IT and the NHS: Investigating different perspectives of IT using soft systems methodology

The UK NHS National Programme for IT has been criticized for a lack of clinical engagement. This paper uses a soft systems methodology (SSM) analysis of a case study from the use of electronic systems within a National Health Service (NHS) Mental Health Trust in the United Kingdom (UK) to explore the legal and ethical implications of the failure to develop clinical systems which are fit for purpose. Soft systems methodology (SSM) was used as a theoretical model both to derive deeper insights into the survey data and suggest how communication between those producing information and those using it, could be improved. Multiple methods were employed which included a postal survey and participant interviews to triangulate the data The use of SSM reinforced the concept that the national IT programme is based on a 'hard' systems view and does not take local factors (which are related to 'soft systems' thinking) into account. The study found administrative staff to be a crucial link between clinicians and information departments and highlighted the need for a joint-up information strategy and integrated systems. The article concludes with a discussion of the legal and ethical implications of the findings and the lessons for the broader UK national programme. It argues that the failure to deliver systems that are fit for purpose is not value neutral but an ethical issue

Managing information

This chapter explores the provision of good data for monitoring the quality of primary care. Three issues need to be addressed - the kit (IT infrastructure), the way it is used, and the capability of the people using it

COVID-19 trajectories among 57 million adults in England: a cohort study using electronic health records

BACKGROUND: Updatable estimates of COVID-19 onset, progression, and trajectories underpin pandemic mitigation efforts. To identify and characterise disease trajectories, we aimed to define and validate ten COVID-19 phenotypes from nationwide linked electronic health records (EHR) using an extensible framework. METHODS: In this cohort study, we used eight linked National Health Service (NHS) datasets for people in England alive on Jan 23, 2020. Data on COVID-19 testing, vaccination, primary and secondary care records, and death registrations were collected until Nov 30, 2021. We defined ten COVID-19 phenotypes reflecting clinically relevant stages of disease severity and encompassing five categories: positive SARS-CoV-2 test, primary care diagnosis, hospital admission, ventilation modality (four phenotypes), and death (three phenotypes). We constructed patient trajectories illustrating transition frequency and duration between phenotypes. Analyses were stratified by pandemic waves and vaccination status. FINDINGS: Among 57 032 174 individuals included in the cohort, 13 990 423 COVID-19 events were identified in 7 244 925 individuals, equating to an infection rate of 12·7% during the study period. Of 7 244 925 individuals, 460 737 (6·4%) were admitted to hospital and 158 020 (2·2%) died. Of 460 737 individuals who were admitted to hospital, 48 847 (10·6%) were admitted to the intensive care unit (ICU), 69 090 (15·0%) received non-invasive ventilation, and 25 928 (5·6%) received invasive ventilation. Among 384 135 patients who were admitted to hospital but did not require ventilation, mortality was higher in wave 1 (23 485 [30·4%] of 77 202 patients) than wave 2 (44 220 [23·1%] of 191 528 patients), but remained unchanged for patients admitted to the ICU. Mortality was highest among patients who received ventilatory support outside of the ICU in wave 1 (2569 [50·7%] of 5063 patients). 15 486 (9·8%) of 158 020 COVID-19-related deaths occurred within 28 days of the first COVID-19 event without a COVID-19 diagnoses on the death certificate. 10 884 (6·9%) of 158 020 deaths were identified exclusively from mortality data with no previous COVID-19 phenotype recorded. We observed longer patient trajectories in wave 2 than wave 1. INTERPRETATION: Our analyses illustrate the wide spectrum of disease trajectories as shown by differences in incidence, survival, and clinical pathways. We have provided a modular analytical framework that can be used to monitor the impact of the pandemic and generate evidence of clinical and policy relevance using multiple EHR sources. FUNDING: British Heart Foundation Data Science Centre, led by Health Data Research UK

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

A problem solving strategy based on knowledge-based systems

The historical development of knowledge based systems (KBS) from artificial intelligence (AT) has led to a number of characteristics which isolate knowledge based systems from the rest of software development. In particular, it has led to the growth of 'stand alone' systems. This thesis argues that this has restricted the use of KBS to a narrow range of problems, and has reduced the effectiveness of the consequent solutions. By considering first a specific problem in some depth, the thesis seeks to develop an alternative approach, where KBS is considered as simply another software technology to be used within an integrated solution. The problem considered is the automatic analysis of photoelastic fringe patterns, and KBS methods are employed alongside conventional image processing techniques to produce an integrated solution. The conventional algorithmic solution is first constructed and evaluated. This solution, having proved partially successful, is then enhanced by the use of KBS techniques to provide a full solution. From this specific example, a framework for integration is derived. This framework is tested in an unrelated application to consider whether the approach adopted has more general utility than one specific class of problem. This problem was the provision of decision support for business planning based upon market research. The resulting strategy and design is described together with details of how the system was implemented under the supervision of the author. The thesis concludes with an evaluation of the work and its conthbution to knowledge in the twin areas of the specific solutions and the underlying methods

Using healthcare system archetypes to help hospitals become learning organisations

Purpose – Internationally, change in healthcare is often a result of a knee jerk reaction to high-profile adverse events. Alternatively, change is driven by a reductionist set of targets and indicators, which do not reflect the complexity of hospitals. This paper posits that hospitals would benefit from promoting organisational learning, and that system archetypes offer a mechanism for achieving this. It seeks to examine the application of healthcare system archetypes in an Australian hospital. Design/methodology/approach – Archetypes do not describe any one problem specifically. They describe families of problems generically. Their value comes from the insights they offer into the dynamic interaction of complex systems. As part of a suite of tools, they are extremely valuable in developing broad understandings about the hospital and its environment. Findings – Diagnostically, archetypes helped the hospital managers recognize patterns of behaviour that are already present in their organizations. They served as the means for gaining insight into the underlying systems structures from which the archetypal behaviour emerges. The application of system archetypes to the strategic analysis of the hospital case reveals that it is possible to identify loop holes in management's strategic thinking processes and it is possible to defy these fallacies during policy implementation as illustrated by the results of the archetype simulation model. In this study, hospital executives found that policy modification helped to avoid such pitfalls and avoid potentially cost prohibitive learning had these policies been implemented in practice. Originality/value – The paper demonstrates how system archetypes were deployed within a hospital to improve organizational learning, and provides an approach that may be deployed in other large complex health care organisations

Building an Electronic Disease Register: Getting the Computer to Work for You (Primary Care Health Informatics)

Widespread recognition of the benefits of minimally invasive procedures in surgery and medicine is resulting in the rapid development of new advances and new techniques in every speciality. This series of books sets out to meet the needs of those responsible for applying the techniques. This volume deals with the field of minimal access surgery. It covers the philosophy of the concept, team training, pre-operative preparation of the patient, anaesthetic considerations, equipment, lasers, and operative techniques for the various body systems