29,940 research outputs found

    Practice-centred e-health system design for cross-boundary clinical decision support

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    The idea of cross-boundary clinical decision support has the potential to transform the design of future work environments for e-health through a connected healthcare system that allows for harnessing of information and peer opinion across geographical boundaries for better decision-making. The trouble, however, is that the use of healthcare information in decision-making usually occurs within the context of a complex structure of clinical work practices that is often shaped by a wide range of factors, including organisational culture, local work contexts, socially constructed traditions of actions, experiences and patients’ circumstances. They vary across geographical boundaries, and have remained largely unaccounted for in the design of current e-health systems. As a result, achieving the visions of e-health, particularly in relation to cross-boundary clinical decision support, requires a rethinking of key clinical and organisational processes in a manner that accommodates work practice as a fundamental part of how clinicians work and make decisions in the real-world. This thesis investigates the concept of work practice as a design requirement for cross-boundary clinical decision support systems in e-health. It is argued that the task of enabling informed decision support across geographical boundaries in e-health can be enhanced through an understanding, and a formal characterisation, of work practices in various healthcare work contexts, and a specification of how practice can be used, managed and transformed to suit various clinical problem situations and patients’ needs. This research takes a clinical practice-centred approach to inform e-health system design, and draws on the concept of work practice and cultural-historical theory in social science as well as situation awareness in order to describe the local traditions of actions that guide clinicians’ work in the real world. It contributes a coherent conceptual architecture comprising a practice-centred awareness model for cross-boundary awareness, a frame-based technique, named PracticeFrame, for formalising and representing work practice for system design, and ContextMorph, for adaptively transforming a suggestion across work boundaries to suit a user’s local work context and practices. An in-depth user-informed requirements capture was used to gain an understanding of clinical work practices for designing e-health system for cross-boundary decision support. A proof of concept prototype, named CaDHealth, which is based on the Brahms work practice modelling tool and includes a work practice visualisation model, named the practice display, was developed and used to conduct user-based evaluation. The evaluation revealed that incorporating practice-centred awareness enhances usefulness, acceptance and user adoption of e-health systems for cross-boundary clinical decision support

    Systematic review of transition models for young people with long-term conditions: A report for NHS Diabetes.

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    Aims For many young people with Type 1 diabetes, transition from paediatric to adult care can result in a marked deterioration in glycaemic control. A systematic review assessed the effectiveness of transition models, or components of models, for managing the transition process in young people with long-term conditions, including Type 1 diabetes. This involved identifying (i) the main barriers and facilitators in implementing a successful transition programme, and (ii) the key issues for young people with long-term conditions and professionals involved in the transition process. Methods The following databases were searched from inception to August 2012: MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, Social Services Abstracts, Academic Search Complete, Social Science Citation Index, Cochrane and Campbell Libraries. Selected studies included young people aged 11 to 25 diagnosed with long-term conditions who were in transition from paediatric to adult secondary health care services. Results 16 systematic reviews and 13 primary studies were included from 9992 records retrieved. No single transition model was uniquely effective. The most successful transitions centred around: young person-focused; age and developmentally appropriate content and delivery; self-management education; family participation; paediatric and adult collaboration; designated transition clinics; transition co-ordinator; young person’s portfolio; specific professionals training; multidisciplinary approach; structured process embedded in service delivery. There were no distinctive characteristics of condition-specific Type 1 diabetes services. Conclusion This important and timely review summarises the key factors that need to be considered for the development of transition programmes for young people with long-term conditions, including those with Type 1 diabetes

    Designing for practice-based context-awareness in ubiquitous e-health environments

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    Existing approaches for supporting context-aware knowledge sharing in ubiquitous healthcare give little attention to practice-based structures of knowledge representation. They guide knowledge re-use at an abstract level and hardly incorporate details of actionable tasks and processes necessary for accomplishing work in a real-world context. This paper presents a context-aware model for supporting clinical knowledge sharing across organizational and geographical boundaries in ubiquitous e-health. The model draws on activity and situation awareness theories as well as the Belief-Desire Intention and Case-based Reasoning techniques in intelligent systems with the goal of enabling clinicians in disparate locations to gain a common representation of relevant situational information in each other's work contexts based on the notion of practice. We discuss the conceptual design of the model, present a formal approach for representing practice as context in a ubiquitous healthcare environment, and describe an application scenario and a prototype system to evaluate the proposed approach

    Electronic Health Records: Cure-all or Chronic Condition?

