Practices and views on fetal heart monitoring:A structured observation and interview study

Objective: To assess and explain deviations from recommended practice in National Institute for Clinical Excellence (NICE) guidelines in relation to fetal heart monitoring. Design: Qualitative study. Setting: Large teaching hospital in the UK. Sample: Sixty-six hours of observation of 25 labours and interviews with 20 midwives of varying grades. Methods: Structured observations of labour and semistructured interviews with midwives. Interviews were undertaken using a prompt guide, audiotaped, and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software. Main outcome measures: Deviations from recommended practice in relation to fetal monitoring and insights into why these occur. Results: All babies involved in the study were safely delivered, but 243 deviations from recommended practice in relation to NICE guidelines on fetal monitoring were identified, with the majority (80%) of these occurring in relation to documentation. Other deviations from recommended practice included indications for use of electronic fetal heart monitoring and conduct of fetal heart monitoring. There is evidence of difficulties with availability and maintenance of equipment, and some deficits in staff knowledge and skill. Differing orientations towards fetal monitoring were reported by midwives, which were likely to have impacts on practice. The initiation, management, and interpretation of fetal heart monitoring is complex and distributed across time, space, and professional boundaries, and practices in relation to fetal heart monitoring need to be understood within an organisational and social context. Conclusion: Some deviations from best practice guidelines may be rectified through straightforward interventions including improved systems for managing equipment and training. Other deviations from recommended practice need to be understood as the outcomes of complex processes that are likely to defy easy resolution. © RCOG 2006.

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non- participant observation of meetings and documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process.

The attitudes of students and academic staff towards electronic course support:are we convergent?

The present study investigates the views and attitudes of both the students and staff with regard to the usefulness of electronic course support throughout all four years of the MPharm programme at Aston University. Students were sampled between January and March 2001 using a self-completion questionnaire administered during the start of a practical or tutorial class. All internal academic staff were interviewed using a semi-structured interview format. Response rates were 100 and 89.5%, respectively. The study found that students rapidly embraced the use of electronic course support within the undergraduate programme, although they view its role as augmenting traditional course delivery. This view was mirrored by the academic staff, although only around a half currently place their material on the University's virtual learning environment (VLE), WebCT. The failure of staff to completely embrace the VLE is grounded in a lack of confidence and ability in its use. A majority of the academic staff indicated that they wish to be trained further in the use of information technology. Academic institutions need to understand and meet these needs in parallel with the introduction of any electronic course support.

Joining the dots:using structured e-portfolio assignments to enhance reflection

Although there has been an increased interest in the use of electronic portfolios in higher education over the last five years, relatively little is known about the potential of such tools to support the development of higher order abilities for students, such as reflection, in a structured way that is suitable for assessment. This paper reports the findings from a small-scale research which sets out to compare the outcomes of reflective assignments in two cohorts of participants in a Postgraduate Certificate in Professional Practice in Higher Education in the UK. Participants in the programme were asked to submit reflective accounts using an e-portfolio system as part of their formal assessment. One cohort completed the assessment using some generic guidelines of how to reflect and construct an e-portfolio page without a given template or structure, whereas another cohort was given a specific template with clear assessment criteria to gauge the assembly of their reflections. The authors, who are also tutors in the programme, analysed the submitted reflections following open coding procedures. The analysis found a tendency for the reflection in the first cohort to be merely descriptive without progressing to speculating objectively about answers to relevant analytical questions about the process involved in the ability under scrutiny. In contrast the assignments of cohort two were found to be more insightful in terms of assimilating random bits of materials, thoughts and self-questions into complete reflective accounts. These findings bring some evidence to support and indeed promote a more structured approach to reflective practice, which can be further enhanced through a carefully created e-portfolio template and associated assessment criteria.

