Integrated clinical pathway management for medical quality improvement – based on a semiotically inspired systems architecture

Healthcare Quality Received by Insured Patients in Two Indonesian Regional Public Hospitals

Background: Hospitals are required to improve the quality of health services provided to patients. Purpose: Evaluating and comparing the healthcare quality received by insured patients hospitalized in two Indonesian regional public hospitals. Methods: Secondary data analysis used the 2019 and 2020 Indonesian National Health Insurance e-claim databases of Hospital A and Hospital B. Descriptive and crosstabs analyses were used to determine INA-CBGs diagnoses that were categorized as high volume, high risk, and high cost. Results: The admissions that caused financial loss at the Hospital A were 21.1% in 2019 and 19.8% in 2020, while 30.3% in 2019 and 27.5% at the Hospital B. More than 60% of these admissions were placed in the 3rd class of inpatient wards of the two hospitals. Of these admissions, < 5% at the Hospital A and >5% at the Hospital B were readmitted within 30 days, although more than 90% were previously discharged based on physicians' approval. Conclusions: Inadequate healthcare quality received by insured patients. Hence, an integrated clinical pathways based professional nursing practice model is highly recommended to increase patient outcomes and decrease 30 days hospital readmission rates.

The cocreation of care pathways for patients treated with oral anticancer drugs: From assessment data to an actual care pathway

RATIONALE

Due to the emergence of oral anticancer therapies, existing care processes in oncology - that are mainly focused on in-hospital treatments - must be rethought. The development of a care pathway is a well-known methodology to reorganise and standardise care for a specific patient group. However, care pathway development might be complex and burdensome for healthcare teams, requiring a well-thought-out methodology that provides guidance to the teams.

AIMS AND OBJECTIVES

In 10 Belgian oncology departments, multidisciplinary teams developed a tailored care pathway, aimed to offer high-quality patient-centred care. Each department followed a cocreation methodology, consisting of a current practice assessment, a priority setting, and the actual development of the care pathway. The aim of this study was to investigate how and to which extent underperformed evidence-based key elements (KEs), identified in the current practice assessment, guided the development of the care pathway, and how compliant the final care pathways are with the list of evidence-based KEs.

METHODS

A qualitative content analysis was conducted to describe and compare the results of each phase of the cocreation methodology.

RESULTS

This study shows that much of the evidence and feedback on current practice that was used as a starting point, got lost throughout the cocreation process. Only a limited proportion of the (seriously) underperformed KEs were prioritised by the multidisciplinary teams. Furthermore, several prioritised KEs could not be retrieved in the care pathway documents. Also, the final care pathways were not fully compliant with existing evidence.

CONCLUSION

Based on the findings, a more rigorous cocreation methodology seems needed, offering very concrete support for multidisciplinary teams to integrate the prioritised KEs in the care process (e.g., by using a model care pathway). Next to the selfreported performance data from healthcare professionals and patients, more objective data (e.g., walkthrough, medical records) and more extensive patient involvement should be considered in the priority setting.

Development of Care Pathway for Assessment and Treatment of Fatigue in Palliative Care

Objectives

Fatigue is a frequent and burdensome symptom in patients with advanced disease in palliative care. However, it is under-assessed and undertreated in clinical practice, even though many treatment options have been identified in systematic reviews. Care pathways with defined and standardised steps have been recommended for effective management in the clinical setting. This paper describes a care pathway for managing fatigue in palliative care patients. This study aims to develop a care pathway with detailed guidance for screening, assessment, diagnosis, and treatment of fatigue in palliative care patients.

Material and methods

A collaborative effort of multidisciplinary clinicians participated in constructing the care pathway. The care pathway was developed using the following steps: (a) Developing an intervention; (b) piloting and feasibility; (c) evaluating the intervention; (d) reporting; and (e) implementation. This paper covers the first step, which includes the evidence base identification, theory identification/development, and process/outcomes modeling. A literature search was conducted to understand the extent of the fatigue problem in the palliative care setting and identify existing guidelines and strategies for managing fatigue. Consistent recommendations emanating from the included papers were then contributed to a care pathway. Patient representatives and palliative care professionals provided feedback on the draft.

Results

The care pathway address the following care processes: (1) Screening for the presence of fatigue; (2) assessment to evaluate the severity of fatigue; (3) diagnostic procedure, including history, physical examination, and laboratory finding; (4) therapeutic management pathway for clinical decision-making; and (5) valuation of treatment effect, using questionnaires, diaries and physical activity monitoring with body-worn sensors.

