Assessing the motivation of MDs to use computer-based support at the point-of-care in the emergency department

A significant body of research investigates the acceptance of computer-based support (including devices and applications ranging from e-mail to specialized clinical systems, like PACS) among clinicians. Much of this research has focused on measuring the usability of systems using characteristics related to the clarity of interactions and ease of use. We propose that an important attribute of any clinical computer-based support tool is the intrinsic motivation of the end-user (i.e. a clinician) to use the system in practice. In this paper we present the results of a study that investigated factors motivating medical doctors (MDs) to use computer-based support. Our results demonstrate that MDs value computer-based support, find it useful and easy to use, however, uptake is hindered by perceived incompetence, and pressure and tension associated with using technology.

A concept-based framework for retrieving evidence to support emergency physician decision making at the point of care

The goal of evidence-based medicine is to uniformly apply evidence gained from scientific research to aspects of clinical practice. In order to achieve this goal, new applications that integrate increasingly disparate health care information resources are required. Access to and provision of evidence must be seamlessly integrated with existing clinical workflow and evidence should be made available where it is most often required - at the point of care. In this paper we address these requirements and outline a concept-based framework that captures the context of a current patient-physician encounter by combining disease and patient-specific information into a logical query mechanism for retrieving relevant evidence from the Cochrane Library. Returned documents are organized by automatically extracting concepts from the evidence-based query to create meaningful clusters of documents which are presented in a manner appropriate for point of care support. The framework is currently being implemented as a prototype software agent that operates within the larger context of a multi-agent application for supporting workflow management of emergency pediatric asthma exacerbations. © 2008 Springer-Verlag Berlin Heidelberg.

Clinical decision support system for point of care use: ontology driven design and software implementation

OBJECTIVES: The objective of this research was to design a clinical decision support system (CDSS) that supports heterogeneous clinical decision problems and runs on multiple computing platforms. Meeting this objective required a novel design to create an extendable and easy to maintain clinical CDSS for point of care support. The proposed solution was evaluated in a proof of concept implementation. METHODS: Based on our earlier research with the design of a mobile CDSS for emergency triage we used ontology-driven design to represent essential components of a CDSS. Models of clinical decision problems were derived from the ontology and they were processed into executable applications during runtime. This allowed scaling applications' functionality to the capabilities of computing platforms. A prototype of the system was implemented using the extended client-server architecture and Web services to distribute the functions of the system and to make it operational in limited connectivity conditions. RESULTS: The proposed design provided a common framework that facilitated development of diversified clinical applications running seamlessly on a variety of computing platforms. It was prototyped for two clinical decision problems and settings (triage of acute pain in the emergency department and postoperative management of radical prostatectomy on the hospital ward) and implemented on two computing platforms-desktop and handheld computers. CONCLUSIONS: The requirement of the CDSS heterogeneity was satisfied with ontology-driven design. Processing of application models described with the help of ontological models allowed having a complex system running on multiple computing platforms with different capabilities. Finally, separation of models and runtime components contributed to improved extensibility and maintainability of the system.

Automatic indexing and retrieval of encounter-specific evidence for point-of-care support

Evidence-based medicine relies on repositories of empirical research evidence that can be used to support clinical decision making for improved patient care. However, retrieving evidence from such repositories at local sites presents many challenges. This paper describes a methodological framework for automatically indexing and retrieving empirical research evidence in the form of the systematic reviews and associated studies from The Cochrane Library, where retrieved documents are specific to a patient-physician encounter and thus can be used to support evidence-based decision making at the point of care. Such an encounter is defined by three pertinent groups of concepts - diagnosis, treatment, and patient, and the framework relies on these three groups to steer indexing and retrieval of reviews and associated studies. An evaluation of the indexing and retrieval components of the proposed framework was performed using documents relevant for the pediatric asthma domain. Precision and recall values for automatic indexing of systematic reviews and associated studies were 0.93 and 0.87, and 0.81 and 0.56, respectively. Moreover, precision and recall for the retrieval of relevant systematic reviews and associated studies were 0.89 and 0.81, and 0.92 and 0.89, respectively. With minor modifications, the proposed methodological framework can be customized for other evidence repositories. © 2010 Elsevier Inc.

