Unity in diversity: electronic patient record use in multidisciplinary practice

In this paper we examine the use of electronic patient records (EPR) by clinical specialists in their development of multidisciplinary care for diagnosis and treatment of breast cancer. We develop a practice theory lens to investigate EPR use across multidisciplinary team practice. Our findings suggest that there are oppositional tendencies towards diversity in EPR use and unity which emerges across multidisciplinary work, and this influences the outcomes of EPR use. The value of this perspective is illustrated through the analysis of a year-long, longitudinal case study of a multidisciplinary team of surgeons, oncologists, pathologists, radiologists, and nurse specialists adopting a new EPR. Each group adapted their use of the EPR to their diverse specialist practices, but they nonetheless orientated their use of the EPR to each others' practices sufficiently to support unity in multidisciplinary teamwork. Multidisciplinary practice elements were also reconfigured in an episode of explicit negotiations, resulting in significant changes in EPR use within team meetings. Our study contributes to the growing literature that questions the feasibility and necessity of achieving high levels of standardized, uniform health information technology use in healthcare.

Physicians in leadership: the association between medical director involvement and staff-to-patient ratios

In a hospital environment that demands a careful balance between commercial and clinical interests, the extent to which physicians are involved in hospital leadership varies greatly. This paper assesses the influence of the extent of this involvement on staff-to-patient ratios. Using data gathered from 604 hospitals across Germany, this study evidences the positive relationship between a full-time medical director (MD) or heavily involved part-time MD and a higher staff-to-patient ratio. The data allows us to control for a range of confounding variables, such as size, rural/urban location, ownership structure, and case-mix. The results contribute to the sparse body of empirical research on the effect of clinical leadership on organizational outcomes.

A clinical system for three-dimensional extended-field-of-view ultrasound.

OBJECTIVE: This work is concerned with the creation of three-dimensional (3D) extended-field-of-view ultrasound from a set of volumes acquired using a mechanically swept 3D probe. 3D volumes of ultrasound data can be registered by attaching a position sensor to the probe; this can be an inconvenience in a clinical setting. A position sensor can also cause some misalignment due to patient movement and respiratory motion. We propose a combination of three-degrees-of-freedom image registration and an unobtrusively integrated inertial sensor for measuring orientation. The aim of this research is to produce a reliable and portable ultrasound system that is able to register 3D volumes quickly, making it suitable for clinical use. METHOD: As part of a feasibility study we recruited 28 pregnant females attending for routine obstetric scans to undergo 3D extended-field-of-view ultrasound. A total of 49 data sets were recorded. Each registered data set was assessed for correct alignment of each volume by two independent observers. RESULTS: In 77-83% of the data sets more than four consecutive volumes registered. The successful registration relies on good overlap between volumes and is adversely affected by advancing gestational age and foetal movement. CONCLUSION: The development of reliable 3D extended-field-of-view ultrasound may help ultrasound practitioners to demonstrate the anatomical relation of pathology and provide a convenient way to store data.

Stakeholder challenges in purchasing medical devices for patient safety.

OBJECTIVE: This study identifies the stakeholders who have a role in medical device purchasing within the wider system of health-care delivery and reports on their particular challenges to promote patient safety during purchasing decisions. METHODS: Data was collected through observational work, participatory workshops, and semi-structured qualitative interviews, which were analyzed and coded. The study takes a systems-based and engineering design approach to the study. Five hospitals took part in this study, and the participants included maintenance, training, clinical end-users, finance, and risk departments. RESULTS: The main stakeholders for purchasing were identified to be staff from clinical engineering (Maintenance), device users (Clinical), device trainers (Training), and clinical governance for analyzing incidents involving devices (Risk). These stakeholders display varied characteristics in terms of interpretation of their own roles, competencies for selecting devices, awareness and use of resources for purchasing devices, and attitudes toward the purchasing process. The role of "clinical engineering" is seen by these stakeholders to be critical in mediating between training, technical, and financial stakeholders but not always recognized in practice. CONCLUSIONS: The findings show that many device purchasing decisions are tackled in isolation, which is not optimal for decisions requiring knowledge that is currently distributed among different people within different departments. The challenges expressed relate to the wider system of care and equipment management, calling for a more systemic view of purchasing for medical devices.

On the relation of slow feature analysis and Laplacian eigenmaps

The past decade has seen a rise of interest in Laplacian eigenmaps (LEMs) for nonlinear dimensionality reduction. LEMs have been used in spectral clustering, in semisupervised learning, and for providing efficient state representations for reinforcement learning. Here, we show that LEMs are closely related to slow feature analysis (SFA), a biologically inspired, unsupervised learning algorithm originally designed for learning invariant visual representations. We show that SFA can be interpreted as a function approximation of LEMs, where the topological neighborhoods required for LEMs are implicitly defined by the temporal structure of the data. Based on this relation, we propose a generalization of SFA to arbitrary neighborhood relations and demonstrate its applicability for spectral clustering. Finally, we review previous work with the goal of providing a unifying view on SFA and LEMs. © 2011 Massachusetts Institute of Technology.