A DFuzzy-DAHP Decision-Making Model for Evaluating Energy-Saving Design Strategies for Residential Buildings

Directory of Open Access Journals (Sweden)

Yu-Lung Chen

2012-11-01

Full Text Available The construction industry is a high-pollution and high-energy-consumption industry. Energy-saving designs for residential buildings not only reduce the energy consumed during construction, but also reduce long-term energy consumption in completed residential buildings. Because building design affects investment costs, designs are often influenced by investors’ decisions. A set of appropriate decision-support tools for residential buildings are required to examine how building design influences corporations externally and internally. From the perspective of energy savings and environmental protection, we combined three methods to develop a unique model for evaluating the energy-saving design of residential buildings. Among these methods, the Delphi group decision-making method provides a co-design feature, the analytical hierarchy process (AHP includes multi-criteria decision-making techniques, and fuzzy logic theory can simplify complex internal and external factors into easy-to-understand numbers or ratios that facilitate decisions. The results of this study show that incorporating solar building materials, double-skin facades, and green roof designs can effectively provide high energy-saving building designs.

Early stage decision support for sustainable building renovation – A review

DEFF Research Database (Denmark)

Nielsen, Anne Nørkjær; Jensen, Rasmus Lund; Larsen, Tine Steen

2016-01-01

Decision support tools for building renovation are important as assistance to professional building owners when setting goals for sustainability, and for making sure that the objectives are met throughout the design process, both when renovating a single building or choosing renovation actions wi...

How to make the best decision. Philosophical aspects of clinical decision theory.

Science.gov (United States)

Wulff, H R

1981-01-01

An attempt is made to discuss some of the philosophical implications of the use of decision-analytic techniques. The probabilities of a decision analysis are subjective measures of belief, and it is concluded that clinicians base their subjective beliefs on both recorded observations and theoretical knowledge. The clinical decision maker also evaluates the consequences of his actions, and therefore clinical decision theory transcends medical science. A number of different schools of normative ethics are mentioned to illustrate the complexity of everyday decision making. The philosophical terminology is useful for the analysis of clinical problems, and it is argued that clinical decision making has both a teleological and a deontological component. The results of decision-analytic studies depend on such factors as the wealth of the country, the organization of the health service, and cultural norms.

Multi-criteria decision model for retrofitting existing buildings

Directory of Open Access Journals (Sweden)

M. D. Bostenaru Dan

2004-01-01

Full Text Available Decision is an element in the risk management process. In this paper the way how science can help in decision making and implementation for retrofitting buildings in earthquake prone urban areas is investigated. In such interventions actors from various spheres are involved. Their interests range among minimising the intervention for maximal preservation or increasing it for seismic safety. Research was conducted to see how to facilitate collaboration between these actors. A particular attention was given to the role of time in actors' preferences. For this reason, on decision level, both the processural and the personal dimension of risk management, the later seen as a task, were considered. A systematic approach was employed to determine the functional structure of a participative decision model. Three layers on which actors implied in this multi-criteria decision problem interact were identified: town, building and element. So-called 'retrofit elements' are characteristic bearers in the architectural survey, engineering simulations, costs estimation and define the realms perceived by the inhabitants. This way they represent an interaction basis for the interest groups considered in a deeper study. Such orientation means for actors' interaction were designed on other levels of intervention as well. Finally, an 'experiment' for the implementation of the decision model is presented: a strategic plan for an urban intervention towards reduction of earthquake hazard impact through retrofitting. A systematic approach proves thus to be a very good communication basis among the participants in the seismic risk management process. Nevertheless, it can only be applied in later phases (decision, implementation, control only, since it serves verifying and improving solution and not developing the concept. The 'retrofit elements' are a typical example of the detailing degree reached in the retrofit design plans in these phases.

Multi-criteria decision model for retrofitting existing buildings

Science.gov (United States)

Bostenaru Dan, M. D.

2004-08-01

Decision is an element in the risk management process. In this paper the way how science can help in decision making and implementation for retrofitting buildings in earthquake prone urban areas is investigated. In such interventions actors from various spheres are involved. Their interests range among minimising the intervention for maximal preservation or increasing it for seismic safety. Research was conducted to see how to facilitate collaboration between these actors. A particular attention was given to the role of time in actors' preferences. For this reason, on decision level, both the processural and the personal dimension of risk management, the later seen as a task, were considered. A systematic approach was employed to determine the functional structure of a participative decision model. Three layers on which actors implied in this multi-criteria decision problem interact were identified: town, building and element. So-called 'retrofit elements' are characteristic bearers in the architectural survey, engineering simulations, costs estimation and define the realms perceived by the inhabitants. This way they represent an interaction basis for the interest groups considered in a deeper study. Such orientation means for actors' interaction were designed on other levels of intervention as well. Finally, an 'experiment' for the implementation of the decision model is presented: a strategic plan for an urban intervention towards reduction of earthquake hazard impact through retrofitting. A systematic approach proves thus to be a very good communication basis among the participants in the seismic risk management process. Nevertheless, it can only be applied in later phases (decision, implementation, control) only, since it serves verifying and improving solution and not developing the concept. The 'retrofit elements' are a typical example of the detailing degree reached in the retrofit design plans in these phases.

Intervention strategies for energy efficient municipal buildings: Influencing energy decisions throughout buildings` lifetimes

Energy Technology Data Exchange (ETDEWEB)

NONE

1993-12-31

The current energy-related decisionmaking processes that take place during the lifetimes of municipal buildings in San Francisco do not reflect our ideal picture of energy efficiency as a part of staff awareness and standard practice. Two key problems that undermine the success of energy efficiency programs are lost opportunities and incomplete actions. These problems can be caused by technology-related issues, but often the causes are institutional barriers (organizational or procedural {open_quotes}people problems{close_quotes}). Energy efficient decisions are not being made because of a lack of awareness or policy mandate, or because financial resources are not available to decisionmakers. The Bureau of Energy Conservation (BEC) is working to solve such problems in the City & County of San Francisco through the Intervention Strategies project. In the first phase of the project, using the framework of the building lifetime, we learned how energy efficiency in San Francisco municipal buildings can be influenced through delivering services to support decisionmakers; at key points in the process of funding, designing, constructing and maintaining them. The second phase of the project involved choosing and implementing five pilot projects. Through staff interviews, we learned how decisions that impact energy use are made at various levels. We compiled information about city staff and their needs, and resources available to meet those needs. We then designed actions to deliver appropriate services to staff at these key access points. BEC implemented five pilot projects corresponding to various stages in the building`s lifetime. These were: Bond Guidelines, Energy Efficient Design Practices, Commissioning, Motor Efficiency, and Facilities Condition Monitoring Program.

Patients' Values in Clinical Decision-Making.

Science.gov (United States)

Faggion, Clovis Mariano; Pachur, Thorsten; Giannakopoulos, Nikolaos Nikitas

2017-09-01

Shared decision-making involves the participation of patient and dental practitioner. Well-informed decision-making requires that both parties understand important concepts that may influence the decision. This fourth article in a series of 4 aims to discuss the importance of patients' values when a clinical decision is made. We report on how to incorporate important concepts for well-informed, shared decision-making. Here, we present patient values as an important issue, in addition to previously established topics such as the risk of bias of a study, cost-effectiveness of treatment approaches, and a comparison of therapeutic benefit with potential side effects. We provide 2 clinical examples and suggestions for a decision tree, based on the available evidence. The information reported in this article may improve the relationship between patient and dental practitioner, resulting in more well-informed clinical decisions. Copyright © 2017 Elsevier Inc. All rights reserved.

Method and simulation program informed decisions in the early stages of building design

DEFF Research Database (Denmark)

Petersen, Steffen; Svendsen, Svend

2010-01-01

variations. The program then presents the output in a way that enables designers to make informed decisions. The method and the program reduce the need for design iterations, reducing time consumption and construction costs, to obtain the intended energy performance and indoor environment....... for making informed decisions in the early stages of building design to fulfil performance requirements with regard to energy consumption and indoor environment. The method is operationalised in a program that utilises a simple simulation program to make performance predictions of user-defined parameter......The early stages of building design include a number of decisions which have a strong influence on the performance of the building throughout the rest of the process. It is therefore important that designers are aware of the consequences of these design decisions. This paper presents a method...

Sustainability-Related Decision Making in Industrial Buildings: An AHP Analysis

Directory of Open Access Journals (Sweden)

Jesús Cuadrado

2015-01-01

Full Text Available Few other sectors have such a great impact on sustainability as the construction industry, in which concerns over the environmental dimension have been growing for some time. The sustainability assessment methodology presented in this paper is an AHP (Analytic Hierarchy Process based on Multicriteria Decision Making (MCDM and includes the main sustainability factors for consideration in the construction of an industrial building (environmental, economic, and social, as well as other factors that greatly influence the conceptual design of the building (employee safety, corporate image. Its simplicity is well adapted to its main objective, to serve as a sustainability-related decision making tool in industrial building projects, during the design stage. Accompanied by an economic valuation of the actions to be undertaken, this tool means that the most cost-effective solution may be selected from among the various options.

Building Stakeholder Trust: Defensible Government Decisions - 13110

Energy Technology Data Exchange (ETDEWEB)

Franklin, Victor A. [Savannah River Remediation LLC, Bldg. 705-1C, Aiken, SC 29808 (United States)

2013-07-01

Administrative decisions must be grounded in reasonable expectations, founded on sound principles, and bounded by societal norms. Without these first principles, attaining and retaining public trust is a Herculean task. Decisions made by governmental administrators must be both transparent and defensible: without the former the agency will lose the public's trust and support (possibly prompting a legal challenge to the decision) and without the latter the decision may fail to withstand judicial scrutiny. This presentation and accompanying paper delves into the process by which governmental decisions can achieve both defensibility and openness through building stakeholder trust with transparency. Achieving and maintaining stakeholder trust is crucial, especially in the environs of nuclear waste management. Proving confidence, stability, and security to the surrounding citizenry as well as those throughout the country is the goal of governmental nuclear waste remediation. Guiding administrative decision-making processes and maintaining a broad bandwidth of communication are of incalculable importance to all those charged with serving the public, but are especially essential to those whose decisional impacts will be felt for millennia. A strong, clear, and concise administrative record documenting discrete decisions and overarching policy choices is the strongest defense to a decisional challenge. However, this can be accomplished using transparency as the fundamental building block. This documentation allows the decision-makers to demonstrate the synthesis of legal and technical challenges and fortifies the ground from which challenges will be defended when necessary. Further, administrative actions which capture the public's interest and captivate that interest throughout the process will result in a better-informed, more deeply-involved, and more heavily-invested group of interested parties. Management of information, involvement, and investment on the

Building Stakeholder Trust: Defensible Government Decisions - 13110

International Nuclear Information System (INIS)

Franklin, Victor A.

2013-01-01

Administrative decisions must be grounded in reasonable expectations, founded on sound principles, and bounded by societal norms. Without these first principles, attaining and retaining public trust is a Herculean task. Decisions made by governmental administrators must be both transparent and defensible: without the former the agency will lose the public's trust and support (possibly prompting a legal challenge to the decision) and without the latter the decision may fail to withstand judicial scrutiny. This presentation and accompanying paper delves into the process by which governmental decisions can achieve both defensibility and openness through building stakeholder trust with transparency. Achieving and maintaining stakeholder trust is crucial, especially in the environs of nuclear waste management. Proving confidence, stability, and security to the surrounding citizenry as well as those throughout the country is the goal of governmental nuclear waste remediation. Guiding administrative decision-making processes and maintaining a broad bandwidth of communication are of incalculable importance to all those charged with serving the public, but are especially essential to those whose decisional impacts will be felt for millennia. A strong, clear, and concise administrative record documenting discrete decisions and overarching policy choices is the strongest defense to a decisional challenge. However, this can be accomplished using transparency as the fundamental building block. This documentation allows the decision-makers to demonstrate the synthesis of legal and technical challenges and fortifies the ground from which challenges will be defended when necessary. Further, administrative actions which capture the public's interest and captivate that interest throughout the process will result in a better-informed, more deeply-involved, and more heavily-invested group of interested parties. Management of information, involvement, and investment on the front-end of

The prefabricated building risk decision research of DM technology on the basis of Rough Set

Science.gov (United States)

Guo, Z. L.; Zhang, W. B.; Ma, L. H.

2017-08-01

With the resources crises and more serious pollution, the green building has been strongly advocated by most countries and become a new building style in the construction field. Compared with traditional building, the prefabricated building has its own irreplaceable advantages but is influenced by many uncertainties. So far, a majority of scholars have been studying based on qualitative researches from all of the word. This paper profoundly expounds its significance about the prefabricated building. On the premise of the existing research methods, combined with rough set theory, this paper redefines the factors which affect the prefabricated building risk. Moreover, it quantifies risk factors and establish an expert knowledge base through assessing. And then reduced risk factors about the redundant attributes and attribute values, finally form the simplest decision rule. This simplest decision rule, which is based on the DM technology of rough set theory, provides prefabricated building with a controllable new decision-making method.

Key decisions in a generic process for disposition of buildings that have actual or potential radiological contamination

International Nuclear Information System (INIS)

Spesard, A.; Donavan, K.; Bowden, B.; Crane, L.; Jensen, G.; Fox, K.L.; Goodwin, R.; Vandegrift, R.

1997-01-01

The Cleanup Standards Committee, formed within the Ohio Federal Facilities Forum, focuses on addressing issues related to cleanup levels and standards. To facilitate decision-making for the disposition of buildings that have potential or actual radiological contamination, the Cleanup Standards Committee developed a process to support building disposition decisions. This process is needed for two reasons: (1) due to changing missions, an increasing number of buildings on federal properties require disposition, and (2) current federal initiatives encourage the transfer of buildings and land for reuse and economic redevelopment. Since the committee developed this process using a teaming effort, the process reflects the experience, expertise, and opinions of committee members and other individuals with a broad range of experience and knowledge. The Generic Process for the Disposition of Buildings that have Potential or Actual Radiological Contamination is intended for use by Federal Facilities responsible for the cleanup of buildings at sites that have radiological process history. This process provides (1) a framework and supporting implementation guidelines for evaluating buildings that have actual or potential radiological contamination, and (2) a process for making building disposition decisions. This paper outlines on the key decision points and the associated data requirements of the process. Specifically, this paper focuses on the following decisions: Which decision-makers are appropriate to involve in the building disposition process; What is the preferred disposition of a building; What criteria are applicable for unconditional release; Is there sufficient existing information to proceed with disposition of a building; What level of survey is appropriate to determine and/or implement a preferred disposition of a building; and how are uncertainties addressed when implementing a building disposition

The energy investment decision in the nonresidential building sector: Research into the areas of influence

Energy Technology Data Exchange (ETDEWEB)

Harkreader, S.A.; Ivey, D.L.

1987-04-01

The purpose of this report is to describe and to characterize the decision process in the nonresidential building sector as well as the variables influencing energy investment decisions, both of which impact the development of R and D agendas for the Office of Building and Community Systems (BCS). The report reviews the available information on the factors that influence energy investment decisions and identifies information gaps where additional research is needed. This report focuses on variables and combinations of these variables (descriptive states) that influence the non residential energy investment decision maker. Economic and demographic descriptors, energy investment decision maker characteristics, and variables affecting energy investments are identified. This response examines the physical characteristics of buildings, characteristics of the legal environment surrounding buildings, demographic factors, economic factors, and decision processes, all of which impact the nonresidential energy investment market. The emphasis of the report is on providing possible methodologies for projecting the future of the nonresidential energy investment market, as well as, collecting the data necessary for such projections. The use of alternate scenarios is suggested as a projection tool and suggestions for collecting the appropriate data are made in the recommendations.

Legal Considerations in Clinical Decision Making.

Science.gov (United States)

Ursu, Samuel C.

1992-01-01

Discussion of legal issues in dental clinical decision making looks at the nature and elements of applicable law, especially malpractice, locus of responsibility, and standards of care. Greater use of formal decision analysis in clinical dentistry and better research on diagnosis and treatment are recommended, particularly in light of increasing…

Value based building renovation - A tool for decision-making and evaluation

DEFF Research Database (Denmark)

Jensen, Per Anker; Maslesa, Esmir

2015-01-01

Research on the barriers for building renovation in Denmark has revealed that an important obstacle is a lack of simple and holistic tools that can assist stakeholders in prioritisation and decision-making during the early stages of building renovation projects. The purpose of this article...... is to present a tool - RENO-EVALUE, which can be used as decision support for sustainable renovation projects, and for evaluation, during and after building renovations. The tool is a result from the European Eracobuild project ACES - "A concept for promotion of sustainable retrofitting and renovation in early...... stages". This article presents the main result of a work package concerning benefits of renovation. RENO-EVALUE has been developed from four case studies on renovation projects in Denmark, tested and validated on the cases and in a Delphi study. The tool is value based by focusing on the different...

A computational intelligence decision-support environment for architectural and building design : CIDEA

NARCIS (Netherlands)

Chatzikonstantinou, I.

2016-01-01

Environmentally friendly and comfortable buildings are a much sought after goal in today's architectural practice. In order to improve energy consumption of buildings without sacrificing indoor comfort, careful consideration of design decisions is needed. Simulation tools provide a solution to

Building models for marketing decisions : Past, present and future

NARCIS (Netherlands)

Leeflang, PSH; Wittink, DR

We review five eras of model building in marketing, with special emphasis on the fourth and the fifth eras, the present and the future. At many firms managers now routinely use model-based results for marketing decisions. Given an increasing number of successful applications, the demand for models

An expandable software model for collaborative decision making during the whole building life cycle

International Nuclear Information System (INIS)

Papamichael, K.; Pal, V.; Bourassa, N.; Loffeld, J.; Capeluto, G.

2000-01-01

Decisions throughout the life cycle of a building, from design through construction and commissioning to operation and demolition, require the involvement of multiple interested parties (e.g., architects, engineers, owners, occupants and facility managers). The performance of alternative designs and courses of action must be assessed with respect to multiple performance criteria, such as comfort, aesthetics, energy, cost and environmental impact. Several stand-alone computer tools are currently available that address specific performance issues during various stages of a building's life cycle. Some of these tools support collaboration by providing means for synchronous and asynchronous communications, performance simulations, and monitoring of a variety of performance parameters involved in decisions about a building during building operation. However, these tools are not linked in any way, so significant work is required to maintain and distribute information to all parties. In this paper we describe a software model that provides the data management and process control required for collaborative decision making throughout a building's life cycle. The requirements for the model are delineated addressing data and process needs for decision making at different stages of a building's life cycle. The software model meets these requirements and allows addition of any number of processes and support databases over time. What makes the model infinitely expandable is that it is a very generic conceptualization (or abstraction) of processes as relations among data. The software model supports multiple concurrent users, and facilitates discussion and debate leading to decision making. The software allows users to define rules and functions for automating tasks and alerting all participants to issues that need attention. It supports management of simulated as well as real data and continuously generates information useful for improving performance prediction and

Clinical decision-making: physicians' preferences and experiences

Directory of Open Access Journals (Sweden)

White Martha

2007-03-01

Full Text Available Abstract Background Shared decision-making has been advocated; however there are relatively few studies on physician preferences for, and experiences of, different styles of clinical decision-making as most research has focused on patient preferences and experiences. The objectives of this study were to determine 1 physician preferences for different styles of clinical decision-making; 2 styles of clinical decision-making physicians perceive themselves as practicing; and 3 the congruence between preferred and perceived style. In addition we sought to determine physician perceptions of the availability of time in visits, and their role in encouraging patients to look for health information. Methods Cross-sectional survey of a nationally representative sample of U.S. physicians. Results 1,050 (53% response rate physicians responded to the survey. Of these, 780 (75% preferred to share decision-making with their patients, 142 (14% preferred paternalism, and 118 (11% preferred consumerism. 87% of physicians perceived themselves as practicing their preferred style. Physicians who preferred their patients to play an active role in decision-making were more likely to report encouraging patients to look for information, and to report having enough time in visits. Conclusion Physicians tend to perceive themselves as practicing their preferred role in clinical decision-making. The direction of the association cannot be inferred from these data; however, we suggest that interventions aimed at promoting shared decision-making need to target physicians as well as patients.

Clinical decision-making and secondary findings in systems medicine.

Science.gov (United States)

Fischer, T; Brothers, K B; Erdmann, P; Langanke, M

2016-05-21

Systems medicine is the name for an assemblage of scientific strategies and practices that include bioinformatics approaches to human biology (especially systems biology); "big data" statistical analysis; and medical informatics tools. Whereas personalized and precision medicine involve similar analytical methods applied to genomic and medical record data, systems medicine draws on these as well as other sources of data. Given this distinction, the clinical translation of systems medicine poses a number of important ethical and epistemological challenges for researchers working to generate systems medicine knowledge and clinicians working to apply it. This article focuses on three key challenges: First, we will discuss the conflicts in decision-making that can arise when healthcare providers committed to principles of experimental medicine or evidence-based medicine encounter individualized recommendations derived from computer algorithms. We will explore in particular whether controlled experiments, such as comparative effectiveness trials, should mediate the translation of systems medicine, or if instead individualized findings generated through "big data" approaches can be applied directly in clinical decision-making. Second, we will examine the case of the Riyadh Intensive Care Program Mortality Prediction Algorithm, pejoratively referred to as the "death computer," to demonstrate the ethical challenges that can arise when big-data-driven scoring systems are applied in clinical contexts. We argue that the uncritical use of predictive clinical algorithms, including those envisioned for systems medicine, challenge basic understandings of the doctor-patient relationship. Third, we will build on the recent discourse on secondary findings in genomics and imaging to draw attention to the important implications of secondary findings derived from the joint analysis of data from diverse sources, including data recorded by patients in an attempt to realize their

Software Tools For Building Decision-support Models For Flood Emergency Situations

Science.gov (United States)

Garrote, L.; Molina, M.; Ruiz, J. M.; Mosquera, J. C.

The SAIDA decision-support system was developed by the Spanish Ministry of the Environment to provide assistance to decision-makers during flood situations. SAIDA has been tentatively implemented in two test basins: Jucar and Guadalhorce, and the Ministry is currently planning to have it implemented in all major Spanish basins in a few years' time. During the development cycle of SAIDA, the need for providing as- sistance to end-users in model definition and calibration was clearly identified. System developers usually emphasise abstraction and generality with the goal of providing a versatile software environment. End users, on the other hand, require concretion and specificity to adapt the general model to their local basins. As decision-support models become more complex, the gap between model developers and users gets wider: Who takes care of model definition, calibration and validation?. Initially, model developers perform these tasks, but the scope is usually limited to a few small test basins. Before the model enters operational stage, end users must get involved in model construction and calibration, in order to gain confidence in the model recommendations. However, getting the users involved in these activities is a difficult task. The goal of this re- search is to develop representation techniques for simulation and management models in order to define, develop and validate a mechanism, supported by a software envi- ronment, oriented to provide assistance to the end-user in building decision models for the prediction and management of river floods in real time. The system is based on three main building blocks: A library of simulators of the physical system, an editor to assist the user in building simulation models, and a machine learning method to calibrate decision models based on the simulation models provided by the user.

Factors and Drivers Effecting the Decision of Using Off-Site Manufacturing (OSM Systems in House Building Industry

Directory of Open Access Journals (Sweden)

Hussein Elnaas

2014-01-01

Full Text Available Much has been written on Off-site Manufacturing (OSM in construction, particularly regarding the perceived benefits and barriers to implementation. However, there seems to be a wide misunderstanding of the state of OSM associated with the concept of decision by many of those involved in decision making process within the house building industry. This has led to a demand for guidance’s on decision making process for construction project leaders particularly at early project stages. Choosing a construction method for a project will require an optimum decision strategy which involves careful understanding, measurement and evaluation of a number of decision factors that can have the most influence on successful decision action. This paper, therefore, aims to identify the key decision factors to be considered at evaluation stage when choosing to use Off-Site Manufacturing (OSM as a construction strategy in house building projects. This will reveal the key drivers for change in the industry towards the use of OSM in house building.

Renovation versus New Construction and Building Decision Tool for Educational Facilities

OpenAIRE

Pope, Carrie; Marks, Eric; Back, Edward; Leopard, Tim; Love, Thomas

2016-01-01

Renovation of an existing building is an accomplished stem of the construction industry because it supplies financial diversification for construction stakeholders. Although several construction planning tools and stakeholder alignment exercises have been developed, no tool exists to assist project owners to decide between renovating an existing building and new construction with a comprehensive decision criteria. The objective of this research is to create and test a renovation versus new bu...

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice.

Science.gov (United States)

Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y

2010-05-01

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

Is it the time to rethink clinical decision-making strategies? From a single clinical outcome evaluation to a Clinical Multi-criteria Decision Assessment (CMDA).

Science.gov (United States)

Migliore, Alberto; Integlia, Davide; Bizzi, Emanuele; Piaggio, Tomaso

2015-10-01

There are plenty of different clinical, organizational and economic parameters to consider in order having a complete assessment of the total impact of a pharmaceutical treatment. In the attempt to follow, a holistic approach aimed to provide an evaluation embracing all clinical parameters in order to choose the best treatments, it is necessary to compare and weight multiple criteria. Therefore, a change is required: we need to move from a decision-making context based on the assessment of one single criteria towards a transparent and systematic framework enabling decision makers to assess all relevant parameters simultaneously in order to choose the best treatment to use. In order to apply the MCDA methodology to clinical decision making the best pharmaceutical treatment (or medical devices) to use to treat a specific pathology, we suggest a specific application of the Multiple Criteria Decision Analysis for the purpose, like a Clinical Multi-criteria Decision Assessment CMDA. In CMDA, results from both meta-analysis and observational studies are used by a clinical consensus after attributing weights to specific domains and related parameters. The decision will result from a related comparison of all consequences (i.e., efficacy, safety, adherence, administration route) existing behind the choice to use a specific pharmacological treatment. The match will yield a score (in absolute value) that link each parameter with a specific intervention, and then a final score for each treatment. The higher is the final score; the most appropriate is the intervention to treat disease considering all criteria (domain an parameters). The results will allow the physician to evaluate the best clinical treatment for his patients considering at the same time all relevant criteria such as clinical effectiveness for all parameters and administration route. The use of CMDA model will yield a clear and complete indication of the best pharmaceutical treatment to use for patients

How do small groups make decisions? : A theoretical framework to inform the implementation and study of clinical competency committees.

Science.gov (United States)

Chahine, Saad; Cristancho, Sayra; Padgett, Jessica; Lingard, Lorelei

2017-06-01

In the competency-based medical education (CBME) approach, clinical competency committees are responsible for making decisions about trainees' competence. However, we currently lack a theoretical model for group decision-making to inform this emerging assessment phenomenon. This paper proposes an organizing framework to study and guide the decision-making processes of clinical competency committees.This is an explanatory, non-exhaustive review, tailored to identify relevant theoretical and evidence-based papers related to small group decision-making. The search was conducted using Google Scholar, Web of Science, MEDLINE, ERIC, and PsycINFO for relevant literature. Using a thematic analysis, two researchers (SC & JP) met four times between April-June 2016 to consolidate the literature included in this review.Three theoretical orientations towards group decision-making emerged from the review: schema, constructivist, and social influence. Schema orientations focus on how groups use algorithms for decision-making. Constructivist orientations focus on how groups construct their shared understanding. Social influence orientations focus on how individual members influence the group's perspective on a decision. Moderators of decision-making relevant to all orientations include: guidelines, stressors, authority, and leadership.Clinical competency committees are the mechanisms by which groups of clinicians will be in charge of interpreting multiple assessment data points and coming to a shared decision about trainee competence. The way in which these committees make decisions can have huge implications for trainee progression and, ultimately, patient care. Therefore, there is a pressing need to build the science of how such group decision-making works in practice. This synthesis suggests a preliminary organizing framework that can be used in the implementation and study of clinical competency committees.

Clinical Decision Support (CDS) Inventory

Data.gov (United States)

U.S. Department of Health & Human Services — The Clinical Decision Support (CDS) Inventory contains descriptions of past and present CDS projects across the Federal Government. It includes Federal projects,...

Smart Building: Decision Making Architecture for Thermal Energy Management.

Science.gov (United States)

Uribe, Oscar Hernández; Martin, Juan Pablo San; Garcia-Alegre, María C; Santos, Matilde; Guinea, Domingo

2015-10-30

Smart applications of the Internet of Things are improving the performance of buildings, reducing energy demand. Local and smart networks, soft computing methodologies, machine intelligence algorithms and pervasive sensors are some of the basics of energy optimization strategies developed for the benefit of environmental sustainability and user comfort. This work presents a distributed sensor-processor-communication decision-making architecture to improve the acquisition, storage and transfer of thermal energy in buildings. The developed system is implemented in a near Zero-Energy Building (nZEB) prototype equipped with a built-in thermal solar collector, where optical properties are analysed; a low enthalpy geothermal accumulation system, segmented in different temperature zones; and an envelope that includes a dynamic thermal barrier. An intelligent control of this dynamic thermal barrier is applied to reduce the thermal energy demand (heating and cooling) caused by daily and seasonal weather variations. Simulations and experimental results are presented to highlight the nZEB thermal energy reduction.

Smart Building: Decision Making Architecture for Thermal Energy Management

Directory of Open Access Journals (Sweden)

Oscar Hernández Uribe

2015-10-01

Full Text Available Smart applications of the Internet of Things are improving the performance of buildings, reducing energy demand. Local and smart networks, soft computing methodologies, machine intelligence algorithms and pervasive sensors are some of the basics of energy optimization strategies developed for the benefit of environmental sustainability and user comfort. This work presents a distributed sensor-processor-communication decision-making architecture to improve the acquisition, storage and transfer of thermal energy in buildings. The developed system is implemented in a near Zero-Energy Building (nZEB prototype equipped with a built-in thermal solar collector, where optical properties are analysed; a low enthalpy geothermal accumulation system, segmented in different temperature zones; and an envelope that includes a dynamic thermal barrier. An intelligent control of this dynamic thermal barrier is applied to reduce the thermal energy demand (heating and cooling caused by daily and seasonal weather variations. Simulations and experimental results are presented to highlight the nZEB thermal energy reduction.

A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders

Directory of Open Access Journals (Sweden)

R. Christopher Sheldrick

2016-11-01

Full Text Available Abstract Background Clinical decision-making has been conceptualized as a sequence of two separate processes: assessment of patients’ functioning and application of a decision threshold to determine whether the evidence is sufficient to justify a given decision. A range of factors, including use of evidence-based screening instruments, has the potential to influence either or both processes. However, implementation studies seldom specify or assess the mechanism by which screening is hypothesized to influence clinical decision-making, thus limiting their ability to address unexpected findings regarding clinicians’ behavior. Building on prior theory and empirical evidence, we created a system dynamics (SD model of how physicians’ clinical decisions are influenced by their assessments of patients and by factors that may influence decision thresholds, such as knowledge of past patient outcomes. Using developmental-behavioral disorders as a case example, we then explore how referral decisions may be influenced by changes in context. Specifically, we compare predictions from the SD model to published implementation trials of evidence-based screening to understand physicians’ management of positive screening results and changes in referral rates. We also conduct virtual experiments regarding the influence of a variety of interventions that may influence physicians’ thresholds, including improved access to co-located mental health care and improved feedback systems regarding patient outcomes. Results Results of the SD model were consistent with recent implementation trials. For example, the SD model suggests that if screening improves physicians’ accuracy of assessment without also influencing decision thresholds, then a significant proportion of children with positive screens will not be referred and the effect of screening implementation on referral rates will be modest—results that are consistent with a large proportion of published

Improving Breast Cancer Surgical Treatment Decision Making: The iCanDecide Randomized Clinical Trial.

Science.gov (United States)

Hawley, Sarah T; Li, Yun; An, Lawrence C; Resnicow, Kenneth; Janz, Nancy K; Sabel, Michael S; Ward, Kevin C; Fagerlin, Angela; Morrow, Monica; Jagsi, Reshma; Hofer, Timothy P; Katz, Steven J

2018-03-01

Purpose This study was conducted to determine the effect of iCanDecide, an interactive and tailored breast cancer treatment decision tool, on the rate of high-quality patient decisions-both informed and values concordant-regarding locoregional breast cancer treatment and on patient appraisal of decision making. Methods We conducted a randomized clinical trial of newly diagnosed patients with early-stage breast cancer making locoregional treatment decisions. From 22 surgical practices, 537 patients were recruited and randomly assigned online to the iCanDecide interactive and tailored Web site (intervention) or the iCanDecide static Web site (control). Participants completed a baseline survey and were mailed a follow-up survey 4 to 5 weeks after enrollment to assess the primary outcome of a high-quality decision, which consisted of two components, high knowledge and values-concordant treatment, and secondary outcomes (decision preparation, deliberation, and subjective decision quality). Results Patients in the intervention arm had higher odds of making a high-quality decision than did those in the control arm (odds ratio, 2.00; 95% CI, 1.37 to 2.92; P = .0004), which was driven primarily by differences in the rates of high knowledge between groups. The majority of patients in both arms made values-concordant treatment decisions (78.6% in the intervention arm and 81.4% in the control arm). More patients in the intervention arm had high decision preparation (estimate, 0.18; 95% CI, 0.02 to 0.34; P = .027), but there were no significant differences in the other decision appraisal outcomes. The effect of the intervention was similar for women who were leaning strongly toward a treatment option at enrollment compared with those who were not. Conclusion The tailored and interactive iCanDecide Web site, which focused on knowledge building and values clarification, positively affected high-quality decisions largely by improving knowledge compared with static online

The trigger matters: The decision-making process for heating systems in the residential building sector

International Nuclear Information System (INIS)

Hecher, Maria; Hatzl, Stefanie; Knoeri, Christof; Posch, Alfred

2017-01-01

As heat demand of buildings accounts for a significant amount of final energy use and related carbon emissions, it’s important to gain insights into the homeowners’ decision-making processes and to identify factors determining the choice of heating systems. In this study, data was collected in an online survey carried out in 2015, from private homeowners of existing and newly built single and double-family houses in Austria who had invested in a new heating system within the last ten years (N=484). In contrast to previous studies, this study specifically investigates the triggers behind homeowner decisions to invest in a new heating system (e.g. problem, opportunity, or new building situation). Results of binary logistic regression analysis show that subsidies for heating system tabinvestments and infrastructural adjustments reveal to be most effective for homeowners in problem situations to foster alternative heating systems. For homeowners in opportunity situations (e.g. building refurbishment), in addition operational convenience appears to be important. For new buildings, the main barriers for alternative heating system adoption were found in the positive perception of fuel supply security and feasibility of fossil systems. Thus, the use of trigger-specific policy measures is proposed to foster alternative heating systems in the residential building sector. - Highlights: • Homeowners’ triggers determine heating system adoption decisions. • It is crucial to reach homeowners early enough to avoid problem situations. • For problem-triggered homeowners, subsidies are most effective. • Opportunity-triggered homeowners prefer alternative heating systems. • Opportunity-triggered homeowners need solid decision basis for technology comparison.