Conclusion

The development of a care pathway will help to implement regular and structured assessment, diagnosis, and treatment of fatigue for healthcare professionals treating palliative care patients. Reviewing the pathway with a multidisciplinary expert group and field testing the pathway will be the next steps toward implementation.

Information Technology Ambidexterity-Driven Patient Agility, Patient Service- and Market Performance: A Variance and fsQCA Approach

Modern hospitals are on the brink of a monumental change. They are currently exploring their options to digitally transform their clinical procedures and overall patient engagement. This work thoroughly investigates how hospital departments in the Netherlands can simultaneously leverage their strategic exploration of new IT resources and practices and exploit their current IT practices, i.e., IT ambidexterity, to drive digital transformation. Specifically, we investigate IT ambidexterity’s role in shaping patient agility at the departmental level, i.e., the ability to sense patients’ needs and respond accordingly. In this study, we use the dynamic capability view as our theoretical lens to develop a theoretical model with associated hypotheses and test it using cross-sectional survey data from 90 clinical hospital departments in the Netherlands. We use partial least squares (PLS) structural equation modeling (SEM) and a Fuzzy-set qualitative comparative analysis (fsQCA) approach for our analyses. This study shows that IT ambidexterity positively influences patient agility, providing a foundation for the achievement of high patient service and market performance. Furthermore, this study’s outcomes show that IT ambidexterity is present in each configuration following the fsQCA analyses, showcasing the vital role of a dual strategic approach to IT practices. The study outcomes support the theorized model and the subsequently developed IT-driven patient agility framework and illuminate how to transform clinical practice and drive patient agility.

Information Technology Ambidexterity, Digital Dynamic Capability, and Knowledge Processes as Enablers of Patient Agility: Empirical Study

BACKGROUND

There is a limited understanding of information technology's (IT) role as an enabler of patient agility and the department's ability to respond to patients' needs and wishes adequately.

OBJECTIVE

This study aims to contribute to the insights of the validity of the hypothesized relationship among IT resources, practices and capabilities, and hospital departments' knowledge processes, and the department's ability to adequately sense and respond to patient needs and wishes (ie, patient agility).

METHODS

This study conveniently sampled data from 107 clinical hospital departments in the Netherlands and used structural equation modeling for model assessment.

RESULTS

IT ambidexterity positively enhanced the development of a digital dynamic capability (β=.69; t4999=13.43; P<.001). Likewise, IT ambidexterity also positively impacted the hospital department's knowledge processes (β=.32; t4999=2.85; P=.005). Both digital dynamic capability (β=.36; t4999=3.95; P<.001) and knowledge processes positively influenced patient agility (β=.33; t4999=3.23; P=.001).

CONCLUSIONS

IT ambidexterity promotes taking advantage of IT resources and experiments to reshape patient services and enhance patient agility.

Questioning Racial and Gender Bias in AI-based Recommendations: Do Espoused National Cultural Values Matter?

One realm of AI, recommender systems have attracted significant research attention due to concerns about its devastating effects to society's most vulnerable and marginalised communities. Both media press and academic literature provide compelling evidence that AI-based recommendations help to perpetuate and exacerbate racial and gender biases. Yet, there is limited knowledge about the extent to which individuals might question AI-based recommendations when perceived as biased. To address this gap in knowledge, we investigate the effects of espoused national cultural values on AI questionability, by examining how individuals might question AI-based recommendations due to perceived racial or gender bias. Data collected from 387 survey respondents in the United States indicate that individuals with espoused national cultural values associated to collectivism, masculinity and uncertainty avoidance are more likely to question biased AI-based recommendations. This study advances understanding of how cultural values affect AI questionability due to perceived bias and it contributes to current academic discourse about the need to hold AI accountable.

The effectiveness of clinical pathway software in inpatient settings: A systematic review

BACKGROUND

Various studies have assessed the effectiveness of clinical pathways (CPs) in inpatient settings and provided systematic evidence that they positively affect patient outcomes and efficiency of care, thus lowering costs. In recent years, CP implementation is often combined or extended with clinical pathway software (CPS). Until now, no systematic literature review appears to exist which synthesizes the evidence on the effectiveness of CPS in inpatient settings, in relation to the CPs they support.

OBJECTIVES

The purpose of this study was to systematically review evidence on (perceived) effectiveness of clinical pathway software (CPS) and investigate mechanisms explaining the effects of CPS implementation on outcomes.

