A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Hoy en día, por primera vez en la historia, la mayor parte de la población podrá vivir hasta los sesenta años y más (United Nations, 2015). Sin embargo, todavía existe poca evidencia que demuestre que las personas mayores, estén viviendo con mejor salud que sus padres, a la misma edad, ya que la mayoría de los problemas de salud en edades avanzadas están asociados a las enfermedades crónicas (WHO, 2015). Los sistemas sanitarios de los países desarrollados funcionan adecuadamente cuando se trata del cuidado de enfermedades agudas, pero no son lo suficientemente eficaces en la gestión de las enfermedades crónicas. Durante la última década, se han realizado esfuerzos para mejorar esta gestión, por medio de la utilización de estrategias de prevención y de reenfoque de la provisión de los servicios de atención para la salud (Kane et al. 2005). Según una revisión sistemática de modelos de cuidado de salud, comisionada por el sistema nacional de salud Británico, pocos modelos han conceptualizado cuáles son los componentes que hay que utilizar para proporcionar un cuidado crónico efectivo, y estos componentes no han sido suficientemente estructurados y articulados. Por lo tanto, no hay suficiente evidencia sobre el impacto real de cualquier modelo existente en la actualidad (Ham, 2006). Las innovaciones podrían ayudar a conseguir mejores diagnósticos, tratamientos y gestión de pacientes crónicos, así como a dar soporte a los profesionales y a los pacientes en el cuidado. Sin embargo, la forma en las que estas innovaciones se proporcionan no es lo suficientemente eficiente, efectiva y amigable para el usuario. Para mejorar esto, hace falta crear equipos de trabajo y estrategias multidisciplinares. En conclusión, hacen falta actividades que permitan conseguir que las innovaciones sean utilizadas en los sistemas de salud que quieren mejorar la gestión del cuidado crónico, para que sea posible: 1) traducir la “atención sanitaria basada en la evidencia” en “conocimiento factible”; 2) hacer frente a la complejidad de la atención sanitaria a través de una investigación multidisciplinaria; 3) identificar una aproximación sistemática para que se establezcan intervenciones innovadoras en el cuidado de salud. El marco de referencia desarrollado en este trabajo de investigación es un intento de aportar estas mejoras. Las siguientes hipótesis han sido propuestas: Hipótesis 1: es posible definir un proceso de traducción que convierta un modelo de cuidado crónico en una descripción estructurada de objetivos, requisitos e indicadores clave de rendimiento. Hipótesis 2: el proceso de traducción, si se ejecuta a través de elementos basados en la evidencia, multidisciplinares y de orientación económica, puede convertir un modelo de cuidado crónico en un marco descriptivo, que define el ciclo de vida de soluciones innovadoras para el cuidado de enfermedades crónicas. Hipótesis 3: es posible definir un método para evaluar procesos, resultados y capacidad de desarrollar habilidades, y asistir equipos multidisciplinares en la creación de soluciones innovadoras para el cuidado crónico. Hipótesis 4: es posible dar soporte al desarrollo de soluciones innovadoras para el cuidado crónico a través de un marco de referencia y conseguir efectos positivos, medidos en indicadores clave de rendimiento. Para verificar las hipótesis, se ha definido una aproximación metodológica compuesta de cuatro Fases, cada una asociada a una hipótesis. Antes de esto, se ha llevado a cabo una “Fase 0”, donde se han analizado los antecedentes sobre el problema (i.e. adopción sistemática de la innovación en el cuidado crónico) desde una perspectiva multi-dominio y multi-disciplinar. Durante la fase 1, se ha desarrollado un Proceso de Traducción del Conocimiento, elaborado a partir del JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare (Pearson, 2005), y sobre el cual se han definido cuatro Bloques de Innovación. Estos bloques consisten en una descripción de elementos innovadores, definidos en la fase 0, que han sido añadidos a los cuatros elementos que componen el modelo JBI. El trabajo llevado a cabo en esta fase ha servido también para definir los materiales que el proceso de traducción tiene que ejecutar. La traducción que se ha llevado a cabo en la fase 2, y que traduce la mejor evidencia disponible de cuidado crónico en acción: resultado de este proceso de traducción es la parte descriptiva del marco de referencia, que consiste en una descripción de un modelo de cuidado crónico (se ha elegido el Chronic Care Model, Wagner, 1996) en términos de objetivos, especificaciones e indicadores clave de rendimiento y organizada en tres ciclos de innovación (diseño, implementación y evaluación). Este resultado ha permitido verificar la segunda hipótesis. Durante la fase 3, para demostrar la tercera hipótesis, se ha desarrollado un método-mixto de evaluación de equipos multidisciplinares que trabajan en innovaciones para el cuidado crónico. Este método se ha creado a partir del método mixto usado para la evaluación de equipo multidisciplinares translacionales (Wooden, 2013). El método creado añade una dimensión procedural al marco. El resultado de esta fase consiste, por lo tanto, en una primera versión del marco de referencia, lista para ser experimentada. En la fase 4, se ha validado el marco a través de un caso de estudio multinivel y con técnicas de observación-participante como método de recolección de datos. Como caso de estudio se han elegido las actividades de investigación que el grupo de investigación LifeStech ha desarrollado desde el 2008 para mejorar la gestión de la diabetes, actividades realizadas en un contexto internacional. Los resultados demuestran que el marco ha permitido mejorar las actividades de trabajo en distintos niveles: 1) la calidad y cantidad de las publicaciones; 2) se han conseguido dos contratos de investigación sobre diabetes: el primero es un proyecto de investigación aplicada, el segundo es un proyecto financiado para acelerar las innovaciones en el mercado; 3) a través de los indicadores claves de rendimiento propuestos en el marco, una prueba de concepto de un prototipo desarrollado en un proyecto de investigación ha sido transformada en una evaluación temprana de una intervención eHealth para el manejo de la diabetes, que ha sido recientemente incluida en Repositorio de prácticas innovadoras del Partenariado de Innovación Europeo en Envejecimiento saludable y