Clinical decision regret among critical care nurses: a qualitative analysis.

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Arslanian-Engoren, Cynthia; Scott, Linda D

2014-01-01

Decision regret is a negative cognitive emotion associated with experiences of guilt and situations of interpersonal harm. These negative affective responses may contribute to emotional exhaustion in critical care nurses (CCNs), increased staff turnover rates and high medication error rates. Yet, little is known about clinical decision regret among CCNs or the conditions or situations (e.g., feeling sleepy) that may precipitate its occurrence. To examine decision regret among CCNs, with an emphasis on clinical decisions made when nurses were most sleepy. A content analytic approach was used to examine the narrative descriptions of clinical decisions by CCNs when sleepy. Six decision regret themes emerged that represented deviations in practice or performance behaviors that were attributed to fatigued CCNs. While 157 CCNs disclosed a clinical decision they made at work while sleepy, the prevalence may be underestimated and warrants further investigation. Copyright © 2014 Elsevier Inc. All rights reserved.

Clinical decision making: how surgeons do it.

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Crebbin, Wendy; Beasley, Spencer W; Watters, David A K

2013-06-01

Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decision-making skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

Building energy retrofit index for policy making and decision support at regional and national scales

International Nuclear Information System (INIS)

Khayatian, Fazel; Sarto, Luca; Dall'O', Giuliano

2017-01-01

Highlights: •Machine learning is used for pre-processing, fine-tuning and post-processing data. •A new indicator is introduced to support building energy retrofit policies. •The presented indicator is evaluated by a case study of 4767 buildings. •Current energy indicators can misrepresent the building energy retrofit potential. -- Abstract: The vast data collected since the enforcement of building energy labelling in Italy has provided valuable information that is useful for planning the future of building energy efficiency. However, the indicators provided through energy certificates are not suitable to support decisions, which target building energy retrofit in a regional scale. Considering the bias of the energy performance index toward a building’s shape, decisions based on this index will favor buildings with a specific geometric characteristics. This study tends to overcome this issue by introducing a new indicator, tailored to rank buildings based on retrofitable characteristics. The proposed framework is validated by a case study, in which a large dataset of office buildings are assigned with the new index. Results indicate that the proposed indicator succeeds to extract a single index, which is representative of all building characteristics subject to energy retrofit. A new labeling procedure is also compared with the conventional classification of buildings. It is observed that the proposed labels properly partitions the dataset, according to buildings’ potential to undergo energy retrofit.

The Pedagogical Reflection Model - an educational perspective on clinical decisions

DEFF Research Database (Denmark)

Voergaard Poulsen, Bettina; Vibholm Persson, Stine; Skriver, Mette

Clinical decision-making is important in patient-centred nursing, which is known in nursing education and research (1) The Pedagogical Reflection Model (PRM) can provide a framework that supports students’ decision-making in patient-specific situations. PRM is based on the assumption that clinical......) The aims of this study were to explore how nurse students and clinical supervisors use PRM as method to reflect before, during and after PRM guidance in relation to clinical decisions in the first year of clinical practice...... decision-making needs to take into account; 1) clinical experiences, 2) the perspective of the patient, 3) clinical observations and investigations, 4) knowledge about patients experiences of being a patient and ill, 5) medical knowledge about diseases, and 6) the organizational framework (2,3,4)(Figure 1...

A tool for design decision making - zero energy residential buildings in hot humid climates

NARCIS (Netherlands)

Attia, S.G.

2012-01-01

In this thesis, the development and evaluation of a simulation-based decision aid for Net Zero Energy Buildings (NZEBs) design, ZEBO, was explored. The thesis investigates the ability to achieve informed decision making for NZEB design, in hot climate. Four main questions were posed. Firstly, how to

Conceptualising a system for quality clinical decision-making in ...

African Journals Online (AJOL)

As a feedback mechanism to promote or improve the quality of clinical decisions in nursing, standards for quality clinical decision-making are proposed in an exemplary manner. In addition, a system for quality clinical decisionmaking in nursing capitalises on the heritage of the nursing process. Considering the changes and ...

Agile Acceptance Test-Driven Development of Clinical Decision Support Advisories: Feasibility of Using Open Source Software.

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Basit, Mujeeb A; Baldwin, Krystal L; Kannan, Vaishnavi; Flahaven, Emily L; Parks, Cassandra J; Ott, Jason M; Willett, Duwayne L

2018-04-13

Moving to electronic health records (EHRs) confers substantial benefits but risks unintended consequences. Modern EHRs consist of complex software code with extensive local configurability options, which can introduce defects. Defects in clinical decision support (CDS) tools are surprisingly common. Feasible approaches to prevent and detect defects in EHR configuration, including CDS tools, are needed. In complex software systems, use of test-driven development and automated regression testing promotes reliability. Test-driven development encourages modular, testable design and expanding regression test coverage. Automated regression test suites improve software quality, providing a "safety net" for future software modifications. Each automated acceptance test serves multiple purposes, as requirements (prior to build), acceptance testing (on completion of build), regression testing (once live), and "living" design documentation. Rapid-cycle development or "agile" methods are being successfully applied to CDS development. The agile practice of automated test-driven development is not widely adopted, perhaps because most EHR software code is vendor-developed. However, key CDS advisory configuration design decisions and rules stored in the EHR may prove amenable to automated testing as "executable requirements." We aimed to establish feasibility of acceptance test-driven development of clinical decision support advisories in a commonly used EHR, using an open source automated acceptance testing framework (FitNesse). Acceptance tests were initially constructed as spreadsheet tables to facilitate clinical review. Each table specified one aspect of the CDS advisory's expected behavior. Table contents were then imported into a test suite in FitNesse, which queried the EHR database to automate testing. Tests and corresponding CDS configuration were migrated together from the development environment to production, with tests becoming part of the production regression test

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

OpenAIRE

Hajjaj, FM; Salek, MS; Basra, MKA; Finlay, AY

2010-01-01

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional co...

Factors and outcomes of decision making for cancer clinical trial participation.

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Biedrzycki, Barbara A

2011-09-01

To describe factors and outcomes related to the decision-making process regarding participation in a cancer clinical trial. Cross-sectional, descriptive. Urban, academic, National Cancer Institute-designated comprehensive cancer center in the mid-Atlantic United States. 197 patients with advanced gastrointestinal cancer. Mailed survey using one investigator-developed instrument, eight instruments used in published research, and a medical record review. disease context, sociodemographics, hope, quality of life, trust in healthcare system, trust in health professional, preference for research decision control, understanding risks, and information. decision to accept or decline research participation and satisfaction with this decision. All of the factors within the Research Decision Making Model together predicted cancer clinical trial participation and satisfaction with this decision. The most frequently preferred decision-making style for research participation was shared (collaborative) (83%). Multiple factors affect decision making for cancer clinical trial participation and satisfaction with this decision. Shared decision making previously was an unrecognized factor and requires further investigation. Enhancing the process of research decision making may facilitate an increase in cancer clinical trial enrollment rates. Oncology nurses have unique opportunities as educators and researchers to support shared decision making by those who prefer this method for deciding whether to accept or decline cancer clinical trial participation.

Accuracy of intuition in clinical decision-making among novice clinicians.

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Price, Amanda; Zulkosky, Kristen; White, Krista; Pretz, Jean

2017-05-01

To assess the reliance on intuitive and analytical approaches during clinical decision-making among novice clinicians and whether that reliance is associated with accurate decision-making. Nurse educators and managers tend to emphasize analysis over intuition during clinical decision-making though nurses typically report some reliance on intuition in their practice. We hypothesized that under certain conditions, reliance on intuition would support accurate decision-making, even among novices. This study utilized an experimental design with clinical complication (familiar vs. novel) and decision phase (cue acquisition, diagnosis and action) as within-subjects' factors, and simulation role (observer, family, auxiliary nurse and primary nurse) as between-subjects' factor. We examined clinical decision-making accuracy among final semester pre-licensure nursing students in a simulation experience. Students recorded their reasoning about emerging clinical complications with their patient during two distinct points in the simulation; one point involved a familiar complication and the other a relatively novel complication. All data were collected during Spring 2015. Although most participants relied more heavily on analysis than on intuition, use of intuition during the familiar complication was associated with more accurate decision-making, particularly in guiding attention to relevant cues. With the novel complication, use of intuition appeared to hamper decision-making, particularly for those in an observer role. Novice clinicians should be supported by educators and nurse managers to note when their intuitions are likely to be valid. Our findings emphasize the integrated nature of intuition and analysis in clinical decision-making. © 2016 John Wiley & Sons Ltd.

Factors influencing the clinical decision-making of midwives: a qualitative study.

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Daemers, Darie O A; van Limbeek, Evelien B M; Wijnen, Hennie A A; Nieuwenhuijze, Marianne J; de Vries, Raymond G

2017-10-06

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives' decisions are based on more than the evidence based medicine (EBM) model - i.e. clinical evidence, midwife's expertise, and woman's values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently. We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives' clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts. We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives' clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged. Midwives' clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are

User-centered design to improve clinical decision support in primary care.

Science.gov (United States)

Brunner, Julian; Chuang, Emmeline; Goldzweig, Caroline; Cain, Cindy L; Sugar, Catherine; Yano, Elizabeth M

2017-08-01

A growing literature has demonstrated the ability of user-centered design to make clinical decision support systems more effective and easier to use. However, studies of user-centered design have rarely examined more than a handful of sites at a time, and have frequently neglected the implementation climate and organizational resources that influence clinical decision support. The inclusion of such factors was identified by a systematic review as "the most important improvement that can be made in health IT evaluations." (1) Identify the prevalence of four user-centered design practices at United States Veterans Affairs (VA) primary care clinics and assess the perceived utility of clinical decision support at those clinics; (2) Evaluate the association between those user-centered design practices and the perceived utility of clinical decision support. We analyzed clinic-level survey data collected in 2006-2007 from 170 VA primary care clinics. We examined four user-centered design practices: 1) pilot testing, 2) provider satisfaction assessment, 3) formal usability assessment, and 4) analysis of impact on performance improvement. We used a regression model to evaluate the association between user-centered design practices and the perceived utility of clinical decision support, while accounting for other important factors at those clinics, including implementation climate, available resources, and structural characteristics. We also examined associations separately at community-based clinics and at hospital-based clinics. User-centered design practices for clinical decision support varied across clinics: 74% conducted pilot testing, 62% conducted provider satisfaction assessment, 36% conducted a formal usability assessment, and 79% conducted an analysis of impact on performance improvement. Overall perceived utility of clinical decision support was high, with a mean rating of 4.17 (±.67) out of 5 on a composite measure. "Analysis of impact on performance

Translating shared decision-making into health care clinical practices: Proof of concepts

Directory of Open Access Journals (Sweden)

St-Jacques Sylvie

2008-01-01

Full Text Available Abstract Background There is considerable interest today in shared decision-making (SDM, defined as a decision-making process jointly shared by patients and their health care provider. However, the data show that SDM has not been broadly adopted yet. Consequently, the main goal of this proposal is to bring together the resources and the expertise needed to develop an interdisciplinary and international research team on the implementation of SDM in clinical practice using a theory-based dyadic perspective. Methods Participants include researchers from Canada, US, UK, and Netherlands, representing medicine, nursing, psychology, community health and epidemiology. In order to develop a collaborative research network that takes advantage of the expertise of the team members, the following research activities are planned: 1 establish networking and on-going communication through internet-based forum, conference calls, and a bi-weekly e-bulletin; 2 hold a two-day workshop with two key experts (one in theoretical underpinnings of behavioral change, and a second in dyadic data analysis, and invite all investigators to present their views on the challenges related to the implementation of SDM in clinical practices; 3 conduct a secondary analyses of existing dyadic datasets to ensure that discussion among team members is grounded in empirical data; 4 build capacity with involvement of graduate students in the workshop and online forum; and 5 elaborate a position paper and an international multi-site study protocol. Discussion This study protocol aims to inform researchers, educators, and clinicians interested in improving their understanding of effective strategies to implement shared decision-making in clinical practice using a theory-based dyadic perspective.

Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies.

Science.gov (United States)

Djulbegovic, Benjamin; Hozo, Iztok; Dale, William

2018-02-27

Contemporary delivery of health care is inappropriate in many ways, largely due to suboptimal Q5 decision-making. A typical approach to improve practitioners' decision-making is to develop evidence-based clinical practice guidelines (CPG) by guidelines panels, who are instructed to use their judgments to derive practice recommendations. However, mechanisms for the formulation of guideline judgments remains a "black-box" operation-a process with defined inputs and outputs but without sufficient knowledge of its internal workings. Increased explicitness and transparency in the process can be achieved by implementing CPG as clinical pathways (CPs) (also known as clinical algorithms or flow-charts). However, clinical recommendations thus derived are typically ad hoc and developed by experts in a theory-free environment. As any recommendation can be right (true positive or negative), or wrong (false positive or negative), the lack of theoretical structure precludes the quantitative assessment of the management strategies recommended by CPGs/CPs. To realize the full potential of CPGs/CPs, they need to be placed on more solid theoretical grounds. We believe this potential can be best realized by converting CPGs/CPs within the heuristic theory of decision-making, often implemented as fast-and-frugal (FFT) decision trees. This is possible because FFT heuristic strategy of decision-making can be linked to signal detection theory, evidence accumulation theory, and a threshold model of decision-making, which, in turn, allows quantitative analysis of the accuracy of clinical management strategies. Fast-and-frugal provides a simple and transparent, yet solid and robust, methodological framework connecting decision science to clinical care, a sorely needed missing link between CPGs/CPs and patient outcomes. We therefore advocate that all guidelines panels express their recommendations as CPs, which in turn should be converted into FFTs to guide clinical care. © 2018 John Wiley

Improving clinical decision support using data mining techniques

Science.gov (United States)

Burn-Thornton, Kath E.; Thorpe, Simon I.

1999-02-01

Physicians, in their ever-demanding jobs, are looking to decision support systems for aid in clinical diagnosis. However, clinical decision support systems need to be of sufficiently high accuracy that they help, rather than hinder, the physician in his/her diagnosis. Decision support systems with accuracies, of patient state determination, of greater than 80 percent, are generally perceived to be sufficiently accurate to fulfill the role of helping the physician. We have previously shown that data mining techniques have the potential to provide the underpinning technology for clinical decision support systems. In this paper, an extension of the work in reverence 2, we describe how changes in data mining methodologies, for the analysis of 12-lead ECG data, improve the accuracy by which data mining algorithms determine which patients are suffering from heart disease. We show that the accuracy of patient state prediction, for all the algorithms, which we investigated, can be increased by up to 6 percent, using the combination of appropriate test training ratios and 5-fold cross-validation. The use of cross-validation greater than 5-fold, appears to reduce the improvement in algorithm classification accuracy gained by the use of this validation method. The accuracy of 84 percent in patient state predictions, obtained using the algorithm OCI, suggests that this algorithm will be capable of providing the required accuracy for clinical decision support systems.

The impact of simulation sequencing on perceived clinical decision making.

Science.gov (United States)

Woda, Aimee; Hansen, Jamie; Paquette, Mary; Topp, Robert

2017-09-01

An emerging nursing education trend is to utilize simulated learning experiences as a means to optimize competency and decision making skills. The purpose of this study was to examine differences in students' perception of clinical decision making and clinical decision making-related self-confidence and anxiety based on the sequence (order) in which they participated in a block of simulated versus hospital-based learning experiences. A quasi-experimental crossover design was used. Between and within group differences were found relative to self-confidence with the decision making process. When comparing groups, at baseline the simulation followed by hospital group had significantly higher self-confidence scores, however, at 14-weeks both groups were not significantly different. Significant within group differences were found in the simulation followed by hospital group only, demonstrating a significant decrease in clinical decision making related anxiety across the semester. Finally, there were no significant difference in; perceived clinical decision making within or between the groups at the two measurement points. Preliminary findings suggest that simulated learning experiences can be offered with alternating sequences without impacting the process, anxiety or confidence with clinical decision making. This study provides beginning evidence to guide curriculum development and allow flexibility based on student needs and available resources. Copyright © 2017. Published by Elsevier Ltd.

An exploration of clinical decision making in mental health triage.

Science.gov (United States)

Sands, Natisha

2009-08-01

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

Decision aids for people considering taking part in clinical trials.

Science.gov (United States)

Gillies, Katie; Cotton, Seonaidh C; Brehaut, Jamie C; Politi, Mary C; Skea, Zoe

2015-11-27

Several interventions have been developed to promote informed consent for participants in clinical trials. However, many of these interventions focus on the content and structure of information (e.g. enhanced information or changes to the presentation format) rather than the process of decision making. Patient decision aids support a decision making process about medical options. Decision aids support the decision process by providing information about available options and their associated outcomes, alongside information that enables patients to consider what value they place on particular outcomes, and provide structured guidance on steps of decision making. They have been shown to be effective for treatment and screening decisions but evidence on their effectiveness in the context of informed consent for clinical trials has not been synthesised. To assess the effectiveness of decision aids for clinical trial informed consent compared to no intervention, standard information (i.e. usual practice) or an alternative intervention on the decision making process. We searched the following databases and to March 2015: Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library; MEDLINE (OvidSP) (from 1950); EMBASE (OvidSP) (from 1980); PsycINFO (OvidSP) (from 1806); ASSIA (ProQuest) (from 1987); WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/); ClinicalTrials.gov; ISRCTN Register (http://www.controlled-trials.com/isrctn/). We also searched reference lists of included studies and relevant reviews. We contacted study authors and other experts. There were no language restrictions. We included randomised and quasi-randomised controlled trials comparing decision aids in the informed consent process for clinical trials alone, or in conjunction with standard information (such as written or verbal) or alongside alternative interventions (e.g. paper-based versus web-based decision aids). Included trials involved

Understanding complex clinical reasoning in infectious diseases for improving clinical decision support design.

Science.gov (United States)

Islam, Roosan; Weir, Charlene R; Jones, Makoto; Del Fiol, Guilherme; Samore, Matthew H

2015-11-30

Clinical experts' cognitive mechanisms for managing complexity have implications for the design of future innovative healthcare systems. The purpose of the study is to examine the constituents of decision complexity and explore the cognitive strategies clinicians use to control and adapt to their information environment. We used Cognitive Task Analysis (CTA) methods to interview 10 Infectious Disease (ID) experts at the University of Utah and Salt Lake City Veterans Administration Medical Center. Participants were asked to recall a complex, critical and vivid antibiotic-prescribing incident using the Critical Decision Method (CDM), a type of Cognitive Task Analysis (CTA). Using the four iterations of the Critical Decision Method, questions were posed to fully explore the incident, focusing in depth on the clinical components underlying the complexity. Probes were included to assess cognitive and decision strategies used by participants. The following three themes emerged as the constituents of decision complexity experienced by the Infectious Diseases experts: 1) the overall clinical picture does not match the pattern, 2) a lack of comprehension of the situation and 3) dealing with social and emotional pressures such as fear and anxiety. All these factors contribute to decision complexity. These factors almost always occurred together, creating unexpected events and uncertainty in clinical reasoning. Five themes emerged in the analyses of how experts deal with the complexity. Expert clinicians frequently used 1) watchful waiting instead of over- prescribing antibiotics, engaged in 2) theory of mind to project and simulate other practitioners' perspectives, reduced very complex cases into simple 3) heuristics, employed 4) anticipatory thinking to plan and re-plan events and consulted with peers to share knowledge, solicit opinions and 5) seek help on patient cases. The cognitive strategies to deal with decision complexity found in this study have important

A Conceptual Framework for Occupant-Centered Building Management Decision Support System

DEFF Research Database (Denmark)

Lazarova-Molnar, Sanja; Shaker, Hamid Reza

2016-01-01

-obvious/-direct incentive to reduce energy use and no access to their levels of consumption. In this paper we present a framework for a building energy management decision support system that is motivated by these findings, and therefore, centres the occupants and motivates them to both achieve business-wise and improve......Buildings’ energy consumption makes the largest portion of the overall energy consumption. Commercial buildings are specific and their energy efficiency should not be viewed as a standalone issue. On the contrary, it needs to be viewed in function of the goals of the hosted businesses...

Modeling a Decision Support Tool for Buildable and Sustainable Building Envelope Designs

Directory of Open Access Journals (Sweden)

Natee Singhaputtangkul

2015-05-01

Full Text Available Sustainability and buildability requirements in building envelope design have significantly gained more importance nowadays, yet there is a lack of an appropriate decision support system (DSS that can help a building design team to incorporate these requirements and manage their tradeoffs at once. The main objective of this study is to build such a tool to facilitate a building design team to take into account sustainability and buildability criteria for assessment of building envelopes of high-rise residential buildings in Singapore. Literature reviews were conducted to investigate a comprehensive set of the sustainability and buildability criteria. This also included development of the tool using a Quality Functional Deployment (QFD approach combined with fuzzy set theory. A building design team was engaged to test the tool with the aim to evaluate usefulness of the tool in managing the tradeoffs among the sustainability and buildability criteria. The results from a qualitative data analysis suggested that the tool allowed the design team to effectively find a balance between the tradeoffs among the criteria when assessing multiple building envelope design alternatives. Main contributions of using this tool are achievement of a more efficient assessment of the building envelopes and more sustainable and buildable building envelope design.

Computerized Clinical Decision Support: Contributions from 2015

Science.gov (United States)

Bouaud, J.

2016-01-01

Summary Objective To summarize recent research and select the best papers published in 2015 in the field of computerized clinical decision support for the Decision Support section of the IMIA yearbook. Method A literature review was performed by searching two bibliographic databases for papers related to clinical decision support systems (CDSSs) and computerized provider order entry (CPOE) systems. The aim was to identify a list of candidate best papers from the retrieved papers that were then peer-reviewed by external reviewers. A consensus meeting between the two section editors and the IMIA editorial team was finally conducted to conclude in the best paper selection. Results Among the 974 retrieved papers, the entire review process resulted in the selection of four best papers. One paper reports on a CDSS routinely applied in pediatrics for more than 10 years, relying on adaptations of the Arden Syntax. Another paper assessed the acceptability and feasibility of an important CPOE evaluation tool in hospitals outside the US where it was developed. The third paper is a systematic, qualitative review, concerning usability flaws of medication-related alerting functions, providing an important evidence-based, methodological contribution in the domain of CDSS design and development in general. Lastly, the fourth paper describes a study quantifying the effect of a complex, continuous-care, guideline-based CDSS on the correctness and completeness of clinicians’ decisions. Conclusions While there are notable examples of routinely used decision support systems, this 2015 review on CDSSs and CPOE systems still shows that, despite methodological contributions, theoretical frameworks, and prototype developments, these technologies are not yet widely spread (at least with their full functionalities) in routine clinical practice. Further research, testing, evaluation, and training are still needed for these tools to be adopted in clinical practice and, ultimately, illustrate

Clinical Decision Making of Nurses Working in Hospital Settings

OpenAIRE

Ida Torunn Bjørk; Glenys A. Hamilton

2011-01-01

This study analyzed nurses' perceptions of clinical decision making (CDM) in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with d...

Clinical decision making in veterinary practice

OpenAIRE

Everitt, Sally

2011-01-01

Aim The aim of this study is to develop an understanding of the factors which influence veterinary surgeons’ clinical decision making during routine consultations. Methods The research takes a qualitative approach using video-cued interviews, in which one of the veterinary surgeon’s own consultations is used as the basis of a semi-structured interview exploring decision making in real cases. The research focuses primarily on small animal consultations in first opinion practice, how...

Modelling and Decision Support of Clinical Pathways

Science.gov (United States)

Gabriel, Roland; Lux, Thomas

The German health care market is under a rapid rate of change, forcing especially hospitals to provide high-quality services at low costs. Appropriate measures for more effective and efficient service provision are process orientation and decision support by information technology of clinical pathway of a patient. The essential requirements are adequate modelling of clinical pathways as well as usage of adequate systems, which are capable of assisting the complete path of a patient within a hospital, and preferably also outside of it, in a digital way. To fulfil these specifications the authors present a suitable concept, which meets the challenges of well-structured clinical pathways as well as rather poorly structured diagnostic and therapeutic decisions, by interplay of process-oriented and knowledge-based hospital information systems.

Optimal Decision Model for Sustainable Hospital Building Renovation—A Case Study of a Vacant School Building Converting into a Community Public Hospital

Science.gov (United States)

Juan, Yi-Kai; Cheng, Yu-Ching; Perng, Yeng-Horng; Castro-Lacouture, Daniel

2016-01-01

Much attention has been paid to hospitals environments since modern pandemics have emerged. The building sector is considered to be the largest world energy consumer, so many global organizations are attempting to create a sustainable environment in building construction by reducing energy consumption. Therefore, maintaining high standards of hygiene while reducing energy consumption has become a major task for hospitals. This study develops a decision model based on genetic algorithms and A* graph search algorithms to evaluate existing hospital environmental conditions and to recommend an optimal scheme of sustainable renovation strategies, considering trade-offs among minimal renovation cost, maximum quality improvement, and low environmental impact. Reusing vacant buildings is a global and sustainable trend. In Taiwan, for example, more and more school space will be unoccupied due to a rapidly declining birth rate. Integrating medical care with local community elder-care efforts becomes important because of the aging population. This research introduces a model that converts a simulated vacant school building into a community public hospital renovation project in order to validate the solutions made by hospital managers and suggested by the system. The result reveals that the system performs well and its solutions are more successful than the actions undertaken by decision-makers. This system can improve traditional hospital building condition assessment while making it more effective and efficient. PMID:27347986

Optimal Decision Model for Sustainable Hospital Building Renovation-A Case Study of a Vacant School Building Converting into a Community Public Hospital.

Science.gov (United States)

Juan, Yi-Kai; Cheng, Yu-Ching; Perng, Yeng-Horng; Castro-Lacouture, Daniel

2016-06-24

Much attention has been paid to hospitals environments since modern pandemics have emerged. The building sector is considered to be the largest world energy consumer, so many global organizations are attempting to create a sustainable environment in building construction by reducing energy consumption. Therefore, maintaining high standards of hygiene while reducing energy consumption has become a major task for hospitals. This study develops a decision model based on genetic algorithms and A* graph search algorithms to evaluate existing hospital environmental conditions and to recommend an optimal scheme of sustainable renovation strategies, considering trade-offs among minimal renovation cost, maximum quality improvement, and low environmental impact. Reusing vacant buildings is a global and sustainable trend. In Taiwan, for example, more and more school space will be unoccupied due to a rapidly declining birth rate. Integrating medical care with local community elder-care efforts becomes important because of the aging population. This research introduces a model that converts a simulated vacant school building into a community public hospital renovation project in order to validate the solutions made by hospital managers and suggested by the system. The result reveals that the system performs well and its solutions are more successful than the actions undertaken by decision-makers. This system can improve traditional hospital building condition assessment while making it more effective and efficient.

Research utilization in the building industry: decision model and preliminary assessment

Energy Technology Data Exchange (ETDEWEB)

Watts, R.L.; Johnson, D.R.; Smith, S.A.; Westergard, E.J.

1985-10-01

The Research Utilization Program was conceived as a far-reaching means for managing the interactions of the private sector and the federal research sector as they deal with energy conservation in buildings. The program emphasizes a private-public partnership in planning a research agenda and in applying the results of ongoing and completed research. The results of this task support the hypothesis that the transfer of R and D results to the buildings industry can be accomplished more efficiently and quickly by a systematic approach to technology transfer. This systematic approach involves targeting decision makers, assessing research and information needs, properly formating information, and then transmitting the information through trusted channels. The purpose of this report is to introduce elements of a market-oriented knowledge base, which would be useful to the Building Systems Division, the Office of Buildings and Community Systems and their associated laboratories in managing a private-public research partnership on a rational systematic basis. This report presents conceptual models and data bases that can be used in formulating a technology transfer strategy and in planning technology transfer programs.

Implementation of workflow engine technology to deliver basic clinical decision support functionality.

Science.gov (United States)

Huser, Vojtech; Rasmussen, Luke V; Oberg, Ryan; Starren, Justin B

2011-04-10

Workflow engine technology represents a new class of software with the ability to graphically model step-based knowledge. We present application of this novel technology to the domain of clinical decision support. Successful implementation of decision support within an electronic health record (EHR) remains an unsolved research challenge. Previous research efforts were mostly based on healthcare-specific representation standards and execution engines and did not reach wide adoption. We focus on two challenges in decision support systems: the ability to test decision logic on retrospective data prior prospective deployment and the challenge of user-friendly representation of clinical logic. We present our implementation of a workflow engine technology that addresses the two above-described challenges in delivering clinical decision support. Our system is based on a cross-industry standard of XML (extensible markup language) process definition language (XPDL). The core components of the system are a workflow editor for modeling clinical scenarios and a workflow engine for execution of those scenarios. We demonstrate, with an open-source and publicly available workflow suite, that clinical decision support logic can be executed on retrospective data. The same flowchart-based representation can also function in a prospective mode where the system can be integrated with an EHR system and respond to real-time clinical events. We limit the scope of our implementation to decision support content generation (which can be EHR system vendor independent). We do not focus on supporting complex decision support content delivery mechanisms due to lack of standardization of EHR systems in this area. We present results of our evaluation of the flowchart-based graphical notation as well as architectural evaluation of our implementation using an established evaluation framework for clinical decision support architecture. We describe an implementation of a free workflow technology

Implementation of workflow engine technology to deliver basic clinical decision support functionality

Science.gov (United States)

2011-01-01

Background Workflow engine technology represents a new class of software with the ability to graphically model step-based knowledge. We present application of this novel technology to the domain of clinical decision support. Successful implementation of decision support within an electronic health record (EHR) remains an unsolved research challenge. Previous research efforts were mostly based on healthcare-specific representation standards and execution engines and did not reach wide adoption. We focus on two challenges in decision support systems: the ability to test decision logic on retrospective data prior prospective deployment and the challenge of user-friendly representation of clinical logic. Results We present our implementation of a workflow engine technology that addresses the two above-described challenges in delivering clinical decision support. Our system is based on a cross-industry standard of XML (extensible markup language) process definition language (XPDL). The core components of the system are a workflow editor for modeling clinical scenarios and a workflow engine for execution of those scenarios. We demonstrate, with an open-source and publicly available workflow suite, that clinical decision support logic can be executed on retrospective data. The same flowchart-based representation can also function in a prospective mode where the system can be integrated with an EHR system and respond to real-time clinical events. We limit the scope of our implementation to decision support content generation (which can be EHR system vendor independent). We do not focus on supporting complex decision support content delivery mechanisms due to lack of standardization of EHR systems in this area. We present results of our evaluation of the flowchart-based graphical notation as well as architectural evaluation of our implementation using an established evaluation framework for clinical decision support architecture. Conclusions We describe an implementation of

Clinical decision-making by midwives: managing case complexity.

Science.gov (United States)

Cioffi, J; Markham, R

1997-02-01

In making clinical judgements, it is argued that midwives use 'shortcuts' or heuristics based on estimated probabilities to simplify the decision-making task. Midwives (n = 30) were given simulated patient assessment situations of high and low complexity and were required to think aloud. Analysis of verbal protocols showed that subjective probability judgements (heuristics) were used more frequently in the high than low complexity case and predominated in the last quarter of the assessment period for the high complexity case. 'Representativeness' was identified more frequently in the high than in the low case, but was the dominant heuristic in both. Reports completed after each simulation suggest that heuristics based on memory for particular conditions affect decisions. It is concluded that midwives use heuristics, derived mainly from their clinical experiences, in an attempt to save cognitive effort and to facilitate reasonably accurate decisions in the decision-making process.

Building Energy Consumption Pattern Analysis of Detached Housing for the Policy Decision Simulator

Science.gov (United States)

Lim, Jiyoun; Lee, Seung-Eon

2018-03-01

The Korean government announced its plan to raise the previous reduction goal of greenhouse gas emission from buildings by 26.9% until 2020 on July 2015. Therefore, policies regarding efficiency in the building energy are implemented fast, but the level of building owners and market understanding is low in general, and the government service system which supports decision making for implementing low-energy buildings has not been provided yet. The purpose of this study is to present the design direction for establishing user customized building energy database to perform a role to provide autonomous ecosystem of low-energy buildings. In order to reduce energy consumption in buildings, it is necessary to carry out the energy performance analysis based on the characteristics of target building. By analysing about 20-thousand cases of the amount of housing energy consumption in Korea, this study suggested the real energy consumption pattern by building types. Also, the energy performance of a building could be determined by energy consumption, but previous building energy consumption analysis programs required expert knowledge and experience in program usage, so it was difficult for normal building users to use such programs. Therefore, a measure to provide proper default using the level of data which general users with no expert knowledge regarding building energy could enter easily was suggested in this study.

Record of Decision for the Ford Building Waste Unit (643-11G) Operable Unit; FINAL

International Nuclear Information System (INIS)

Fraley, S.

2002-01-01

This decision document presents the selected remedial for the Ford Building Waste Unit (FBWU), in Aiken, South Carolina, which was chosen in accordance with CERCLA, as amended by SARA, and, to the extent practical, the National Oil and Hazardous Substances Pollution Contingency Plan (NCP). This decision is based on the Administrative Record File for this specific RCRA/CERCLA site

Enhancing clinical decision making: development of a contiguous definition and conceptual framework.