Fibre optics sensors in tear electrolyte analysis:towards a novel point of care potassium sensor

The diagnosis of ocular disease is increasingly important in optometric practice and there is a need for cost effective point of care assays to assist in that. Although tears are a potentially valuable source of diagnostic information difficulties associated with sample collection and limited sample size together with sample storage and transport have proved major limitations. Progressive developments in electronics and fibre optics together with innovation in sensing technology mean that the construction of inexpensive point of care fibre optic sensing devices is now possible. Tear electrolytes are an obvious family of target analytes, not least to complement the availability of devices that make the routine measurement of tear osmolarity possible in the clinic. In this paper we describe the design, fabrication and calibration of a fibre-optic based electrolyte sensor for the quantification of potassium in tears using the ex vivo contact lens as the sample source. The technology is generic and the same principles can be used in the development of calcium and magnesium sensors. An important objective of this sensor technology development is to provide information at the point of routine optometric examination, which would provide supportive evidence of tear abnormality.

Medicines reconciliation at the point of hospital discharge for children

Objectives: Hospital discharge is a transition of care, where medication discrepancies are likely to occur and potentially cause patient harm. The purpose of our study was to assess the prescribing accuracy of hospital discharge medication orders at a London, UK teaching hospital. The timeliness of the discharge summary reaching the general practitioner (GP, family physician) was also assessed based on the 72 h target referenced in the Care Quality Commission report.1 Method: 501 consecutive discharge medication orders from 142 patients were examined and the following records were compared (1) the final inpatient drug chart at the point of discharge, (2) printed signed copy of the initial to take away (TTA) discharge summary produced electronically by the physician, (3) the pharmacist's amendments on the initial TTA that were hand written, (4) the final electronic patient discharge summary record, (5) the patients final take home medication from the hospital. Discrepancies between the physician's order (6) and pharmacist's change(s) (7) were compared with two types of failures – ‘failure to make a required change’ and ‘change where none was required’. Once the patient was discharged, the patient's GP, was contacted 72 h after discharge to see if the patient discharge summary, sent by post or via email, was received. Results: Over half the patients seen (73 out of 142) patients had at least one discrepancy that was made on the initial TTA by the doctor and amended by the pharmacist. Out of the 501 drugs, there were 140 discrepancies, 108 were ‘failures to make a required change’ (77%) and 32 were ‘changes where none were required’ (23%). The types of ‘failures to make required changes’ discrepancies that were found between the initial TTA and pharmacist's amendments were paracetamol and ibuprofen changes (dose banding) 38 (27%), directions of use 34 (24%), incorrect formulation of medication 28 (20%) and incorrect strength 8 (6%). The types of ‘changes where none were required discrepancies’ were omitted medication 15 (11%), unnecessary drug 14 (10%) and incorrect medicine including spelling mistakes 3 (2%). After contacting the GPs of the discharged patients 72 h postdischarge; 49% had received the discharge summary and 45% had not, the remaining 6% were patients who were discharged without a GP. Conclusion: This study shows that doctor prescribing at discharge is often not accurate, and interventions made by pharmacist to reconcile are important at this point of care. It was also found that half the discharge summaries had not reached the patient's family physician (according to the GP) within 72 h.

A composite framework for the strategic alignment of information systems development

Information systems are corporate resources, therefore information systems development must be aligned with corporate strategy. This thesis proposes that effective strategic alignment of information systems requires information systems development, information systems planning and strategic management to be united. Literature in these areas is examined, breaching the academic boundaries which separate these areas, to contribute a synthesised approach to the strategic alignment of information systems development. Previous work in information systems planning has extended information systems development techniques, such as data modelling, into strategic planning activities, neglecting techniques of strategic management. Examination of strategic management in this thesis, identifies parallel trends in strategic management and information systems development; the premises of the learning school of strategic management are similar to those of soft systems approaches to information systems development. It is therefore proposed that strategic management can be supported by a soft systems approach. Strategic management tools and techniques frame individual views of a strategic situation; soft systems approaches can integrate these diverse views to explore the internal and external environments of an organisation. The information derived from strategic analysis justifies the need for an information system and provides a starting point for information systems development. This is demonstrated by a composite framework which enables each information system to be justified according to its direct contribution to corporate strategy. The proposed framework was developed through action research conducted in a number of organisations of varying types. This suggests that the framework can be widely used to support the strategic alignment of information systems development, thereby contributing to organisational success.

