•Computerized screening tools support clinicians in reducing inappropriate prescribing.•STOPP/START criteria were converted into coded algorithms modeled as inference rules.•Multidisciplinary ...consensus facilitates universal interpretation of ambiguous criteria.
The rapid digitalization of medical practice has attracted growing interest in developing software applications for clinical guidelines and explicit screening tools to detect potentially inappropriate prescribing, such as STOPP/START criteria. The aim of the current study was to develop and provide logically unambiguous algorithms of STOPP/START criteria version 2, encoded with international disease and medication classification codes, to facilitate the development of software applications for multiple purposes.
A four round multidisciplinary consensus and validation procedure was conducted to develop implementable coded algorithms for software applications of STOPP/START criteria version 2, based on ICD, ICPC, LOINC and ATC classification databases.
Consensus was reached for all 34 START criteria and 76 out of 80 STOPP criteria. The resulting 110 algorithms, modeled as inference rules in decision tables, are provided as supplementary data.
This is the first study providing implementable algorithms for software applications based on STOPP/START version 2, validated in a computer decision support system. These algorithms could serve as a template for applying STOPP/START criteria version 2 to any software application, allowing for adaptations of the included ICD, ICPC and ATC codes and changing the cut-off levels for laboratory measurements to match local guidelines or clinical expertise.
To determine if implementing attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment guidelines in a clinical decision support system would result in better care, including higher ...rates of adherence to clinical care guidelines.
We conducted a cluster randomized controlled trial in which we compared diagnosis and management of ADHD in 6- to 12-year-olds after implementation of a computer decision support system in 4 practices.
Eighty-four charts were reviewed. In the control group, the use of structured diagnostic assessments dropped from 50% in the baseline period to 38% in the intervention period. In the intervention group, however, it rose from 60% to 81%. This difference was statistically significant, even after controlling for age, gender, and race (odds ratio of structured diagnostic assessment in intervention group versus control group = 8.0, 95% confidence interval 1.6-40.6). Significant differences were also seen in the number of ADHD core symptoms noted at the time of diagnosis. Our study was not powered to detect changes in care and management, but the percent of patients who had documented medication adjustments, mental health referrals, and visits to mental health specialists were higher in the intervention group than the control.
The introduction of a clinical decision support module resulted in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. Future work will examine how to further develop the ADHD module and add support for other chronic conditions.
Chronic kidney disease (CKD) is common. A small proportion of patients with CKD progress to require interventions, which may include dialysis. Monitoring patients with CKD is supported by national ...guidelines. Monitoring systems to plan management of CKD vary in form. A novel monitoring system, the virtual CKD clinic (VC) was introduced at our hospital. The VC is a non-face-to-face results review of patients with CKD. We found that the VC was an effective monitoring system. None of the patients from the VC required emergency dialysis, suggesting robust surveillance. Survival was similar to patients with CKD discharged to primary care.
Purpose
The purpose of this paper is to explore the human work entailed in the deployment of digital health care technology. It draws on imagined configurations of computers and machines in fiction ...and social science to think about the relationship between technology and people, and why this makes implementation of digital technology so difficult. The term hubots is employed as a metaphorical device to examine how machines and humans come together to do the work of healthcare.
Design/methodology/approach
This paper uses the fictional depiction of hubots to reconceptualise the deployment of a particular technology – a computer decision support system (CDSS) used in emergency and urgent care services. Data from two ethnographic studies are reanalysed to explore the deployment of digital technologies in health services. These studies used comparative mixed-methods case study approaches to examine the use of the CDSS in eight different English NHS settings. The data include approximately 900 hours of observation, with 64 semi-structured interviews, 47 focus groups, and surveys of some 700 staff in call centres and urgent care centres. The paper reanalyses these data, deductively, using the metaphor of the hubot as an analytical device.