Science.gov (United States)

Tiffen, Jennifer; Corbridge, Susan J; Slimmer, Lynda

2014-01-01

Clinical decision making is a term frequently used to describe the fundamental role of the nurse practitioner; however, other terms have been used interchangeably. The purpose of this article is to begin the process of developing a definition and framework of clinical decision making. The developed definition was "Clinical decision making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action." A contiguous framework for clinical decision making specific for nurse practitioners is also proposed. Having a clear and unique understanding of clinical decision making will allow for consistent use of the term, which is relevant given the changing educational requirements for nurse practitioners and broadening scope of practice. Copyright © 2014 Elsevier Inc. All rights reserved.

Towards the Significance of Decision Aid in Building Information Modeling (BIM Software Selection Process

Directory of Open Access Journals (Sweden)

Omar Mohd Faizal

2014-01-01

Full Text Available Building Information Modeling (BIM has been considered as a solution in construction industry to numerous problems such as delays, increased lead in times and increased costs. This is due to the concept and characteristic of BIM that will reshaped the way construction project teams work together to increase productivity and improve the final project outcomes (cost, time, quality, safety, functionality, maintainability, etc.. As a result, the construction industry has witnesses numerous of BIM software available in market. Each of this software has offers different function, features. Furthermore, the adoption of BIM required high investment on software, hardware and also training expenses. Thus, there is indentified that there is a need of decision aid for appropriated BIM software selection that fulfill the project needs. However, research indicates that there is limited study attempt to guide decision in BIM software selection problem. Thus, this paper highlight the importance of decision making and support for BIM software selection as it is vital to increase productivity, construction project throughout building lifecycle.

Clinical decision-making: predictors of patient participation in nursing care.

Science.gov (United States)

Florin, Jan; Ehrenberg, Anna; Ehnfors, Margareta

2008-11-01

To investigate predictors of patients' preferences for participation in clinical decision-making in inpatient nursing care. Patient participation in decision-making in nursing care is regarded as a prerequisite for good clinical practice regarding the person's autonomy and integrity. A cross-sectional survey of 428 persons, newly discharged from inpatient care. The survey was conducted using the Control Preference Scale. Multiple logistic regression analysis was used for testing the association of patient characteristics with preferences for participation. Patients, in general, preferred adopting a passive role. However, predictors for adopting an active participatory role were the patient's gender (odds ratio = 1.8), education (odds ratio = 2.2), living condition (odds ratio = 1.8) and occupational status (odds ratio = 2.0). A probability of 53% was estimated, which female senior citizens with at least a high school degree and who lived alone would prefer an active role in clinical decision-making. At the same time, a working cohabiting male with less than a high school degree had a probability of 8% for active participation in clinical decision making in nursing care. Patient preferences for participation differed considerably and are best elicited by assessment of the individual patient. Relevance to clinical practice. The nurses have a professional responsibility to act in such a way that patients can participate and make decisions according to their own values from an informed position. Access to knowledge of patients'basic assumptions and preferences for participation is of great value for nurses in the care process. There is a need for nurses to use structured methods and tools for eliciting individual patient preferences regarding participation in clinical decision-making.

Decision Analysis: Engineering Science or Clinical Art

Science.gov (United States)

1979-11-01

TECHNICAL REPORT TR 79-2-97 DECISION ANALYSIS: ENGINEERING SCIENCE OR CLINICAL ART ? by Dennis M. Buede Prepared for Defense Advanced Research...APPLICATIONS OF THE ENGINEER- ING SCIENCE AND CLINICAL ART EXTREMES 9 3.1 Applications of the Engineering Science Approach 9 3.1.1 Mexican electrical...DISCUSSION 29 4.1 Engineering Science versus Clinical Art : A Characterization of When Each is Most Attractive 30 4.2 The Implications of the Engineering

Scalable software architectures for decision support.

Science.gov (United States)

Musen, M A

1999-12-01

Interest in decision-support programs for clinical medicine soared in the 1970s. Since that time, workers in medical informatics have been particularly attracted to rule-based systems as a means of providing clinical decision support. Although developers have built many successful applications using production rules, they also have discovered that creation and maintenance of large rule bases is quite problematic. In the 1980s, several groups of investigators began to explore alternative programming abstractions that can be used to build decision-support systems. As a result, the notions of "generic tasks" and of reusable problem-solving methods became extremely influential. By the 1990s, academic centers were experimenting with architectures for intelligent systems based on two classes of reusable components: (1) problem-solving methods--domain-independent algorithms for automating stereotypical tasks--and (2) domain ontologies that captured the essential concepts (and relationships among those concepts) in particular application areas. This paper highlights how developers can construct large, maintainable decision-support systems using these kinds of building blocks. The creation of domain ontologies and problem-solving methods is the fundamental end product of basic research in medical informatics. Consequently, these concepts need more attention by our scientific community.

[Clinical decision making and critical thinking in the nursing diagnostic process].

Science.gov (United States)

Müller-Staub, Maria

2006-10-01

The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".

Clinical decision making in dermatology: observation of consultations and the patients' perspectives.

Science.gov (United States)

Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y

2010-01-01

Clinical decision making is a complex process and might be influenced by a wide range of clinical and non-clinical factors. Little is known about this process in dermatology. The aim of this study was to explore the different types of management decisions made in dermatology and to identify factors influencing those decisions from observation of consultations and interviews with the patients. 61 patient consultations were observed by a physician with experience in dermatology. The patients were interviewed immediately after each consultation. Consultations and interviews were audio recorded, transcribed and their content analysed using thematic content analysis. The most common management decisions made during the consultations included: follow-up, carrying out laboratory investigation, starting new topical treatment, renewal of systemic treatment, renewal of topical treatment, discharging patients and starting new systemic treatment. Common influences on those decisions included: clinical factors such as ineffectiveness of previous therapy, adherence to prescribing guidelines, side-effects of medications, previous experience with the treatment, deterioration or improvement in the skin condition, and chronicity of skin condition. Non-clinical factors included: patient's quality of life, patient's friends or relatives, patient's time commitment, travel or transportation difficulties, treatment-related costs, availability of consultant, and availability of treatment. The study has shown that patients are aware that management decisions in dermatology are influenced by a wide range of clinical and non-clinical factors. Education programmes should be developed to improve the quality of decision making. Copyright © 2010 S. Karger AG, Basel.

Clinical decision-making of rural novice nurses.

Science.gov (United States)

Seright, T J

2011-01-01

Nurses in rural settings are often the first to assess and interpret the patient's clinical presentations. Therefore, an understanding of how nurses experience decision-making is important in terms of educational preparation, resource allocation to rural areas, institutional cultures, and patient outcomes. Theory development was based on the in-depth investigation of 12 novice nurses practicing in rural critical access hospitals in a north central state. This grounded theory study consisted of face-to-face interviews with 12 registered nurses, nine of whom were observed during their work day. The participants were interviewed a second time, as a method of member checking, and during this interview they reviewed their transcripts, the emerging themes and categories. Directors of nursing from both the research sites and rural hospitals not involved in the study, experienced researchers, and nurse educators facilitated triangulation of the findings. 'Sociocentric rationalizing' emerged as the central phenomenon and referred to the sense of belonging and agency which impacted the decision-making in this small group of novice nurses in rural critical access hospitals. The observed consequences, which were conceptualized during the axial coding process and were derived from observations and interviews of the 12 novice nurses in this study include: (1) gathering information before making a decision included assessment of: the credibility of co-workers, patients' subjective and objective data, and one's own past and current experiences; (2) conferring with co-workers as a direct method of confirming/denying decisions being made was considered more realistic and expedient than policy books and decision trees; (3) rural practicum clinical experiences, along with support after orientation, provide for transition to the rural nurse role; (4) involved directors of nursing served as both models and protectors of novice nurses placed in high accountability positions early in

Building trust and diversity in patient-centered oncology clinical trials: An integrated model.

Science.gov (United States)

Hurd, Thelma C; Kaplan, Charles D; Cook, Elise D; Chilton, Janice A; Lytton, Jay S; Hawk, Ernest T; Jones, Lovell A

2017-04-01

Trust is the cornerstone of clinical trial recruitment and retention. Efforts to decrease barriers and increase clinical trial participation among diverse populations have yielded modest results. There is an urgent need to better understand the complex interactions between trust and clinical trial participation. The process of trust-building has been a focus of intense research in the business community. Yet, little has been published about trust in oncology clinical trials or the process of building trust in clinical trials. Both clinical trials and business share common dimensions. Business strategies for building trust may be transferable to the clinical trial setting. This study was conducted to understand and utilize contemporary thinking about building trust to develop an Integrated Model of Trust that incorporates both clinical and business perspectives. A key word-directed literature search of the PubMed, Medline, Cochrane, and Google Search databases for entries dated between 1 January 1985 and 1 September 2015 was conducted to obtain information from which to develop an Integrated Model of Trust. Successful trial participation requires both participants and clinical trial team members to build distinctly different types of interpersonal trust to effect recruitment and retention. They are built under conditions of significant emotional stress and time constraints among people who do not know each other and have never worked together before. Swift Trust and Traditional Trust are sequentially built during the clinical trial process. Swift trust operates during the recruitment and very early active treatment phases of the clinical trial process. Traditional trust is built over time and operates during the active treatment and surveillance stages of clinical trials. The Psychological Contract frames the participants' and clinical trial team members' interpersonal trust relationship. The "terms" of interpersonal trust are negotiated through the psychological

Development and evaluation of learning module on clinical decision-making in Prosthodontics.

Science.gov (United States)

Deshpande, Saee; Lambade, Dipti; Chahande, Jayashree

2015-01-01

Best practice strategies for helping students learn the reasoning skills of problem solving and critical thinking (CT) remain a source of conjecture, particularly with regard to CT. The dental education literature is fundamentally devoid of research on the cognitive components of clinical decision-making. This study was aimed to develop and evaluate the impact of blended learning module on clinical decision-making skills of dental graduates for planning prosthodontics rehabilitation. An interactive teaching module consisting of didactic lectures on clinical decision-making and a computer-assisted case-based treatment planning software was developed Its impact on cognitive knowledge gain in clinical decision-making was evaluated using an assessment involving problem-based multiple choice questions and paper-based case scenarios. Mean test scores were: Pretest (17 ± 1), posttest 1 (21 ± 2) and posttest 2 (43 ± 3). Comparison of mean scores was done with one-way ANOVA test. There was overall significant difference in between mean scores at all the three points (P posttest 1 > pretest. Blended teaching methods employing didactic lectures on the clinical decision-making as well as computer assisted case-based learning can be used to improve quality of clinical decision-making in prosthodontic rehabilitation for dental graduates.

Clinical Decision Support Tools: The Evolution of a Revolution

NARCIS (Netherlands)

Mould, D. R.; D'Haens, G.; Upton, R. N.

2016-01-01

Dashboard systems for clinical decision support integrate data from multiple sources. These systems, the newest in a long line of dose calculators and other decision support tools, utilize Bayesian approaches to fully individualize dosing using information gathered through therapeutic drug

Implementation of a scalable, web-based, automated clinical decision support risk-prediction tool for chronic kidney disease using C-CDA and application programming interfaces.

Science.gov (United States)

Samal, Lipika; D'Amore, John D; Bates, David W; Wright, Adam

2017-11-01

Clinical decision support tools for risk prediction are readily available, but typically require workflow interruptions and manual data entry so are rarely used. Due to new data interoperability standards for electronic health records (EHRs), other options are available. As a clinical case study, we sought to build a scalable, web-based system that would automate calculation of kidney failure risk and display clinical decision support to users in primary care practices. We developed a single-page application, web server, database, and application programming interface to calculate and display kidney failure risk. Data were extracted from the EHR using the Consolidated Clinical Document Architecture interoperability standard for Continuity of Care Documents (CCDs). EHR users were presented with a noninterruptive alert on the patient's summary screen and a hyperlink to details and recommendations provided through a web application. Clinic schedules and CCDs were retrieved using existing application programming interfaces to the EHR, and we provided a clinical decision support hyperlink to the EHR as a service. We debugged a series of terminology and technical issues. The application was validated with data from 255 patients and subsequently deployed to 10 primary care clinics where, over the course of 1 year, 569 533 CCD documents were processed. We validated the use of interoperable documents and open-source components to develop a low-cost tool for automated clinical decision support. Since Consolidated Clinical Document Architecture-based data extraction extends to any certified EHR, this demonstrates a successful modular approach to clinical decision support. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association.

Building organizational knowledge and value: informed decision making in Kansas children's community-based mental health services.

Science.gov (United States)

Stipp, Karen Flint; Kapp, Stephen A

2012-02-01

Knowledge is managers' principal asset and knowledge building is managers' primary work. This qualitative study explores knowledge building by directors of children's community-based mental health services in Kansas. Of the state's 27 directors, 25 completed a survey about knowledge building, in their preference of online or telephone format. Fourteen participants took part either in preliminary interviews for study development, or in follow-up interviews for further detail and member checking. Study findings indicate that with requisite resources, directors inform their decision making with streams of information, which they manage and generate to build organizational knowledge and value for local practice effectiveness.

Decision-theoretic planning of clinical patient management

OpenAIRE

Peek, Niels Bastiaan

2000-01-01

When a doctor is treating a patient, he is constantly facing decisions. From the externally visible signs and symptoms he must establish a hypothesis of what might be wrong with the patient; then he must decide whether additional diagnostic procedures are required to verify this hypothesis, whether therapeutic action is necessary, and which post-therapeutic trajectory is to be followed. All these bedside decisions are related to each other, and the whole task of clinical patient management ca...

Bayesian networks for clinical decision support: A rational approach to dynamic decision-making under uncertainty

NARCIS (Netherlands)

Gerven, M.A.J. van

2007-01-01

This dissertation deals with decision support in the context of clinical oncology. (Dynamic) Bayesian networks are used as a framework for (dynamic) decision-making under uncertainty and applied to a variety of diagnostic, prognostic, and treatment problems in medicine. It is shown that the proposed

Decision Analysis for Metric Selection on a Clinical Quality Scorecard.

Science.gov (United States)

Guth, Rebecca M; Storey, Patricia E; Vitale, Michael; Markan-Aurora, Sumita; Gordon, Randolph; Prevost, Traci Q; Dunagan, Wm Claiborne; Woeltje, Keith F

2016-09-01

Clinical quality scorecards are used by health care institutions to monitor clinical performance and drive quality improvement. Because of the rapid proliferation of quality metrics in health care, BJC HealthCare found it increasingly difficult to select the most impactful scorecard metrics while still monitoring metrics for regulatory purposes. A 7-step measure selection process was implemented incorporating Kepner-Tregoe Decision Analysis, which is a systematic process that considers key criteria that must be satisfied in order to make the best decision. The decision analysis process evaluates what metrics will most appropriately fulfill these criteria, as well as identifies potential risks associated with a particular metric in order to identify threats to its implementation. Using this process, a list of 750 potential metrics was narrowed to 25 that were selected for scorecard inclusion. This decision analysis process created a more transparent, reproducible approach for selecting quality metrics for clinical quality scorecards. © The Author(s) 2015.

Decision process for the retrofit of municipal buildings with solar energy systems: a technical guide

Energy Technology Data Exchange (ETDEWEB)

Licciardello, Michael R.; Wood, Brian; Dozier, Warner; Braly, Mark; Yates, Alan

1980-11-01

As a background for solar applications, the following topics are covered: solar systems and components for retrofit installations; cost, performance, and quality considerations; and financing alternatives for local government. The retrofit decision process is discussed as follows: pre-screening of buildings, building data requirements, the energy conservation audit, solar system sizing and economics, comparison of alternatives, and implementation. Sample studies are presented for the West Valley Animal Shelter and the Hollywood Police Station. (MHR)

Creating and sharing clinical decision support content with Web 2.0: Issues and examples.

Science.gov (United States)

Wright, Adam; Bates, David W; Middleton, Blackford; Hongsermeier, Tonya; Kashyap, Vipul; Thomas, Sean M; Sittig, Dean F

2009-04-01

Clinical decision support is a powerful tool for improving healthcare quality and patient safety. However, developing a comprehensive package of decision support interventions is costly and difficult. If used well, Web 2.0 methods may make it easier and less costly to develop decision support. Web 2.0 is characterized by online communities, open sharing, interactivity and collaboration. Although most previous attempts at sharing clinical decision support content have worked outside of the Web 2.0 framework, several initiatives are beginning to use Web 2.0 to share and collaborate on decision support content. We present case studies of three efforts: the Clinfowiki, a world-accessible wiki for developing decision support content; Partners Healthcare eRooms, web-based tools for developing decision support within a single organization; and Epic Systems Corporation's Community Library, a repository for sharing decision support content for customers of a single clinical system vendor. We evaluate the potential of Web 2.0 technologies to enable collaborative development and sharing of clinical decision support systems through the lens of three case studies; analyzing technical, legal and organizational issues for developers, consumers and organizers of clinical decision support content in Web 2.0. We believe the case for Web 2.0 as a tool for collaborating on clinical decision support content appears strong, particularly for collaborative content development within an organization.

Effects of reflection on clinical decision-making of intensive care unit nurses.

Science.gov (United States)

Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani

2018-07-01

Nurses are one of the most influential factors in overcoming the main challenges faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. This study evaluated the effects of implementing Tanner's reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). This study used an experimental, pretest, posttest design. The setting was the intensive care unit of Amin Hospital Isfahan, Iran. The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-14). The questionnaire was completed before and one week after the intervention. The data were analyzed using SPSS 21.0. The two groups were not significantly different in terms of the level and mean scores of clinical decision-making before the intervention (P = 0.786). Based on the results of independent t-test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann Whitney test showed that one week after the intervention, the nurses' level of clinical decision-making in the case group rose to the next level (P = 0.001). Reflection could improve the clinical decision-making of ICU nurses. It is, thus, recommended to incorporate this method into the nursing curriculum and care practices. Copyright © 2018. Published by Elsevier Ltd.

Risk perception and clinical decision making in primary care

DEFF Research Database (Denmark)

Barfoed, Benedicte Marie Lind

2015-01-01

Objectives We aim to present new knowledge about different perspectives of health care professionals’ risk perceptions and clinical decision making. Furthermore, we intend to discuss differences between professional and personal risk perceptions and the impact on decisions in terms of both short...... and long-term outcomes. Background Insight into healthcare professionals’ perception of risk is a cornerstone for understanding their strategies for practising preventive care. The way people perceive risk can be seen as part of a general personality trait influenced by a mixture of individual...... considerations and the specific context. Most research has been focused on understanding of the concepts of risk. However healthcare professionals’ risk perception and personal attitudes also affect their clinical decision-making and risk communication. The differences between health care professionals’ personal...

Forms of Knowledge Incorporated in Clinical Decision-making among Newly-Graduated Nurses: A Metasynthesis

DEFF Research Database (Denmark)

Voldbjerg, Siri; Elgaard Sørensen, Erik; Grønkjær, Mette

2014-01-01

Clinical-decision-making is of decisive importance to how evidence-based practice is put into practice. Schools of Nursing have a responsibility to teach and train nursing students to make clinical decisions within a frame of evidence-based practice. Clinical decision-making among nurses has been...... explored from numerous angles using a diversity of methodologies. Existing research has mainly focused on promoting and inhibiting factors for implementation of evidence-based practice and incorporation of research evidence in the clinical-decision. Little attention has been given to the nurses' behavior......, including the knowledge that actually informs the newly graduated nurses’ clinical decision. The aim of the study is to combine and synthesize results from qualitative research. Noblit and Hare’s meta-ethnographic approach is used to conduct a metasynthesis of qualitative research that has studied...

A distributed clinical decision support system architecture

Directory of Open Access Journals (Sweden)

Shaker H. El-Sappagh

2014-01-01

Full Text Available This paper proposes an open and distributed clinical decision support system architecture. This technical architecture takes advantage of Electronic Health Record (EHR, data mining techniques, clinical databases, domain expert knowledge bases, available technologies and standards to provide decision-making support for healthcare professionals. The architecture will work extremely well in distributed EHR environments in which each hospital has its own local EHR, and it satisfies the compatibility, interoperability and scalability objectives of an EHR. The system will also have a set of distributed knowledge bases. Each knowledge base will be specialized in a specific domain (i.e., heart disease, and the model achieves cooperation, integration and interoperability between these knowledge bases. Moreover, the model ensures that all knowledge bases are up-to-date by connecting data mining engines to each local knowledge base. These data mining engines continuously mine EHR databases to extract the most recent knowledge, to standardize it and to add it to the knowledge bases. This framework is expected to improve the quality of healthcare, reducing medical errors and guaranteeing the safety of patients by helping clinicians to make correct, accurate, knowledgeable and timely decisions.

Clinical Decision Making of Nurses Working in Hospital Settings

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Ida Torunn Bjørk

2011-01-01

Full Text Available This study analyzed nurses' perceptions of clinical decision making (CDM in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with descriptive frequencies, t-tests, Chi-Square test, and linear regression. Nurses' decision making was categorized into analytic-systematic, intuitive-interpretive, and quasi-rational models of CDM. Most nurses reported the use of quasi-rational models during CDM thereby supporting the tenet that cognition most often includes properties of both analysis and intuition. Increased use of intuitive-interpretive models of CDM was associated with years in present job, further education, male gender, higher age, and working in predominantly surgical units.

Personalized Clinical Decision Making in Gastrointestinal Malignancies

DEFF Research Database (Denmark)

Hess, Søren; Bjerring, Ole Steen; Pfeiffer, Per

2016-01-01

and initial stages. This article outlines the potential use of fluorodeoxyglucose-PET/CT in clinical decision making with special regard to preoperative evaluation and response assessment in gastric cancer (including the gastroesophageal junction), pancreatic cancer (excluding neuroendocrine tumors...

The role of emotions in clinical reasoning and decision making.

Science.gov (United States)

Marcum, James A

2013-10-01

What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care.

Clinical trial or standard treatment? Shared decision making at the department of oncology

DEFF Research Database (Denmark)

Gregersen, Trine Ammentorp; Birkelund, Regner; Ammentorp, Jette

2016-01-01

Title: Clinical trial or standard treatment? Shared decision making at the department of oncology. Authors: Ph.d. student, Trine A. Gregersen. Trine.gregersen@rsyd.dk. Department of Oncology. Health Services Research Unit Lillebaelt Hospital / IRS University of Southern Denmark. Professor, Regner...... are involved in difficult treatment decisions including participation in clinical trials. The literature indicates that the decision is very often based on little knowledge about the treatment and that many patients who have consented to participate in a clinical trial are not always aware...... that they are participating in a trial. This place great demand on the healthcare providers’ ability to involve and advise patients in the decisions. The aim of this study is to investigate the characteristics of the communication when decisions about participation in clinical oncology trial are made and the patients...

Ethically-based clinical decision-making in physical therapy: process and issues.

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Finch, Elspeth; Geddes, E Lynne; Larin, Hélène

2005-01-01

The identification and consideration of relevant ethical issues in clinical decision-making, and the education of health care professionals (HCPs) in these skills are key factors in providing quality health care. This qualitative study explores the way in which physical therapists (PTs) integrate ethical issues into clinical practice decisions and identifies ethical themes used by PTs. A purposive sample of eight PTs was asked to describe a recent ethically-based clinical decision. Transcribed interviews were coded and themes identified related to the following categories: 1) the integration of ethical issues in the clinical decision-making process, 2) patient welfare, 3) professional ethos of the PT, and 4) health care economics and business practices. Participants readily described clinical situations involving ethical issues but rarely identified specific conflicting ethical issues in their description. Ethical dilemmas were more frequently resolved when there were fewer emotional sequelae associated with the dilemma, and the PT had a clear understanding of professional ethos, valued patient autonomy, and explored a variety of alternative actions before implementing one. HCP students need to develop a clear professional ethos and an increased understanding of the economic factors that will present ethical issues in practice.

The DEVELOP National Program: Building Dual Capacity in Decision Makers and Young Professionals Through NASA Earth Observations

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Childs, L. M.; Rogers, L.; Favors, J.; Ruiz, M.

2012-12-01

Through the years, NASA has played a distinct/important/vital role in advancing Earth System Science to meet the challenges of environmental management and policy decision making. Within NASA's Earth Science Division's Applied Sciences' Program, the DEVELOP National Program seeks to extend NASA Earth Science for societal benefit. DEVELOP is a capacity building program providing young professionals and students the opportunity to utilize NASA Earth observations and model output to demonstrate practical applications of those resources to society. Under the guidance of science advisors, DEVELOP teams work in alignment with local, regional, national and international partner organizations to identify the widest array of practical uses for NASA data to enhance related management decisions. The program's structure facilitates a two-fold approach to capacity building by fostering an environment of scientific and professional development opportunities for young professionals and students, while also providing end-user organizations enhanced management and decision making tools for issues impacting their communities. With the competitive nature and growing societal role of science and technology in today's global workplace, DEVELOP is building capacity in the next generation of scientists and leaders by fostering a learning and growing environment where young professionals possess an increased understanding of teamwork, personal development, and scientific/professional development and NASA's Earth Observation System. DEVELOP young professionals are partnered with end user organizations to conduct 10 week feasibility studies that demonstrate the use of NASA Earth science data for enhanced decision making. As a result of the partnership, end user organizations are introduced to NASA Earth Science technologies and capabilities, new methods to augment current practices, hands-on training with practical applications of remote sensing and NASA Earth science, improved remote

Encounter Decision Aid vs. Clinical Decision Support or Usual Care to Support Patient-Centered Treatment Decisions in Osteoporosis: The Osteoporosis Choice Randomized Trial II.

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Annie LeBlanc

Full Text Available Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01, improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively, had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001. Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer. There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07; medication adherence at 6 months was no different across arms.Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.clinical trials.gov NCT00949611.

Building the Clinical Bridge: An Australian Success

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Marianne Wallis

2012-01-01

Full Text Available Nursing effectiveness science includes primary, secondary, and translational, clinically focused research activities which aim to improve patient or client outcomes. It is imperative, for the successful conduct of a program of nursing effectiveness science, that a clinical bridge is established between academic and healthcare service facilities. An Australian example of the development of a robust clinical bridge through the use of jointly funded positions at the professorial level is outlined. In addition, an analysis of the practical application of Lewin’s model of change management and the contribution of both servant and transformational leadership styles to the bridge building process is provided.

Knowledge bases, clinical decision support systems, and rapid learning in oncology.

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Yu, Peter Paul

2015-03-01

One of the most important benefits of health information technology is to assist the cognitive process of the human mind in the face of vast amounts of health data, limited time for decision making, and the complexity of the patient with cancer. Clinical decision support tools are frequently cited as a technologic solution to this problem, but to date useful clinical decision support systems (CDSS) have been limited in utility and implementation. This article describes three unique sources of health data that underlie fundamentally different types of knowledge bases which feed into CDSS. CDSS themselves comprise a variety of models which are discussed. The relationship of knowledge bases and CDSS to rapid learning health systems design is critical as CDSS are essential drivers of rapid learning in clinical care. Copyright © 2015 by American Society of Clinical Oncology.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: Methods of a decision-maker-researcher partnership systematic review

OpenAIRE

Wilczynski Nancy L; Haynes R Brian

2010-01-01

Abstract Background Computerized clinical decision support systems are information technology-based systems designed to improve clinical decision-making. As with any healthcare intervention with claims to improve process of care or patient outcomes, decision support systems should be rigorously evaluated before widespread dissemination into clinical practice. Engaging healthcare providers and managers in the review process may facilitate knowledge translation and uptake. The objective of this...

Are patient decision aids the best way to improve clinical decision making? Report of the IPDAS Symposium.

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Holmes-Rovner, Margaret; Nelson, Wendy L; Pignone, Michael; Elwyn, Glyn; Rovner, David R; O'Connor, Annette M; Coulter, Angela; Correa-de-Araujo, Rosaly

2007-01-01

This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that "decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against.

Postnatal Psychosocial Assessment and Clinical Decision-Making, a Descriptive Study.

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Sims, Deborah; Fowler, Cathrine

2018-05-18

The aim of this study is to describe experienced child and family health nurses' clinical decision-making during a postnatal psychosocial assessment. Maternal emotional wellbeing in the postnatal year optimises parenting and promotes infant development. Psychosocial assessment potentially enables early intervention and reduces the risk of a mental disorder occurring during this time of change. Assessment accuracy, and the interventions used are determined by the standard of nursing decision-making. A qualitative methodology was employed to explore decision-making behaviour when conducting a postnatal psychosocial assessment. This study was conducted in an Australian early parenting organisation. Twelve experienced child and family health nurses were interviewed. A detailed description of a postnatal psychosocial assessment process was obtained using a critical incident technique. Template analysis was used to determine the information domains the nurses accessed, and content analysis was used to determine the nurses' thinking strategies, to make clinical decisions from this assessment. The nurses described 24 domains of information and used 17 thinking strategies, in a variety of combinations. The four information domains most commonly used were parenting, assessment tools, women-determined issues and sleep. The seven thinking strategies most commonly used were searching for information, forming relationships between the information, recognising a pattern, drawing a conclusion, setting priorities, providing explanations for the information and judging the value of the information. The variety and complexity of the clinical decision-making involved in postnatal psychosocial assessment confirms that the nurses use information appropriately and within their scope of nursing practice. The standard of clinical decision-making determines the results of the assessment and the optimal access to care. Knowledge of the information domains and the decision-making strategies

The relationship between patient data and pooled clinical management decisions.

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Ludbrook, G I; O'Loughlin, E J; Corcoran, T B; Grant, C

2013-01-01

A strong relationship between patient data and preoperative clinical decisions could potentially be used to support clinical decisions in preoperative management. The aim of this exploratory study was to determine the relationship between key patient data and pooled clinical opinions on management. In a previous study, panels of anaesthetists compared the quality of computer-assisted patient health assessments with outpatient consultations and made decisions on the need for preoperative tests, no preoperative outpatient assessment, possible postoperative intensive care unit/high dependency unit requirements and aspiration prophylaxis. In the current study, the relationship between patient data and these decisions was examined using binomial logistic regression analysis. Backward stepwise regression was used to identify independent predictors of each decision (at P >0.15), which were then incorporated into a predictive model. The number of factors related to each decision varied: blood picture (four factors), biochemistry (six factors), coagulation studies (three factors), electrocardiography (eight factors), chest X-ray (seven factors), preoperative outpatient assessment (17 factors), intensive care unit requirement (eight factors) and aspiration prophylaxis (one factor). The factor types also varied, but included surgical complexity, age, gender, number of medications or comorbidities, body mass index, hypertension, central nervous system condition, heart disease, sleep apnoea, smoking, persistent pain and stroke. Models based on these relationships usually demonstrated good sensitivity and specificity, with receiver operating characteristics in the following areas under curve: blood picture (0.75), biochemistry (0.86), coagulation studies (0.71), electrocardiography (0.90), chest X-ray (0.85), outpatient assessment (0.85), postoperative intensive care unit requirement (0.88) and aspiration prophylaxis (0.85). These initial results suggest modelling of patient

SANDS: an architecture for clinical decision support in a National Health Information Network.

Science.gov (United States)

Wright, Adam; Sittig, Dean F

2007-10-11

A new architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support) is introduced and its performance evaluated. The architecture provides a method for performing clinical decision support across a network, as in a health information exchange. Using the prototype we demonstrated that, first, a number of useful types of decision support can be carried out using our architecture; and, second, that the architecture exhibits desirable reliability and performance characteristics.

[Cancer screening in clinical practice: the value of shared decision-making].

Science.gov (United States)

Cornuz, Jacques; Junod, Noëlle; Pasche, Olivier; Guessous, Idris

2010-07-14

Shared decision-making approach to uncertain clinical situations such as cancer screening seems more appropriate than ever. Shared decision making can be defined as an interactive process where physician and patient share all the stages of the decision making process. For patients who wish to be implicated in the management of their health conditions, physicians might express difficulty to do so. Use of patient decision aids appears to improve such process of shared decision making.

Newly graduated nurses' use of knowledge sources in clinical decision-making

DEFF Research Database (Denmark)

Voldbjerg, Siri Lygum; Grønkjaer, Mette; Wiechula, Rick

2017-01-01

AIMS AND OBJECTIVES: To explore which knowledge sources newly graduated nurses' use in clinical decision-making and why and how they are used. BACKGROUND: In spite of an increased educational focus on skills and competencies within evidence based practice newly graduated nurses' ability to use...... approaches to strengthen the knowledgebase used in clinical decision-making. DESIGN AND METHODS: Ethnographic study using participant-observation and individual semi-structured interviews of nine Danish newly graduated nurses in medical and surgical hospital settings. RESULTS: Newly graduates use...... in clinical decision-making. If newly graduates are to be supported in an articulate and reflective use of a variety of sources, they have to be allocated to experienced nurses who model a reflective, articulate and balanced use of knowledge sources. This article is protected by copyright. All rights reserved....

The thinking doctor: clinical decision making in contemporary medicine.

Science.gov (United States)

Trimble, Michael; Hamilton, Paul

2016-08-01

Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised. © 2016 Royal College of Physicians.

Experiential and rational decision making: a survey to determine how emergency physicians make clinical decisions.