A Generic model for the design and analysis of production systems

This dissertation studies the process of operations systems design within the context of the manufacturing organization. Using the DRAMA (Design Routine for Adopting Modular Assembly) model as developed by a team from the IDOM Research Unit at Aston University as a starting point, the research employed empirically based fieldwork and a survey to investigate the process of production systems design and implementation within four UK manufacturing industries: electronics assembly, electrical engineering, mechanical engineering and carpet manufacturing. The intention was to validate the basic DRAMA model as a framework for research enquiry within the electronics industry, where the initial IDOM work was conducted, and then to test its generic applicability, further developing the model where appropriate, within the other industries selected. The thesis contains a review of production systems design theory and practice prior to presenting thirteen industrial case studies of production systems design from the four industry sectors. The results and analysis of the postal survey into production systems design are then presented. The strategic decisions of manufacturing and their relationship to production systems design, and the detailed process of production systems design and operation are then discussed. These analyses are used to develop the generic model of production systems design entitled DRAMA II (Decision Rules for Analysing Manufacturing Activities). The model contains three main constituent parts: the basic DRAMA model, the extended DRAMA II model showing the imperatives and relationships within the design process, and a benchmark generic approach for the design and analysis of each component in the design process. DRAMA II is primarily intended for use by researchers as an analytical framework of enquiry, but is also seen as having application for manufacturing practitioners.

Typical case behaviour of spin systems in random graph and composite ensembles

This thesis includes analysis of disordered spin ensembles corresponding to Exact Cover, a multi-access channel problem, and composite models combining sparse and dense interactions. The satisfiability problem in Exact Cover is addressed using a statistical analysis of a simple branch and bound algorithm. The algorithm can be formulated in the large system limit as a branching process, for which critical properties can be analysed. Far from the critical point a set of differential equations may be used to model the process, and these are solved by numerical integration and exact bounding methods. The multi-access channel problem is formulated as an equilibrium statistical physics problem for the case of bit transmission on a channel with power control and synchronisation. A sparse code division multiple access method is considered and the optimal detection properties are examined in typical case by use of the replica method, and compared to detection performance achieved by interactive decoding methods. These codes are found to have phenomena closely resembling the well-understood dense codes. The composite model is introduced as an abstraction of canonical sparse and dense disordered spin models. The model includes couplings due to both dense and sparse topologies simultaneously. The new type of codes are shown to outperform sparse and dense codes in some regimes both in optimal performance, and in performance achieved by iterative detection methods in finite systems.

The effect of care solutions on the bulk and surface properties of soft contact lenses

Purpose: Soft contact lenses for continuous wear require the use of cleaning regimes which utilise hydrogen peroxide systems or multipurpose cleaning solutions (MPS). The compositions of MPS are becoming increasingly complex and often include disinfectants, cleaning agents, preservatives, wetting agents, demulcents, chelating and buffering agents. Recent research on solution–lens interactions has focused on specific ocular parameters such as corneal staining. However the effect of a solution on the lens, particularly silicone hydrogel lenses, itself has received less attention. The purpose of this work was to establish and understand the effects that care solutions have on selected bulk and surface material properties. Methods: Selected bulk and surface properties of each material (etafilcon A, vifilcon A, balafilcon A, senofilcon A, lotrafilcon A and lotrafilcon B, galyfilcon A) were measured after a 24 h soak in a variety of care solutions. Additionally the lenses were soaked for 24 h in hyperosmolar (680 mOsm L-1) and hyposmolar (170 mOsm L-1) PBS. A bulk property parameter the total diameter (TD) was measured using an Optimec contact lens analyser. The surface property related CoF of soaked lenses was measured on a nano-tribometer with conditions of load 30 mN, at a distance of 20 mm and speed 30 mm/min. Results: In terms of bulk properties, change is related to the EWC of the lens, the higher the EWC of the lens the greater the TD changes. Silicone hydrogel lenses have EWCs of <47% and little or no TD changes were observed; lotrafilcon A exhibited no change irrespective of the cleaning solution. Conventional contact lenses have higher EWCs (58% for etafilcon A and 55% for vifilcon A) and the TD was seen to change to a greater extent, for example the etafilcon A material in ReNu MPS had an increase to 14.45± 0.07 mm from the cited 14.2 mm. Other lenses increased or decreased in TD depending on the solution used. The osmolarity of the solution although important is not the only factor governing change in the TD, for example soaking senofilcon A in hyperosmolar PBS (680 mOsm L-1) for 24 h increased the TD of the lens (+0.25 ± 0.07 mm), however when the same lens type was soaked for 24 h in a MPS with a lower osmolarity there was a similar effect. Biotribology measurements demonstrated that some solution–lens combinations can reduce the CoF by 55%, when compared with biotribology with the native packing solution. An increase in the CoF was observed for other solution–lens combinations. Conclusions: There is a dramatic difference in bulk and surface performance of specific lens materials with particular care solutions. Individual components of the care solutions have effects on the bulk and surface properties of contact lenses. The affects are not as great with the silicone hydrogel as compared with conventional hydrogels.