activo. La verificación de las 4 hipótesis ha permitido demonstrar la hipótesis principal de este trabajo de investigación: es posible contribuir a crear un puente entre la atención sanitaria y la innovación y, por lo tanto, mejorar la manera en que el cuidado crónico sea procurado en los sistemas sanitarios. ABSTRACT Nowadays, for the first time in history, most people can expect to live into their sixties and beyond (United Nations, 2015). However, little evidence suggests that older people are experiencing better health than their parents, and most of the health problems of older age are linked to Chronic Diseases (WHO, 2015). The established health care systems in developed countries are well suited to the treatment of acute diseases but are mostly inadequate for dealing with CDs. Healthcare systems are challenging the burden of chronic diseases by putting more emphasis on the prevention of disease and by looking for new ways to reorient the provision of care (Kane et al., 2005). According to an evidence-based review commissioned by the British NHS Institute, few models have conceptualized effective components of care for CDs and these components have been not structured and articulated. “Consequently, there is limited evidence about the real impact of any of the existing models” (Ham, 2006). Innovations could support to achieve better diagnosis, treatment and management for patients across the continuum of care, by supporting health professionals and empowering patients to take responsibility. However, the way they are delivered is not sufficiently efficient, effective and consumer friendly. The improvement of innovation delivery, involves the creation of multidisciplinary research teams and taskforces, rather than just working teams. There are several actions to improve the adoption of innovations from healthcare systems that are tackling the epidemics of CDs: 1) Translate Evidence-Based Healthcare (EBH) into actionable knowledge; 2) Face the complexity of healthcare through multidisciplinary research; 3) Identify a systematic approach to support effective implementation of healthcare interventions through innovation. The framework proposed in this research work is an attempt to provide these improvements. The following hypotheses have been drafted: Hypothesis 1: it is possible to define a translation process to convert a model of chronic care into a structured description of goals, requirements and key performance indicators. Hypothesis 2: a translation process, if executed through evidence-based, multidisciplinary, holistic and business-oriented elements, can convert a model of chronic care in a descriptive framework, which defines the whole development cycle of innovative solutions for chronic disease management. Hypothesis 3: it is possible to design a method to evaluate processes, outcomes and skill acquisition capacities, and assist multidisciplinary research teams in the creation of innovative solutions for chronic disease management. Hypothesis 4: it is possible to assist the development of innovative solutions for chronic disease management through a reference framework and produce positive effects, measured through key performance indicators. In order to verify the hypotheses, a methodological approach, composed of four Phases that correspond to each one of the stated hypothesis, was defined. Prior to this, a “Phase 0”, consisting in a multi-domain and multi-disciplinary background analysis of the problem (i.e.: systematic adoption of innovation to chronic care), was carried out. During phase 1, in order to verify the first hypothesis, a Knowledge Translation Process (KTP) was developed, starting from the JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare was used (Pearson, 2005) and adding Four Innovation Blocks. These blocks represent an enriched description, added to the JBI model, to accelerate the transformation of evidence-healthcare through innovation; the innovation blocks are built on top of the conclusions drawn after Phase 0. The background analysis gave also indication on the materials and methods to be used for the execution of the KTP, carried out during phase 2, that translates the actual best available evidence for chronic care into action: this resulted in a descriptive Framework, which is a description of a model of chronic care (the Chronic Care Model was chosen, Wagner, 1996) in terms of goals, specified requirements and Key Performance Indicators, and articulated in the three development cycles of innovation (i.e. design, implementation and evaluation). Thanks to this result the second hypothesis was verified. During phase 3, in order to verify the third hypothesis, a mixed-method to evaluate multidisciplinary teams working on innovations for chronic care, was created, based on a mixed-method used for the evaluation of Multidisciplinary Translational Teams (Wooden, 2013). This method adds a procedural dimension to the descriptive component of the Framework, The result of this phase consisted in a draft version of the framework, ready to be tested in a real scenario. During phase 4, a single and multilevel case study, with participant-observation data collection, was carried out, in order to have a complete but at the same time multi-sectorial evaluation of the framework. The activities that the LifeStech research group carried out since 2008 to improve the management of diabetes have been selected as case study. The results achieved showed that the framework allowed to improve the research activities in different directions: the quality and quantity of the research publications that LifeStech has issued, have increased substantially; 2 project grants to improve the management of diabetes, have been assigned: the first is a grant funding applied research while the second is about accelerating innovations into the market; by using the assessment KPIs of the framework, the proof of concept validation of a prototype developed in a research project was transformed into an early stage assessment of innovative eHealth intervention for Diabetes Management, which has been recently included in the repository of innovative practice of the European Innovation Partnership on Active and Health Ageing initiative. The verification of the 4 hypotheses lead to verify the main hypothesis of this research work: it is possible to contribute to bridge the gap between healthcare and innovation and, in turn, improve the way chronic care is delivered by healthcare systems.