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Calder, Lisa A; Forster, Alan J; Stiell, Ian G; Carr, Laura K; Brehaut, Jamie C; Perry, Jeffrey J; Vaillancourt, Christian; Croskerry, Patrick

2012-10-01

Dual-process psychological theories argue that clinical decision making is achieved through a combination of experiential (fast and intuitive) and rational (slower and systematic) cognitive processes. To determine whether emergency physicians perceived their clinical decisions in general to be more experiential or rational and how this compared with other physicians. A validated psychometric tool, the Rational Experiential Inventory (REI-40), was sent through postal mail to all emergency physicians registered with the College of Physicians and Surgeons of Ontario, according to their website in November 2009. Forty statements were ranked on a Likert scale from 1 (Definitely False) to 5 (Definitely True). An initial survey was sent out, followed by reminder cards and a second survey to non-respondents. Analysis included descriptive statistics, Student t tests, analysis of variance and comparison of mean scores with those of cardiologists from New Zealand. The response rate in this study was 46.9% (434/925). The respondents' median age was 41-50 years; they were mostly men (72.6%) and most had more than 10 years of clinical experience (66.8%). The mean REI-40 rational scores were higher than the experiential scores (3.93/5 (SD 0.35) vs 3.33/5 (SD 0.49), prational 3.93/5, mean experiential 3.05/5). The mean experiential scores were significantly higher for female respondents than for male respondents (3.40/5 (SD 0.49) vs 3.30/5 (SD 0.48), p=0.003). Overall, emergency physicians favoured rational decision making rather than experiential decision making; however, female emergency physicians had higher experiential scores than male emergency physicians. This has important implications for future knowledge translation and decision support efforts among emergency physicians.

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare.

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Dolan, James G

2010-01-01

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).

Mobile clinical decision support systems and applications: a literature and commercial review.

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Martínez-Pérez, Borja; de la Torre-Díez, Isabel; López-Coronado, Miguel; Sainz-de-Abajo, Beatriz; Robles, Montserrat; García-Gómez, Juan Miguel

2014-01-01

The latest advances in eHealth and mHealth have propitiated the rapidly creation and expansion of mobile applications for health care. One of these types of applications are the clinical decision support systems, which nowadays are being implemented in mobile apps to facilitate the access to health care professionals in their daily clinical decisions. The aim of this paper is twofold. Firstly, to make a review of the current systems available in the literature and in commercial stores. Secondly, to analyze a sample of applications in order to obtain some conclusions and recommendations. Two reviews have been done: a literature review on Scopus, IEEE Xplore, Web of Knowledge and PubMed and a commercial review on Google play and the App Store. Five applications from each review have been selected to develop an in-depth analysis and to obtain more information about the mobile clinical decision support systems. Ninety-two relevant papers and 192 commercial apps were found. Forty-four papers were focused only on mobile clinical decision support systems. One hundred seventy-one apps were available on Google play and 21 on the App Store. The apps are designed for general medicine and 37 different specialties, with some features common in all of them despite of the different medical fields objective. The number of mobile clinical decision support applications and their inclusion in clinical practices has risen in the last years. However, developers must be careful with their interface or the easiness of use, which can impoverish the experience of the users.

When to trust our learners? Clinical teachers' perceptions of decision variables in the entrustment process.

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Duijn, Chantal C M A; Welink, Lisanne S; Bok, Harold G J; Ten Cate, Olle T J

2018-06-01

Clinical training programs increasingly use entrustable professional activities (EPAs) as focus of assessment. However, questions remain about which information should ground decisions to trust learners. This qualitative study aimed to identify decision variables in the workplace that clinical teachers find relevant in the elaboration of the entrustment decision processes. The findings can substantiate entrustment decision-making in the clinical workplace. Focus groups were conducted with medical and veterinary clinical teachers, using the structured consensus method of the Nominal Group Technique to generate decision variables. A ranking was made based on a relevance score assigned by the clinical teachers to the different decision variables. Field notes, audio recordings and flip chart lists were analyzed and subsequently translated and, as a form of axial coding, merged into one list, combining the decision variables that were similar in their meaning. A list of 11 and 17 decision variables were acknowledged as relevant by the medical and veterinary teacher groups, respectively. The focus groups yielded 21 unique decision variables that were considered relevant to inform readiness to perform a clinical task on a designated level of supervision. The decision variables consisted of skills, generic qualities, characteristics, previous performance or other information. We were able to group the decision variables into five categories: ability, humility, integrity, reliability and adequate exposure. To entrust a learner to perform a task at a specific level of supervision, a supervisor needs information to support such a judgement. This trust cannot be credited on a single case at a single moment of assessment, but requires different variables and multiple sources of information. This study provides an overview of decision variables giving evidence to justify the multifactorial process of making an entrustment decision.

Science and intuition: do both have a place in clinical decision making?

Science.gov (United States)

Pearson, Helen

Intuition is widely used in clinical decision making yet its use is underestimated compared to scientific decision-making methods. Information processing is used within scientific decision making and is methodical and analytical, whereas intuition relies more on a practitioner's perception. Intuition is an unconscious process and may be referred to as a 'sixth sense', 'hunch' or 'gut feeling'. It is not underpinned by valid and reliable measures. Expert health professionals use a rapid, automatic process to recognise familiar problems instantly. Intuition could therefore involve pattern recognition, where experts draw on experiences, so could be perceived as a cognitive skill rather than a perception or knowing without knowing how. The NHS places great importance on evidence-based practice but intuition is seemingly becoming an acceptable way of thinking and knowing in clinical decision making. Recognising nursing as an art allows intuition to be used and the environment or situation to be interpreted to help inform decision making. Intuition can be used in conjunction with evidence-based practice and to achieve good outcomes and deserves to be acknowledged within clinical practice.

The Utility of the Frailty Index in Clinical Decision Making.

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Khatry, K; Peel, N M; Gray, L C; Hubbard, R E

2018-01-01

Using clinical vignettes, this study aimed to determine if a measure of patient frailty would impact management decisions made by geriatricians regarding commonly encountered clinical situations. Electronic surveys consisting of three vignettes derived from cases commonly seen in an acute inpatient ward were distributed to geriatricians. Vignettes included patients being considered for intensive care treatment, rehabilitation, or coronary artery bypass surgery. A frailty index was generated through Comprehensive electronic Geriatric Assessment. For each vignette, respondents were asked to make a recommendation for management, based on either a brief or detailed amount of clinical information and to reconsider their decision after the addition of the frailty index. The study suggests that quantification of frailty might aid the clinical judgment now employed daily to proceed with usual care, or to modify it based on the vulnerability of the person to whom it is aimed.

Complex contexts and relationships affect clinical decisions in group therapy.

Science.gov (United States)

Tasca, Giorgio A; Mcquaid, Nancy; Balfour, Louise

2016-09-01

Clinical errors tend to be underreported even though examining them can provide important training and professional development opportunities. The group therapy context may be prone to clinician errors because of the added complexity within which therapists work and patients receive treatment. We discuss clinical errors that occurred within a group therapy in which a patient for whom group was not appropriate was admitted to the treatment and then was not removed by the clinicians. This was countertherapeutic for both patient and group. Two clinicians were involved: a clinical supervisor who initially assessed and admitted the patient to the group, and a group therapist. To complicate matters, the group therapy occurred within the context of a clinical research trial. The errors, possible solutions, and recommendations are discussed within Reason's Organizational Accident Model (Reason, 2000). In particular, we discuss clinician errors in the context of countertransference and clinician heuristics, group therapy as a local work condition that complicates clinical decision-making, and the impact of the research context as a latent organizational factor. We also present clinical vignettes from the pregroup preparation, group therapy, and supervision. Group therapists are more likely to avoid errors in clinical decisions if they engage in reflective practice about their internal experiences and about the impact of the context in which they work. Therapists must keep in mind the various levels of group functioning, especially related to the group-as-a-whole (i.e., group composition, cohesion, group climate, and safety) when making complex clinical decisions in order to optimize patient outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

A social-technological epistemology of clinical decision-making as mediated by imaging.

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van Baalen, Sophie; Carusi, Annamaria; Sabroe, Ian; Kiely, David G

2017-10-01

In recent years there has been growing attention to the epistemology of clinical decision-making, but most studies have taken the individual physicians as the central object of analysis. In this paper we argue that knowing in current medical practice has an inherently social character and that imaging plays a mediating role in these practices. We have analyzed clinical decision-making within a medical expert team involved in diagnosis and treatment of patients with pulmonary hypertension (PH), a rare disease requiring multidisciplinary team involvement in diagnosis and management. Within our field study, we conducted observations, interviews, video tasks, and a panel discussion. Decision-making in the PH clinic involves combining evidence from heterogeneous sources into a cohesive framing of a patient, in which interpretations of the different sources can be made consistent with each other. Because pieces of evidence are generated by people with different expertise and interpretation and adjustments take place in interaction between different experts, we argue that this process is socially distributed. Multidisciplinary team meetings are an important place where information is shared, discussed, interpreted, and adjusted, allowing for a collective way of seeing and a shared language to be developed. We demonstrate this with an example of image processing in the PH service, an instance in which knowledge is distributed over multiple people who play a crucial role in generating an evaluation of right heart function. Finally, we argue that images fulfill a mediating role in distributed knowing in 3 ways: first, as enablers or tools in acquiring information; second, as communication facilitators; and third, as pervasively framing the epistemic domain. With this study of clinical decision-making in diagnosis and treatment of PH, we have shown that clinical decision-making is highly social and mediated by technologies. The epistemology of clinical decision-making needs

Clinical use of patient decision-making aids for stone patients.

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Lim, Amy H; Streeper, Necole M; Best, Sara L; Penniston, Kristina L; Nakada, Stephen Y

2017-08-01

Patient decision-making aids (PDMAs) help patients make informed healthcare decisions and improve patient satisfaction. The utility of PDMAs for patients considering treatments for urolithiasis has not yet been published. We report our experience using PDMAs developed at our institution in the outpatient clinical setting in patients considering a variety of treatment options for stones. Patients with radiographically confirmed urolithiasis were given PDMAs regarding treatment options for their stone(s) based on their clinical profile. We assessed patients' satisfaction, involvedness, and feeling of making a more informed decision with utilization of the PDMAs using a Likert Scale Questionnaire. Information was also collected regarding previous stone passage, history and type of surgical intervention for urolithiasis, and level of education. Patients (n = 43; 18 males, 23 females and two unknown) 53 +/- 14years old were included. Patients reported that they understood the advantages and disadvantages outlined in the PDMAs (97%), that the PDMAs helped them make a more informed decision (83%) and felt more involved in the decision making process (88%). Patients reported that the aids were presented in a balanced manner and used up-to-date scientific information (100%, 84% respectively). Finally, a majority of the patients prefer an expert's opinion when making a treatment decision (98%) with 73% of patients preferring to form their own opinion based on available information. Previous stone surgery was associated with patients feeling more involved with the decision making process (p = 0.0465). PDMAs have a promising role in shared decision-making in the setting of treatment options for nephrolithiasis.

SANDS: a service-oriented architecture for clinical decision support in a National Health Information Network.

Science.gov (United States)

Wright, Adam; Sittig, Dean F

2008-12-01

In this paper, we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record. Some of these use cases utilize existing decision support systems, which are either commercially or freely available at present, and developed outside of the SANDS project, while other use cases are based on decision support systems developed specifically for the project. Open source code for many of these components is available, and an open source reference parser is also available for comparison and testing of other clinical information systems and clinical decision support systems that wish to implement the SANDS architecture. The SANDS architecture for decision support has several significant advantages over other architectures for clinical decision support. The most salient of these are:

Clinical Decision Support to Implement CYP2D6 Drug-Gene Interaction.

Science.gov (United States)

Caraballo, Pedro J; Parkulo, Mark; Blair, David; Elliott, Michelle; Schultz, Cloann; Sutton, Joseph; Rao, Padma; Bruflat, Jamie; Bleimeyer, Robert; Crooks, John; Gabrielson, Donald; Nicholson, Wayne; Rohrer Vitek, Carolyn; Wix, Kelly; Bielinski, Suzette J; Pathak, Jyotishman; Kullo, Iftikhar

2015-01-01

The level of CYP2D6 metabolic activity can be predicted by pharmacogenomic testing, and concomitant use of clinical decision support has the potential to prevent adverse effects from those drugs metabolized by this enzyme. Our initial findings after implementation of clinical decision support alerts integrated in the electronic health records suggest high feasibility, but also identify important challenges.

Patients' perceptions of sharing in decisions: a systematic review of interventions to enhance shared decision making in routine clinical practice.

Science.gov (United States)

Légaré, France; Turcotte, Stéphane; Stacey, Dawn; Ratté, Stéphane; Kryworuchko, Jennifer; Graham, Ian D

2012-01-01

Shared decision making is the process in which a healthcare choice is made jointly by the health professional and the patient. Little is known about what patients view as effective or ineffective strategies to implement shared decision making in routine clinical practice. This systematic review evaluates the effectiveness of interventions to improve health professionals' adoption of shared decision making in routine clinical practice, as seen by patients. We searched electronic databases (PubMed, the Cochrane Library, EMBASE, CINAHL, and PsycINFO) from their inception to mid-March 2009. We found additional material by reviewing the reference lists of the studies found in the databases; systematic reviews of studies on shared decision making; the proceedings of various editions of the International Shared Decision Making Conference; and the transcripts of the Society for Medical Decision Making's meetings. In our study selection, we included randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series analyses in which patients evaluated interventions to improve health professionals' adoption of shared decision making. The interventions in question consisted of the distribution of printed educational material; educational meetings; audit and feedback; reminders; and patient-mediated initiatives (e.g. patient decision aids). Two reviewers independently screened the studies and extracted data. Statistical analyses considered categorical and continuous process measures. We computed the standardized effect size for each outcome at the 95% confidence interval. The primary outcome of interest was health professionals' adoption of shared decision making as reported by patients in a self-administered questionnaire. Of the 6764 search results, 21 studies reported 35 relevant comparisons. Overall, the quality of the studies ranged from 0% to 83%. Only three of the 21 studies reported a clinically significant effect

Multicriteria Decision Analysis of Material Selection of High Energy Performance Residential Building

Science.gov (United States)

Čuláková, Monika; Vilčeková, Silvia; Katunská, Jana; Krídlová Burdová, Eva

2013-11-01

In world with limited amount of energy sources and with serious environmental pollution, interest in comparing the environmental embodied impacts of buildings using different structure systems and alternative building materials will be increased. This paper shows the significance of life cycle energy and carbon perspective and the material selection in reducing energy consumption and emissions production in the built environment. The study evaluates embodied environmental impacts of nearly zero energy residential structures. The environmental assessment uses framework of LCA within boundary: cradle to gate. Designed alternative scenarios of material compositions are also assessed in terms of energy effectiveness through selected thermal-physical parameters. This study uses multi-criteria decision analysis for making clearer selection between alternative scenarios. The results of MCDA show that alternative E from materials on nature plant base (wood, straw bales, massive wood panel) present possible way to sustainable perspective of nearly zero energy houses in Slovak republic

[Cognitive traps and clinical decisions].

Science.gov (United States)

Motterlini, Matteo

2017-12-01

We are fallible, we have limited computational capabilities, limited access to information, little memory. Moreover, in everyday life, we feel joy, fear, anger, and other emotions that influence our decisions in a little, "calculated" way. Not everyone, however, is also aware that the mistakes we make are often systematic and therefore, in particular circumstances, are foreseeable. Doctors and patients are constantly called upon to make decisions. They need to identify relevant information (for example, the symptoms or outcome of an examination), formulate a judgment (for example a diagnosis), choose an action course among the various possible ones based on one's own preferences (e.g. medication or surgery), so act. The exact size of the medical error is unknown, but probably huge. In fact, the more we investigate and the more we find. Often these mistakes depend on the cognitive process. Any (rational) decision requires, in particular, an assessment of the possible effects of the action it implements; for example how much pleasure or pain it will cause us. In the medical field, too, the principle of informed consent provides that the patient's preferences and values are to guide clinical choices. Yet, not always the preferences that people express before making an experience match with their preferences after living that experience. Some ingenious experiments suggest (in a seemingly paradoxical way) that before a direct experience, people prefer less pain; after that experience they prefer more, but with a better memory.

Interoperability of clinical decision-support systems and electronic health records using archetypes: a case study in clinical trial eligibility.

Science.gov (United States)

Marcos, Mar; Maldonado, Jose A; Martínez-Salvador, Begoña; Boscá, Diego; Robles, Montserrat

2013-08-01

Clinical decision-support systems (CDSSs) comprise systems as diverse as sophisticated platforms to store and manage clinical data, tools to alert clinicians of problematic situations, or decision-making tools to assist clinicians. Irrespective of the kind of decision-support task CDSSs should be smoothly integrated within the clinical information system, interacting with other components, in particular with the electronic health record (EHR). However, despite decades of developments, most CDSSs lack interoperability features. We deal with the interoperability problem of CDSSs and EHRs by exploiting the dual-model methodology. This methodology distinguishes a reference model and archetypes. A reference model is represented by a stable and small object-oriented model that describes the generic properties of health record information. For their part, archetypes are reusable and domain-specific definitions of clinical concepts in the form of structured and constrained combinations of the entities of the reference model. We rely on archetypes to make the CDSS compatible with EHRs from different institutions. Concretely, we use archetypes for modelling the clinical concepts that the CDSS requires, in conjunction with a series of knowledge-intensive mappings relating the archetypes to the data sources (EHR and/or other archetypes) they depend on. We introduce a comprehensive approach, including a set of tools as well as methodological guidelines, to deal with the interoperability of CDSSs and EHRs based on archetypes. Archetypes are used to build a conceptual layer of the kind of a virtual health record (VHR) over the EHR whose contents need to be integrated and used in the CDSS, associating them with structural and terminology-based semantics. Subsequently, the archetypes are mapped to the EHR by means of an expressive mapping language and specific-purpose tools. We also describe a case study where the tools and methodology have been employed in a CDSS to support

Towards meaningful medication-related clinical decision support: recommendations for an initial implementation.

Science.gov (United States)

Phansalkar, S; Wright, A; Kuperman, G J; Vaida, A J; Bobb, A M; Jenders, R A; Payne, T H; Halamka, J; Bloomrosen, M; Bates, D W

2011-01-01

Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

TUW @ TREC Clinical Decision Support Track

Science.gov (United States)

2014-11-01

and the ShARe/CLEF eHealth Evaluation Lab [8,3] running in 2013 and 2014. Here we briefly describe the goals of the first TREC Clinical Decision...Wendy W. Chapman, David Mart́ınez, Guido Zuccon, and João R. M. Palotti. Overview of the share/clef ehealth evalu- ation lab 2014. In Information Access...Zuccon. Overview of the share/clef ehealth evaluation lab 2013. In Information Access Evaluation. Multilinguality, Multimodality, and Visualization

Complexity perspectives on clinical decision making in an intensive care unit

NARCIS (Netherlands)

De Bock, Ben A.; Willems, Dick L.; Weinstein, Henry C.

2017-01-01

How to clarify the implications of complexity thinking for decision making in the intensive care unit (ICU)? Retrospective qualitative empirical research. Practitioners in an ICU were interviewed on how their decisions were made regarding a particular patient in a difficult, clinical situation.

Clinical decision-making and therapeutic approaches in osteopathy - a qualitative grounded theory study.

Science.gov (United States)

Thomson, Oliver P; Petty, Nicola J; Moore, Ann P

2014-02-01

There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths. Copyright © 2013 Elsevier Ltd. All rights reserved.

Artificial intelligence framework for simulating clinical decision-making: a Markov decision process approach.

Science.gov (United States)

Bennett, Casey C; Hauser, Kris

2013-01-01

In the modern healthcare system, rapidly expanding costs/complexity, the growing myriad of treatment options, and exploding information streams that often do not effectively reach the front lines hinder the ability to choose optimal treatment decisions over time. The goal in this paper is to develop a general purpose (non-disease-specific) computational/artificial intelligence (AI) framework to address these challenges. This framework serves two potential functions: (1) a simulation environment for exploring various healthcare policies, payment methodologies, etc., and (2) the basis for clinical artificial intelligence - an AI that can "think like a doctor". This approach combines Markov decision processes and dynamic decision networks to learn from clinical data and develop complex plans via simulation of alternative sequential decision paths while capturing the sometimes conflicting, sometimes synergistic interactions of various components in the healthcare system. It can operate in partially observable environments (in the case of missing observations or data) by maintaining belief states about patient health status and functions as an online agent that plans and re-plans as actions are performed and new observations are obtained. This framework was evaluated using real patient data from an electronic health record. The results demonstrate the feasibility of this approach; such an AI framework easily outperforms the current treatment-as-usual (TAU) case-rate/fee-for-service models of healthcare. The cost per unit of outcome change (CPUC) was $189 vs. $497 for AI vs. TAU (where lower is considered optimal) - while at the same time the AI approach could obtain a 30-35% increase in patient outcomes. Tweaking certain AI model parameters could further enhance this advantage, obtaining approximately 50% more improvement (outcome change) for roughly half the costs. Given careful design and problem formulation, an AI simulation framework can approximate optimal

Building consensus in strategic decision-making : system dynamics as a group support system

OpenAIRE

Vennix, J.A.M.

1995-01-01

System dynamics was originally founded as a method for modeling and simulating the behavior of industrial systems. In recent years it is increasingly employed as a Group Support System for strategic decision-making groups. The model is constructed in direct interaction with a management team, and the procedure is generally referred to as group model-building. The model can be conceptual (qualitative) or a full-blown (quantitative) computer simulation model. In this article, a case is describe...

Privacy-preserving clinical decision support system using Gaussian kernel-based classification.

Science.gov (United States)

Rahulamathavan, Yogachandran; Veluru, Suresh; Phan, Raphael C-W; Chambers, Jonathon A; Rajarajan, Muttukrishnan

2014-01-01

A clinical decision support system forms a critical capability to link health observations with health knowledge to influence choices by clinicians for improved healthcare. Recent trends toward remote outsourcing can be exploited to provide efficient and accurate clinical decision support in healthcare. In this scenario, clinicians can use the health knowledge located in remote servers via the Internet to diagnose their patients. However, the fact that these servers are third party and therefore potentially not fully trusted raises possible privacy concerns. In this paper, we propose a novel privacy-preserving protocol for a clinical decision support system where the patients' data always remain in an encrypted form during the diagnosis process. Hence, the server involved in the diagnosis process is not able to learn any extra knowledge about the patient's data and results. Our experimental results on popular medical datasets from UCI-database demonstrate that the accuracy of the proposed protocol is up to 97.21% and the privacy of patient data is not compromised.

Real-Time Clinical Decision Support Decreases Inappropriate Plasma Transfusion.

Science.gov (United States)

Shah, Neil; Baker, Steven A; Spain, David; Shieh, Lisa; Shepard, John; Hadhazy, Eric; Maggio, Paul; Goodnough, Lawrence T

2017-08-01

To curtail inappropriate plasma transfusions, we instituted clinical decision support as an alert upon order entry if the patient's recent international normalized ratio (INR) was 1.7 or less. The alert was suppressed for massive transfusion and within operative or apheresis settings. The plasma order was automatically removed upon alert acceptance while clinical exception reasons allowed for continued transfusion. Alert impact was studied comparing a 7-month control period with a 4-month intervention period. Monthly plasma utilization decreased 17.4%, from a mean ± SD of 3.40 ± 0.48 to 2.82 ± 0.6 plasma units per hundred patient days (95% confidence interval [CI] of difference, -0.1 to 1.3). Plasma transfused below an INR of 1.7 or less decreased from 47.6% to 41.6% (P = .0002; odds ratio, 0.78; 95% CI, 0.69-0.89). The alert recommendation was accepted 33% of the time while clinical exceptions were chosen in the remaining cases (active bleeding, 31%; other clinical indication, 33%; and apheresis, 2%). Alert acceptance rate varied significantly among different provider specialties. Clinical decision support can help curtail inappropriate plasma use but needs to be part of a comprehensive strategy including audit and feedback for comprehensive, long-term changes. © American Society for Clinical Pathology, 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

The role of emotion in clinical decision making: an integrative literature review.

Science.gov (United States)

Kozlowski, Desirée; Hutchinson, Marie; Hurley, John; Rowley, Joanne; Sutherland, Joanna

2017-12-15

Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning. Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement. Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a

The use of emotional intelligence capabilities in clinical reasoning and decision-making: A qualitative, exploratory study.

Science.gov (United States)

Hutchinson, Marie; Hurley, John; Kozlowski, Desirée; Whitehair, Leeann

2018-02-01

To explore clinical nurses' experiences of using emotional intelligence capabilities during clinical reasoning and decision-making. There has been little research exploring whether, or how, nurses employ emotional intelligence (EI) in clinical reasoning and decision-making. Qualitative phase of a larger mixed-methods study. Semistructured qualitative interviews with a purposive sample of registered nurses (n = 12) following EI training and coaching. Constructivist thematic analysis was employed to analyse the narrative transcripts. Three themes emerged: the sensibility to engage EI capabilities in clinical contexts, motivation to actively engage with emotions in clinical decision-making and incorporating emotional and technical perspectives in decision-making. Continuing to separate cognition and emotion in research, theorising and scholarship on clinical reasoning is counterproductive. Understanding more about nurses' use of EI has the potential to improve the calibre of decisions, and the safety and quality of care delivered. © 2017 John Wiley & Sons Ltd.

Modeling the green building (GB) investment decisions of developers and end-users with transaction costs (TCs) considerations

NARCIS (Netherlands)

Qian, Q.K.; Chan, E.H.W.; Visscher, H.J.; Lehmann, S.

2015-01-01

The paper, through a “regenerative” lens, has focused upon a new conceptual game system involving transaction costs (TCs) for creating a more accessible green buildings (GB) market. Individual stakeholders steadfastly guard their own interests in any investment decision, which seldom considers any

Evaluating online diagnostic decision support tools for the clinical setting.

Science.gov (United States)

Pryor, Marie; White, David; Potter, Bronwyn; Traill, Roger

2012-01-01

Clinical decision support tools available at the point of care are an effective adjunct to support clinicians to make clinical decisions and improve patient outcomes. We developed a methodology and applied it to evaluate commercially available online clinical diagnostic decision support (DDS) tools for use at the point of care. We identified 11 commercially available DDS tools and assessed these against an evaluation instrument that included 6 categories; general information, content, quality control, search, clinical results and other features. We developed diagnostically challenging clinical case scenarios based on real patient experience that were commonly missed by junior medical staff. The evaluation was divided into 2 phases; an initial evaluation of all identified and accessible DDS tools conducted by the Clinical Information Access Portal (CIAP) team and a second phase that further assessed the top 3 tools identified in the initial evaluation phase. An evaluation panel consisting of senior and junior medical clinicians from NSW Health conducted the second phase. Of the eleven tools that were assessed against the evaluation instrument only 4 tools completely met the DDS definition that was adopted for this evaluation and were able to produce a differential diagnosis. From the initial phase of the evaluation 4 DDS tools scored 70% or more (maximum score 96%) for the content category, 8 tools scored 65% or more (maximum 100%) for the quality control category, 5 tools scored 65% or more (maximum 94%) for the search category, and 4 tools score 70% or more (maximum 81%) for the clinical results category. The second phase of the evaluation was focused on assessing diagnostic accuracy for the top 3 tools identified in the initial phase. Best Practice ranked highest overall against the 6 clinical case scenarios used. Overall the differentiating factor between the top 3 DDS tools was determined by diagnostic accuracy ranking, ease of use and the confidence and

Continuous quality improvement for the clinical decision unit.

Science.gov (United States)

Mace, Sharon E

2004-01-01

Clinical decision units (CDUs) are a relatively new and growing area of medicine in which patients undergo rapid evaluation and treatment. Continuous quality improvement (CQI) is important for the establishment and functioning of CDUs. CQI in CDUs has many advantages: better CDU functioning, fulfillment of Joint Commission on Accreditation of Healthcare Organizations mandates, greater efficiency/productivity, increased job satisfaction, better performance improvement, data availability, and benchmarking. Key elements include a database with volume indicators, operational policies, clinical practice protocols (diagnosis specific/condition specific), monitors, benchmarks, and clinical pathways. Examples of these important parameters are given. The CQI process should be individualized for each CDU and hospital.

The impact of an electronic clinical decision support for pulmonary ...

African Journals Online (AJOL)

State-of-the-art electronic radiology workflow can provide clinical decision support (CDS) for specialised imaging requests, but there has been limited work on the clinical impact of CDS in PE, particularly in resource-constrained environments. Objective. To determine the impact of an electronic CDS for PE on the efficiency ...

Constructing diagnostic likelihood: clinical decisions using subjective versus statistical probability.

Science.gov (United States)

Kinnear, John; Jackson, Ruth

2017-07-01

Although physicians are highly trained in the application of evidence-based medicine, and are assumed to make rational decisions, there is evidence that their decision making is prone to biases. One of the biases that has been shown to affect accuracy of judgements is that of representativeness and base-rate neglect, where the saliency of a person's features leads to overestimation of their likelihood of belonging to a group. This results in the substitution of 'subjective' probability for statistical probability. This study examines clinicians' propensity to make estimations of subjective probability when presented with clinical information that is considered typical of a medical condition. The strength of the representativeness bias is tested by presenting choices in textual and graphic form. Understanding of statistical probability is also tested by omitting all clinical information. For the questions that included clinical information, 46.7% and 45.5% of clinicians made judgements of statistical probability, respectively. Where the question omitted clinical information, 79.9% of clinicians made a judgement consistent with statistical probability. There was a statistically significant difference in responses to the questions with and without representativeness information (χ2 (1, n=254)=54.45, pprobability. One of the causes for this representativeness bias may be the way clinical medicine is taught where stereotypic presentations are emphasised in diagnostic decision making. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Making reasonable decisions: a qualitative study of medical decision making in the care of patients with a clinically significant haemoglobin disorder.

Science.gov (United States)

Crowther, Helen J; Kerridge, Ian

2015-10-01

Therapies utilized in patients with clinically significant haemoglobin disorders appear to vary between clinicians and units. This study aimed to investigate the processes of evidence implementation and medical decision making in the care of such patients in NSW, Australia. Using semi-structured interviews, 11 haematologists discussed their medical decision-making processes with particular attention paid to the use of published evidence. Transcripts were thematically analysed by a single investigator on a line-by-line basis. Decision making surrounding the care of patients with significant haemoglobin disorders varied and was deeply contextual. Three main determinants of clinical decision making were identified - factors relating to the patient and to their illness, factors specific to the clinician and the institution in which they were practising and factors related to the notion of evidence and to utility and role of evidence-based medicine in clinical practice. Clinicians pay considerable attention to medical decision making and evidence incorporation and attempt to tailor these to particular patient contexts. However, the patient context is often inferred and when discordant with the clinician's own contexture can lead to discomfort with decision recommendations. Clinicians strive to improve comfort through the use of experience and trustworthy evidence. © 2015 John Wiley & Sons, Ltd.

Build, Buy, Open Source, or Web 2.0?: Making an Informed Decision for Your Library

Science.gov (United States)

Fagan, Jody Condit; Keach, Jennifer A.

2010-01-01

When improving a web presence, today's libraries have a choice: using a free Web 2.0 application, opting for open source, buying a product, or building a web application. This article discusses how to make an informed decision for one's library. The authors stress that deciding whether to use a free Web 2.0 application, to choose open source, to…

Refurbishment and school buildings management in a smart building environment

Science.gov (United States)

Di Giuda, Giuseppe Martino; Villa, Valentina; Tagliabue, Lavinia Chiara; Giana, Paolo Ettore; Rinaldi, Stefano; Ciribini, Angelo Luigi Camillo

2018-05-01

Building Information Modelling is a methodology, which is able to take into account many data, both geometrical and non-geometrical, in order to evaluate at the actual condition of the asset. The project has the scope of evaluating the conditions of different school buildings, in order to develop a way to choose the best-tailored management solution to the owner. A further step is the management and planning of design solutions during the life cycle customized on monitored buildings' conditions. The research work focuses on providing a support decisions concerning the gap between the present building state laws and the current state of the existing buildings. The process will be developed in an expanded BIM environment, using sensors, which will give back the state of the consistency of the actual conditions to enable the buildings to adapt themselves in the best way into their specific constraints and boundaries. The results of the study are (i) a complete workflow to make decision and the possibility to shape the decision process on an objective through a scientific approach, (ii) evaluate the current state of the asset and (iii) manage maintenance in the lifespan. Further development will take in consideration all the aspects related to management of big data environment generated by a smart buildings system.

Critical care nurse practitioners and clinical nurse specialists interface patterns with computer-based decision support systems.

Science.gov (United States)

Weber, Scott

2007-11-01

The purposes of this review are to examine the types of clinical decision support systems in use and to identify patterns of how critical care advanced practice nurses (APNs) have integrated these systems into their nursing care patient management practices. The decision-making process itself is analyzed with a focus on how automated systems attempt to capture and reflect human decisional processes in critical care nursing, including how systems actually organize and process information to create outcome estimations based on patient clinical indicators and prognosis logarithms. Characteristics of APN clinicians and implications of these characteristics on decision system use, based on the body of decision system user research, are introduced. A review of the Medline, Ovid, CINAHL, and PubMed literature databases was conducted using "clinical decision support systems,"computerized clinical decision making," and "APNs"; an examination of components of several major clinical decision systems was also undertaken. Use patterns among APNs and other clinicians appear to vary; there is a need for original research to examine how APNs actually use these systems in their practices in critical care settings. Because APNs are increasingly responsible for admission to, and transfer from, critical care settings, more understanding is needed on how they interact with this technology and how they see automated decision systems impacting their practices. APNs who practice in critical care settings vary significantly in how they use the clinical decision systems that are in operation in their practice settings. These APNs must have an understanding of their use patterns with these systems and should critically assess whether their patient care decision making is affected by the technology.

Identifying design considerations for a shared decision aid for use at the point of outpatient clinical care: An ethnographic study at an inner city clinic.