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    Computer-based information systems feature in almost every aspect of our lives, and yet most of us receive handwritten prescriptions when we visit our doctors and rely on paper-based medical records in our healthcare. Although electronic health record (EHR) systems have long been promoted as a cost-effective and efficient alternative to this situation, clear-cut evidence of their success has not been forthcoming. An examination of some of the underlying problems that prevent EHR systems from delivering the benefits that their proponents tout identifies four broad objectives - reducing cost, reducing errors, improving coordination and improving adherence to standards - and shows that they are not always met. The three possible causes for this failure to deliver involve problems with the codification of knowledge, group and tacit knowledge, and coordination and communication. There is, however, reason to be optimistic that EHR systems can fulfil a healthy part, if not all, of their potential

    Inter-agency adult support and protection practice:a realistic evaluation with police, health and social care professionals

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    Purpose: Collaborative inter-agency working is of paramount importance for the public protection agenda worldwide. The purpose of this paper is to disseminate the findings from a research study on the inter-agency working within adult support and protection (ASP) roles in the police, health and social care.Design/methodology/approach: This realistic evaluation study with two inter-related phases was funded by the Scottish Institute for Policing Research. This paper reports on Phase 1 which identified existing gaps in the implementation of effective inter-agency practice by reviewing the “state of play” in inter-agency collaboration between the police and health and social care professionals. In total, 13 focus groups comprising representatives from Police Scotland (n¼52), Social Care (n¼31) and Health (n¼18), engaged in single profession and mixed profession groups addressing issues including referral and information exchange.Findings: On analysing context-mechanism-outcome (CMO), gaps in joint working were identified and attributed to the professionals’ own understanding of inter-agency working and the expectations of partner agencies. It recommended the need for further research and inter-agency training on public protection. Research limitations/implications – This unique Scottish study successfully identified the inter-agency practices of health, social services and police. By means of a modified realistic evaluation approach, it provides an in-depth understanding of the challenges that professionals face on a day-to-day basis when safeguarding adults and informed strategic recommendations to overcome the barriers to good practices in organisational working. The methods used to determine CMO could benefit other researchers to develop studies exploring the complexities of multi-causal effects of cross-boundary working. The use of the same case study in each focus group helped to neutralise bias. However, the voluntary nature of participation could have resulted in biased perceptions. The limited numbers of health professionals may have resulted in less representation of health sector views.Practical implications: Collaborative inter-agency working is of paramount importance for public protection worldwide. This paper reports on a Scottish study that focussed on the coordinated and integrated practices amongst the police, health and social services’ professionals who support and protect adult members of society at risk of harm.Social implications: Whilst the focus of this study has been on ASP, the conclusions and recommendations are transferable to public protection issues in many other contexts.Originality/value: Studies on the joint-working practices amongst police and health and social services’ professionals who support and protect adult members of society at risk of harm are uncommon. This  study investigated professionals’ perceptions of gaps and concerns pertaining to integrated working by means of a realistic evaluation approach. It recommended the need for further research and inter-agency training on public protection

    Supporting community engagement through teaching, student projects and research

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    The Education Acts statutory obligations for ITPs are not supported by the Crown funding model. Part of the statutory role of an ITP is “... promotes community learning and by research, particularly applied and technological research ...” [The education act 1989]. In relation to this a 2017 TEC report highlighted impaired business models and an excessive administrative burden as restrictive and impeding success. Further restrictions are seen when considering ITPs attract < 3 % of the available TEC funding for research, and ~ 20 % available TEC funding for teaching, despite having overall student efts of ~ 26 % nationally. An attempt to improve performance and engage through collaboration (community, industry, tertiary) at our institution is proving successful. The cross-disciplinary approach provides students high level experience and the technical stretch needed to be successful engineers, technologists and technicians. This study presents one of the methods we use to collaborate externally through teaching, student projects and research

    Social networks : the future for health care delivery

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    With the rapid growth of online social networking for health, health care systems are experiencing an inescapable increase in complexity. This is not necessarily a drawback; self-organising, adaptive networks could become central to future health care delivery. This paper considers whether social networks composed of patients and their social circles can compete with, or complement, professional networks in assembling health-related information of value for improving health and health care. Using the framework of analysis of a two-sided network – patients and providers – with multiple platforms for interaction, we argue that the structure and dynamics of such a network has implications for future health care. Patients are using social networking to access and contribute health information. Among those living with chronic illness and disability and engaging with social networks, there is considerable expertise in assessing, combining and exploiting information. Social networking is providing a new landscape for patients to assemble health information, relatively free from the constraints of traditional health care. However, health information from social networks currently complements traditional sources rather than substituting for them. Networking among health care provider organisations is enabling greater exploitation of health information for health care planning. The platforms of interaction are also changing. Patient-doctor encounters are now more permeable to influence from social networks and professional networks. Diffuse and temporary platforms of interaction enable discourse between patients and professionals, and include platforms controlled by patients. We argue that social networking has the potential to change patterns of health inequalities and access to health care, alter the stability of health care provision and lead to a reformulation of the role of health professionals. Further research is needed to understand how network structure combined with its dynamics will affect the flow of information and potentially the allocation of health care resources

    Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

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    Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

    Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

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    Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings
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