Autonomous Acquisition of Natural Situated Communication

An important part of human intelligence, both historically and operationally, is our ability to communicate. We learn how to communicate, and maintain our communicative skills, in a society of communicators – a highly effective way to reach and maintain proficiency in this complex skill. Principles that might allow artificial agents to learn language this way are in completely known at present – the multi-dimensional nature of socio-communicative skills are beyond every machine learning framework so far proposed. Our work begins to address the challenge of proposing a way for observation-based machine learning of natural language and communication. Our framework can learn complex communicative skills with minimal up-front knowledge. The system learns by incrementally producing predictive models of causal relationships in observed data, guided by goal-inference and reasoning using forward-inverse models. We present results from two experiments where our S1 agent learns human communication by observing two humans interacting in a realtime TV-style interview, using multimodal communicative gesture and situated language to talk about recycling of various materials and objects. S1 can learn multimodal complex language and multimodal communicative acts, a vocabulary of 100 words forming natural sentences with relatively complex sentence structure, including manual deictic reference and anaphora. S1 is seeded only with high-level information about goals of the interviewer and interviewee, and a small ontology; no grammar or other information is provided to S1 a priori. The agent learns the pragmatics, semantics, and syntax of complex utterances spoken and gestures from scratch, by observing the humans compare and contrast the cost and pollution related to recycling aluminum cans, glass bottles, newspaper, plastic, and wood. After 20 hours of observation S1 can perform an unscripted TV interview with a human, in the same style, without making mistakes.