Science.gov (United States)

Hajizadeh, Negin; Perez Figueroa, Rafael E; Uhler, Lauren M; Chiou, Erin; Perchonok, Jennifer E; Montague, Enid

2013-03-06

Computerized decision aids could facilitate shared decision-making at the point of outpatient clinical care. The objective of this study was to investigate whether a computerized shared decision aid would be feasible to implement in an inner-city clinic by evaluating the current practices in shared decision-making, clinicians' use of computers, patient and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision-making. Qualitative data analysis of observations and semi-structured interviews with patients and clinicians at an inner-city outpatient clinic. The findings provided an exploratory look at the prevalence of shared decision-making and attitudes about health information technology and decision aids. A prominent barrier to clinicians engaging in shared decision-making was a lack of perceived patient understanding of medical information. Some patients preferred their clinicians make recommendations for them rather than engage in formal shared decision-making. Health information technology was an integral part of the clinic visit and welcomed by most clinicians and patients. Some patients expressed the desire to engage with health information technology such as viewing their medical information on the computer screen with their clinicians. All participants were receptive to the idea of a decision aid integrated within the clinic visit although some clinicians were concerned about the accuracy of prognostic estimates for complex medical problems. We identified several important considerations for the design and implementation of a computerized decision aid including opportunities to: bridge clinician-patient communication about medical information while taking into account individual patients' decision-making preferences, complement expert clinician judgment with prognostic estimates, take advantage of patient waiting times, and make tasks involved during the clinic visit more efficient. These findings

The role of emotion in clinical decision making: an integrative literature review

OpenAIRE

Kozlowski, Desirée; Hutchinson, Marie; Hurley, John; Rowley, Joanne; Sutherland, Joanna

2017-01-01

Background Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. Methods A systematic search of the bibliographic databases PubMed,...

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: methods of a decision-maker-researcher partnership systematic review.

Science.gov (United States)

Haynes, R Brian; Wilczynski, Nancy L

2010-02-05

Computerized clinical decision support systems are information technology-based systems designed to improve clinical decision-making. As with any healthcare intervention with claims to improve process of care or patient outcomes, decision support systems should be rigorously evaluated before widespread dissemination into clinical practice. Engaging healthcare providers and managers in the review process may facilitate knowledge translation and uptake. The objective of this research was to form a partnership of healthcare providers, managers, and researchers to review randomized controlled trials assessing the effects of computerized decision support for six clinical application areas: primary preventive care, therapeutic drug monitoring and dosing, drug prescribing, chronic disease management, diagnostic test ordering and interpretation, and acute care management; and to identify study characteristics that predict benefit. The review was undertaken by the Health Information Research Unit, McMaster University, in partnership with Hamilton Health Sciences, the Hamilton, Niagara, Haldimand, and Brant Local Health Integration Network, and pertinent healthcare service teams. Following agreement on information needs and interests with decision-makers, our earlier systematic review was updated by searching Medline, EMBASE, EBM Review databases, and Inspec, and reviewing reference lists through 6 January 2010. Data extraction items were expanded according to input from decision-makers. Authors of primary studies were contacted to confirm data and to provide additional information. Eligible trials were organized according to clinical area of application. We included randomized controlled trials that evaluated the effect on practitioner performance or patient outcomes of patient care provided with a computerized clinical decision support system compared with patient care without such a system. Data will be summarized using descriptive summary measures, including proportions

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: Methods of a decision-maker-researcher partnership systematic review

Directory of Open Access Journals (Sweden)

Wilczynski Nancy L

2010-02-01

Full Text Available Abstract Background Computerized clinical decision support systems are information technology-based systems designed to improve clinical decision-making. As with any healthcare intervention with claims to improve process of care or patient outcomes, decision support systems should be rigorously evaluated before widespread dissemination into clinical practice. Engaging healthcare providers and managers in the review process may facilitate knowledge translation and uptake. The objective of this research was to form a partnership of healthcare providers, managers, and researchers to review randomized controlled trials assessing the effects of computerized decision support for six clinical application areas: primary preventive care, therapeutic drug monitoring and dosing, drug prescribing, chronic disease management, diagnostic test ordering and interpretation, and acute care management; and to identify study characteristics that predict benefit. Methods The review was undertaken by the Health Information Research Unit, McMaster University, in partnership with Hamilton Health Sciences, the Hamilton, Niagara, Haldimand, and Brant Local Health Integration Network, and pertinent healthcare service teams. Following agreement on information needs and interests with decision-makers, our earlier systematic review was updated by searching Medline, EMBASE, EBM Review databases, and Inspec, and reviewing reference lists through 6 January 2010. Data extraction items were expanded according to input from decision-makers. Authors of primary studies were contacted to confirm data and to provide additional information. Eligible trials were organized according to clinical area of application. We included randomized controlled trials that evaluated the effect on practitioner performance or patient outcomes of patient care provided with a computerized clinical decision support system compared with patient care without such a system. Results Data will be summarized

Clinical decision making-a functional medicine perspective.

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Pizzorno, Joseph E

2012-09-01

As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care.

Acceptance of clinical decision support surveillance technology in the clinical pharmacy.

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English, Dan; Ankem, Kalyani; English, Kathleen

2017-03-01

There are clinical and economic benefits to incorporating clinical decision support systems (CDSSs) in patient care interventions in the clinical pharmacy setting. However, user dissatisfaction and resistance to HIT can prevent optimal use of such systems, particularly when users employ system workarounds and overrides. The present study applied a modified version of the unified theory of acceptance and use of technology (UTAUT) to evaluate the disposition and satisfaction with CDSS among clinical pharmacists who perform surveillance to identify potential medication therapy interventions on patients in the hospital setting. A survey of clinical pharmacists (N = 48) was conducted. Partial least squares (PLS) regression was used to analyze the influence of the UTAUT-related variables on behavioral intention and satisfaction with CDSS among clinical pharmacists. While behavioral intention did not predict actual use of HIT, facilitating conditions had a direct effect on pharmacists' use of CDSS. Likewise, satisfaction with CDSS was found to have a direct effect on use, with more satisfied users being less inclined to employ workarounds or overrides of the system. Based on the findings, organizational structures that facilitate CDSS use and user satisfaction affect the extent to which pharmacy and health care management maximize use in the clinical pharmacy setting.

Students' stereotypes of patients as barriers to clinical decision-making.

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Johnson, S M; Kurtz, M E; Tomlinson, T; Howe, K R

1986-09-01

The ability to formulate quick, accurate clinical judgments is stressed in medical training. Speed is usually an asset when a physician sorts through his biomedical knowledge, but it is often a liability when the physician assesses the sociocultural context of a clinical encounter. At the Michigan State University College of Osteopathic Medicine, a study was designed which graphically illustrated to beginning students that unconscious sociocultural stereotypes may influence clinical decision-making. Three entering classes of students were shown a videotape depicting five simulated patients (attractive black woman, attractive white woman, professional man, middle-aged housewife, and elderly man), each presenting with the same physical complaint. Elements of positive and negative stereotypes were incorporated into each of the portrayals, and the students rated these patients on positive and negative characteristics. The results suggested that the students attributed both positive and negative characteristics to patients on the basis of irrelevant characteristics, such as attractiveness, and with little further justification for their attributions. Such stereotypic generalizations held by students may become barriers to the students' objective clinical decision-making.

Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage

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Dustin G. Mark

2015-10-01

Full Text Available Introduction: Application of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT performed within six hours of ictus (early cranial CT, may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH. This study’s objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED patients with aSAH and a normal mental status. Methods: Patients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age >40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset were abstracted from the chart and assessed for inter-rater reliability. Results: One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9-98.2]. The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9-98.2]. Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6-100.0]. Conclusion: Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.

Info-gap decision theory decisions under severe uncertainty

CERN Document Server

Ben-Haim, Yakov

2006-01-01

Everyone makes decisions, but not everyone is a decision analyst. A decision analyst uses quantitative models and computational methods to formulate decision algorithms, assess decision performance, identify and evaluate options, determine trade-offs and risks, evaluate strategies for investigation, and so on. This book is written for decision analysts. The term ""decision analyst"" covers an extremely broad range of practitioners. Virtually all engineers involved in design (of buildings, machines, processes, etc.) or analysis (of safety, reliability, feasibility, etc.) are decision analysts,

Exploring a clinically friendly web-based approach to clinical decision support linked to the electronic health record: design philosophy, prototype implementation, and framework for assessment.

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Miller, Perry; Phipps, Michael; Chatterjee, Sharmila; Rajeevan, Nallakkandi; Levin, Forrest; Frawley, Sandra; Tokuno, Hajime

2014-07-01

Computer-based clinical decision support (CDS) is an important component of the electronic health record (EHR). As an increasing amount of CDS is implemented, it will be important that this be accomplished in a fashion that assists in clinical decision making without imposing unacceptable demands and burdens upon the provider's practice. The objective of our study was to explore an approach that allows CDS to be clinician-friendly from a variety of perspectives, to build a prototype implementation that illustrates features of the approach, and to gain experience with a pilot framework for assessment. The paper first discusses the project's design philosophy and goals. It then describes a prototype implementation (Neuropath/CDS) that explores the approach in the domain of neuropathic pain and in the context of the US Veterans Administration EHR. Finally, the paper discusses a framework for assessing the approach, illustrated by a pilot assessment of Neuropath/CDS. The paper describes the operation and technical design of Neuropath/CDS, as well as the results of the pilot assessment, which emphasize the four areas of focus, scope, content, and presentation. The work to date has allowed us to explore various design and implementation issues relating to the approach illustrated in Neuropath/CDS, as well as the development and pilot application of a framework for assessment.

Clinical decisions for anterior restorations: the concept of restorative volume.

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Cardoso, Jorge André; Almeida, Paulo Júlio; Fischer, Alex; Phaxay, Somano Luang

2012-12-01

The choice of the most appropriate restoration for anterior teeth is often a difficult decision. Numerous clinical and technical factors play an important role in selecting the treatment option that best suits the patient and the restorative team. Experienced clinicians have developed decision processes that are often more complex than may seem. Less experienced professionals may find difficulties making treatment decisions because of the widely varied restorative materials available and often numerous similar products offered by different manufacturers. The authors reviewed available evidence and integrated their clinical experience to select relevant factors that could provide a logical and practical guideline for restorative decisions in anterior teeth. The presented concept of restorative volume is based on structural, optical, and periodontal factors. Each of these factors will influence the short- and long-term behavior of restorations in terms of esthetics, biology, and function. Despite the marked evolution of esthetic restorative techniques and materials, significant limitations still exist, which should be addressed by researchers. The presented guidelines must be regarded as a mere orientation for risk analysis. A comprehensive individual approach should always be the core of restorative esthetic treatments. The complex decision process for anterior esthetic restorations can be clarified by a systematized examination of structural, optical, and periodontal factors. The basis for the proposed thought process is the concept of restorative volume that is a contemporary interpretation of restoration categories and their application. © 2012 Wiley Periodicals, Inc.

Clinical intuition in the nursing process and decision-making-A mixed-studies review.

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Melin-Johansson, Christina; Palmqvist, Rebecca; Rönnberg, Linda

2017-12-01

To review what is characteristic of registered nurses' intuition in clinical settings, in relationships and in the nursing process. Intuition is a controversial concept and nurses believe that there are difficulties in how they should explain their nursing actions or decisions based on intuition. Much of the evidence from the body of research indicates that nurses value their intuition in a variety of clinical settings. More information on how nurses integrate intuition as a core element in daily clinical work would contribute to an improved understanding on how they go about this. Intuition deserves a place in evidence-based activities, where intuition is an important component associated with the nursing process. An integrative review strengthened with a mixed-studies review. Literature searches were conducted in the databases CINAHL, PubMed and PsycINFO, and literature published 1985-2016 were included. The findings in the studies were analysed with content analysis, and the synthesis process entailed a reasoning between the authors. After a quality assessment, 16 studies were included. The analysis and synthesis resulted in three categories. The characteristics of intuition in the nurse's daily clinical activities include application, assertiveness and experiences; in the relationships with patients' intuition include unique connections, mental and bodily responses, and personal qualities; and in the nursing process include support and guidance, component and clues in decision-making, and validating decisions. Intuition is more than simply a "gut feeling," and it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of intuition alongside objective data when making decisions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care. We find that intuition plays a

A hybrid decision support system for sustainable office building renovation and energy performance improvement

Energy Technology Data Exchange (ETDEWEB)

Juan, Yi-Kai [Department of Architecture, National Taiwan University of Science and Technology (NTUST) (China); Center for Sustainable Development and Global Competitiveness, Stanford University (United States); Gao, Peng [Department of Traffic and Transportation Engineering, Tongji University (China); Wang, Jie [Center for Sustainable Development and Global Competitiveness, Stanford University (United States)

2010-03-15

Energy consumption of buildings accounts for around 20-40% of all energy consumed in advanced countries. Over the last decade, more and more global organizations are investing significant resources to create sustainably built environments, emphasizing sustainable building renovation processes to reduce energy consumption and carbon dioxide emissions. This study develops an integrated decision support system to assess existing office building conditions and to recommend an optimal set of sustainable renovation actions, considering trade-offs between renovation cost, improved building quality, and environmental impacts. A hybrid approach that combines A* graph search algorithm with genetic algorithms (GA) is used to analyze all possible renovation actions and their trade-offs to develop the optimal solution. A two-stage system validation is performed to demonstrate the practical application of the hybrid approach: zero-one goal programming (ZOGP) and genetic algorithms are adopted to validate the effectiveness of the algorithm. A real-world renovation project is introduced to validate differences in energy performance projected for the renovation solution suggested by the system. The results reveal that the proposed hybrid system is more computationally effective than either ZOGP or GA alone. The system's suggested renovation actions would provide substantial energy performance improvements to the real project if implemented. (author)

IBM’s Health Analytics and Clinical Decision Support

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Sun, J.; Knoop, S.; Shabo, A.; Carmeli, B.; Sow, D.; Syed-Mahmood, T.; Rapp, W.

2014-01-01

Summary Objectives This survey explores the role of big data and health analytics developed by IBM in supporting the transformation of healthcare by augmenting evidence-based decision-making. Methods Some problems in healthcare and strategies for change are described. It is argued that change requires better decisions, which, in turn, require better use of the many kinds of healthcare information. Analytic resources that address each of the information challenges are described. Examples of the role of each of the resources are given. Results There are powerful analytic tools that utilize the various kinds of big data in healthcare to help clinicians make more personalized, evidenced-based decisions. Such resources can extract relevant information and provide insights that clinicians can use to make evidence-supported decisions. There are early suggestions that these resources have clinical value. As with all analytic tools, they are limited by the amount and quality of data. Conclusion Big data is an inevitable part of the future of healthcare. There is a compelling need to manage and use big data to make better decisions to support the transformation of healthcare to the personalized, evidence-supported model of the future. Cognitive computing resources are necessary to manage the challenges in employing big data in healthcare. Such tools have been and are being developed. The analytic resources, themselves, do not drive, but support healthcare transformation. PMID:25123736

Pregnancy outcomes in Ghana : Relavance of clinical decision making support tools for frontline providers of care

OpenAIRE

Amoakoh-Coleman, M.

2016-01-01

Ghana’s slow progress towards attaining millennium development goal 5 has been associated with gaps in quality of care, particularly quality of clinical decision making for clients. This thesis reviews the relevance and effect of clinical decision making support tools on pregnancy outcomes. Relevance of three clinical decision making support tools available to frontline providers of care in the Greater Accra region is discussed. These are routine maternal health service delivery data populati...

Whole mind and shared mind in clinical decision-making.

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Epstein, Ronald Mark

2013-02-01

To review the theory, research evidence and ethical implications regarding "whole mind" and "shared mind" in clinical practice in the context of chronic and serious illnesses. Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy. Decision-making involves analytic thinking as well as affect and intuition ("whole mind") and sharing cognitive and affective schemas of two or more individuals ("shared mind"). Social relationships can help processing of complex information that otherwise would overwhelm individuals' cognitive capacities. Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference. Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

The comparison of the energy performance of hotel buildings using PROMETHEE decision-making method

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Vujosevic Milica L.

2016-01-01

Full Text Available Annual energy performance of the atrium type hotel buildings in Belgrade climate conditions are analysed in this paper. The objective is to examine the impact of the atrium on the hotel building’s energy needs for space heating and cooling, thus establishing the best design among four proposed alternatives of the hotels with atrium. The energy performance results are obtained using EnergyPlus simulation engine, taking into account Belgrade climate data and thermal comfort parameters. The selected results are compared and the hotels are ranked according to certain criteria. Decision-making process that resulted in the ranking of the proposed alternatives is conducted using PROMETHEE method and Borda model. The methodological approach in this research includes the creation of a hypothetical model of an atrium type hotel building, numerical simulation of energy performances of four design alternatives of the hotel building with an atrium, comparative analysis of the obtained results and ranking of the proposed alternatives from the building’s energy performance perspective. The main task of the analysis is to examine the influence of the atrium, with both its shape and position, on the energy performance of the hotel building. Based on the results of the research it can be to determine the most energy efficient model of the hotel building with atrium for Belgrade climate condition areas. [Projekat Ministarstva nauke Republike Srbije: Spatial, Environmental, Energy and Social aspects of the Developing Settlements and Climate Change - Mutual Impacts

Studying the effect of clinical uncertainty on physicians' decision-making using ILIAD.

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Anderson, J D; Jay, S J; Weng, H C; Anderson, M M

1995-01-01

The influence of uncertainty on physicians' practice behavior is not well understood. In this research, ILIAD, a diagnostic expert system, has been used to study physicians' responses to uncertainty and how their responses affected clinical performance. The simulation mode of ILIAD was used to standardize the presentation and scoring of two cases to 46 residents in emergency medicine, internal medicine, family practice and transitional medicine at Methodist Hospital of Indiana. A questionnaire was used to collect additional data on how physicians respond to clinical uncertainty. A structural equation model was developed, estimated, and tested. The results indicate that stress that physicians experience in dealing with clinical uncertainty has a negative effect on their clinical performance. Moreover, the way that physicians respond to uncertainty has positive and negative effects on their performance. Open discussions with patients about clinical decisions and the use of practice guidelines improves performance. However, when the physician's clinical decisions are influenced by patient demands or their peers, their performance scores decline.

Medical students, clinical preventive services, and shared decision-making.

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Keefe, Carole W; Thompson, Margaret E; Noel, Mary Margaret

2002-11-01

Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. Our medical students appear quite willing to accept shared decision making as

An integrated review of the correlation between critical thinking ability and clinical decision-making in nursing.

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Lee, Daphne Sk; Abdullah, Khatijah Lim; Subramanian, Pathmawathi; Bachmann, Robert Thomas; Ong, Swee Leong

2017-12-01

To explore whether there is a correlation between critical thinking ability and clinical decision-making among nurses. Critical thinking is currently considered as an essential component of nurses' professional judgement and clinical decision-making. If confirmed, nursing curricula may be revised emphasising on critical thinking with the expectation to improve clinical decision-making and thus better health care. Integrated literature review. The integrative review was carried out after a comprehensive literature search using electronic databases Ovid, EBESCO MEDLINE, EBESCO CINAHL, PROQuest and Internet search engine Google Scholar. Two hundred and 22 articles from January 1980 to end of 2015 were retrieved. All studies evaluating the relationship between critical thinking and clinical decision-making, published in English language with nurses or nursing students as the study population, were included. No qualitative studies were found investigating the relationship between critical thinking and clinical decision-making, while 10 quantitative studies met the inclusion criteria and were further evaluated using the Quality Assessment and Validity Tool. As a result, one study was excluded due to a low-quality score, with the remaining nine accepted for this review. Four of nine studies established a positive relationship between critical thinking and clinical decision-making. Another five studies did not demonstrate a significant correlation. The lack of refinement in studies' design and instrumentation were arguably the main reasons for the inconsistent results. Research studies yielded contradictory results as regard to the relationship between critical thinking and clinical decision-making; therefore, the evidence is not convincing. Future quantitative studies should have representative sample size, use critical thinking measurement tools related to the healthcare sector and evaluate the predisposition of test takers towards their willingness and ability to think

Do educational interventions improve nurses' clinical decision making and judgement? A systematic review.

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Thompson, Carl; Stapley, Sally

2011-07-01

Despite the growing popularity of decision making in nursing curricula, the effectiveness of educational interventions to improve nursing judgement and decision making is unknown. We sought to synthesise and summarise the comparative evidence for educational interventions to improve nursing judgements and clinical decisions. A systematic review. Electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL and PsycINFO, Social Sciences Citation Index, OpenSIGLE conference proceedings and hand searching nursing journals. Studies published since 1960, reporting any educational intervention that aimed to improve nurses' clinical judgements or decision making were included. Studies were assessed for relevance and quality. Data extracted included study design; educational setting; the nature of participants; whether the study was concerned with the clinical application of skills or the application of theory; the type of decision targeted by the intervention (e.g. diagnostic reasoning) and whether the evaluation of the intervention focused on efficacy or effectiveness. A narrative approach to study synthesis was used due to heterogeneity in interventions, study samples, outcomes and settings and incomplete reporting of effect sizes. From 5262 initial citations 24 studies were included in the review. A variety of educational approaches were reported. Study quality and content reporting was generally poor. Pedagogical theories were widely used but use of decision theory (with the exception of subjective expected utility theory implicit in decision analysis) was rare. The effectiveness and efficacy of interventions was mixed. Educational interventions to improve nurses' judgements and decisions are complex and the evidence from comparative studies does little to reduce the uncertainty about 'what works'. Nurse educators need to pay attention to decision, as well as pedagogical, theory in the design of interventions. Study design and

Molecular diagnostics clinical utility strategy: a six-part framework.

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Frueh, Felix W; Quinn, Bruce

2014-09-01

The clinical utility of a molecular test rises proportional to a favorable regulatory risk/benefit assessment, and clinical utility is the driver of payer coverage decisions. Although a great deal has been written about clinical utility, debates still center on its 'definition.' We argue that the definition (an impact on clinical outcomes) is self-evident, and improved communications should focus on sequential steps in building and proving an adequate level of confidence for the diagnostic test's clinical value proposition. We propose a six-part framework to facilitate communications between test developers and health technology evaluators, relevant to both regulatory and payer decisions.

Development of an evidence-based decision pathway for vestibular schwannoma treatment options.

Science.gov (United States)

Linkov, Faina; Valappil, Benita; McAfee, Jacob; Goughnour, Sharon L; Hildrew, Douglas M; McCall, Andrew A; Linkov, Igor; Hirsch, Barry; Snyderman, Carl

To integrate multiple sources of clinical information with patient feedback to build evidence-based decision support model to facilitate treatment selection for patients suffering from vestibular schwannomas (VS). This was a mixed methods study utilizing focus group and survey methodology to solicit feedback on factors important for making treatment decisions among patients. Two 90-minute focus groups were conducted by an experienced facilitator. Previously diagnosed VS patients were recruited by clinical investigators at the University of Pittsburgh Medical Center (UPMC). Classical content analysis was used for focus group data analysis. Providers were recruited from practices within the UPMC system and were surveyed using Delphi methods. This information can provide a basis for multi-criteria decision analysis (MCDA) framework to develop a treatment decision support system for patients with VS. Eight themes were derived from these data (focus group + surveys): doctor/health care system, side effects, effectiveness of treatment, anxiety, mortality, family/other people, quality of life, and post-operative symptoms. These data, as well as feedback from physicians were utilized in building a multi-criteria decision model. The study illustrated steps involved in the development of a decision support model that integrates evidence-based data and patient values to select treatment alternatives. Studies focusing on the actual development of the decision support technology for this group of patients are needed, as decisions are highly multifactorial. Such tools have the potential to improve decision making for complex medical problems with alternate treatment pathways. Copyright © 2016 Elsevier Inc. All rights reserved.

Building workplace social capital: A longitudinal study of student nurses' clinical placement experiences.

Science.gov (United States)

Materne, Michelle; Henderson, Amanda; Eaton, Emma

2017-09-01

Quality clinical placement experiences have been associated with nurses' workplace social capital. Social capital is broadly understood as the social organisation of trust, norms and networks that benefit society. Building social capital in the workplace may benefit experiences of staff and students. The aim of this study was to assess the impact of building workplace social capital on student nurse perceptions of clinical learning experiences. A quality improvement process was measured through repeated student surveys. First, second, third year students (n = 1176) from three universities completed a validated Student Clinical Learning Culture Survey (SCLCS) following their placement, at the commencement of quality improvement initiatives and five years later. The SCLCS measured students' perceptions of social affiliation, their motivation, satisfaction and dissatisfaction with clinical contexts. The first year of systematic changes focused on increasing student numbers along with improving communication, trust and knowledge sharing, antecedents to workplace social capital. No change was evident after the first year. Six years after commencement of building workplace social capital differences across all subscales, except dissatisfaction, were significant (p social capital that enhances student placement experiences. Copyright © 2017 Elsevier Ltd. All rights reserved.

Human Cognitive Limitations. Broad, Consistent, Clinical Application of Physiological Principles Will Require Decision Support.

Science.gov (United States)

Morris, Alan H

2018-02-01

Our education system seems to fail to enable clinicians to broadly understand core physiological principles. The emphasis on reductionist science, including "omics" branches of research, has likely contributed to this decrease in understanding. Consequently, clinicians cannot be expected to consistently make clinical decisions linked to best physiological evidence. This is a large-scale problem with multiple determinants, within an even larger clinical decision problem: the failure of clinicians to consistently link their decisions to best evidence. Clinicians, like all human decision-makers, suffer from significant cognitive limitations. Detailed context-sensitive computer protocols can generate personalized medicine instructions that are well matched to individual patient needs over time and can partially resolve this problem.

Assessing an Adolescent's Capacity for Autonomous Decision-Making in Clinical Care.

Science.gov (United States)

Michaud, Pierre-André; Blum, Robert Wm; Benaroyo, Lazare; Zermatten, Jean; Baltag, Valentina

2015-10-01

The purpose of this article is to provide policy guidance on how to assess the capacity of minor adolescents for autonomous decision-making without a third party authorization, in the field of clinical care. In June 2014, a two-day meeting gathered 20 professionals from all continents, working in the field of adolescent medicine, neurosciences, developmental and clinical psychology, sociology, ethics, and law. Formal presentations and discussions were based on a literature search and the participants' experience. The assessment of adolescent decision-making capacity includes the following: (1) a review of the legal context consistent with the principles of the Convention on the Rights of the Child; (2) an empathetic relationship between the adolescent and the health care professional/team; (3) the respect of the adolescent's developmental stage and capacities; (4) the inclusion, if relevant, of relatives, peers, teachers, or social and mental health providers with the adolescent's consent; (5) the control of coercion and other social forces that influence decision-making; and (6) a deliberative stepwise appraisal of the adolescent's decision-making process. This stepwise approach, already used among adults with psychiatric disorders, includes understanding the different facets of the given situation, reasoning on the involved issues, appreciating the outcomes linked with the decision(s), and expressing a choice. Contextual and psychosocial factors play pivotal roles in the assessment of adolescents' decision-making capacity. The evaluation must be guided by a well-established procedure, and health professionals should be trained accordingly. These proposals are the first to have been developed by a multicultural, multidisciplinary expert panel. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Strategies to facilitate shared decision-making about pediatric oncology clinical trial enrollment: A systematic review.

Science.gov (United States)

Robertson, Eden G; Wakefield, Claire E; Signorelli, Christina; Cohn, Richard J; Patenaude, Andrea; Foster, Claire; Pettit, Tristan; Fardell, Joanna E

2018-07-01

We conducted a systematic review to identify the strategies that have been recommended in the literature to facilitate shared decision-making regarding enrolment in pediatric oncology clinical trials. We searched seven databases for peer-reviewed literature, published 1990-2017. Of 924 articles identified, 17 studies were eligible for the review. We assessed study quality using the 'Mixed-Methods Appraisal Tool'. We coded the results and discussions of papers line-by-line using nVivo software. We categorized strategies thematically. Five main themes emerged: 1) decision-making as a process, 2) individuality of the process; 3) information provision, 4) the role of communication, or 5) decision and psychosocial support. Families should have adequate time to make a decision. HCPs should elicit parents' and patients' preferences for level of information and decision involvement. Information should be clear and provided in multiple modalities. Articles also recommended providing training for healthcare professionals and access to psychosocial support for families. High quality, individually-tailored information, open communication and psychosocial support appear vital in supporting decision-making regarding enrollment in clinical trials. These data will usefully inform future decision-making interventions/tools to support families making clinical trial decisions. A solid evidence-base for effective strategies which facilitate shared decision-making is needed. Copyright © 2018 Elsevier B.V. All rights reserved.

Appreciative inquiry enhances cardiology nurses’ clinical decision making when using a clinical guideline on delirium

DEFF Research Database (Denmark)

Vedsegaard, Helle; Schrader, Anne-Marie; Rom, Gitte

2016-01-01

The current study responds to implementation challenges with translating evidence-based knowledge into practice. We explore how appreciative inquiry can be used in in-house learning sessions for nurses to enhance their knowledge in using a guideline on delirium as part of clinical decision making...... and axial coding drawing on the principles of grounded theory. The study shows that appreciative inquiry was meaningful to cardiology nurses in providing them with knowledge of using a guideline on delirium in clinical decision making, the main reasons being a) data on a current patient were included, b....... Through 18 sessions with 3–12 nurses, an appreciative inquiry approach was used. Specialist nurses from the Heart Centre of Copenhagen and senior lecturers from the Department of Nursing at Metropolitan University College facilitated the sessions. Field notes from the sessions were analysed using open...

Pilot study of a point-of-use decision support tool for cancer clinical trials eligibility.

Science.gov (United States)

Breitfeld, P P; Weisburd, M; Overhage, J M; Sledge, G; Tierney, W M

1999-01-01

Many adults with cancer are not enrolled in clinical trials because caregivers do not have the time to match the patient's clinical findings with varying eligibility criteria associated with multiple trials for which the patient might be eligible. The authors developed a point-of-use portable decision support tool (DS-TRIEL) to automate this matching process. The support tool consists of a hand-held computer with a programmable relational database. A two-level hierarchic decision framework was used for the identification of eligible subjects for two open breast cancer clinical trials. The hand-held computer also provides protocol consent forms and schemas to further help the busy oncologist. This decision support tool and the decision framework on which it is based could be used for multiple trials and different cancer sites.

CLAMP - a toolkit for efficiently building customized clinical natural language processing pipelines.

Science.gov (United States)

Soysal, Ergin; Wang, Jingqi; Jiang, Min; Wu, Yonghui; Pakhomov, Serguei; Liu, Hongfang; Xu, Hua

2017-11-24

Existing general clinical natural language processing (NLP) systems such as MetaMap and Clinical Text Analysis and Knowledge Extraction System have been successfully applied to information extraction from clinical text. However, end users often have to customize existing systems for their individual tasks, which can require substantial NLP skills. Here we present CLAMP (Clinical Language Annotation, Modeling, and Processing), a newly developed clinical NLP toolkit that provides not only state-of-the-art NLP components, but also a user-friendly graphic user interface that can help users quickly build customized NLP pipelines for their individual applications. Our evaluation shows that the CLAMP default pipeline achieved good performance on named entity recognition and concept encoding. We also demonstrate the efficiency of the CLAMP graphic user interface in building customized, high-performance NLP pipelines with 2 use cases, extracting smoking status and lab test values. CLAMP is publicly available for research use, and we believe it is a unique asset for the clinical NLP community. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Building Capacity for Data-Driven Decision Making in African HIV Testing Programs: Field Perspectives on Data Use Workshops.

Science.gov (United States)

Courtenay-Quirk, Cari; Spindler, Hilary; Leidich, Aimee; Bachanas, Pam

2016-12-01

Strategic, high quality HIV testing services (HTS) delivery is an essential step towards reaching the end of AIDS by 2030. We conducted HTS Data Use workshops in five African countries to increase data use for strategic program decision-making. Feedback was collected on the extent to which workshop skills and tools were applied in practice and to identify future capacity-building needs. We later conducted six semistructured phone interviews with workshop planning teams and sent a web-based survey to 92 past participants. The HTS Data Use workshops provided accessible tools that were readily learned by most respondents. While most respondents reported increased confidence in interpreting data and frequency of using such tools over time, planning team representatives indicated ongoing needs for more automated tools that can function across data systems. To achieve ambitious global HIV/AIDS targets, national decision makers may continue to seek tools and skill-building opportunities to monitor programs and identify opportunities to refine strategies.

Preferred information sources for clinical decision making: critical care nurses' perceptions of information accessibility and usefulness.

Science.gov (United States)

Marshall, Andrea P; West, Sandra H; Aitken, Leanne M

2011-12-01

Variability in clinical practice may result from the use of diverse information sources to guide clinical decisions. In routine clinical practice, nurses privilege information from colleagues over more formal information sources. It is not clear whether similar information-seeking behaviour is exhibited when critical care nurses make decisions about a specific clinical practice, where extensive practice variability exists alongside a developing research base. This study explored the preferred sources of information intensive care nurses used and their perceptions of the accessibility and usefulness of this information for making decisions in clinically uncertain situations specific to enteral feeding practice. An instrumental case study design, incorporating concurrent verbal protocols, Q methodology and focus groups, was used to determine intensive care nurses' perspectives of information use in the resolution of clinical uncertainty. A preference for information from colleagues to support clinical decisions was observed. People as information sources were considered most useful and most accessible in the clinical setting. Text and electronic information sources were seen as less accessible, mainly because of the time required to access the information within the documents. When faced with clinical uncertainty, obtaining information from colleagues allows information to be quickly accessed and applied within the context of a specific clinical presentation. Seeking information from others also provides opportunities for shared decision-making and potential validation of clinical judgment, although differing views may exacerbate clinical uncertainty. The social exchange of clinical information may meet the needs of nurses working in a complex, time-pressured environment but the extent of the evidence base for information passed through verbal communication is unclear. The perceived usefulness and accessibility of information is premised on the ease of use and access

Deepening the quality of clinical reasoning and decision-making in rural hospital nursing practice.

Science.gov (United States)

Sedgwick, M G; Grigg, L; Dersch, S

2014-01-01

Rural acute care nursing requires an extensive breadth and depth of knowledge as well as the ability to quickly reason through problems in order to make sound clinical decisions. This reasoning often occurs within an environment that has minimal medical or ancillary support. Registered nurses (RN) new to rural nursing, and employers, have raised concerns about patient safety while new nurses make the transition into rural practice. In addition, feeling unprepared for the rigors of rural hospital nursing practice is a central issue influencing RN recruitment and retention. Understanding how rural RNs reason is a key element for identifying professional development needs and may support recruitment and retention of skilled rural nurses. The purpose of this study was to explore how rural RNs reason through clinical problems as well as to assess the quality of such reasoning. This study used a non-traditional approach for data collection. Fifteen rural acute care nurses with varying years of experience working in southern Alberta, Canada, were observed while they provided care to patients of varying acuity within a simulated rural setting. Following the simulation, semi-structured interviews were conducted using a substantive approach to critical thinking. Findings revealed that the ability to engage in deep clinical reasoning varied considerably among participants despite being given the same information under the same circumstances. Furthermore, the number of years of experience did not seem to be directly linked to the ability to engage in sound clinical reasoning. Novice nurses, however, did rely heavily on others in their decision making in order to ensure they were making the right decision. Hence, their relationships with other staff members influenced their ability to engage in clinical reasoning and decision making. In situations where the patient's condition was deteriorating quickly, regardless of years of experience, all of the participants depended on

Building a learning health system using clinical registers: a non-technical introduction.