METHODS

We searched MEDLINE via PubMed and Scopus, for English-language original articles. Articles were included if they examined the effectiveness and/or the perceived effectiveness of CPS in the inpatient setting. They were analyzed for evidence on structure, process and outcome effects, as well as for mechanisms explaining such effects in relation to contextual factors.

RESULTS

From 2904 articles, 12 studies met our inclusion criteria. The seven studies reporting on adherence provide conclusive evidence that CPSs can improve adherence. We also found conclusive evidence of improvement of process related measures regarding appropriate diagnostics, timeliness of care, and length of stay (LOS). Evidence on costs and outcomes is weak and/or less conclusive. This holds true both for patient outcomes (e.g. mortality/patient satisfaction) and caregiver outcomes (e.g. user satisfaction). The studies presented no direct evidence on mechanisms explaining how CPS relate to process and outcome improvements.

CONCLUSIONS

The primary effects of CPS to increase adherence may in turn positively impact other process indicators such as LOS, timeliness of care, and diagnostic effectiveness. Subsequent effects on costs, outcomes for patients, physicians and nurses remain inconclusive and call for further research. Further research should explicitly take context into account. The scarce and weak evidence-base relating CPS implementation to process and outcome effects needs development along the same lines.

Ontological framework for standardizing and digitizing clinical pathways in healthcare information systems

BACKGROUND AND OBJECTIVE

Most healthcare institutions are reorganizing their healthcare delivery systems based on Clinical Pathways (CPs). CPs are novel medical management plans to standardize medical activities, reduce cost, optimize resource usage, and improve the quality of service. However, most CPs are still paper-based and not fully integrated with Health Information Systems (HIS). More CP computerization research is therefore needed to fully benefit from CP's practical potentials. A major contribution of this research is the vision that CP systems deserve to be placed at the centre of HIS, because within CPs lies the very heart of medical planning, treatment and impressions, including healthcare quality and cost factors.

METHODS

An important contribution to the realization of this vision is to fully standardize and digitize CPs so that they become machine-readable and smoothly linkable across various HIS. To achieve this goal, this research proposes a framework for (i) CP knowledge representation and sharing using ontologies, (ii) CP standardization based on SNOMED CT and HL7, and (iii) CP digitization based on a novel coding system to encode CP data. To show the feasibility of the proposed framework we developed a prototype clinical pathway management system (CPMS) based on CPs currently in use at hospitals.

RESULTS

The results show that CPs can be fully standardized and digitized using SNOMED CT terms and codes, and the CPMS can work as an independent system, performing novel CP-related functions, including useful data analytics. CPs can be compared easily for auditing and quality management. Furthermore, the CPMS was smoothly linked to a hospital EMR and CP data were captured in EMR without any loss.

CONCLUSION

The proposed framework is promising and contributes toward solving major challenges related to CP standardization, digitization, and inclusion in today's modern computerized hospitals.

Towards standardisation of evidence-based clinical care process specifications

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

Perceived effectiveness of clinical pathway software: A before-after study in the Netherlands

BACKGROUND

Clinical pathways (CPs) increase in popularity and are known to lead to several benefits in the hospital environment. Clinical pathways can be either paper-based or software-based. It is known that paper-based CPs can result in more paperwork instead of simplifying daily routines of healthcare workers. Insufficient research has been done on the acceptance of software-based CPs by different user groups. Our aim in this study was to assess the effectiveness of the software-based CPs (CPS) from the perspective of healthcare professionals in the hospital environment as well as to investigate the differences in perceived effectiveness between user groups.

METHODS

Using surveys and interviews, data were collected in four departments of an academic medical center. A distinction was made between decision makers (DM) and executive staff (ES). The surveys contained questions based on the Technology Acceptance Model and four objectives of the software defined by the hospital. Statistical tests were used to investigate the effectiveness of CPS and study the differences between DM and ES. Interviews were recorded and transcribed based on grounded theory principals.

RESULTS

After implementation, monitoring protocol-based working was significantly improved (p = .026) and significantly higher efficiency on the work floor was reported (p = .046). ES perceived the software as less useful than expected (Md = 3.25 vs. Md = 2.75, p = .028) compared to DM and were less convinced of its ability to improve monitoring protocol-based working. The most important benefits of CPS as perceived by its users are the better overview of tasks it provides and facilitating documentation. Negative aspects mentioned were the lack of usability and the inflexibility of the software, and particularly ES claimed that the software did not increase their effectiveness.