Implementing a knowledge management system within an NHS hospital:a case study exploring the roll-out of an Electronic Patient Record (EPR)

This research aims to contribute to understanding the implementation of knowledge management systems (KMS) in the field of health through a case study, leading to theory building and theory extension. We use the concept of the business process approach to knowledge management as a theoretical lens to analyse and explore how a large teaching hospital developed, executed and practically implemented a KMS. A qualitative study was conducted over a 2.5 year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non-participant observation of meetings and documents. The theoretical propositions strategy was used as the overarching approach for data analysis. Our case study provides evidence that true patient centred approaches to supporting care delivery with a KMS benefit from process thinking at both the planning and implementation stages, and an emphasis on the knowledge demands resulting from: the activities along the care pathways; where cross-overs in care occur; and knowledge sharing for the integration of care. The findings also suggest that despite the theoretical awareness of KMS implementation methodologies, the actual execution of such systems requires practice and learning. Flexible, fluid approaches through rehearsal are important and communications strategies should focus heavily on transparency incorporating both structured and unstructured communication methods.

The framework for REVIEWS: an exploration into design principles for an electronic medical early warning system observation chart

The observation chart is for many health professionals (HPs) the primary source of objective information relating to the health of a patient. Information Systems (IS) research has demonstrated the positive impact of good interface design on decision making and it is logical that good observation chart design can positively impact healthcare decision making. Despite the potential for good observation chart design, there is a paucity of observation chart design literature, with the primary source of literature leveraging Human Computer Interaction (HCI) literature to design better charts. While this approach has been successful, this design approach introduces a gap between understanding of the tasks performed by HPs when using charts and the design features implemented in the chart. Good IS allow for the collection and manipulation of data so that it can be presented in a timely manner that support specific tasks. Good interface design should therefore consider the specific tasks being performed prior to designing the interface. This research adopts a Design Science Research (DSR) approach to formalise a framework of design principles that incorporates knowledge of the tasks performed by HPs when using observation charts and knowledge pertaining to visual representations of data and semiology of graphics. This research is presented in three phases, the initial two phases seek to discover and formalise design knowledge embedded in two situated observation charts: the paper-based NEWS chart developed by the Health Service Executive in Ireland and the electronically generated eNEWS chart developed by the Health Information Systems Research Centre in University College Cork. A comparative evaluation of each chart is also presented in the respective phases. Throughout each of these phases, tentative versions of a design framework for electronic vital sign observation charts are presented, with each subsequent iteration of the framework (versions Alpha, Beta, V0.1 and V1.0) representing a refinement of the design knowledge. The design framework will be named the framework for the Retrospective Evaluation of Vital Sign Information from Early Warning Systems (REVIEWS). Phase 3 of the research presents the deductive process for designing and implementing V0.1 of the framework, with evaluation of the instantiation allowing for the final iteration V1.0 of the framework. This study makes a number of contributions to academic research. First the research demonstrates that the cognitive tasks performed by nurses during clinical reasoning can be supported through good observation chart design. Secondly the research establishes the utility of electronic vital sign observation charts in terms of supporting the cognitive tasks performed by nurses during clinical reasoning. Third the framework for REVIEWS represents a comprehensive set of design principles which if applied to chart design will improve the usefulness of the chart in terms of supporting clinical reasoning. Fourth the electronic observation chart that emerges from this research is demonstrated to be significantly more useful than previously designed charts and represents a significant contribution to practice. Finally the research presents a research design that employs a combination of inductive and deductive design activities to iterate on the design of situated artefacts.

Preparation and characterization of Pr0.6Sr0.4FeO3-δ-Ce0.9Pr0.1O2-δ nanofiber structured composite cathode for IT-SOFCs

In this work, Pr_0.6Sr_0.4FeO_3-δ -Ce_0.9Pr_0.1O_2-δ (PSFO-CPO) nanofibers were synthesized by a one-step electrospin technique for use in intermediate-temperature solid oxide fuel cell (IT-SOFC) applications. PSFO-CPO nanofibers were produced with a diameter of about 100nm and lengths exceeding tens of microns. The thermal expansion coefficient (TEC) matches with standard GDC electrolytes and the resulting conductivity also satisfies the needs of IT-SOFCs cathodes. EIS analysis of the nanofiber structured electrode gives a polarization resistance of 0.072Ωcm² at 800°C, smaller than that from the powdered cathode with the same composition. The excellent electrochemical performance can be attributed to the well-constructed microstructure of the nanofiber structured cathode, which promotes surface oxygen diffusion and charge transfer processes. All the results imply that the one-step electrospin method is a facile and practical way of improving the cathode properties and that PSFO-CPO is a promising cathode material for IT-SOFCs.