Science.gov (United States)

Ovretveit, John; Nelson, Eugene; James, Brent

2016-10-10

Purpose The purpose of this paper is to describe how clinical registers were designed and used to serve multiple purposes in three health systems, in order to contribute practical experience for building learning healthcare systems. Design/methodology/approach Case description and comparison of the development and use of clinical registries, drawing on participants' experience and published and unpublished research. Findings Clinical registers and new software systems enable fact-based decisions by patients, clinicians, and managers about better care, as well as new and more economical research. Designing systems to present the data for users' daily work appears to be the key to effective use of the potential afforded by digital data. Research limitations/implications The case descriptions draw on the experience of the authors who were involved in the development of the registers, as well as on published and unpublished research. There is limited data about outcomes for patients or cost-effectiveness. Practical implications The cases show the significant investments which are needed to make effective use of clinical register data. There are limited skills to design and apply the digital systems to make the best use of the systems and to reduce their disadvantages. More use can be made of digital data for quality improvement, patient empowerment and support, and for research. Social implications Patients can use their data combined with other data to self-manage their chronic conditions. There are challenges in designing and using systems so that those with lower health and computer literacy and incomes also benefit from these systems, otherwise the digital revolution may increase health inequalities. Originality/value The paper shows three real examples of clinical registers which have been developed as part of their host health systems' strategies to develop learning healthcare systems. The paper gives a simple non-technical introduction and overview for

The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions.

Science.gov (United States)

Hirsh, Adam T; Hollingshead, Nicole A; Ashburn-Nardo, Leslie; Kroenke, Kurt

2015-06-01

Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty-nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and nonopioid analgesics) decisions for 12 virtual patients with acute pain. Race (black/white) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers' decisions, such that decisions varied as a function of ambiguity for white but not for black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however, providers' implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between white and black patients are, in part, attributable to the nature (ie, ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors. This study examined the unique and collective influence of patient race, provider racial bias, and clinical ambiguity on providers' pain management decisions. These results could inform the development of interventions aimed at reducing disparities and improving pain care. Copyright © 2015 American Pain Society. Published by Elsevier Inc. All rights reserved.

Variation in clinical decision-making for induction of labour: a qualitative study.

Science.gov (United States)

Nippita, Tanya A; Porter, Maree; Seeho, Sean K; Morris, Jonathan M; Roberts, Christine L

2017-09-22

Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals. We undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes. Forty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician's perception of medical risk in the pregnancy (influenced by the obstetrician's personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a 'gatekeeper' in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates. Improved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.

A pilot study of distributed knowledge management and clinical decision support in the cloud.

Science.gov (United States)

Dixon, Brian E; Simonaitis, Linas; Goldberg, Howard S; Paterno, Marilyn D; Schaeffer, Molly; Hongsermeier, Tonya; Wright, Adam; Middleton, Blackford

2013-09-01

Implement and perform pilot testing of web-based clinical decision support services using a novel framework for creating and managing clinical knowledge in a distributed fashion using the cloud. The pilot sought to (1) develop and test connectivity to an external clinical decision support (CDS) service, (2) assess the exchange of data to and knowledge from the external CDS service, and (3) capture lessons to guide expansion to more practice sites and users. The Clinical Decision Support Consortium created a repository of shared CDS knowledge for managing hypertension, diabetes, and coronary artery disease in a community cloud hosted by Partners HealthCare. A limited data set for primary care patients at a separate health system was securely transmitted to a CDS rules engine hosted in the cloud. Preventive care reminders triggered by the limited data set were returned for display to clinician end users for review and display. During a pilot study, we (1) monitored connectivity and system performance, (2) studied the exchange of data and decision support reminders between the two health systems, and (3) captured lessons. During the six month pilot study, there were 1339 patient encounters in which information was successfully exchanged. Preventive care reminders were displayed during 57% of patient visits, most often reminding physicians to monitor blood pressure for hypertensive patients (29%) and order eye exams for patients with diabetes (28%). Lessons learned were grouped into five themes: performance, governance, semantic interoperability, ongoing adjustments, and usability. Remote, asynchronous cloud-based decision support performed reasonably well, although issues concerning governance, semantic interoperability, and usability remain key challenges for successful adoption and use of cloud-based CDS that will require collaboration between biomedical informatics and computer science disciplines. Decision support in the cloud is feasible and may be a reasonable

mHealth for Clinical Decision-Making in Sub-Saharan Africa : A Scoping Review

NARCIS (Netherlands)

Adepoju, Ibukun-Oluwa Omolade; Albersen, Bregje Joanna Antonia; De Brouwere, Vincent; van Roosmalen, Jos; Zweekhorst, M.B.M.

2017-01-01

BACKGROUND: In a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for

Exploring the use of Option Grid™ patient decision aids in a sample of clinics in Poland.

Science.gov (United States)

Scalia, Peter; Elwyn, Glyn; Barr, Paul; Song, Julia; Zisman-Ilani, Yaara; Lesniak, Monika; Mullin, Sarah; Kurek, Krzysztof; Bushell, Matt; Durand, Marie-Anne

2018-05-29

Research on the implementation of patient decision aids to facilitate shared decision making in clinical settings has steadily increased across Western countries. A study which implements decision aids and measures their impact on shared decision making has yet to be conducted in the Eastern part of Europe. To study the use of Option Grid TM patient decision aids in a sample of Grupa LUX MED clinics in Warsaw, Poland, and measure their impact on shared decision making. We conducted a pre-post interventional study. Following a three-month period of usual care, clinicians from three Grupa LUX MED clinics received a one-hour training session on how to use three Option Grid TM decision aids and were provided with copies for use for four months. Throughout the study, all eligible patients were asked to complete the three-item CollaboRATE patient-reported measure of shared decision making after their clinical encounter. CollaboRATE enables patients to assess the efforts clinicians make to: (i) inform them about their health issues; (ii) listen to 'what matters most'; (iii) integrate their treatment preference in future plans. A Hierarchical Logistic Regression model was performed to understand which variables had an effect on CollaboRATE. 2,048 patients participated in the baseline phase; 1,889 patients participated in the intervention phase. Five of the thirteen study clinicians had a statistically significant increase in their CollaboRATE scores (pOption Grid TM helped some clinicians practice shared decision making as reflected in CollaboRATE scores, but most clinicians did not have a significant increase in their scores. Our study indicates that the effect of these interventions may be dependent on clinic contexts and clinician engagement. Copyright © 2018. Published by Elsevier GmbH.

Enhancing decision making about participation in cancer clinical trials: development of a question prompt list

Science.gov (United States)

Brown, Richard F.; Shuk, Elyse; Leighl, Natasha; Butow, Phyllis; Ostroff, Jamie; Edgerson, Shawna; Tattersall, Martin

2016-01-01

Purpose Slow accrual to cancer clinical trials impedes the progress of effective new cancer treatments. Poor physician–patient communication has been identified as a key contributor to low trial accrual. Question prompt lists (QPLs) have demonstrated a significant promise in facilitating communication in general, surgical, and palliative oncology settings. These simple patient interventions have not been tested in the oncology clinical trial setting. We aimed to develop a targeted QPL for clinical trials (QPL-CT). Method Lung, breast, and prostate cancer patients who either had (trial experienced) or had not (trial naive) participated in a clinical trial were invited to join focus groups to help develop and explore the acceptability of a QPL-CT. Focus groups were audio-recorded and transcribed. A research team, including a qualitative data expert, analyzed these data to explore patients’ decision-making processes and views about the utility of the QPL-CT prompt to aid in trial decision making. Results Decision making was influenced by the outcome of patients’ comparative assessment of perceived risks versus benefits of a trial, and the level of trust patients had in their doctors’ recommendation about the trial. Severity of a patient’s disease influenced trial decision making only for trial-naive patients. Conclusion Although patients were likely to prefer a paternalistic decision-making style, they expressed valuation of the QPL as an aid to decision making. QPL-CT utility extended beyond the actual consultation to include roles both before and after the clinical trial discussion. PMID:20593202

A method for optimizing the performance of buildings

DEFF Research Database (Denmark)

Pedersen, Frank

2007-01-01

needed for solving the optimization problem. Furthermore, the algorithm uses so-called domain constraint functions in order to ensure that the input to the simulation software is feasible. Using this technique avoids performing time-consuming simulations for unrealistic design decisions. The algorithm......This thesis describes a method for optimizing the performance of buildings. Design decisions made in early stages of the building design process have a significant impact on the performance of buildings, for instance, the performance with respect to the energy consumption, economical aspects......, and the indoor environment. The method is intended for supporting design decisions for buildings, by combining methods for calculating the performance of buildings with numerical optimization methods. The method is able to find optimum values of decision variables representing different features of the building...

Earthquake Vulnerability Assessment for Hospital Buildings Using a Gis-Based Group Multi Criteria Decision Making Approach: a Case Study of Tehran, Iran

Science.gov (United States)

Delavar, M. R.; Moradi, M.; Moshiri, B.

2015-12-01

Nowadays, urban areas are threatened by a number of natural hazards such as flood, landslide and earthquake. They can cause huge damages to buildings and human beings which necessitates disaster mitigation and preparation. One of the most important steps in disaster management is to understand all impacts and effects of disaster on urban facilities. Given that hospitals take care of vulnerable people reaction of hospital buildings against earthquake is vital. In this research, the vulnerability of hospital buildings against earthquake is analysed. The vulnerability of buildings is related to a number of criteria including age of building, number of floors, the quality of materials and intensity of the earthquake. Therefore, the problem of seismic vulnerability assessment is a multi-criteria assessment problem and multi criteria decision making methods can be used to address the problem. In this paper a group multi criteria decision making model is applied because using only one expert's judgments can cause biased vulnerability maps. Sugeno integral which is able to take into account the interaction among criteria is employed to assess the vulnerability degree of buildings. Fuzzy capacities which are similar to layer weights in weighted linear averaging operator are calculated using particle swarm optimization. Then, calculated fuzzy capacities are included into the model to compute a vulnerability degree for each hospital.

EARTHQUAKE VULNERABILITY ASSESSMENT FOR HOSPITAL BUILDINGS USING A GIS-BASED GROUP MULTI CRITERIA DECISION MAKING APPROACH: A CASE STUDY OF TEHRAN, IRAN

Directory of Open Access Journals (Sweden)

M. R. Delavar

2015-12-01

Full Text Available Nowadays, urban areas are threatened by a number of natural hazards such as flood, landslide and earthquake. They can cause huge damages to buildings and human beings which necessitates disaster mitigation and preparation. One of the most important steps in disaster management is to understand all impacts and effects of disaster on urban facilities. Given that hospitals take care of vulnerable people reaction of hospital buildings against earthquake is vital. In this research, the vulnerability of hospital buildings against earthquake is analysed. The vulnerability of buildings is related to a number of criteria including age of building, number of floors, the quality of materials and intensity of the earthquake. Therefore, the problem of seismic vulnerability assessment is a multi-criteria assessment problem and multi criteria decision making methods can be used to address the problem. In this paper a group multi criteria decision making model is applied because using only one expert’s judgments can cause biased vulnerability maps. Sugeno integral which is able to take into account the interaction among criteria is employed to assess the vulnerability degree of buildings. Fuzzy capacities which are similar to layer weights in weighted linear averaging operator are calculated using particle swarm optimization. Then, calculated fuzzy capacities are included into the model to compute a vulnerability degree for each hospital.

Decaying relevance of clinical data towards future decisions in data-driven inpatient clinical order sets.

Science.gov (United States)

Chen, Jonathan H; Alagappan, Muthuraman; Goldstein, Mary K; Asch, Steven M; Altman, Russ B

2017-06-01

Determine how varying longitudinal historical training data can impact prediction of future clinical decisions. Estimate the "decay rate" of clinical data source relevance. We trained a clinical order recommender system, analogous to Netflix or Amazon's "Customers who bought A also bought B..." product recommenders, based on a tertiary academic hospital's structured electronic health record data. We used this system to predict future (2013) admission orders based on different subsets of historical training data (2009 through 2012), relative to existing human-authored order sets. Predicting future (2013) inpatient orders is more accurate with models trained on just one month of recent (2012) data than with 12 months of older (2009) data (ROC AUC 0.91 vs. 0.88, precision 27% vs. 22%, recall 52% vs. 43%, all P<10 -10 ). Algorithmically learned models from even the older (2009) data was still more effective than existing human-authored order sets (ROC AUC 0.81, precision 16% recall 35%). Training with more longitudinal data (2009-2012) was no better than using only the most recent (2012) data, unless applying a decaying weighting scheme with a "half-life" of data relevance about 4 months. Clinical practice patterns (automatically) learned from electronic health record data can vary substantially across years. Gold standards for clinical decision support are elusive moving targets, reinforcing the need for automated methods that can adapt to evolving information. Prioritizing small amounts of recent data is more effective than using larger amounts of older data towards future clinical predictions. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Towards patient-centered colorectal cancer surgery : focus on risks, decisions and clinical auditing

NARCIS (Netherlands)

Snijders, Heleen Simone

2014-01-01

The aim of this thesis was to explore several aspects of both clinical decision making and quality assessment in colorectal cancer surgery. Part one focusses on benefits and risks of treatment options, preoperative information provision and Shared Decision Making (SDM); part two investigates changes

Pregnancy outcomes in Ghana : Relavance of clinical decision making support tools for frontline providers of care

NARCIS (Netherlands)

Amoakoh-Coleman, M.

2016-01-01

Ghana’s slow progress towards attaining millennium development goal 5 has been associated with gaps in quality of care, particularly quality of clinical decision making for clients. This thesis reviews the relevance and effect of clinical decision making support tools on pregnancy

Clinical decision making and mental health service use in people with severe mental illness across Europe

OpenAIRE

Cosh, S.; Zentner, N.; Ay, E.; Loos, S.; Slade, Mike; Maj, Mario; Salzano, A.; Berecz, R.; Glaub, T.; Munk-Jørgensen, Povl; Krogsgaard Bording, M.; Rössler, Wulf; Kawohl, Wolfram; Puschner, Bernd

2017-01-01

Objective: This study aims to explore relationships between preferred and experienced clinical decision making with service use, and associated costs, by people with severe mental illness.\\ud Methods: Prospective observational study of mental healthcare in six European countries: Germany, UK, Italy Hungary, Denmark and Switzerland. Patients (N = 588) and treating clinicians (N = 213) reported preferred and experienced decision making at baseline using the Clinical Decision Making Style Scale ...

Impact of a Clinical Decision Support System on Pharmacy Clinical Interventions, Documentation Efforts, and Costs

OpenAIRE

Calloway, Stacy; Akilo, Hameed A.; Bierman, Kyle

2013-01-01

Health care organizations are turning to electronic clinical decision support systems (CDSSs) to increase quality of patient care and promote a safer environment. A CDSS is a promising approach to the aggregation and use of patient data to identify patients who would most benefit from interventions by pharmacy clinicians. However, there are limited published reports describing the impact of CDSS on clinical pharmacy measures. In February 2011, Good Shepherd Medical Center, a 425-bed acute car...

Shared decision making in mental health: the importance for current clinical practice.

Science.gov (United States)

Alguera-Lara, Victoria; Dowsey, Michelle M; Ride, Jemimah; Kinder, Skye; Castle, David

2017-12-01

We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice. Narrative review of published English-language articles. After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications. Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.

Asheville, North Carolina: Reducing Electricity Demand through Building Programs & Policies (City Energy: From Data to Decisions)

Energy Technology Data Exchange (ETDEWEB)

Office of Strategic Programs, Strategic Priorities and Impact Analysis Team

2017-09-29

This fact sheet "Asheville, North Carolina: Reducing Electricity Demand through Building Programs & Policies" explains how the City of Asheville used data from the U.S. Department of Energy's Cities Leading through Energy Analysis and Planning (Cities-LEAP) and the State and Local Energy Data (SLED) programs to inform its city energy planning. It is one of ten fact sheets in the "City Energy: From Data to Decisions" series.

Carrboro, North Carolina: Achieving Building Efficiencies for Low-Income Households (City Energy: From Data to Decisions)

Energy Technology Data Exchange (ETDEWEB)

Office of Strategic Programs, Strategic Priorities and Impact Analysis Team

2017-09-29

This fact sheet "Carrboro, North Carolina: Achieving Building Efficiencies for Low-Income Households" explains how the Town of Carrboro used data from the U.S. Department of Energy's Cities Leading through Energy Analysis and Planning (Cities-LEAP) and the State and Local Energy Data (SLED) programs to inform its city energy planning. It is one of ten fact sheets in the "City Energy: From Data to Decisions" series.

Guideline Formalization and Knowledge Representation for Clinical Decision Support

Directory of Open Access Journals (Sweden)

Tiago OLIVEIRA

2012-09-01

Full Text Available Normal 0 21 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Tabla normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin:0cm; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-ansi-language:EN-US;} The prevalence of situations of medical error and defensive medicine in healthcare institutions is a great concern of the medical community. Clinical Practice Guidelines are regarded by most researchers as a way to mitigate theseoccurrences; however, there is a need to make them interactive, easier to update and to deploy. This paper provides a model for Computer-Interpretable Guidelines based on the generic tasks of the clinical process, devised to be included in the framework of a Clinical Decision Support System. Aiming to represent medical recommendations in a simple and intuitive way. Hence, this work proposes a knowledge representation formalism that uses an Extension to Logic Programming to handle incomplete information. This model is used to represent different cases of missing, conflicting and inexact information with the aid of a method to quantify its quality. The integration of the guideline model with the knowledge representation formalism yields a clinical decision model that relies on the development of multiple information scenarios and the exploration of different clinical hypotheses.

Guideline Formalization and Knowledge Representation for Clinical Decision Support

Directory of Open Access Journals (Sweden)

Paulo NOVAIS

2013-07-01

Full Text Available Normal 0 21 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Tabla normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin:0cm; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-ansi-language:EN-US;} The prevalence of situations of medical error and defensive medicine in healthcare institutions is a great concern of the medical community. Clinical Practice Guidelines are regarded by most researchers as a way to mitigate these occurrences; however, there is a need to make them interactive, easier to update and to deploy. This paper provides a model for Computer-Interpretable Guidelines based on the generic tasks of the clinical process, devised to be included in the framework of a Clinical Decision Support System. Aiming to represent medical recommendations in a simple and intuitive way. Hence, this work proposes a knowledge representation formalism that uses an Extension to Logic Programming to handle incomplete information. This model is used to represent different cases of missing, conflicting and inexact information with the aid of a method to quantify its quality. The integration of the guideline model with the knowledge representation formalism yields a clinical decision model that relies on the development of multiple information scenarios and the exploration of different clinical hypotheses.

Decision Making in the PICU: An Examination of Factors Influencing Participation Decisions in Phase III Randomized Clinical Trials

Science.gov (United States)

Slosky, Laura E.; Burke, Natasha L.; Siminoff, Laura A.

2014-01-01

Background. In stressful situations, decision making processes related to informed consent may be compromised. Given the profound levels of distress that surrogates of children in pediatric intensive care units (PICU) experience, it is important to understand what factors may be influencing the decision making process beyond the informed consent. The purpose of this study was to evaluate the role of clinician influence and other factors on decision making regarding participation in a randomized clinical trial (RCT). Method. Participants were 76 children under sedation in a PICU and their surrogate decision makers. Measures included the Post Decision Clinician Survey, observer checklist, and post-decision interview. Results. Age of the pediatric patient was related to participation decisions in the RCT such that older children were more likely to be enrolled. Mentioning the sponsoring institution was associated with declining to participate in the RCT. Type of health care provider and overt recommendations to participate were not related to enrollment. Conclusion. Decisions to participate in research by surrogates of children in the PICU appear to relate to child demographics and subtleties in communication; however, no modifiable characteristics were related to increased participation, indicating that the informed consent process may not be compromised in this population. PMID:25161672

Evaluating a Clinical Decision Support Interface for End-of-Life Nurse Care.

Science.gov (United States)

Febretti, Alessandro; Stifter, Janet; Keenan, Gail M; Lopez, Karen D; Johnson, Andrew; Wilkie, Diana J

2014-01-01

Clinical Decision Support Systems (CDSS) are tools that assist healthcare personnel in the decision-making process for patient care. Although CDSSs have been successfully deployed in the clinical setting to assist physicians, few CDSS have been targeted at professional nurses, the largest group of health providers. We present our experience in designing and testing a CDSS interface embedded within a nurse care planning and documentation tool. We developed four prototypes based on different CDSS feature designs, and tested them in simulated end-of-life patient handoff sessions with a group of 40 nurse clinicians. We show how our prototypes directed nurses towards an optimal care decision that was rarely performed in unassisted practice. We also discuss the effect of CDSS layout and interface navigation in a nurse's acceptance of suggested actions. These findings provide insights into effective nursing CDSS design that are generalizable to care scenarios different than end-of-life.

The Need for Clinical Decision Support Integrated with the Electronic Health Record for the Clinical Application of Whole Genome Sequencing Information

Directory of Open Access Journals (Sweden)

Brandon M. Welch

2013-12-01

Full Text Available Whole genome sequencing (WGS is rapidly approaching widespread clinical application. Technology advancements over the past decade, since the first human genome was decoded, have made it feasible to use WGS for clinical care. Future advancements will likely drive down the price to the point wherein WGS is routinely available for care. However, were this to happen today, most of the genetic information available to guide clinical care would go unused due to the complexity of genetics, limited physician proficiency in genetics, and lack of genetics professionals in the clinical workforce. Furthermore, these limitations are unlikely to change in the future. As such, the use of clinical decision support (CDS to guide genome-guided clinical decision-making is imperative. In this manuscript, we describe the barriers to widespread clinical application of WGS information, describe how CDS can be an important tool for overcoming these barriers, and provide clinical examples of how genome-enabled CDS can be used in the clinical setting.

Partnering Community Decision Makers with Early Career Scientists - The NASA DEVELOP Method for Dual Capacity Building

Science.gov (United States)

Ross, K. W.; Childs-Gleason, L. M.; Cripps, G. S.; Clayton, A.; Remillard, C.; Watkins, L. E.; Allsbrook, K. N.; Rogers, L.; Ruiz, M. L.

2017-12-01

The NASA DEVELOP National Program carries out many projects every year with the goal of bringing the benefits of NASA Earth science to bear on decision-making challenges that are local in scale. Every DEVELOP project partners end users with early/transitioning science professionals. Many of these projects invited communities to consider NASA science data in new ways to help them make informed decisions. All of these projects shared three characteristics: they were rapid, nimble and risk-taking. These projects work well for some communities, but might best be suited as a feasibility studies that build community/institutional capacity towards eventual solutions. This presentation will discuss DEVELOP's lessons learned and best practices in conducting short-term feasibility projects with communities, as well as highlight several past successes.

Incorporating uncertainty regarding applicability of evidence from meta-analyses into clinical decision making.

Science.gov (United States)

Kriston, Levente; Meister, Ramona

2014-03-01

Judging applicability (relevance) of meta-analytical findings to particular clinical decision-making situations remains challenging. We aimed to describe an evidence synthesis method that accounts for possible uncertainty regarding applicability of the evidence. We conceptualized uncertainty regarding applicability of the meta-analytical estimates to a decision-making situation as the result of uncertainty regarding applicability of the findings of the trials that were included in the meta-analysis. This trial-level applicability uncertainty can be directly assessed by the decision maker and allows for the definition of trial inclusion probabilities, which can be used to perform a probabilistic meta-analysis with unequal probability resampling of trials (adaptive meta-analysis). A case study with several fictitious decision-making scenarios was performed to demonstrate the method in practice. We present options to elicit trial inclusion probabilities and perform the calculations. The result of an adaptive meta-analysis is a frequency distribution of the estimated parameters from traditional meta-analysis that provides individually tailored information according to the specific needs and uncertainty of the decision maker. The proposed method offers a direct and formalized combination of research evidence with individual clinical expertise and may aid clinicians in specific decision-making situations. Copyright © 2014 Elsevier Inc. All rights reserved.

Clinical decision support systems in child and adolescent psychiatry: a systematic review.

Science.gov (United States)

Koposov, Roman; Fossum, Sturla; Frodl, Thomas; Nytrø, Øystein; Leventhal, Bennett; Sourander, Andre; Quaglini, Silvana; Molteni, Massimo; de la Iglesia Vayá, María; Prokosch, Hans-Ulrich; Barbarini, Nicola; Milham, Michael Peter; Castellanos, Francisco Xavier; Skokauskas, Norbert

2017-11-01

Psychiatric disorders are amongst the most prevalent and impairing conditions in childhood and adolescence. Unfortunately, it is well known that general practitioners (GPs) and other frontline health providers (i.e., child protection workers, public health nurses, and pediatricians) are not adequately trained to address these ubiquitous problems (Braddick et al. Child and Adolescent mental health in Europe: infrastructures, policy and programmes, European Communities, 2009; Levav et al. Eur Child Adolesc Psychiatry 13:395-401, 2004). Advances in technology may offer a solution to this problem with clinical decision support systems (CDSS) that are designed to help professionals make sound clinical decisions in real time. This paper offers a systematic review of currently available CDSS for child and adolescent mental health disorders prepared according to the PRISMA-Protocols (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols). Applying strict eligibility criteria, the identified studies (n = 5048) were screened. Ten studies, describing eight original clinical decision support systems for child and adolescent psychiatric disorders, fulfilled inclusion criteria. Based on this systematic review, there appears to be a need for a new, readily available CDSS for child neuropsychiatric disorder which promotes evidence-based, best practices, while enabling consideration of national variation in practices by leveraging data-reuse to generate predictions regarding treatment outcome, addressing a broader cluster of clinical disorders, and targeting frontline practice environments.

Changes in patient satisfaction related to hospital renovation: experience with a new clinical building.

Science.gov (United States)

Siddiqui, Zishan K; Zuccarelli, Rebecca; Durkin, Nowella; Wu, Albert W; Brotman, Daniel J

2015-03-01

There is an increasing trend toward designing hospitals with patient-centered features like reduced noise, improved natural light, visitor friendly facilities, well-decorated rooms, and hotel-like amenities. It has also been suggested that because patients cannot reliably distinguish positive experiences with the physical environment from positive experience with care, an improved hospital environment leads to higher satisfaction with physicians, nursing, food service, housekeeping, and higher overall satisfaction. To characterize changes in patient satisfaction that occurred when clinical services (comprised of stable nursing, physician, and unit teams) were relocated to a new clinical building with patient-centered features. We hypothesized that new building features would positively impact provider, ancillary staff, and overall satisfaction, as well as improved satisfaction with the facility. Natural experiment utilizing a pre-post design with concurrent controls. Academic tertiary care hospital. We included all patients discharged from 12 clinical units that relocated to the new clinical building who returned surveys in the 7.5-month period following the move. Premove baseline data were captured from the year prior to the move. Patients on unmoved clinical units who returned satisfaction surveys served as concurrent controls. Patient-centered design features incorporated into the new clinical building. All patients during the baseline period and control patients during the study period were located in usual patient rooms with standard hospital amenities. The primary outcome was satisfaction scores on the Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems survey, dichotomized at highest category versus lower categories. We performed logistic regression to identify predictors of "top-box" scores. The move was associated with improved room- and visitor-related satisfaction without significant improvement in satisfaction with clinical

Revisiting the 'Buy versus Build' decision for publicly owned utilities in California considering wind and geothermal resources; TOPICAL

International Nuclear Information System (INIS)

Bolinger, Mark; Wiser, Ryan; Golove, William

2001-01-01

The last two decades have seen a dramatic increase in the market share of independent, non-utility generators (NUGs) relative to traditional, utility-owned generation assets. Accordingly, the ''buy versus build'' decision facing utilities--i.e., whether a utility should sign a power purchase agreement (PPA) with a NUG, or develop and own the generation capacity itself-has gained prominence in the industry. Specific debates have revolved around the relative advantages of, the types of risk created by, and the regulatory incentives favoring each approach. Very little of this discussion has focused specifically on publicly owned electric utilities, however, perhaps due to the belief that public power's tax-free financing status leaves little space in which NUGs can compete. With few exceptions (Wiser and Kahn 1996), renewable sources of supply have received similarly scant attention in the buy versus build debate. In this report, we revive the ''buy versus build'' debate and apply it to the two sectors of the industry traditionally underrepresented in the discussion: publicly owned utilities and renewable energy. Contrary to historical treatment, this debate is quite relevant to public utilities and renewables because publicly owned utilities are able to take advantage of some renewable energy incentives only in a ''buy'' situation, while others accrue only in a ''build'' situation. In particular, possible economic advantages of public utility ownership include: (1) the tax-free status of publicly owned utilities and the availability of low-cost debt, and (2) the renewable energy production incentive (REPI) available only to publicly owned utilities. Possible economic advantages to entering into a PPA with a NUG include: (1) the availability of federal tax credits and accelerated depreciation schedules for certain forms of NUG-owned renewable energy, and (2) the California state production incentives available to NUGs but not utilities. This report looks at a publicly

How to Reach Decision Makers: Build a network of educators and practitioners with common goals

Science.gov (United States)

Boudrias, M. A.; Estrada, M.; Anders, S.; Silva-Send, N. J.; Gershunov, A.

2013-12-01

In San Diego County, the Climate Education Partners (CEP) includes climate scientists, science educators, behavioral scientists, environmental practitioners and community organizations that are dedicated to providing local decision makers (elected officials, business leaders, community leaders) with sound climate science learning opportunities and resources that promote informed decision making. Their work over the past three years has found that effective climate education programs are designed for specific audiences with tailored information that is relevant to them, while simultaneously building community efficacy, identity and values. An integrated approach that blends rigorous scientific facts, local climate change impact, and social science education theory is contributing towards the development of a cadre of engaged leaders and communities. To track project progress and to inform the project strategy, local Key Influentials are being interviewed to gauge their current understanding of climate change and their interest in either becoming messengers to their community or becoming the portal to their constituency. Innovation comes from productive collaboration. For this reason, CEP has been working with leading scientists (climatologists, hydrologists, meteorologists, ecologists), environmental groups, museums and zoos, media experts and government agencies (Water Authority, CalFire) to develop and refine a program of learning activities and resources geared specifically for Key Influentials. For example, a water tour has been designed to bring 25 key influential leaders in San Diego County to a dam, a pumping station and a reservoir and provide climate change facts, impacts and potential solutions to the critical issue of water supply for the San Diego Region. While learning local facts about the causes and impacts of climate change, participants also learn about what they can do (increasing efficacy), that they can be a part of a solution centered community

Applying Probabilistic Decision Models to Clinical Trial Design

Science.gov (United States)

Smith, Wade P; Phillips, Mark H

2018-01-01

Clinical trial design most often focuses on a single or several related outcomes with corresponding calculations of statistical power. We consider a clinical trial to be a decision problem, often with competing outcomes. Using a current controversy in the treatment of HPV-positive head and neck cancer, we apply several different probabilistic methods to help define the range of outcomes given different possible trial designs. Our model incorporates the uncertainties in the disease process and treatment response and the inhomogeneities in the patient population. Instead of expected utility, we have used a Markov model to calculate quality adjusted life expectancy as a maximization objective. Monte Carlo simulations over realistic ranges of parameters are used to explore different trial scenarios given the possible ranges of parameters. This modeling approach can be used to better inform the initial trial design so that it will more likely achieve clinical relevance.

Clinical decision support system for early detection of prostate cancer from benign hyperplasia of prostate.

Science.gov (United States)

Ghaderzadeh, Mustafa

2013-01-01

There has been a growing research interest in the use of intelligent methods in medical informatics studies. Intelligent computer programs were implemented to aid physicians and other medical professionals in making difficult medical decisions. Prostate Neoplasia problems including benign hyperplasia and cancer of prostate are very common and cause significant delay in recovery and often require costly investigations before coming to its diagnosis. The conventional approach to build medical diagnostic system requires the formulation of rules by which the input data can be analyzed. But the formulation of such rules is very difficult with large sets of input data. Realizing the difficulty, a number of quantitative mathematical and statistical models including pattern classification technique such as Artificial neural networks (ANN), rolled based system, discriminate analysis and regression analysis has been applied as an alternative to conventional clinical and medical diagnostic. Among the mathematical and statistical modeling techniques used in medical decision support, Artificial neural networks attract many attentions in recent studies and in the last decade, the use of neural networks has become widely accepted in medical applications. This is manifested by an increasing number of medical devices currently available on the market with embedded AI algorithms, together with an accelerating pace of publication in medical journals, with over 500 academic publications year featuring Artificial Neural Networks (ANNs).

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study.

Science.gov (United States)

Harris, Ricci; Cormack, Donna; Stanley, James; Curtis, Elana; Jones, Rhys; Lacey, Cameron

2018-01-23

Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses. NZ medical students demonstrated ethnic bias, although

Development of a clinical decision support system for diabetes care: A pilot study.