Findings
This paper focuses on the interconnected but paradoxical features of both the fictional hubots and the CDSS. Health care call handling using a CDSS has created a new occupation, and enabled the substitution of some clinical labour. However, at the same time, the introduction of the technology has created additional work. There are more tasks, both physical and emotional, and more training activity is required. Thus, the labour has been intensified.
Practical implications
This paper implies that if we want to realise the promise of digital health care technologies, we need to understand that these technologies substitute for and intensify labour.
Originality/value
This is a novel analysis using a metaphor drawn from fiction. This allows the authors to recognise the human effort required to implement digital technologies.
Adverse Drug Events (ADE) due to medication errors and human factors are a major public health issue. They endanger patient safety and cause considerable extra healthcare costs. The European project ...PSIP (Patient Safety through Intelligent Procedures in medication) aims to identify and prevent ADE. Data mining of the structured hospital data bases will give a list of observed ADE with frequencies and probabilities, thereby giving a better understanding of potential risks. The main objective of the project is to develop innovative knowledge based on the mining results and to deliver to professionals and patients, in the form of alerts and decision support functions, a contextualized knowledge fitting the local risk parameters.
This paper presents the information about the statistical process control (SPC) procedures that can be found in the international ISO standards. When there is a need to design more effective ...procedures, the computer decision support system, which is developed under the framework of COPERNICUS CP93:12074 project by the team of specialists from Germany and Poland, can be used.
La pneumopathie médicamenteuse (PM), souvent évoquée, reste un diagnostic difficile car les médicaments pneumotoxiques sont nombreux, la clinique est hétérogène, et il n’y a pas de critère ...diagnostique formel. PneumoDoc est un système informatisé qui propose une formalisation de la démarche diagnostique du pneumologue devant un tableau évocateur sur la base d’arguments chronologiques, sémiologiques, d’imagerie et cytologiques (lavage broncho-alvéolaire). Ces critères dits « intrinsèques » sont croisés avec les critères extrinsèques tirés de la littérature, en particulier Pneumotox. Ils sont renseignés sous forme de questions/réponses successives à choix fermé. Un récapitulatif final permet de visualiser l’ensemble des données caractérisant la situation clinique observée. Le logiciel estime la probabilité de PM selon une des cinq modalités suivantes : incompatible, douteux, compatible, suggestif, très suggestif. La multiplicité des drogues, l’intrication à une pathologie cardiopulmonaire et l’absence de cas rapporté constituent les limites du système.
Establishing the diagnosis of drug-related pulmonary disease (DRPD) remains a difficult task because of the large number of drug-related toxic situations and the variety of clinical presentations. PneumoDoc is a computer-based support system designed to facilitate the diagnosis of lung disease using chronological, clinical, imaging, and cytological (alveolar lavage) input. These intrinsic items are crosschecked against extrinsic items reported in the literature (Pneumotox). Data input is in the form of yes-no questions. The final output displays the characteristic features of the observed clinical situation and calculates the probability of DRPD defined in five categories: incompatible, doubtful, compatible, suggestive, and highly suggestive. Use of multiple drugs, interaction with cardiopulmonary disease, and the absence of reported cases are limitations of the system.
Critical care medicine combines physicians, nurses, and allied health professional in the coordinated and collaborative management of patients with life-threatening single- or multiple-organ ...failures, including stabilization after surgical interventions.1 Critical care medicine requires the continuous (i.e., 24 h) monitoring and support of failing or threatened organ systems while at the same time treating the patients’ underlying disease process. The common goals of the intensive care unit (ICU) are to restore and maintain the function of vital organs, to enhance the patient’s chance of survival, and to achieve an acceptable clinical outcome.
Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage ...patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse–caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting ‘telling cases’ of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the ‘interactional workability’ of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.
•First study using real-time audio-visual data to analyse telephone triage with CDSS.•Nurses rarely side-stepped constraints of CDSS to follow-up patients' own agendas.•Nurses may need to manage interactional dilemmas and issues of accountability.•Nurses, patients and CDSS function as multiple participants in triage interactions.•Our findings reveal potential limits to software development and nurse training.
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