Interface-mediated ferroelectric patterning and Mn valency in nano-structured PbTiO3/La0.7Sr0.3MnO3

We employed a multitechnique approach using piezo-force response microscopy and photoemission microscopy to investigate a self-organizing polarization domain pattern in PbTiO3/La0.7Sr0.3MnO3 (PTO/LSMO) nanostructures. The polarization is correlated with the nanostructure morphology as well as with the thickness and Mn valence of the LSMO template layer. On the LSMO dots, the PTO is upwards polarized, whereas outside the nanodots, the polarization appears both strain and interface roughness dependent. The results suggest that the electronic structure and strain of the PTO/LSMO interface contribute to determining the internal bias of the ferroelectric layer.

Validation of Electronic Health Record Phenotyping of Bipolar Disorder Cases and Controls

Objective: The study was designed to validate use of elec-tronic health records (EHRs) for diagnosing bipolar disorder and classifying control subjects. Method: EHR data were obtained from a health care system of more than 4.6 million patients spanning more than 20 years. Experienced clinicians reviewed charts to identify text features and coded data consistent or inconsistent with a diagnosis of bipolar disorder. Natural language processing was used to train a diagnostic algorithm with 95% specificity for classifying bipolar disorder. Filtered coded data were used to derive three additional classification rules for case subjects and one for control subjects. The positive predictive value (PPV) of EHR-based bipolar disorder and subphenotype di- agnoses was calculated against diagnoses from direct semi- structured interviews of 190 patients by trained clinicians blind to EHR diagnosis. Results: The PPV of bipolar disorder defined by natural language processing was 0.85. Coded classification based on strict filtering achieved a value of 0.79, but classifications based on less stringent criteria performed less well. No EHR- classified control subject received a diagnosis of bipolar dis- order on the basis of direct interview (PPV=1.0). For most subphenotypes, values exceeded 0.80. The EHR-based clas- sifications were used to accrue 4,500 bipolar disorder cases and 5,000 controls for genetic analyses. Conclusions: Semiautomated mining of EHRs can be used to ascertain bipolar disorder patients and control subjects with high specificity and predictive value compared with diagnostic interviews. EHRs provide a powerful resource for high-throughput phenotyping for genetic and clinical research.

Separate compilation of structured documents

This paper draws a parallel between document preparation and the traditional processes of compilation and link editing for computer programs. A block-based document model is described which allows for separate compilation of various portions of a document. These portions are brought together and merged by a linker program, called dlink, whose pilot implementation is based on ditroff and on its underlying intermediate code. In the light of experiences with dlink the requirements for a universal object-module language for documents are discussed. These requirements often resemble the characteristics of the intermediate codes used by programming-language compilers but with interesting extra constraints which arise from the way documents are executed .

Towards structured, block-based PDF

The Portable Document Format (PDF), defined by Adobe Systems Inc. as the basis of its Acrobat product range, is discussed in some detail. Particular emphasis is given to its flexible object-oriented structure, which has yet to be fully exploited. It is currently used to represent not logical structure but simply a series of pages and associated resources. A definition of an Encapsulated PDF (EPDF) is presented, in which EPDF blocks carry with them their own resource requirements, together with geometrical and logical information. A block formatter called Juggler is described which can lay out EPDF blocks from various sources onto new pages. Future revisions of PDF supporting uniquely-named EPDF blocks tagged with semantic information would assist in composite-pagemakeup and could even lead to fully revisable PDF.