Directory of Open Access Journals (Sweden)

Livvi Li Wei Sim

Full Text Available Management of complex chronic diseases such as diabetes requires the assimilation and interpretation of multiple laboratory test results. Traditional electronic health records tend to display laboratory results in a piecemeal and segregated fashion. This makes the assembly and interpretation of results related to diabetes care challenging. We developed a diabetes-specific clinical decision support system (Diabetes Dashboard interface for displaying glycemic, lipid and renal function results, in an integrated form with decision support capabilities, based on local clinical practice guidelines. The clinical decision support system included a dashboard feature that graphically summarized all relevant laboratory results and displayed them in a color-coded system that allowed quick interpretation of the metabolic control of the patients. An alert module informs the user of tests that are due for repeat testing. An interactive graph module was also developed for better visual appreciation of the trends of the laboratory results of the patient. In a pilot study involving case scenarios administered via an electronic questionnaire, the Diabetes Dashboard, compared to the existing laboratory reporting interface, significantly improved the identification of abnormal laboratory results, of the long-term trend of the laboratory tests and of tests due for repeat testing. However, the Diabetes Dashboard did not significantly improve the identification of patients requiring treatment adjustment or the amount of time spent on each case scenario. In conclusion, we have developed and shown that the use of the Diabetes Dashboard, which incorporates several decision support features, can improve the management of diabetes. It is anticipated that this dashboard will be most helpful when deployed in an outpatient setting, where physicians can quickly make clinical decisions based on summarized information and be alerted to pertinent areas of care that require

A method of building of decision trees based on data from wearable device during a rehabilitation of patients with tibia fractures

International Nuclear Information System (INIS)

Kupriyanov, M. S.; Shukeilo, E. Y.; Shichkina, J. A.

2015-01-01

Nowadays technologies which are used in traumatology are a combination of mechanical, electronic, calculating and programming tools. Relevance of development of mobile applications for an expeditious data processing which are received from medical devices (in particular, wearable devices), and formulation of management decisions increases. Using of a mathematical method of building of decision trees for an assessment of a patient’s health condition using data from a wearable device considers in this article

A method of building of decision trees based on data from wearable device during a rehabilitation of patients with tibia fractures

Science.gov (United States)

Kupriyanov, M. S.; Shukeilo, E. Y.; Shichkina, J. A.

2015-11-01

Nowadays technologies which are used in traumatology are a combination of mechanical, electronic, calculating and programming tools. Relevance of development of mobile applications for an expeditious data processing which are received from medical devices (in particular, wearable devices), and formulation of management decisions increases. Using of a mathematical method of building of decision trees for an assessment of a patient's health condition using data from a wearable device considers in this article.

A method of building of decision trees based on data from wearable device during a rehabilitation of patients with tibia fractures

Energy Technology Data Exchange (ETDEWEB)

Kupriyanov, M. S., E-mail: mikhail.kupriyanov@gmail.com; Shukeilo, E. Y., E-mail: eyshukeylo@gmail.com; Shichkina, J. A., E-mail: strange.y@mail.ru [Saint Petersburg Electrotechnical University “LETI” (Russian Federation)

2015-11-17

Nowadays technologies which are used in traumatology are a combination of mechanical, electronic, calculating and programming tools. Relevance of development of mobile applications for an expeditious data processing which are received from medical devices (in particular, wearable devices), and formulation of management decisions increases. Using of a mathematical method of building of decision trees for an assessment of a patient’s health condition using data from a wearable device considers in this article.

What is a “good” treatment decision?: Decisional control, knowledge, treatment decision-making, and quality of life in men with clinically localized prostate cancer

Science.gov (United States)

Orom, Heather; Biddle, Caitlin; Underwood, Willie; Nelson, Christian J.; Homish, D. Lynn

2016-01-01

Objective We explored whether active patient involvement in decision making and greater patient knowledge are associated with better treatment decision making experiences and better quality of life (QOL) among men with clinically localized prostate cancer. Localized prostate cancer treatment decision-making is an advantageous model for studying patient treatment decision-making dynamics as there are multiple treatment options and a lack of empirical evidence to recommend one over the other; consequently, it is recommended that patients be fully involved in making the decision. Methods Men with newly diagnosed clinically localized prostate cancer (N=1529) completed measures of decisional control, prostate cancer knowledge, and their decision-making experience (decisional conflict, and decision-making satisfaction and difficulty) shortly after they made their treatment decision. Prostate cancer-specific QOL was assessed 6-months after treatment. Results More active involvement in decision making and greater knowledge were associated with lower decisional conflict and higher decision-making satisfaction, but greater decision-making difficulty. An interaction between decisional control and knowledge revealed that greater knowledge was only associated with greater difficulty for men actively involved in making the decision (67% of sample). Greater knowledge, but not decisional control predicted better QOL 6-months post-treatment. Conclusion Although men who are actively involved in decision making and more knowledgeable may make more informed decisions, they could benefit from decisional support (e.g., decision-making aids, emotional support from providers, strategies for reducing emotional distress) to make the process easier. Men who were more knowledgeable about prostate cancer and treatment side effects at the time they made their treatment decision may have appraised their QOL as higher because they had realistic expectations about side effects. PMID:26957566

Benefit-Risk Analysis for Decision-Making: An Approach.

Science.gov (United States)

Raju, G K; Gurumurthi, K; Domike, R

2016-12-01

The analysis of benefit and risk is an important aspect of decision-making throughout the drug lifecycle. In this work, the use of a benefit-risk analysis approach to support decision-making was explored. The proposed approach builds on the qualitative US Food and Drug Administration (FDA) approach to include a more explicit analysis based on international standards and guidance that enables aggregation and comparison of benefit and risk on a common basis and a lifecycle focus. The approach is demonstrated on six decisions over the lifecycle (e.g., accelerated approval, withdrawal, and traditional approval) using two case studies: natalizumab for multiple sclerosis (MS) and bedaquiline for multidrug-resistant tuberculosis (MDR-TB). © 2016 American Society for Clinical Pharmacology and Therapeutics.

A method for optimizing the performance of buildings

Energy Technology Data Exchange (ETDEWEB)

Pedersen, Frank

2006-07-01

This thesis describes a method for optimizing the performance of buildings. Design decisions made in early stages of the building design process have a significant impact on the performance of buildings, for instance, the performance with respect to the energy consumption, economical aspects, and the indoor environment. The method is intended for supporting design decisions for buildings, by combining methods for calculating the performance of buildings with numerical optimization methods. The method is able to find optimum values of decision variables representing different features of the building, such as its shape, the amount and type of windows used, and the amount of insulation used in the building envelope. The parties who influence design decisions for buildings, such as building owners, building users, architects, consulting engineers, contractors, etc., often have different and to some extent conflicting requirements to buildings. For instance, the building owner may be more concerned about the cost of constructing the building, rather than the quality of the indoor climate, which is more likely to be a concern of the building user. In order to support the different types of requirements made by decision-makers for buildings, an optimization problem is formulated, intended for representing a wide range of design decision problems for buildings. The problem formulation involves so-called performance measures, which can be calculated with simulation software for buildings. For instance, the annual amount of energy required by the building, the cost of constructing the building, and the annual number of hours where overheating occurs, can be used as performance measures. The optimization problem enables the decision-makers to specify many different requirements to the decision variables, as well as to the performance of the building. Performance measures can for instance be required to assume their minimum or maximum value, they can be subjected to upper or

Mapping clinical outcomes expectations to treatment decisions: an application to vestibular schwannoma management.

Science.gov (United States)

Cheung, Steven W; Aranda, Derick; Driscoll, Colin L W; Parsa, Andrew T

2010-02-01

Complex medical decision making obligates tradeoff assessments among treatment outcomes expectations, but an accessible tool to perform the necessary analysis is conspicuously absent. We aimed to demonstrate methodology and feasibility of adapting conjoint analysis for mapping clinical outcomes expectations to treatment decisions in vestibular schwannoma (VS) management. Prospective. Tertiary medical center and US-based otologists/neurotologists. Treatment preference profiles among VS stakeholders-61 younger and 74 older prospective patients, 61 observation patients, and 60 surgeons-were assessed for the synthetic VS case scenario of a 10-mm tumor in association with useful hearing and normal facial function. Treatment attribute utility. Conjoint analysis attribute levels were set in accordance to the results of a meta-analysis. Forty-five case series were disaggregated to formulate microsurgery facial nerve and hearing preservation outcomes expectations models. Attribute utilities were computed and mapped to the realistic treatment choices of translabyrinthine craniotomy, middle fossa craniotomy, and gamma knife radiosurgery. Among the treatment attributes of likelihoods of causing deafness, temporary facial weakness for 2 months, and incurable cancer within 20 years, and recovery time, permanent deafness was less important to tumor surgeons, and temporary facial weakness was more important to tumor surgeons and observation patients (Wilcoxon rank-sum, p knife radiosurgery. Mapping clinical outcomes expectations to treatment decisions for a synthetic clinical scenario revealed inhomogeneous drivers of choice selection among study cohorts. Medical decision engines that analyze personal preferences of outcomes expectations for VS and many other diseases may be developed to promote shared decision making among health care stakeholders and transparency in the informed consent process.

Environmental indicators for buildings

DEFF Research Database (Denmark)

Dammann, S.

Whenever we shop, the products we consider buying are labelled with the economical price we have to pay if we want to purchase them - an important parameter in our decisions as purchasers. The increrasing awareness for environmental limits and backlashes of human activities also in the building...... sector have fostered the wish to define 'the ecological price' of a building as a help for environmental conscious decision-making. In a social constructivist approach this Ph.D. thesis looks across and beyond the manifold existing approaches for environmental indicators for buildings. It acknowledges...... in the Netherlands. It identifies lines of conflict and areas of consent betweeen the relevant actors and elaborates scenarios for a possible closure of ongoing debate about environmental indicators for buildings....

[The effects of case-based learning using video on clinical decision making and learning motivation in undergraduate nursing students].

Science.gov (United States)

Yoo, Moon-Sook; Park, Jin-Hee; Lee, Si-Ra

2010-12-01

The purpose of this study was to examine the effects of case-base learning (CBL) using video on clinical decision-making and learning motivation. This research was conducted between June 2009 and April 2010 as a nonequivalent control group non-synchronized design. The study population was 44 third year nursing students who enrolled in a college of nursing, A University in Korea. The nursing students were divided into the CBL and the control group. The intervention was the CBL with three cases using video. The controls attended a traditional live lecture on the same topics. With questionnaires objective clinical decision-making, subjective clinical decision-making, and learning motivation were measured before the intervention, and 10 weeks after the intervention. Significant group differences were observed in clinical decision-making and learning motivation. The post-test scores of clinical decision-making in the CBL group were statistically higher than the control group. Learning motivation was also significantly higher in the CBL group than in the control group. These results indicate that CBL using video is effective in enhancing clinical decision-making and motivating students to learn by encouraging self-directed learning and creating more interest and curiosity in learning.

Viewpoint. The decision to build the ISR and its consequences: the role of Victor Weisskopf

International Nuclear Information System (INIS)

Hine, Mervyn

1995-01-01

December 1995 marks the thirtieth anniversary of the decision by the CERN Council to approve the proposal by the then Director General Victor Weisskopf to build the Intersecting Storage Rings (ISR). It was probably the Council's most important decision since setting up the Laboratory, judging by its consequences for physics and for CERN over the following three decades. December is also the twenty-fifth anniversary of the startup of the machine which led to a period of developments in accelerator technology with far reaching consequences. They included the production of stable high current stacked beams with high interaction rates in the presence of non-linear resonances and space charge, the inventions of stochastic cooling and of beam instrumentation using Schottky scans, and the technology of large ultra-high vacuum chambers with controlled wall impedance and resonances, to name only a few. Two results from the ISR physics programme of similar importance for the future were the first observation of large particle and photon yields with high transverse momentum (indicative of quark-gluon processes deep inside the colliding protons), and the consequent development of concepts for detectors with full solid angle calorimetry and tracking coverage, now used on all colliders. The technical success of the machine and the significance of the physics results led to a radical switch in physicists' thinking everywhere, away from fixed targets and towards colliders as the way to higher collision energies for hadrons. The ISR ceased to be seen as a toy for accelerator builders and became a window into a future far beyond the possibilities of fixed target accelerators. The ISR advances in accelerator and detector technology stimulated the conversion of the SPS to a proton-antiproton collider and the similar conversion of the Fermilab machine, and led to the proposals for the Superconducting Supercollider (SSC) in the USA and the LHC in Europe, to plans for a

Futuragua: Fostering Cross-Scale Knowledge to Inform Social-Environmental Decision Processes for Building Drought Resilience in Highly Seasonal Environments

Science.gov (United States)

McDaniels, T.; Steyn, D. G.; Johnson, M. S.; Small, M.; Leclerc, G.; Vignola, R.; Chan, K.; Grossmann, I.; Wong-Parodi, G.

2014-12-01

Improving resilience to drought in complex social-environmental systems (SES) is extraordinarily important, particularly for rural tropical locations where small changes in climate regimes can have dramatic SES impacts. Efforts to build drought resilience must necessarily be planned and implemented within SES governance systems that involve linkages in water and land use administration from local to national levels. These efforts require knowledge and understanding that links climate and weather forecasts to regional and local hydrology, to social-economic and environmental systems, and to governance processes. In order to provide structure for such complex choices and investments, we argue that a focus on structured decision processes that involve linkages among science, technological perspectives, and public values conducted with agencies and stakeholders will provide a crucial framework for comparing and building insight for pursuing alternative courses of action to build drought resilience. This paper focuses on a regional case study in the seasonally-dry northwest region of Costa Rica, in watersheds rated as most threatened in the country in terms of drought. We present the overall framework guiding the transdisciplinary efforts to link scientific and technical understanding to public values, in order to foster civil society actions that lead to improved drought resilience. Initial efforts to characterize hydrological and climate regimes will be reported along with our approach to linking natural science findings, social inventories in terms of perspectives on SES, and the psychology and patterns of reliance on forecast information that provide the basis for characterizing public understanding. The overall linkage of technical and value information is focused on creating and comparing alternative actions that can potentially build resilience in short and long time frames by building decision making processes involving stakeholders, agencies and interested

Clinical Decision Making and Mental Health Service Use Among Persons With Severe Mental Illness Across Europe.

Science.gov (United States)

Cosh, Suzanne; Zenter, Nadja; Ay, Esra-Sultan; Loos, Sabine; Slade, Mike; De Rosa, Corrado; Luciano, Mario; Berecz, Roland; Glaub, Theodora; Munk-Jørgensen, Povl; Krogsgaard Bording, Malene; Rössler, Wulf; Kawohl, Wolfram; Puschner, Bernd

2017-09-01

The study explored relationships between preferences for and experiences of clinical decision making (CDM) with service use among persons with severe mental illness. Data from a prospective observational study in six European countries were examined. Associations of baseline staff-rated (N=213) and patient-rated (N=588) preferred and experienced decision making with service use were examined at baseline by using binomial regressions and at 12-month follow-up by using multilevel models. A preference by patients and staff for active patient involvement in decision making, rather than shared or passive decision making, was associated with longer hospital admissions and higher costs at baseline and with increases in admissions over 12 months (p=.043). Low patient-rated satisfaction with an experienced clinical decision was also related to increased costs over the study period (p=.005). A preference for shared decision making may reduce health care costs by reducing inpatient admissions. Patient satisfaction with decisions was a predictor of costs, and clinicians should maximize patient satisfaction with CDM.

Net-zero Building Cluster Simulations and On-line Energy Forecasting for Adaptive and Real-Time Control and Decisions

Science.gov (United States)

Li, Xiwang

Buildings consume about 41.1% of primary energy and 74% of the electricity in the U.S. Moreover, it is estimated by the National Energy Technology Laboratory that more than 1/4 of the 713 GW of U.S. electricity demand in 2010 could be dispatchable if only buildings could respond to that dispatch through advanced building energy control and operation strategies and smart grid infrastructure. In this study, it is envisioned that neighboring buildings will have the tendency to form a cluster, an open cyber-physical system to exploit the economic opportunities provided by a smart grid, distributed power generation, and storage devices. Through optimized demand management, these building clusters will then reduce overall primary energy consumption and peak time electricity consumption, and be more resilient to power disruptions. Therefore, this project seeks to develop a Net-zero building cluster simulation testbed and high fidelity energy forecasting models for adaptive and real-time control and decision making strategy development that can be used in a Net-zero building cluster. The following research activities are summarized in this thesis: 1) Development of a building cluster emulator for building cluster control and operation strategy assessment. 2) Development of a novel building energy forecasting methodology using active system identification and data fusion techniques. In this methodology, a systematic approach for building energy system characteristic evaluation, system excitation and model adaptation is included. The developed methodology is compared with other literature-reported building energy forecasting methods; 3) Development of the high fidelity on-line building cluster energy forecasting models, which includes energy forecasting models for buildings, PV panels, batteries and ice tank thermal storage systems 4) Small scale real building validation study to verify the performance of the developed building energy forecasting methodology. The outcomes of

GELLO: an object-oriented query and expression language for clinical decision support.

Science.gov (United States)

Sordo, Margarita; Ogunyemi, Omolola; Boxwala, Aziz A; Greenes, Robert A

2003-01-01

GELLO is a purpose-specific, object-oriented (OO) query and expression language. GELLO is the result of a concerted effort of the Decision Systems Group (DSG) working with the HL7 Clinical Decision Support Technical Committee (CDSTC) to provide the HL7 community with a common format for data encoding and manipulation. GELLO will soon be submitted for ballot to the HL7 CDSTC for consideration as a standard.

A Clinical Decision Support System for Breast Cancer Patients

Science.gov (United States)

Fernandes, Ana S.; Alves, Pedro; Jarman, Ian H.; Etchells, Terence A.; Fonseca, José M.; Lisboa, Paulo J. G.

This paper proposes a Web clinical decision support system for clinical oncologists and for breast cancer patients making prognostic assessments, using the particular characteristics of the individual patient. This system comprises three different prognostic modelling methodologies: the clinically widely used Nottingham prognostic index (NPI); the Cox regression modelling and a partial logistic artificial neural network with automatic relevance determination (PLANN-ARD). All three models yield a different prognostic index that can be analysed together in order to obtain a more accurate prognostic assessment of the patient. Missing data is incorporated in the mentioned models, a common issue in medical data that was overcome using multiple imputation techniques. Risk group assignments are also provided through a methodology based on regression trees, where Boolean rules can be obtained expressed with patient characteristics.

Developing an Interactive Data Visualization Tool to Assess the Impact of Decision Support on Clinical Operations.

Science.gov (United States)

Huber, Timothy C; Krishnaraj, Arun; Monaghan, Dayna; Gaskin, Cree M

2018-05-18

Due to mandates from recent legislation, clinical decision support (CDS) software is being adopted by radiology practices across the country. This software provides imaging study decision support for referring providers at the point of order entry. CDS systems produce a large volume of data, providing opportunities for research and quality improvement. In order to better visualize and analyze trends in this data, an interactive data visualization dashboard was created using a commercially available data visualization platform. Following the integration of a commercially available clinical decision support product into the electronic health record, a dashboard was created using a commercially available data visualization platform (Tableau, Seattle, WA). Data generated by the CDS were exported from the data warehouse, where they were stored, into the platform. This allowed for real-time visualization of the data generated by the decision support software. The creation of the dashboard allowed the output from the CDS platform to be more easily analyzed and facilitated hypothesis generation. Integrating data visualization tools into clinical decision support tools allows for easier data analysis and can streamline research and quality improvement efforts.

Using Clinical Decision Support Software in Health Insurance Company

Science.gov (United States)

Konovalov, R.; Kumlander, Deniss

This paper proposes the idea to use Clinical Decision Support software in Health Insurance Company as a tool to reduce the expenses related to Medication Errors. As a prove that this class of software will help insurance companies reducing the expenses, the research was conducted in eight hospitals in United Arab Emirates to analyze the amount of preventable common Medication Errors in drug prescription.

Clinical decision making in cancer care: a review of current and future roles of patient age.

Science.gov (United States)

Tranvåg, Eirik Joakim; Norheim, Ole Frithjof; Ottersen, Trygve

2018-05-09

Patient age is among the most controversial patient characteristics in clinical decision making. In personalized cancer medicine it is important to understand how individual characteristics do affect practice and how to appropriately incorporate such factors into decision making. Some argue that using age in decision making is unethical, and how patient age should guide cancer care is unsettled. This article provides an overview of the use of age in clinical decision making and discusses how age can be relevant in the context of personalized medicine. We conducted a scoping review, searching Pubmed for English references published between 1985 and May 2017. References concerning cancer, with patients above the age of 18 and that discussed age in relation to diagnostic or treatment decisions were included. References that were non-medical or concerning patients below the age of 18, and references that were case reports, ongoing studies or opinion pieces were excluded. Additional references were collected through snowballing and from selected reports, guidelines and articles. Three hundred and forty-seven relevant references were identified. Patient age can have many and diverse roles in clinical decision making: Contextual roles linked to access (age influences how fast patients are referred to specialized care) and incidence (association between increasing age and increasing incidence rates for cancer); patient-relevant roles linked to physiology (age-related changes in drug metabolism) and comorbidity (association between increasing age and increasing number of comorbidities); and roles related to interventions, such as treatment (older patients receive substandard care) and outcome (survival varies by age). Patient age is integrated into cancer care decision making in a range of ways that makes it difficult to claim age-neutrality. Acknowledging this and being more transparent about the use of age in decision making are likely to promote better clinical decisions

An Application for Mobile Devices Focused on Clinical Decision Support: Diabetes Mellitus Case

NARCIS (Netherlands)

Klein, Lucas Felipe; Rigo, Sandro José; Cazella, Silvio César; Ben, Angela Jornada

2016-01-01

Clinical decision-making is performed by health professionals and it is currently connected to the need for manual query for these professionals for clinical guidelines, which are generally formed by large text files, which makes this process very slow and laborious. The development of

Installation of a freezer building : a logical, innovative and profitable decision; Installation d'un batiment congelateur : une decision logique, innovatrice et rentable

Energy Technology Data Exchange (ETDEWEB)

Vaillancourt, G. [Nutrifrance Ltd. Saint-Jean-Sur-Richelieu, PQ (Canada)

2009-12-15

This article reported on a food company in Saint-Jean-sur-Richelieu, Quebec that has recently modernized its operations by constructing an entire freezer building. Nutrifrance Ltd made the decision to modernize its facility based on long-term energy savings. Three scenarios were analysed for the construction of the freezer building in terms of interior and exterior walls, panels and shelving. The final plans consisted of a freezer within the building, where the outer walls were used as the structure to insulate against heat loss. A heated attic was built to avoid condensation on top of the freezer. Forced air ventilation with a header space was also integrated. The floor consists of 18 centimetres of reinforced concrete every 13 centimetres, giving a thermal resistance of R40. A rapid defrosting process through hot gas is used to recuperate 100 per cent of the heat. Waste heat is used to heat the floors of the office building, the loading areas, and to warm the hot water. The system is controlled by automated machinery to maximize efficiency and costs. The construction offers optimal thermal comfort for employees, which has helped reduce employee turnover. The economical impact has been significant, even after one year of operation, and the energy savings for the electricity bill is 30 per cent lower than predicted. Nutrifrance chose not to use the lowest bid for construction since the ultimate goal was comfort and security. The company predicts a payback period of 14 years. 5 figs.

Building clinical data groups for electronic medical record in China.

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Tu, Haibo; Yu, Yingtao; Yang, Peng; Tang, Xuejun; Hu, Jianping; Rao, Keqin; Pan, Feng; Xu, Yongyong; Liu, Danhong

2012-04-01

This article aims at building clinical data groups for Electronic Medical Records (EMR) in China. These data groups can be reused as basic information units in building the medical sheets of Electronic Medical Record Systems (EMRS) and serve as part of its implementation guideline. The results were based on medical sheets, the forms that are used in hospitals, which were collected from hospitals. To categorize the information in these sheets into data groups, we adopted the Health Level 7 Clinical Document Architecture Release 2 Model (HL7 CDA R2 Model). The regulations and legal documents concerning health informatics and related standards in China were implemented. A set of 75 data groups with 452 data elements was created. These data elements were atomic items that comprised the data groups. Medical sheet items contained clinical records information and could be described by standard data elements that exist in current health document protocols. These data groups match different units of the CDA model. Twelve data groups with 87 standardized data elements described EMR headers, and 63 data groups with 405 standardized data elements constituted the body. The later 63 data groups in fact formed the sections of the model. The data groups had two levels. Those at the first level contained both the second level data groups and the standardized data elements. The data groups were basically reusable information units that served as guidelines for building EMRS and that were used to rebuild a medical sheet and serve as templates for the clinical records. As a pilot study of health information standards in China, the development of EMR data groups combined international standards with Chinese national regulations and standards, and this was the most critical part of the research. The original medical sheets from hospitals contain first hand medical information, and some of their items reveal the data types characteristic of the Chinese socialist national health system

Utility of bleb imaging with anterior segment optical coherence tomography in clinical decision-making after trabeculectomy.

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Singh, Mandeep; Aung, Tin; Aquino, Maria C; Chew, Paul T K

2009-08-01

To determine if imaging of blebs with anterior segment optical coherence tomography (ASOCT) affects clinical decision-making with regard to laser suture lysis (LSL) after trabeculectomy. In this prospective observational case series, we included patients with poorly controlled intraocular pressure (IOP) after standardized trabeculectomy from May to November 2006. One observer assessed IOP, anterior chamber depth and bleb formation, and recorded a decision of whether or not to undertake LSL based on clinical grounds. A second observer masked to clinical data recorded a decision of whether or not to perform LSL based on ASOCT assessment of scleral flap position, presence of a sub-flap space, patency of the internal ostium, and bleb wall thickening. We compared the 2 observers' decisions to determine how ASOCT influenced decision-making. Seven eyes of 7 patients were included. On the basis of clinical examination, LSL was recommended in all 7 (100.0%) cases due to presence of elevated IOP, deep anterior chambers and poorly formed blebs. Using ASOCT, LSL was recommended in 5/7 (71.4%) cases with apposed scleral flaps, absent sub-flap spaces, and absent bleb wall thickening. In 2/7 (28.7%) cases, LSL was not recommended based on ASOCT findings of an elevated scleral flap, a patent sub-flap space, and bleb wall thickening. All 7 patients had good IOP control and formed blebs at a mean of 8.4+/-2.6 months after trabeculectomy, with a mean IOP of 14.3+/-3.2 mm Hg with no medications. This small study suggests that ASOCT imaging may affect decision-making with regard to LSL by providing information not apparent on clinical examination.

Clinical decision making on the use of physical restraint in intensive care units

Directory of Open Access Journals (Sweden)

Xinqian Li

2014-12-01

Full Text Available Physical restraint is a common nursing intervention in intensive care units and nurses often use it to ensure patients' safety and to prevent unexpected accidents. However, existing literature indicated that the use of physical restraint is a complex one because of inadequate rationales, the negative physical and emotional effects on patients, but the lack of perceived alternatives. This paper is aimed to interpret the clinical decision-making theories related to the use of physical restraint in intensive care units in order to facilitate our understanding on the use of physical restraint and to evaluate the quality of decisions made by nurses. By reviewing the literature, intuition and heuristics are the main decision-making strategies related to the use of physical restraint in intensive care units because the rapid and reflexive nature of intuition and heuristics allow nurses to have a rapid response to urgent and emergent cases. However, it is problematic if nurses simply count their decision-making on experience rather than incorporate research evidence into clinical practice because of inadequate evidence to support the use of physical restraint. Besides that, such a rapid response may lead nurses to make decisions without adequate assessment and thinking and therefore biases and errors may be generated. Therefore, despite the importance of intuition and heuristics in decision-making in acute settings on the use of physical restraint, it is recommended that nurses should incorporate research evidence with their experience to make decisions and adequate assessment before implementing physical restraint is also necessary.

The evolution of integration: innovations in clinical skills and ethics in first year medicine.

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Brunger, Fern; Duke, Pauline S

2012-01-01

Critical self-reflection, medical ethics and clinical skills are each important components of medical education but are seldom linked in curriculum development. We developed a curriculum that builds on the existing integration of ethics education into the clinical skills course to more explicitly link these three skills. The curriculum builds on the existing integration of clinical skills and ethics in first year medicine. It refines the integration through scheduling changes; adds case studies that emphasise the social, economic and political context of our province's patient population; and introduces reflection on the "culture of medicine" as a way to have students articulate and understand their own values and moral decision making frameworks. This structured Clinical Skills course is a model for successfully integrating critical self-reflection, reflection on the political, economic and cultural contexts shaping health and healthcare, and moral decision making into clinical skills training.

Mixture-based gatekeeping procedures in adaptive clinical trials.

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Kordzakhia, George; Dmitrienko, Alex; Ishida, Eiji

2018-01-01

Clinical trials with data-driven decision rules often pursue multiple clinical objectives such as the evaluation of several endpoints or several doses of an experimental treatment. These complex analysis strategies give rise to "multivariate" multiplicity problems with several components or sources of multiplicity. A general framework for defining gatekeeping procedures in clinical trials with adaptive multistage designs is proposed in this paper. The mixture method is applied to build a gatekeeping procedure at each stage and inferences at each decision point (interim or final analysis) are performed using the combination function approach. An advantage of utilizing the mixture method is that it enables powerful gatekeeping procedures applicable to a broad class of settings with complex logical relationships among the hypotheses of interest. Further, the combination function approach supports flexible data-driven decisions such as a decision to increase the sample size or remove a treatment arm. The paper concludes with a clinical trial example that illustrates the methodology by applying it to develop an adaptive two-stage design with a mixture-based gatekeeping procedure.

Building Green: The Adoption Process of LEED- and Energy Star-Rated Office Buildings

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Malkani, Arvin P.

2012-01-01

There are opportunities for green building technology in office buildings to produce energy savings and cost efficiencies that can produce a positive economic and environmental impact. In order for these opportunities to be realized, however, decision makers must appreciate the value of green building technology. The objective of this research is…

Managed care and clinical decision-making in child and adolescent behavioral health: provider perceptions.

Science.gov (United States)

Yanos, Philip T; Garcia, Christine I; Hansell, Stephen; Rosato, Mark G; Minsky, Shula

2003-03-01

This study investigated how managed care affects clinical decision-making in a behavioral health care system. Providers serving children and adolescents under both managed and unmanaged care (n = 28) were interviewed about their awareness of differences between the benefit arrangements, how benefits affect clinical decision-making, outcomes and quality of care; and satisfaction with care. Quantitative and qualitative findings indicated that providers saw both advantages and disadvantages to managed care. Although most providers recognized the advantages of managed care in increasing efficiency, many were concerned that administrative pressures associated with managed care compromise service quality.

Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

Directory of Open Access Journals (Sweden)

Clark Michael E

2010-04-01

Full Text Available Abstract Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR, and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The

A text-based data mining and toxicity prediction modeling system for a clinical decision support in radiation oncology: A preliminary study

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Kim, Kwang Hyeon; Lee, Suk; Shim, Jang Bo; Chang, Kyung Hwan; Yang, Dae Sik; Yoon, Won Sup; Park, Young Je; Kim, Chul Yong; Cao, Yuan Jie

2017-08-01

The aim of this study is an integrated research for text-based data mining and toxicity prediction modeling system for clinical decision support system based on big data in radiation oncology as a preliminary research. The structured and unstructured data were prepared by treatment plans and the unstructured data were extracted by dose-volume data image pattern recognition of prostate cancer for research articles crawling through the internet. We modeled an artificial neural network to build a predictor model system for toxicity prediction of organs at risk. We used a text-based data mining approach to build the artificial neural network model for bladder and rectum complication predictions. The pattern recognition method was used to mine the unstructured toxicity data for dose-volume at the detection accuracy of 97.9%. The confusion matrix and training model of the neural network were achieved with 50 modeled plans (n = 50) for validation. The toxicity level was analyzed and the risk factors for 25% bladder, 50% bladder, 20% rectum, and 50% rectum were calculated by the artificial neural network algorithm. As a result, 32 plans could cause complication but 18 plans were designed as non-complication among 50 modeled plans. We integrated data mining and a toxicity modeling method for toxicity prediction using prostate cancer cases. It is shown that a preprocessing analysis using text-based data mining and prediction modeling can be expanded to personalized patient treatment decision support based on big data.

Emergency nurses' knowledge, attitude and clinical decision making skills about pain.

Science.gov (United States)

Ucuzal, Meral; Doğan, Runida

2015-04-01

Pain is the most common reason that patients come to the emergency department. Emergency nurses have an indispensable role in the management of this pain. The aim of this study was to examine emergency nurses' knowledge, attitude and clinical decision-making skills about pain. This descriptive study was conducted in a state and a university hospital between September and October 2012 in Malatya, Turkey. Of 98 nurses working in the emergency departments of these two hospitals, 57 returned the questionnaires. The response rate was 58%. Data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain and Clinical Decision Making Survey. Frequency, percentage, mean and standard deviation were used to evaluate data. 75.4% of participant nurses knew that patients' own statement about their pain was the most reliable indicator during pain assessment. Almost half of the nurses believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. The results also indicate that most of nurses think that a sleeping patient does not have any pain and pain relief should be postponed as it can influence the diagnosis negatively. It is determined that the pain scale was not used frequently. Only 35.1% of nurses reported keeping records of pain. Despite all the recommendations of substantial past research the results of this study indicate that emergency nurses continue to demonstrate inadequate knowledge, clinical decision-making skills and negative attitudes about pain. Copyright © 2014 Elsevier Ltd. All rights reserved.

Virtual clinics in glaucoma care: face-to-face versus remote decision-making.

Science.gov (United States)

Clarke, Jonathan; Puertas, Renata; Kotecha, Aachal; Foster, Paul J; Barton, Keith

2017-07-01

To examine the agreement in clinical decisions of glaucoma status made in a virtual glaucoma clinic with those made during a face-to-face consultation. A trained nurse and technicians entered data prospectively for 204 patients into a proforma. A subsequent face-to-face clinical assessment was completed by either a glaucoma consultant or fellow. Proformas were reviewed remotely by one of two additional glaucoma consultants, and 12 months later, by the clinicians who had undertaken the original clinical examination. The interobserver and intraobserver decision-making agreements of virtual assessment versus standard care were calculated. We identified adverse disagreement between face-to-face and virtual review in 7/204 (3.4%, 95% CI 0.9% to 5.9%) patients, where virtual review failed to predict a need to accelerated follow-up identified in face-to-face review. Misclassification events were rare, occurring in 1.9% (95% CI 0.3% to 3.8%) of assessments. Interobserver κ (95% CI) showed only fair agreement (0.24 (0.04 to 0.43)); this improved to moderate agreement when only consultant decisions were compared against each other (κ=0.41 (0.16 to 0.65)). The intraobserver agreement κ (95% CI) for the consultant was 0.274 (0.073 to 0.476), and that for the fellow was 0.264 (0.031 to 0.497). The low rate of adverse misclassification, combined with the slowly progressive nature of most glaucoma, and the fact that patients will all be regularly reassessed, suggests that virtual clinics offer a safe, logistically viable option for selected patients with glaucoma. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Building bridges between clinical and forensic toxicology laboratories.