The move to servitization (from a product service system point of view)

Product Service Systems (PSSs) emphasize the substitution of products with services. The term “Servitisation” was introduced by Sandra Vendermerwe in the 80s to represent the addition of services to increase a company’s competitive edge. Key to PSS, and Servitisation more generally, is the “informated product”. The informated product enables health monitoring of the product in use and can be key to a workable PSS. This paper reviews the evolution of servitisation and the associated business benefit. It also then reviews the concept of informated product reconfiguration techniques and remote services that enables PSS to be delivered.

Integration of a 3D hydrogel matrix within a hollow core photonic crystal fibre for DNA probe immobilization

In this paper, we demonstrate the integration of a 3D hydrogel matrix within a hollow core photonic crystal fibre (HC-PCF). In addition, we also show the fluorescence of Cy5-labelled DNA molecules immobilized within the hydrogel formed in two different types of HC-PCF. The 3D hydrogel matrix is designed to bind with the amino groups of biomolecules using an appropriate cross-linker, providing higher sensitivity and selectivity than the standard 2D coverage, enabling a greater number of probe molecules to be available per unit area. The HC-PCFs, on the other hand, can be designed to maximize the capture of fluorescence to improve sensitivity and provide longer interaction lengths. This could enable the development of fibre-based point-of-care and remote systems, where the enhanced sensitivity would relax the constraints placed on sources and detectors. In this paper, we will discuss the formation of such polyethylene glycol diacrylate (PEGDA) hydrogels within a HC-PCF, including their optical properties such as light propagation and auto-fluorescence.

An analysis of the role of soft systems methodology in the change process and the contribution of the facilitator within this process

This research aims to examine the effectiveness of Soft Systems Methodology (SSM) to enable systemic change within local goverment and local NHS environments and to examine the role of the facilitator within this process. Checkland's Mode 2 variant of Soft Systems Methodology was applied on an experimental basis in two environments, Herefordshire Health Authority and Sand well Health Authority. The Herefordshire application used SSM in the design of an Integrated Care Pathway for stroke patients. In Sandwell, SSM was deployed to assist in the design of an Infonnation Management and Technology (IM&T) Strategy for the boundary-spanning Sandwell Partnership. Both of these environments were experiencing significant organisational change as the experiments unfurled. The explicit objectives of the research were: To examine the evolution and development of SSM and to contribute to its further development. To apply the Soft Systems Methodology to change processes within the NHS. To evaluate the potential role of SSM in this wider process of change. To assess the role of the researcher as a facilitator within this process. To develop a critical framework through which the impact of SSM on change might be understood and assessed. In developing these objectives, it became apparent that there was a gap in knowledge relating to SSM. This gap concerns the evaluation of the role of the approach in the change process. The case studies highlighted issues in stakeholder selection and management; the communicative assumptions in SSM; the ambiguous role of the facilitator; and the impact of highly politicised problem environments on the effectiveness of the methodology in the process of change. An augmented variant on SSM that integrates an appropriate (social constructivist) evaluation method is outlined, together with a series of hypotheses about the operationalisation of this proposed method.