Enhancing the Availability of Electronic Health Records for Secondary Purposes – A Case Study

Due to the sensitive nature of patient data, the secondary use of electronic health records (EHR) is restricted in scientific research and product development. Such restrictions pursue to preserve the privacy of respective patients by limiting the availability and variety of sensitive patient data. Current limitations do not correspond with the actual needs requested by the potential secondary users. In this thesis, the secondary use of Finnish and Swedish EHR data is explored for the purpose of enhancing the availability of such data for clinical research and product development. Involved EHR-related procedures and technologies are analysed to identify the issues limiting the secondary use of patient data. Successful secondary use of patient data increases the data value. To explore the identified circumstances, a case study of potential secondary users and use intentions regarding EHR data was carried out in Finland and Sweden. The data collection for the conducted case study was performed using semi-structured interviews. In total, 14 Finnish and Swedish experts representing scientific research, health management, and business were interviewed. The motivation for the corresponding interviews was to evaluate the protection of EHR data used for secondary purposes. The efficiency of implemented procedures and technologies was analysed in terms of data availability and privacy preserving. The results of the conducted case study show that the factors affecting EHR availability are divided to three categories: management of patient data, preservation of patients' privacy, and potential secondary users. Identified issues regarding data management included laborious and inconsistent data request procedures and the role and effect of external service providers. Based on the study findings, two secondary use approaches enabling the secondary use of EHR data are identified: data alteration and protected processing environment. Data alteration increases the availability of relevant EHR data, further decreasing the value of such data. Protected processing approach restricts the amount of potential users and use intentions while providing more valuable data content.

Query routing in cooperative semi-structured peer-to-peer information retrieval networks

Conventional web search engines are centralised in that a single entity crawls and indexes the documents selected for future retrieval, and the relevance models used to determine which documents are relevant to a given user query. As a result, these search engines suffer from several technical drawbacks such as handling scale, timeliness and reliability, in addition to ethical concerns such as commercial manipulation and information censorship. Alleviating the need to rely entirely on a single entity, Peer-to-Peer (P2P) Information Retrieval (IR) has been proposed as a solution, as it distributes the functional components of a web search engine – from crawling and indexing documents, to query processing – across the network of users (or, peers) who use the search engine. This strategy for constructing an IR system poses several efficiency and effectiveness challenges which have been identified in past work. Accordingly, this thesis makes several contributions towards advancing the state of the art in P2P-IR effectiveness by improving the query processing and relevance scoring aspects of a P2P web search. Federated search systems are a form of distributed information retrieval model that route the user’s information need, formulated as a query, to distributed resources and merge the retrieved result lists into a final list. P2P-IR networks are one form of federated search in routing queries and merging result among participating peers. The query is propagated through disseminated nodes to hit the peers that are most likely to contain relevant documents, then the retrieved result lists are merged at different points along the path from the relevant peers to the query initializer (or namely, customer). However, query routing in P2P-IR networks is considered as one of the major challenges and critical part in P2P-IR networks; as the relevant peers might be lost in low-quality peer selection while executing the query routing, and inevitably lead to less effective retrieval results. This motivates this thesis to study and propose query routing techniques to improve retrieval quality in such networks. Cluster-based semi-structured P2P-IR networks exploit the cluster hypothesis to organise the peers into similar semantic clusters where each such semantic cluster is managed by super-peers. In this thesis, I construct three semi-structured P2P-IR models and examine their retrieval effectiveness. I also leverage the cluster centroids at the super-peer level as content representations gathered from cooperative peers to propose a query routing approach called Inverted PeerCluster Index (IPI) that simulates the conventional inverted index of the centralised corpus to organise the statistics of peers’ terms. The results show a competitive retrieval quality in comparison to baseline approaches. Furthermore, I study the applicability of using the conventional Information Retrieval models as peer selection approaches where each peer can be considered as a big document of documents. The experimental evaluation shows comparative and significant results and explains that document retrieval methods are very effective for peer selection that brings back the analogy between documents and peers. Additionally, Learning to Rank (LtR) algorithms are exploited to build a learned classifier for peer ranking at the super-peer level. The experiments show significant results with state-of-the-art resource selection methods and competitive results to corresponding classification-based approaches. Finally, I propose reputation-based query routing approaches that exploit the idea of providing feedback on a specific item in the social community networks and manage it for future decision-making. The system monitors users’ behaviours when they click or download documents from the final ranked list as implicit feedback and mines the given information to build a reputation-based data structure. The data structure is used to score peers and then rank them for query routing. I conduct a set of experiments to cover various scenarios including noisy feedback information (i.e, providing positive feedback on non-relevant documents) to examine the robustness of reputation-based approaches. The empirical evaluation shows significant results in almost all measurement metrics with approximate improvement more than 56% compared to baseline approaches. Thus, based on the results, if one were to choose one technique, reputation-based approaches are clearly the natural choices which also can be deployed on any P2P network.