CONCLUSION

Our study showed that CPS is effective from healthcare professionals' perspective due to its ability to increase monitoring of protocol-based working and by enhancing the efficiency on the work floor. However, the users also acknowledge that the software lacks usability and is not flexible enough, which results in an additional workload. Policy makers should be more focused on informing and training executive staff more thoroughly when implementing a CPS. Our results strongly suggest that executive staff members need to be convinced of its usefulness and the added value a CPS provides. Preferably, they should be involved in the design phase of the software.

The negotiated order and electronic patient records: A sociomaterial perspective

In this article, we consider how the notion of the negotiated order can be reinterpreted by drawing on ideas from sociomateriality. We argue that the negotiated order is an ongoing accomplishment in which a heterogeneous set of situated sociomaterial practices (or actors) are implicated. To do this, we draw upon an in-depth study of the use of a computerised physician order entry system in a hospital in Saudi Arabia. We explore how a computerised physician order entry system, as a new sociomaterial actor, performatively repositions the actors involved and hence offers the conditions of possibility for medical work practices to be renegotiated. We show that it is often contingent, mundane, situated sociomaterial practices that enact the conditions under which the negotiated order becomes re-established in terms of division of labour, legitimacy, collaboration, and social capital. We argue that as the social and material are co-constitutive, or intra-actional, it makes more sense to talk about the negotiated intra-actional order rather than the negotiated order. Importantly, such a change in conceptual vocabulary reveals the empirical and ontological issues at stake; essential for a more nuanced understanding of change/becoming.

Investigating Knowledge Flows between Information Systems and Other Disciplines:

Information systems (IS) is one of the most rapidly changing disciplines in the social science field, and it is currently facing a new academic shift. The prevailing concepts, such as big data and Internet of things (IoT), imply that there is a plethora of research opportunities for IS researchers. Since these opportunities lie mostly in conjunction with other disciplines closely related to IS, it is essential to identify the interaction between IS and those disciplines. A few studies using bibliometric analysis have been published regarding this topic. However, we have identified several limitations in them: (i) inclusion of only a small journal basket, (ii) focus on a very restricted area of discipline, and (iii) a methodological limitation that can lead to the failure to capture the authentic knowledge flow between IS and other disciplines. We attempt to extend previous studies by proposing a comprehensive analysis model with the largest journal basket and areas of disciplines. As a result of our analysis, a knowledge flow structure different from that of past research is identified. In addition, through the discussion on emerging reference disciplines, we discover new research opportunities into which IS researchers can delve.

Evaluation of health information systems research in information systems research: A meta-analysis

Given the importance of the health-care industry and the promise of health information systems, researchers are encouraged to build on the shoulders of giants as the saying goes. The health information systems field has a unique opportunity to learn from and extend the work that has already been done by the highly correlated information systems field. As a result, this research article presents a past, present and future meta-analysis of health information systems research in information systems journals over the 2000–2015 time period. Our analysis reviewed 126 articles on a variety of topics related to health information systems research published in the “Senior Scholars” list of the top eight ranked information systems academic journals. Across the selected information systems academic journals, our findings compare research methodologies applied, health information systems topic areas investigated and research trends. Interesting results emerge in the range and evolution of health information systems research and opportunities for health information systems researchers and practitioners to consider moving forward.

Research and Development of Semantics-based Sharable Clinical Pathway Systems

The clinical pathway (CP) as a novel medical management schema is beneficial for reducing the length of stay, decreasing heath care costs, standardizing clinical activities, and improving medical quality. However, the practicability of CPs is limited by the complexity and expense of adding the standard functions of electronic CPs to existing electronic medical record (EMR) systems. The purpose of this study was to design and develop an independent clinical pathway (ICP) system that is sharable with different EMR systems. An innovative knowledge base pattern was designed with separate namespaces for global knowledge, local knowledge, and real-time instances. Semantic web technologies were introduced to support knowledge sharing and intelligent reasoning. The proposed system, which was developed in a Java integrated development environment, achieved standard functions of electronic CPs without modifying existing EMR systems and integration environments in hospitals. The interaction solution between the pathway system and the EMR system simplifies the integration procedures with other hospital information systems. Five categories of transmission information were summarized to ensure the interaction process. Detailed procedures for the application of CPs to patients and managing exceptional alerts are presented by explicit data flow analysis. Compared to embedded pathway systems, independent pathway systems feature greater feasibility and practicability and are more advantageous for achieving the normalized management of standard CPs.