From bedside to bench: Comroe and dripps revisited

Twenty-five years ago a paper published in Science by Julius Comroe and Robert Dripps purported to demonstrate that 41 per cent of all articles judged to be essential for later clinical advances were not clinically oriented at the time of the study and 62 per cent of key articles were the result of basic research. Since that analysis, support for basic research has increased in the G7 countries. In the UK, Research Council expenditure on basic research has increased from a low of £444 million (or 42 per cent of total civil R&D) in 1991/92 to £769 million (or 61 per cent of total civil R&D) in 1998/99. Although it would be difficult to argue that Comroe and Dripps were directly responsible for a strategic shift (or drift) in the type of science supported by research funders, their arguments are often cited (albeit at times implicitly) in support of the increased funding for basic biomedical research. In 1987 Richard Smith wrote a critical paper reassessing Comroe and Dripps. His main argument was that the original study was in itself ‘unscientific’ and that it should be “followed by bigger and better studies”. This study is, in part, an answer to that challenge. Given the increased support for basic research, and the apparent importance based on the work of Comroe and Dripps, we felt it was important to investigate Smith’s comments by replicating Comroe and Dripps’s study and at the same time try to improve upon the methodology. The current project had two objectives: 1. To see if the original Comroe and Dripps’s methodology was ‘replicable’. 2. To validate the key findings of Comroe and Dripps. By looking at neonatal intensive care (NIC), we concluded that Comroe and Dripps’ study – as reported – is not repeatable, reliable or valid, and thus is an insufficient evidence base for increased expenditure on basic biomedical research. We did, however, develop an alternative methodology which used bibliographic databases and bibliometric techniques to describe the research underpinning five of the most important clinical advances in NIC, as identified through a Delphi survey. Using the revised bibliometric protocol, we demonstrated that after a time-lag of about 17 years, between 2 and 21 per cent of research underpinning the clinical advances could be described as basic. This observation is at odds with Comroe and Dripps’s finding that 62 per cent of key research articles judged to be essential for latter clinical advance were the result of basic research. In reaching this conclusion we are acutely aware of the significant limitations to the revised methodology and, therefore, we caution against the over-interpretation of our results. However, we would argue that there needs to be a greater understanding of how basic research supports healthcare and hope this report will inform part of this wider debate.R&D Directorate of the NHS Executive London; Wellcome Trus

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

Interdisciplinary Team Based Pastoral Care: A Potentially Adaptable Model for Estonian Healthcare

This article aims to build a potentially adaptable model of clinical pastoral care for Estonia’s healthcare institutions. To help the development of spiritual support provision in Estonian healthcare institutions, we are currently working on creating a model of clinical pastoral care that would be in accordance with the local circumstances. Preparatory research in the matter has addressed the socio-cultural and institutional context that shows the great need for interdisciplinary teamwork. The current article offers concrete proposals in the following main points: a) presentation of the pastoral caregiver; b) main actors; c) forms of cooperation; and c) education and internal trainings. The model construction draws information from international research and considers it in Estonia’s local context. Spiritual support provision in Estonia’s healthcare has not yet been taken for granted and the concept is not fully understood. Secularity and religious diversity also set complex frames. Therefore, the model is suggested in guiding proposals, not in a rigorous structure. As such, the model could also be useful for healthcare spiritual support developments in other countries with similar characteristics. The article also poses possible questions of the implementation potential of the model

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

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

Promoting Environments that Measure Outcomes: Partnerships for Change

This paper describes the development of the PrEMO© (Promoting Environments that Measure Outcomes) program. PrEMO© is an innovative model promoting evidence-based practice (EBP) while developing capacity and quality of Level II fieldwork placements. The PrEMO© program is described from initiation to completion, including development of site-specific learning objectives, the twelve week schedule and the role of faculty mentorship. Occupational therapy (OT) students, and university OT program faculty including academic fieldwork coordinators, partner with fieldwork educators at the site to implement EBP using a data-driven decision making (DDDM) process to guide the development of evidence-based practices. PrEMO© appears to be a useful strategy for building Level II fieldwork capacity and enhancing student and fieldwork educators’ knowledge and skills about EBP and outcome measurement in routine OT practice

Implementing Guided Inquiry Learning and Measuring Engagement Using an Electronic Health Record System in an Online Setting

In many courses, practical hands-on experience is critical for knowledge construction. In the traditional lab setting, this construction is easy to observe through student engagement. But in an online virtual lab, there are some challenges to track student engagement. Given the continuing trend of increased enrollment in online courses, learning sciences need to address these challenges soon. To measure student engagement and actualize a social constructivist approach to team-based learning in the virtual lab setting, we developed a novel monitoring tool in an open-source electronic health records system (EHR). The Process Oriented Guided Inquiry Learning (POGIL) approach is used to engage students in learning. In this paper, we present the practice of POGIL and how the monitoring tool measures student engagement in two online courses in the interdisciplinary field of Health Information Management. To the best of our knowledge, this is the first attempt at integrating POGIL to improve learning sciences in the EHR clinical practice. While clinicians spend over 52% of a patient visit time on computers (called desktop medicine), there is very little focus on learning sciences and pedagogy to train clinicians. Our findings provide an approach to implement learning sciences theory to eHealth use training

A service oriented approach for guidelines-based clinical decision support using BPMN

Evidence-based medical practice requires that clinical guidelines need to be documented in such a way that they represent a clinical workflow in its most accessible form. In order to optimize clinical processes to improve clinical outcomes, we propose a Service Oriented Architecture (SOA) based approach for implementing clinical guidelines that can be accessed from an Electronic Health Record (EHR) application with a Web Services enabled communication mechanism with the Enterprise Service Bus. We have used Business Process Modelling Notation (BPMN) for modelling and presenting the clinical pathway in the form of a workflow. The aim of this study is to produce spontaneous alerts in the healthcare workflow in the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The use of BPMN as a tool to automate clinical guidelines has not been previously employed for providing Clinical Decision Support (CDS)

Measuring performance in healthcare

Hospitals invest in process management and process optimization from an organizational and patient perspective to increase efficiency and simultaneously the quality of their operations. Consequently, the use of process-oriented performance measurement systems gains importance. This study contributes to the development of a dashboard for the process of hip surgery using a case study design. We integrate strategic goals of hospital management and different stakeholders with the analysis of Business Process Management and Hospital Information Systems’ data. Process-oriented KPIs were integrated into the dashboard using a three-step approach. Dashboards enable healthcare organizations to put process-oriented performance measurement into practice