Charge accumulation and transport in degenerately doped semiconducting polymers with mixed ionic and electronic conductivity

This thesis is part of the fields of Material Physics and Organic Electronics and aims to determine the charge carrier density and mobility in the hydrated conducting polymer–polyelectrolyte blend PEDOT:PSS. This kind of material combines electronic semiconductor functionality with selective ionic transport, biocompatibility and electrochemical stability in water. This advantageous material properties combination makes PEDOT:PSS a unique material to build organic electrochemical transistors (OECTs), which have relevant application as amplifying transducers for bioelectronic signals. In order to measure charge carrier density and mobility, an innovative 4-wire, contact independent characterization technique was introduced, the electrolyte-gated van der Pauw (EgVDP) method, which was combined with electrochemical impedance spectroscopy. The technique was applied to macroscopic thin film samples and micro-structured PEDOT:PSS thin film devices fabricated using photolithography. The EgVDP method revealed to be effective for the measurements of holes’ mobility in hydrated PEDOT:PSS thin films, which resulted to be <μ>=(0.67±0.02) cm^2/(V*s). By comparing this result with 2-point-probe measurements, we found that contact resistance effects led to a mobility overestimation in the latter. Ion accumulation at the drain contact creates a gate-dependent potential barrier and is discussed as a probable reason for the overestimation in 2-point-probe measurements. The measured charge transport properties of PEDOT:PSS were analyzed in the framework of an extended drift-diffusion model. The extended model fits well also to the non-linear response in the transport characterization and results suggest a Gaussian DOS for PEDOT:PSS. The PEDOT:PSS-electrolyte interface capacitance resulted to be voltage-independent, confirming the hypothesis of its morphological origin, related to the separation between the electronic (PEDOT) and ionic (PSS) phases in the blend.

Electronic And Structural Study Of Pt-modified Au Vicinal Surfaces: A Model System For Pt-au Catalysts.

Two single crystalline surfaces of Au vicinal to the (111) plane were modified with Pt and studied using scanning tunneling microscopy (STM) and X-ray photoemission spectroscopy (XPS) in ultra-high vacuum environment. The vicinal surfaces studied are Au(332) and Au(887) and different Pt coverage (θPt) were deposited on each surface. From STM images we determine that Pt deposits on both surfaces as nanoislands with heights ranging from 1 ML to 3 ML depending on θPt. On both surfaces the early growth of Pt ad-islands occurs at the lower part of the step edge, with Pt ad-atoms being incorporated into the steps in some cases. XPS results indicate that partial alloying of Pt occurs at the interface at room temperature and at all coverage, as suggested by the negative chemical shift of Pt 4f core line, indicating an upward shift of the d-band center of the alloyed Pt. Also, the existence of a segregated Pt phase especially at higher coverage is detected by XPS. Sample annealing indicates that the temperature rise promotes a further incorporation of Pt atoms into the Au substrate as supported by STM and XPS results. Additionally, the catalytic activity of different PtAu systems reported in the literature for some electrochemical reactions is discussed considering our findings.