Characterization and Test of a Data Acquisition System for PET

A small Positron Emission Tomography demonstrator based on LYSO slabs and Silicon Photomultiplier matrices is under construction at the University and INFN of Pisa. In this paper we present the characterization results of the read-out electronics and of the detection system. Two SiPM matrices, composed by 8 × 8 SiPM pixels, 1.5 mm pitch, have been coupled one to one to a LYSO crystals array. Custom Front-End ASICs were used to read the 64 channels of each matrix. Data from each Front-End were multiplexed and sent to a DAQ board for the digital conversion; a motherboard collects the data and communicates with a host computer through a USB port. Specific tests were carried out on the system in order to assess its performance. Futhermore we have measured some of the most important parameters of the system for PET application.

Study of the effect of blurriness in image acquisition for Hand Biometrics in Mobile Devices

This paper presents a study on the effect of blurred images in hand biometrics. Blurred images simulates out-of-focus effects in hand image acquisition, a common consequence of unconstrained, contact-less and platform-free hand biometrics in mobile devices. The proposed biometric system presents a hand image segmentation based on multiscale aggregation, a segmentation method invariant to different changes like noise or blurriness, together with an innovative feature extraction and a template creation, oriented to obtain an invariant performance against blurring effects. The results highlight that the proposed system is invariant to some low degrees of blurriness, requiring an image quality control to detect and correct those images with a high degree of blurriness. The evaluation has considered a synthetic database created based on a publicly available database with 120 individuals. In addition, several biometric techniques could benefit from the approach proposed in this paper, since blurriness is a very common effect in biometric techniques involving image acquisition.

Physical data acquisition and PWM signal generation using a microcontroller allowing control for DC motor rotation speed

El objetivo de este proyecto es diseñar un sistema capaz de controlar la velocidad de rotación de un motor DC en función del valor de temperatura obtenido de un sensor. Para ello se generará con un microcontrolador una señal PWM, cuyo ciclo de trabajo estará en función de la temperatura medida. En lo que respecta a la fase de diseño, hay dos partes claramente diferenciadas, relativas al hardware y al software. En cuanto al diseño del hardware puede hacerse a su vez una división en dos partes. En primer lugar, hubo que diseñar la circuitería necesaria para adaptar los niveles de tensión entregados por el sensor de temperatura a los niveles requeridos por ADC, requerido para digitalizar la información para su posterior procesamiento por parte del microcontrolador. Por tanto hubo que diseñar capaz de corregir el offset y la pendiente de la función tensión-temperatura del sensor, a fin de adaptarlo al rango de tensión requerido por el ADC. Por otro lado, hubo que diseñar el circuito encargado de controlar la velocidad de rotación del motor. Este circuito estará basado en un transistor MOSFET en conmutación, controlado mediante una señal PWM como se mencionó anteriormente. De esta manera, al variar el ciclo de trabajo de la señal PWM, variará de manera proporcional la tensión que cae en el motor, y por tanto su velocidad de rotación. En cuanto al diseño del software, se programó el microcontrolador para que generase una señal PWM en uno de sus pines en función del valor entregado por el ADC, a cuya entrada está conectada la tensión obtenida del circuito creado para adaptar la tensión generada por el sensor. Así mismo, se utiliza el microcontrolador para representar el valor de temperatura obtenido en una pantalla LCD. Para este proyecto se eligió una placa de desarrollo mbed, que incluye el microcontrolador integrado, debido a que facilita la tarea del prototipado. Posteriormente se procedió a la integración de ambas partes, y testeado del sistema para comprobar su correcto funcionamiento. Puesto que el resultado depende de la temperatura medida, fue necesario simular variaciones en ésta, para así comprobar los resultados obtenidos a distintas temperaturas. Para este propósito se empleó una bomba de aire caliente. Una vez comprobado el funcionamiento, como último paso se diseñó la placa de circuito impreso. Como conclusión, se consiguió desarrollar un sistema con un nivel de exactitud y precisión aceptable, en base a las limitaciones del sistema. SUMMARY: It is obvious that day by day people’s daily life depends more on technology and science. Tasks tend to be done automatically, making them simpler and as a result, user life is more comfortable. Every single task that can be controlled has an electronic system behind. In this project, a control system based on a microcontroller was designed for a fan, allowing it to go faster when temperature rises or slowing down as the environment gets colder. For this purpose, a microcontroller was programmed to generate a signal, to control the rotation speed of the fan depending on the data acquired from a temperature sensor. After testing the whole design developed in the laboratory, the next step taken was to build a prototype, which allows future improvements in the system that are discussed in the corresponding section of the thesis.

