThesisBusiness processes are the backbone of organisations used to automate and increase the efficiency and effectiveness of their services and prod- ucts. The rapid growth of the Internet and other Web based technologies has sparked competition between organisations in attempting to provide a faster, cheaper and smarter environment for customers. In response to these requirements, organisations are examining how their business processes may be evaluated so as to improve business performance. This thesis proposes a generic framework to expand the applicability of various quantitative evaluation to a large class of business processes. The framework introduces a novel engineering methodology that defines a modelling formalism to represent business processes that can be solved for a set of performance and optimisation algorithms. The methodology allows various types of algorithms used in model-based business pro- cess improvement and optimisation to be plugged in a single modelling formalism. As a part of the framework, a generic modelling formalism (MWF-wR) is developed to represent business processes so as to allow quantitative evaluation and to select the parameters for the associated performance evaluation and optimisation. The generic framework is designed and implemented by developing soft- ware support tools using Java as object oriented programming language combining three main modules: (i) a business process specification mod- ule to define the components of the business process model, (ii) a stochas- tic Petri net module to map the business process model to a stochastic Petri net, and (iii) an algorithms module to solve the models for various performance optimisation objectives. Furthermore, a literature survey of different aspects of business processes including modelling and analy- sis techniques provides an overview of the current state of research and highlights gaps in business process modelling and performance analy- sis. Finally, experiments are introduced to investigate the validity of the presented approach

Knowledge engineering complex decision support system in managing rheumatoid arthritis.

Background: The management of rheumatoid arthritis (RA) involves partially recursive attempts to make optimal treatment decisions that balance the risks of the treatment to the patient against the benefits of the treatment, while monitoring the patient closely for clinical response, as inferred from prior and residual disease activity, and unwanted drug effects, including abnormal laboratory findings. To the extent that this process is logical, based on best available evidence and determined by considered opinion, it should be amenable to capture within a Clinical Decision Support Systems (CDSSs). The formalisation of logical transformations and their execution by computer tools at point of patient encounter holds the promise of more efficient and consistent use of treatment rules and more reliable clinical decision making. Research Setting: The early Rheumatoid Arthritis (eRA) clinic of the Royal Adelaide Hospital (RAH) with approximately 20 RA patient visits per week, and involving 160 patients with a median duration of treatment of more than 4.5 years. Methods: The study applied a Knowledge Engineering approach to interpret the complexities of RA management, in order to implement a knowledge-based CDSS. The study utilised Knowledge Acquisition processes to elicit and explicitly define the RA management rules underpinning the development of the CDSS; the processes were (1) conducting a comprehensive literature review of RA management, (2) observing clinic consultations and (3) consulting with local clinical experts/leaders. Bayes’ Theorem and Bayes Net were used to generate models for assessing contingent probabilities of unwanted events. A questionnaire based on 16 real patient cases was developed to test the concordance agreement between CDSS generated guidance in response to real-life clinical scenarios and decisions of rheumatologists in response to the scenarios. Results: (1) Complex RA management rules were established which included (a) Rules for Changes in Dose/Agent and (b) Drug Toxicity Monitoring Rules. (2) A computer interpretable dynamic model for implementing the complex clinical guidance was found to be applicable. (3) A framework for a methotrexate (MTX) toxicity prediction model was developed, thereby allowing missing risk ratios (probabilities) to be identified. (4) Clinical decision-making processes and workflows were described. Finally, (5) a preliminary version of the CDSS which computed Rules for Changes in Dose/Agent and Drug Toxicity Monitoring Rules was implemented and tested. One hundred and twenty-eight decisions collected from the 8 participating rheumatologists established the ability of the CDSS to match decisions of clinicians accustomed to application of Rules for Changes in Dose/Agent; rheumatologists unfamiliar with the rules displayed lower concordance (0.7857 vs. 0.3929, P = 0.0027). Neither group of rheumatologists matched the performance of the CDSS in making decisions based on highly complex Drug Toxicity Monitoring Rules (0.3611 vs. 0.4167, P = 0.7215). Conclusion: The study has made important contributions to the development of a CDSS suitable for routine use in the eRA clinic setting. Knowledge Acquisition processes were used to elicit domain knowledge, and to refine, validate and articulate eRA management rules, that came to form the knowledge base of the CDSS. The development of computer interpretable guideline models underpinned the CDSS development. The alignment of CDSS guidance in response to clinical scenarios with questionnaire responses of rheumatologists familiar with and accepting of the management rules (and divergence with responses by rheumatologists not familiar with the rules) indicates that the CDSS can be used to guide toward evidence-based considered opinion. The poor correlation between CDSS generated guidance regarding out of range blood results and response of rheumatologists to questions regarding toxicity scenarios, underlines the value of computer aided guidance when decisions involve greater complexity. It also suggests the need for attention to rule development and considered opinion in this area. Discussion: Effective utilisation of extant knowledge is fundamental to knowledgebased systems in healthcare. CDSSs development for chronic disease management is a complex undertaking which is tractable using Knowledge Engineering and Knowledge Acquisition approaches coupled with modelling into computer interpretable algorithms. Complexities of drug toxicity monitoring were addressed using Bayes’ Theorem and Bayes Net for making probability based decisions under conditions of uncertainty. While for logistic reasons the system could not be developed to full implementation, preliminary analyses support the utility of the approach, both for intensifying treatment on a response contingent basis and also for complex drug toxicity monitoring. CDSSs are inherently suited to iterative refinements based on new knowledge including that arising from analyses of the data they capture during their use. This study has achieved important steps toward implementation and refinement.Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 201

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

Modelling and accessing regulatory knowledge for computer-assisted compliance audit

The ingredients for an effective automated audit of a building design include a building model containing the design information, a computerised regulatory knowledge model, and a practical method of processing these computable representations. There have been numerous approaches to computer-aided compliance audit in the AEC/FM domain over the last four decades, but none has yet evolved into a practical solution. One reason is that they have all been isolated attempts that lack any form of industry-wide standardisation. The current research project, therefore, focuses on investigating the use of the industry standard building information model and the adoption of open standard legal knowledge interchange and executable workflow models for automating conventional compliant design processes. This paper provides a non-exhaustive overview of common approaches to model and access regulatory knowledge for a compliance audit. The strengths and weaknesses of two comparative open standard knowledge representation approaches are discussed using an example regulatory document