Outsourcing and acquisition models comparison related to IT supplier selection decision analysis

This paper presents a comparison of acquisition models related to decision analysis of IT supplier selection. The main standards are: Capability Maturity Model Integration for Acquisition (CMMI-ACQ), ISO / IEC 12207 Information Technology / Software Life Cycle Processes, IEEE 1062 Recommended Practice for Software Acquisition, the IT Infrastructure Library (ITIL) and the Project Management Body of Knowledge (PMBOK) guide. The objective of this paper is to compare the previous models to find the advantages and disadvantages of them for the future development of a decision model for IT supplier selection.

Timing performances of a data acquisition system for time of flight PET

We are investigating the performances of a data acquisition system for Time of Flight PET, based on LYSO crystal slabs and 64 channels Silicon Photomultipliers matrices (1.2 cm2 of active area each). Measurements have been performed to test the timing capability of the detection system (SiPM matices coupled to a LYSO slab and the read-out electronics) with both test signal and radioactive source.

Measuring the influence of Cooperative Learning and Project Based Learning on problem solvin skill.

The aim of this study is to evaluate the effects obtained after applying two active learning methodologies (cooperative learning and project based learning) to the achievement of the competence problem solving. This study was carried out at the Technical University of Madrid, where these methodologies were applied to two Operating Systems courses. The first hypothesis tested was whether the implementation of active learning methodologies favours the achievement of ?problem solving?. The second hypothesis was focused on testing if students with higher rates in problem solving competence obtain better results in their academic performance. The results indicated that active learning methodologies do not produce any significant change in the generic competence ?problem solving? during the period analysed. Concerning this, we consider that students should work with these methodologies for a longer period, besides having a specific training. Nevertheless, a close correlation between problem solving self appraisal and academic performance has been detected.

Experiences of spanish public administration in requirements management and acquisition management processes

This paper shows the main contributions of the 1st Symposium on Improvement Process Models and Software Quality of Public Administrations. The obtained results expose the need to promote the implementation of Software Maturity Models and show possible advantages of its application in software processes of Public Administrations. Specifically, it was analyzed the current status in two process areas: Requirements Management and Subcontracting Management.

Improving the capacity of software acquisition management: An Alternative methodology

The acquisition of the information system technologies using the services of an external supplier could be the the best options to reduce the implementation and maintenance cost of software solutions, and allows a company to improve the efficient use of its resources. The focus of this paper is to outline a methodology structure for the software acquisition management. The methodology proposed in this paper is the result of the study and the convergence of the weakness and strengths of some models (CMMI, SA-CMM, ISO/IEC TR 15504, COBIT, and ITIL) that include the software acquisition process.

Atlas-free Brain Tissue Segmentation Using a Single T1-weighted MRI Acquisition

Many studies investigating the aging brain or disease-induced brain alterations rely on accurate and reproducible brain tissue segmentation. Being a preliminary processing step prior to the segmentation, reliableskull-stripping the removal ofnon-brain tissue is also crucial for all later image assessment. Typically, segmentation algorithms rely on an atlas i.e. pre-segmented template data. Brain morphology, however, differs considerably depending on age, sex and race. In addition, diseased brains may deviate significantly from the atlas information typically gained from healthy volunteers. The imposed prior atlas information can thus lead to degradation of segmentation results. The recently introduced MP2RAGE sequence provides a bias-free T1 contrast with heavily reduced T2*- and PD-weighting compared to the standard MP-RAGE [1]. To this end, it acquires two image volumes at different inversion times in one acquisition, combining them to a uniform, i.e. homogenous image. In this work, we exploit the advantageous contrast properties of the MP2RAGE and combine it with a Dixon (i.e. fat-water separation) approach. The information gained by the additional fat image of the head considerably improves the skull-stripping outcome [2]. In conjunction with the pure T1 contrast of the MP2RAGE uniform image, we achieve robust skull-stripping and brain tissue segmentation without the use of an atlas

Analog mitigation of out of band strong interferers in wide band acquisition for multiband HF transmissions

It is clear that in the near future much broader transmissions in the HF band will replace part of the current narrow band links. Our personal view is that a real wide band signal is infeasible in this environment because the usage is typically very intensive and may suffer interferences from all over the world. Therefore, we envision that dynamic multiband transmissions may provide better satisfactory performance. From the very beginning, we observed that real links with our broadband transceiver suffered interferences out of our multiband but within the acquisition bandwidth that degrade the expected performance. Therefore, we concluded that a mitigation structure is required that operates on severely saturated signals as the interference may be of much higher power. In this paper we address a procedure based on Higher Order Crossings (HOC) statistics that are able to extract most of the signal structure in the case where the amplitude is severely distorted and allows the estimation of the interference carrier frequency to command a variable notch filter that mitigates its effect in the analog domain.

Spatial domain mitigation of out of band strong interferers in HF wide band acquisition using analog beamforming principles

We envision that dynamic multiband transmissions taking advantage of the receiver diversity (even for collocated antennas with different polarization or radiation pattern) will create a new paradigm for these links guaranteeing high quality and reliability. However, there are many challenges to face regarding the use of broadband reception where several out of band (with respect to multiband transmission) strong interferers, but still within the acquisition band, may limit dramatically the expected performance. In this paper we address this problem introducing a specific capability of the communication system that is able to mitigate these interferences using analog beamforming principles. Indeed, Higher Order Crossing (HOCs) joint statistics of the Single Input ? Multiple Output (SIMO) system are shown to effectively determine the angle on arrival of the wavefront even operating over highly distorted signals.

Building the qualification and a skill development program within the ENEN-III European Project

The ENEN III project covers the structuring, organization, coordination and implementation of training schemes in cooperation with local, national and international training organizations, to provide training to professionals active in nuclear organizations or their contractors and sub-contractors. The training schemes provide a portfolio of courses, training sessions, seminars, and workshops for continuous learning for upgrading knowledge and developing skills. The training schemes allow individuals to acquire qualifications and skills, as required by the specific positions in the nuclear sector which will be documented in a training passport. The essence of such passport is to be recognized within the EU by the whole nuclear sector which provides mobility to the individual looking for employment and an EU wide recruitment field for the nuclear employers.

Implementation of intelligent data acquisition system for ITER fast controllers using RIO devices.

A basic requirement of the data acquisition systems used in long pulse fusion experiments is the real time physical events detection in signals. Developing such applications is usually a complex task, so it is necessary to develop a set of hardware and software tools that simplify their implementation. This type of applications can be implemented in ITER using fast controllers. ITER is standardizing the architectures to be used for fast controller implementation. Until now the standards chosen are PXIe architectures (based on PCIe) for the hardware and EPICS middleware for the software. This work presents the methodology for implementing data acquisition and pre-processing using FPGA-based DAQ cards and how to integrate these in fast controllers using EPICS.