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Martin, Bernardino Barcelo; Gomila, Isabel; Noce, Valeria

2018-05-09

Clinical and forensic toxicology can be defined as the two disciplines involved the detection, identification and measurement of xenobiotics in biological and non-biological specimens to help in the diagnosis, treatment, prognosis, prevention of poisonings and to disclose causes and contributory causes of fatal intoxications, respectively. This article explores the close connections between clinical and forensic toxicology in overlapping areas of interest. An update has been carried out of the following seven areas of interest in analytical toxicology: doping control, sudden cardiac death (SCD), brain death, sudden infant death syndrome (SIDS) and Munchausen syndrome by proxy (MSBP), prenatal exposure to drugs and fetal alcohol syndrome (FAS), drug-facilitated crimes (DFC) and intoxications by new psychoactive substances (NPS). While issues such as SCD, SIDS or doping control are investigated mainly in forensic laboratories, other as prenatal exposure to drugs or FAS are mainly treated in clinical laboratories. On the other hand, areas such MSBP, DFC or the intoxications by NPS are of interest in both laboratories. Some of these topics are initially treated in hospital emergency departments, involving clinical laboratories and sometimes lately derived to forensic laboratories. Conversely, cases with initial medical-legal implications and fatalities are directly handled by forensic toxicology, but may trigger further studies in the clinical setting. Many areas of common interest between clinical and forensic laboratories are building bridges between them. The increasing relationships are improving the growth, the reliability and the robustness of both kind of laboratories. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Computer Decision Support to Improve Autism Screening and Care in Community Pediatric Clinics

Science.gov (United States)

Bauer, Nerissa S.; Sturm, Lynne A.; Carroll, Aaron E.; Downs, Stephen M.

2013-01-01

An autism module was added to an existing computer decision support system (CDSS) to facilitate adherence to recommended guidelines for screening for autism spectrum disorders in primary care pediatric clinics. User satisfaction was assessed by survey and informal feedback at monthly meetings between clinical staff and the software team. To assess…

Reward-related decision making in older adults: relationship to clinical presentation of depression.

Science.gov (United States)

McGovern, Amanda R; Alexopoulos, George S; Yuen, Genevieve S; Morimoto, Sarah Shizuko; Gunning-Dixon, Faith M

2014-11-01

Impairment in reward processes has been found in individuals with depression and in the aging population. The purpose of this study was twofold: (1) to use an affective neuroscience probe to identify abnormalities in reward-related decision making in late-life depression; and (2) to examine the relationship of reward-related decision making abnormalities in depressed, older adults to the clinical expression of apathy in depression. We hypothesized that relative to older, healthy subjects, depressed, older patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients. We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, older patients with non-psychotic major depression and 36 older, psychiatrically healthy participants. Apathy was quantified using the Apathy Evaluation Scale. Of those with major depression, 18 individuals reported clinically significant apathy, whereas 42 participants did not have apathy. Older adults with depression and healthy comparison participants did not differ in their performance on the Iowa Gambling Task. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared with non-apathetic, depressed older adults. Non-apathetic, depressed patients showed a failure to adopt a conservative strategy and persisted in making risky decisions throughout the task. This study indicates that apathy in older, depressed adults is associated with a conservative response style on a behavioral probe of the systems involved in reward-related decision making. This conservative response style may be the result of reduced sensitivity to rewards in apathetic individuals. Copyright © 2014 John Wiley & Sons, Ltd.

Remote clinical decision-making: a clinician's definition.

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Brady, Mike; Northstone, Kate

2017-05-12

Aims Remote clinical decision-making (RCDM), commonly known as 'telephone triage' or 'hear and treat', describes clinicians' non-face-to-face involvement with patient care, and is an established strategy in UK ambulance services for managing increasing demand. However, there is no suitable definition of RCDM that fully explains the roles undertaken by clinicians in 999 hubs, or for its use as an ambulance quality indicator (AQI). The aim of this study, which is part of a larger evaluation of a new RCDM module in higher education, is to determine how clinicians define RCDM. Methods Three participants were asked, during semi-structured interviews, to define RCDM. The interviews were recorded, transcribed and thematically analysed. Results Clinicians do not focus on outcomes when defining RCDM, but on the efficacy of the process and the appropriateness of the determined outcome. Conclusion There is no precise description of the role of healthcare professionals in 999 clinical hubs, but there is a need for role clarity, for employees and organisations. The study questions the suitability of the definition of hear and treat as an AQI, as it does not appear to represent fully the various duties undertaken by 999 clinical hub healthcare professionals. More research is needed to consider the definition of RCDM in all its forms.

Factors Predicting Oncology Care Providers' Behavioral Intention to Adopt Clinical Decision Support Systems

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Wolfenden, Andrew

2012-01-01

The purpose of this quantitative correlation study was to examine the predictors of user behavioral intention on the decision of oncology care providers to adopt or reject the clinical decision support system. The Unified Theory of Acceptance and Use of Technology (UTAUT) formed the foundation of the research model and survey instrument. The…

Design and implementation of a decision support system for breast cancer treatment based on clinical practice guidelines

International Nuclear Information System (INIS)

Skevofilakas, M.T.; Nikita, K.S.; Templaleksis, P.H.; Birbas, K.N.; Kaklamanos, I.G.; Bonatsos, G.N.

2007-01-01

Evidence based medicine is the clinical practice that uses medical data and proof in order to make efficient clinical decisions. Information technology (IT) can play a crucial role in exploiting the huge size of raw medical data involved. In an attempt to improve clinical efficacy, health care society nowadays also utilizes a new assistant, clinical guidelines. Our research concerns the medical domain of the breast cancer disease. Our research's focus is twofold; our primary goal is to ensure consistency in clinical practice by importing clinical guidelines in an IT driven decision support system (DSS). Furthermore, we seek to improve visualization of disease specific, clinical data, providing for it's faster and more efficient use. (orig.)

Building prognostic models for breast cancer patients using clinical variables and hundreds of gene expression signatures

Directory of Open Access Journals (Sweden)

Liu Yufeng

2011-01-01

Full Text Available Abstract Background Multiple breast cancer gene expression profiles have been developed that appear to provide similar abilities to predict outcome and may outperform clinical-pathologic criteria; however, the extent to which seemingly disparate profiles provide additive prognostic information is not known, nor do we know whether prognostic profiles perform equally across clinically defined breast cancer subtypes. We evaluated whether combining the prognostic powers of standard breast cancer clinical variables with a large set of gene expression signatures could improve on our ability to predict patient outcomes. Methods Using clinical-pathological variables and a collection of 323 gene expression "modules", including 115 previously published signatures, we build multivariate Cox proportional hazards models using a dataset of 550 node-negative systemically untreated breast cancer patients. Models predictive of pathological complete response (pCR to neoadjuvant chemotherapy were also built using this approach. Results We identified statistically significant prognostic models for relapse-free survival (RFS at 7 years for the entire population, and for the subgroups of patients with ER-positive, or Luminal tumors. Furthermore, we found that combined models that included both clinical and genomic parameters improved prognostication compared with models with either clinical or genomic variables alone. Finally, we were able to build statistically significant combined models for pathological complete response (pCR predictions for the entire population. Conclusions Integration of gene expression signatures and clinical-pathological factors is an improved method over either variable type alone. Highly prognostic models could be created when using all patients, and for the subset of patients with lymph node-negative and ER-positive breast cancers. Other variables beyond gene expression and clinical-pathological variables, like gene mutation status or DNA

Clinical Decision Making in the Management of Patients With Cervicogenic Dizziness: A Case Series.

Science.gov (United States)

Jung, Francis C; Mathew, Sherin; Littmann, Andrew E; MacDonald, Cameron W

2017-11-01

Study Design Case series. Background Although growing recognition of cervicogenic dizziness (CGD) is emerging, there is still no gold standard for the diagnosis of CGD. The purpose of this case series is to describe the clinical decision making utilized in the management of 7 patients presenting with CGD. Case Description Patients presenting with neck pain and accompanying subjective symptoms, including dizziness, unsteadiness, light-headedness, and visual disturbance, were selected. Clinical evidence of a temporal relationship between neck pain and dizziness, with or without sensorimotor disturbances, was assessed. Clinical decision making followed a 4-step process, informed by the current available best evidence. Outcome measures included the numeric rating scale for dizziness and neck pain, the Dizziness Handicap Inventory, Patient-Specific Functional Scale, and global rating of change. Outcomes Seven patients (mean age, 57 years; range, 31-86 years; 7 female) completed physical therapy management at an average of 13 sessions (range, 8-30 sessions) over a mean of 7 weeks. Clinically meaningful improvements were observed in the numeric rating scale for dizziness (mean difference, 5.7; 95% confidence interval [CI]: 4.0, 7.5), neck pain (mean difference, 5.4; 95% CI: 3.8, 7.1), and the Dizziness Handicap Inventory (mean difference, 32.6; 95% CI: 12.9, 52.2) at discontinuation. Patients also demonstrated overall satisfaction via the Patient-Specific Functional Scale (mean difference, 9) and global rating of change (mean, +6). Discussion This case series describes the physical therapist decision making, management, and outcomes in patients with CGD. Further investigation is warranted to develop a valid clinical decision-making guideline to inform management of patients with CGD. Level of Evidence Diagnosis, therapy, level 4. J Orthop Sports Phys Ther 2017;47(11):874-884. Epub 9 Oct 2017. doi:10.2519/jospt.2017.7425.

Building blocks for a clinical imaging informatics environment.

Science.gov (United States)

Kohli, Marc D; Warnock, Max; Daly, Mark; Toland, Christopher; Meenan, Chris; Nagy, Paul G

2014-04-01

Over the past 20 years, imaging informatics has been driven by the widespread adoption of radiology information and picture archiving and communication and speech recognition systems. These three clinical information systems are commonplace and are intuitive to most radiologists as they replicate familiar paper and film workflow. So what is next? There is a surge of innovation in imaging informatics around advanced workflow, search, electronic medical record aggregation, dashboarding, and analytics tools for quality measures (Nance et al., AJR Am J Roentgenol 200:1064-1070, 2013). The challenge lies in not having to rebuild the technological wheel for each of these new applications but instead attempt to share common components through open standards and modern development techniques. The next generation of applications will be built with moving parts that work together to satisfy advanced use cases without replicating databases and without requiring fragile, intense synchronization from clinical systems. The purpose of this paper is to identify building blocks that can position a practice to be able to quickly innovate when addressing clinical, educational, and research-related problems. This paper is the result of identifying common components in the construction of over two dozen clinical informatics projects developed at the University of Maryland Radiology Informatics Research Laboratory. The systems outlined are intended as a mere foundation rather than an exhaustive list of possible extensions.

Clinical decision support systems in hospital care using ubiquitous devices: Current issues and challenges.

Science.gov (United States)

Baig, Mirza Mansoor; GholamHosseini, Hamid; Moqeem, Aasia A; Mirza, Farhaan; Lindén, Maria

2017-11-01

Supporting clinicians in decision making using advanced technologies has been an active research area in biomedical engineering during the past years. Among a wide range of ubiquitous systems, smartphone applications have been increasingly developed in healthcare settings to help clinicians as well as patients. Today, many smartphone applications, from basic data analysis to advanced patient monitoring, are available to clinicians and patients. Such applications are now increasingly integrating into healthcare for clinical decision support, and therefore, concerns around accuracy, stability, and dependency of these applications are rising. In addition, lack of attention to the clinicians' acceptability, as well as the low impact on the medical professionals' decision making, are posing more serious issues on the acceptability of smartphone applications. This article reviews smartphone-based decision support applications, focusing on hospital care settings and their overall impact of these applications on the wider clinical workflow. Additionally, key challenges and barriers of the current ubiquitous device-based healthcare applications are identified. Finally, this article addresses current challenges, future directions, and the adoption of mobile healthcare applications.

32 CFR 176.45 - Disposal of buildings and property.

Science.gov (United States)

2010-07-01

... 32 National Defense 1 2010-07-01 2010-07-01 false Disposal of buildings and property. 176.45... HOMELESS ASSISTANCE § 176.45 Disposal of buildings and property. (a) Puglic benefit transfer screening. Not... shall dispose of buildings and property in accordance with the record of decision or other decision...

Building a Data Warehouse.

Science.gov (United States)

Levine, Elliott

2002-01-01

Describes how to build a data warehouse, using the Schools Interoperability Framework (www.sifinfo.org), that supports data-driven decision making and complies with the Freedom of Information Act. Provides several suggestions for building and maintaining a data warehouse. (PKP)

Corrective Action Decision Document, Area 15 Environmental Protection Agency Farm Laboratory Building, Corrective Action Unit No. 95, Revision 0

Energy Technology Data Exchange (ETDEWEB)

NONE

1997-08-18

This report is the Corrective Action Decision Document (CADD) for the Nevada Test Site (NTS) Area 15 U.S. Environmental Protection Agency (EPA) Farm, Laboratory Building (Corrective Action Unit [CAU] No. 95), at the Nevada Test Site, Nye County, Nevada. The scope of this CADD is to identify and evaluate potential corrective action alternatives for the decommissioning and decontamination (D and D) of the Laboratory Building, which were selected based on the results of investigative activities. Based on this evaluation, a preferred corrective action alternative is recommended. Studies were conducted at the EPA Farm from 1963 to 1981 to determine the animal intake and retention of radionuclides. The main building, the Laboratory Building, has approximately 370 square meters (4,000 square feet) of operational space. Other CAUS at the EPA Farm facility that will be investigated and/or remediated through other environmental restoration subprojects are not included in this CADD, with the exception of housekeeping sites. Associated structures that do not require classification as CAUS are considered in the evaluation of corrective action alternatives for CAU 95.

Corrective Action Decision Document, Area 15 Environmental Protection Agency Farm Laboratory Building, Corrective Action Unit No. 95, Revision 0

International Nuclear Information System (INIS)

1997-01-01

This report is the Corrective Action Decision Document (CADD) for the Nevada Test Site (NTS) Area 15 U.S. Environmental Protection Agency (EPA) Farm, Laboratory Building (Corrective Action Unit [CAU] No. 95), at the Nevada Test Site, Nye County, Nevada. The scope of this CADD is to identify and evaluate potential corrective action alternatives for the decommissioning and decontamination (D and D) of the Laboratory Building, which were selected based on the results of investigative activities. Based on this evaluation, a preferred corrective action alternative is recommended. Studies were conducted at the EPA Farm from 1963 to 1981 to determine the animal intake and retention of radionuclides. The main building, the Laboratory Building, has approximately 370 square meters (4,000 square feet) of operational space. Other CAUS at the EPA Farm facility that will be investigated and/or remediated through other environmental restoration subprojects are not included in this CADD, with the exception of housekeeping sites. Associated structures that do not require classification as CAUS are considered in the evaluation of corrective action alternatives for CAU 95

Clinical Decision Support Knowledge Management: Strategies for Success.

Science.gov (United States)

Khalifa, Mohamed; Alswailem, Osama

2015-01-01

Clinical Decision Support Systems have been shown to increase quality of care, patient safety, improve adherence to guidelines for prevention and treatment, and avoid medication errors. Such systems depend mainly on two types of content; the clinical information related to patients and the medical knowledge related to the specialty that informs the system rules and alerts. At King Faisal Specialist Hospital and Research Center, Saudi Arabia, the Health Information Technology Affairs worked on identifying best strategies and recommendations for successful CDSS knowledge management. A review of literature was conducted to identify main areas of challenges and factors of success. A qualitative survey was used over six months' duration to collect opinions, experiences and suggestions from both IT and healthcare professionals. Recommendations were categorized into ten main topics that should be addressed during the development and implementation of CDSS knowledge management tools in the hospital.

Charting a path forward: building AGU's capacity to help foster scientist-decision maker engagement

Science.gov (United States)

Vano, J. A.; Behar, D. H.; Mote, P.; Ferguson, D. B.; Pandya, R.

2016-12-01

Most research proposals, papers, and presentation abstracts begin with the motivation that the new science presented will benefit society. Behind this, beyond making good on the promises to get funding, is a sincere effort to contribute our knowledge and talent to build a better (safer, sustainable, more resilient) world. For this to happen, however, the science needs to be connected to people in communities who make decisions. While this happens in a variety of ways, often for research to be most useful to society, engagement with decision makers should occur at the beginning and throughout the research process. Increasingly this is being recognized as important, as evidenced by the growing number of boundary organizations (e.g., U.S. Department of the Interior's Climate Science Centers, NOAA's Regional Integrated Sciences and Assessment programs). Even within AGU, in recent years there has been a number of new activities and networks that suggest a growing community of practice for those doing work at the science-society interface (e.g., The Thriving Earth Exchange, the Water and Society Technical Committee in the Hydrology Section). In this presentation, we highlight what these activities are and share insights from those involved. We evaluate trends (e.g., have the number of abstracts on this topic increased?) and present responses from AGU members to questions on where this community of practice should go next (e.g., What is the most important task the AGU community should do to improve decision maker-scientist engagement?). The goal of this presentation is to promote a conversation about how the AGU community can be better prepared to foster engagement with decision makers that will lead to more actionable science. This will help us ensure our science is useful to society, fulfilling our motivations, and arguably responsibilities, both individually and as a community. It will also serve to prepare new scientists for a broader range of careers beyond

Knowledge of risk factors and the periodontal disease-systemic link in dental students' clinical decisions.

Science.gov (United States)

Friesen, Lynn Roosa; Walker, Mary P; Kisling, Rebecca E; Liu, Ying; Williams, Karen B

2014-09-01

This study evaluated second-, third-, and fourth-year dental students' ability to identify systemic conditions associated with periodontal disease, risk factors most important for referral, and medications with an effect on the periodontium and their ability to apply this knowledge to make clinical decisions regarding treatment and referral of periodontal patients. A twenty-one question survey was administered at one U.S. dental school in the spring semester of 2012 to elicit the students' knowledge and confidence regarding clinical reasoning. The response rate was 86 percent. Periodontal risk factors were accurately selected by at least 50 percent of students in all three classes; these were poorly controlled diabetes, ≥6 mm pockets posteriorly, and lack of response to previous non-surgical therapy. Confidence in knowledge, knowledge of risk factors, and knowledge of medications with an effect on the periodontium improved with training and were predictive of better referral decision making. The greatest impact of training was seen on the students' ability to make correct decisions about referral and treatment for seven clinical scenarios. Although the study found a large increase in the students' abilities from the second through fourth years, the mean of 4.6 (out of 7) for the fourth-year students shows that, on average, those students missed correct treatment or referral on more than two of seven clinical cases. These results suggest that dental curricula should emphasize more critical decision making with respect to referral and treatment criteria in managing the periodontal patient.

Many faces of rationality: Implications of the great rationality debate for clinical decision-making.

Science.gov (United States)

Djulbegovic, Benjamin; Elqayam, Shira

2017-10-01

Given that more than 30% of healthcare costs are wasted on inappropriate care, suboptimal care is increasingly connected to the quality of medical decisions. It has been argued that personal decisions are the leading cause of death, and 80% of healthcare expenditures result from physicians' decisions. Therefore, improving healthcare necessitates improving medical decisions, ie, making decisions (more) rational. Drawing on writings from The Great Rationality Debate from the fields of philosophy, economics, and psychology, we identify core ingredients of rationality commonly encountered across various theoretical models. Rationality is typically classified under umbrella of normative (addressing the question how people "should" or "ought to" make their decisions) and descriptive theories of decision-making (which portray how people actually make their decisions). Normative theories of rational thought of relevance to medicine include epistemic theories that direct practice of evidence-based medicine and expected utility theory, which provides the basis for widely used clinical decision analyses. Descriptive theories of rationality of direct relevance to medical decision-making include bounded rationality, argumentative theory of reasoning, adaptive rationality, dual processing model of rationality, regret-based rationality, pragmatic/substantive rationality, and meta-rationality. For the first time, we provide a review of wide range of theories and models of rationality. We showed that what is "rational" behaviour under one rationality theory may be irrational under the other theory. We also showed that context is of paramount importance to rationality and that no one model of rationality can possibly fit all contexts. We suggest that in context-poor situations, such as policy decision-making, normative theories based on expected utility informed by best research evidence may provide the optimal approach to medical decision-making, whereas in the context

The potential value on medication safety of a clinical decision support system in intensive care patients with renal insufficiency.

NARCIS (Netherlands)

Helmons, P.J.; Grouls, R.J.E.; Roos, A.N.; Bindels, A.J.G.H.; Clercq, de P.A.; Wessels-Basten, S.J.W.; Ackerman, E.W.; Korsten, H.H.M.

2007-01-01

Clinical decision support systems (CDSS) are defined as electronic or non-electronic systems designed to aid in clinical decision making, using characteristics of individual patients to generate patient-specific assessments or recommendations that are then presented to clinicians for consideration

Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review

Directory of Open Access Journals (Sweden)

Wu Helen W

2012-08-01

Full Text Available Abstract Background Greater use of computerized decision support (DS systems could address continuing safety and quality problems in healthcare, but the healthcare field has struggled to implement DS technology. This study surveys DS experience across multiple non-healthcare disciplines for new insights that are generalizable to healthcare provider decisions. In particular, it sought design principles and lessons learned from the other disciplines that could inform efforts to accelerate the adoption of clinical decision support (CDS. Methods Our systematic review drew broadly from non-healthcare databases in the basic sciences, social sciences, humanities, engineering, business, and defense: PsychINFO, BusinessSource Premier, Social Sciences Abstracts, Web of Science, and Defense Technical Information Center. Because our interest was in DS that could apply to clinical decisions, we selected articles that (1 provided a review, overview, discussion of lessons learned, or an evaluation of design or implementation aspects of DS within a non-healthcare discipline and (2 involved an element of human judgment at the individual level, as opposed to decisions that can be fully automated or that are made at the organizational level. Results Clinical decisions share some similarities with decisions made by military commanders, business managers, and other leaders: they involve assessing new situations and choosing courses of action with major consequences, under time pressure, and with incomplete information. We identified seven high-level DS system design features from the non-healthcare literature that could be applied to CDS: providing broad, system-level perspectives; customizing interfaces to specific users and roles; making the DS reasoning transparent; presenting data effectively; generating multiple scenarios covering disparate outcomes (e.g., effective; effective with side effects; ineffective; allowing for contingent adaptations; and facilitating

Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review.

Science.gov (United States)

Wu, Helen W; Davis, Paul K; Bell, Douglas S

2012-08-17

Greater use of computerized decision support (DS) systems could address continuing safety and quality problems in healthcare, but the healthcare field has struggled to implement DS technology. This study surveys DS experience across multiple non-healthcare disciplines for new insights that are generalizable to healthcare provider decisions. In particular, it sought design principles and lessons learned from the other disciplines that could inform efforts to accelerate the adoption of clinical decision support (CDS). Our systematic review drew broadly from non-healthcare databases in the basic sciences, social sciences, humanities, engineering, business, and defense: PsychINFO, BusinessSource Premier, Social Sciences Abstracts, Web of Science, and Defense Technical Information Center. Because our interest was in DS that could apply to clinical decisions, we selected articles that (1) provided a review, overview, discussion of lessons learned, or an evaluation of design or implementation aspects of DS within a non-healthcare discipline and (2) involved an element of human judgment at the individual level, as opposed to decisions that can be fully automated or that are made at the organizational level. Clinical decisions share some similarities with decisions made by military commanders, business managers, and other leaders: they involve assessing new situations and choosing courses of action with major consequences, under time pressure, and with incomplete information. We identified seven high-level DS system design features from the non-healthcare literature that could be applied to CDS: providing broad, system-level perspectives; customizing interfaces to specific users and roles; making the DS reasoning transparent; presenting data effectively; generating multiple scenarios covering disparate outcomes (e.g., effective; effective with side effects; ineffective); allowing for contingent adaptations; and facilitating collaboration. The article provides examples of

Constructing a clinical decision-making framework for image-guided radiotherapy using a Bayesian Network

International Nuclear Information System (INIS)

Hargrave, C; Deegan, T; Gibbs, A; Poulsen, M; Moores, M; Harden, F; Mengersen, K

2014-01-01

A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific subregions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.

Constructing a clinical decision-making framework for image-guided radiotherapy using a Bayesian Network

Science.gov (United States)

Hargrave, C.; Moores, M.; Deegan, T.; Gibbs, A.; Poulsen, M.; Harden, F.; Mengersen, K.

2014-03-01

A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific subregions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.

Actionable Knowledge and Strategic Decision Making for Bio- and Agroterrorism Threats: Building a Collaborative Early Warning Culture

DEFF Research Database (Denmark)

Mårtensson, Per-Åke; Hedström, Lars; Sundelius, Bengt

2013-01-01

who must work together with public and animal health organizations as well as environmental and social science organizations. This requires coordinated decision making among these organizations, based on actionable knowledge and information sharing. The risk of not sharing information among...... and the formation of a legal adviser network for decision making. In addition, a seminar on actionable knowledge was held in Stockholm, Sweden, in 2012, which identified the need to bring various agency cultures together to work on developing a resilient capability to identify early signs of bio- and agroterrorism...... organizations compared to the benefit of sharing information can be considered in an “information sharing risk-benefit analysis” to prevent a terrorism incident from occurring and to build a rapid response capability. In the EU project AniBioThreat, early warning is the main topic in work package 3 (WP 3...

A service oriented approach for guidelines-based clinical decision support using BPMN.

Science.gov (United States)

Rodriguez-Loya, Salvador; Aziz, Ayesha; Chatwin, Chris

2014-01-01

Evidence-based medical practice requires that clinical guidelines need to be documented in such a way that they represent a clinical workflow in its most accessible form. In order to optimize clinical processes to improve clinical outcomes, we propose a Service Oriented Architecture (SOA) based approach for implementing clinical guidelines that can be accessed from an Electronic Health Record (EHR) application with a Web Services enabled communication mechanism with the Enterprise Service Bus. We have used Business Process Modelling Notation (BPMN) for modelling and presenting the clinical pathway in the form of a workflow. The aim of this study is to produce spontaneous alerts in the healthcare workflow in the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The use of BPMN as a tool to automate clinical guidelines has not been previously employed for providing Clinical Decision Support (CDS).

Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.

Science.gov (United States)

Hussain, Ahsen; Oestreicher, James

Diagnostic errors have a significant impact on health care outcomes and patient care. The underlying causes and development of diagnostic error are complex with flaws in health care systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician, and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes and the vulnerability of heuristics to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Microfoundations of strategic decision effectiveness

NARCIS (Netherlands)

Jansen, R.J.G.; Van Santen, Sarah

2017-01-01

How do organizations make effective strategic decisions? In this study we build on research on the microfoundations of strategy and strategic decision-making to study the underpinnings of strategic decision effectiveness. We argue that the process-effectiveness link can be more fully understood if

Professional autonomy in 21st century healthcare: Nurses' accounts of clinical decision-making

DEFF Research Database (Denmark)

Traynor, Michael; Boland, Maggie; Buus, Niels

2010-01-01

Autonomy in decision-making has traditionally been described as a feature of professional work, however the work of healthcare professionals has been seen as steadily encroached upon by State and managerialist forces. Nursing has faced particular problems in establishing itself as a credible....... The study uses accounts of decision-making to gain insight into contemporary professional nursing. The study also aims to explore the usefulness of a theory of professional work set out by Jamous and Peloille (1970). The analysis draws on notions of interpretive repertoires and elements of narrative...... analysis. We identified two interpretive repertoires: 'clinical judgement' which was used to describe the different grounds for making judgements; and 'decision-making' which was used to describe organisational circumstances influencing decision-making. Jamous and Peloille's theory proved useful...

Advancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD - an ethnographic study.

Science.gov (United States)

Barken, Tina Lien; Thygesen, Elin; Söderhamn, Ulrika

2017-12-28

Telemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses' reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses' clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated. In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis. When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: "the process of telemedicine nurses' reasoning to assess health change" and "the influence of the telemedicine setting on nurses' reasoning and decision-making processes". An overall theme, termed "advancing beyond the system", represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses' clinical reasoning process. In the telemedicine setting, when supported by a computerised decision support system, nurses' reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision

Evaluating Adaptation of a Cancer Clinical Trial Decision Aid for Rural Cancer Patients: A Mixed-Methods Approach.

Science.gov (United States)

Pathak, Swati; George, Nerissa; Monti, Denise; Robinson, Kathy; Politi, Mary C

2018-06-03

Rural-residing cancer patients often do not participate in clinical trials. Many patients misunderstand cancer clinical trials and their rights as participant. The purpose of this study is to modify a previously developed cancer clinical trials decision aid (DA), incorporating the unique needs of rural populations, and test its impact on knowledge and decision outcomes. The study was conducted in two phases. Phase I recruited 15 rural-residing cancer survivors in a qualitative usability study. Participants navigated the original DA and provided feedback regarding usability and implementation in rural settings. Phase II recruited 31 newly diagnosed rural-residing cancer patients. Patients completed a survey before and after using the revised DA, R-CHOICES. Primary outcomes included decisional conflict, decision self-efficacy, knowledge, communication self-efficacy, and attitudes towards and willingness to consider joining a trial. In phase I, the DA was viewed positively by rural-residing cancer survivors. Participants provided important feedback about factors rural-residing patients consider when thinking about trial participation. In phase II, after using R-CHOICES, participants had higher certainty about their choice (mean post-test = 3.10 vs. pre-test = 2.67; P = 0.025) and higher trial knowledge (mean percentage correct at post-test = 73.58 vs. pre-test = 57.77; P decision self-efficacy, communication self-efficacy, and attitudes towards or willingness to join trials. The R-CHOICES improved rural-residing patients' knowledge of cancer clinical trials and reduced conflict about making a trial decision. More research is needed on ways to further support decisions about trial participation among this population.

Nurse supervisors' actions in relation to their decision-making style and ethical approach to clinical supervision.

Science.gov (United States)

Berggren, Ingela; Severinsson, Elisabeth

2003-03-01

The aim of the study was to explore the decision-making style and ethical approach of nurse supervisors by focusing on their priorities and interventions in the supervision process. Clinical supervision promotes ethical awareness and behaviour in the nursing profession. A focus group comprised of four clinical nurse supervisors with considerable experience was studied using qualitative hermeneutic content analysis. The essence of the nurse supervisors' decision-making style is deliberations and priorities. The nurse supervisors' willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors' ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors' interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings. Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decision-making can strengthen the supervisees' professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.

Enhancing nurse and physician collaboration in clinical decision making through high-fidelity interdisciplinary simulation training.

Science.gov (United States)

Maxson, Pamela M; Dozois, Eric J; Holubar, Stefan D; Wrobleski, Diane M; Dube, Joyce A Overman; Klipfel, Janee M; Arnold, Jacqueline J

2011-01-01

To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making. Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests. Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p = .82), were more likely to be women (95.0% vs 12.5%; p nurses and physicians (p = .04) and that both medical and nursing concerns influence the decision-making process (p = .02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p nurses and physicians and enhanced the patient care decision-making process.

Decision-Making Process Related to Participation in Phase I Clinical Trials: A Nonsystematic Review of the Existing Evidence.

Science.gov (United States)

Gorini, Alessandra; Mazzocco, Ketti; Pravettoni, Gabriella

2015-01-01

Due to the lack of other treatment options, patient candidates for participation in phase I clinical trials are considered the most vulnerable, and many ethical concerns have emerged regarding the informed consent process used in the experimental design of such trials. Starting with these considerations, this nonsystematic review is aimed at analyzing the decision-making processes underlying patients' decision about whether to participate (or not) in phase I trials in order to clarify the cognitive and emotional aspects most strongly implicated in this decision. Considering that there is no uniform decision calculus and that many different variables other than the patient-physician relationship (including demographic, clinical, and personal characteristics) may influence patients' preferences for and processing of information, we conclude that patients' informed decision-making can be facilitated by creating a rigorously developed, calibrated, and validated computer tool modeled on each single patient's knowledge, values, and emotional and cognitive decisional skills. Such a tool will also help oncologists to provide tailored medical information that is useful to improve the shared decision-making process, thereby possibly increasing patient participation in clinical trials. © 2015 S. Karger AG, Basel.

Publication, discovery and interoperability of Clinical Decision Support Systems: A Linked Data approach.

Science.gov (United States)

Marco-Ruiz, Luis; Pedrinaci, Carlos; Maldonado, J A; Panziera, Luca; Chen, Rong; Bellika, J Gustav

2016-08-01

The high costs involved in the development of Clinical Decision Support Systems (CDSS) make it necessary to share their functionality across different systems and organizations. Service Oriented Architectures (SOA) have been proposed to allow reusing CDSS by encapsulating them in a Web service. However, strong barriers in sharing CDS functionality are still present as a consequence of lack of expressiveness of services' interfaces. Linked Services are the evolution of the Semantic Web Services paradigm to process Linked Data. They aim to provide semantic descriptions over SOA implementations to overcome the limitations derived from the syntactic nature of Web services technologies. To facilitate the publication, discovery and interoperability of CDS services by evolving them into Linked Services that expose their interfaces as Linked Data. We developed methods and models to enhance CDS SOA as Linked Services that define a rich semantic layer based on machine interpretable ontologies that powers their interoperability and reuse. These ontologies provided unambiguous descriptions of CDS services properties to expose them to the Web of Data. We developed models compliant with Linked Data principles to create a semantic representation of the components that compose CDS services. To evaluate our approach we implemented a set of CDS Linked Services using a Web service definition ontology. The definitions of Web services were linked to the models developed in order to attach unambiguous semantics to the service components. All models were bound to SNOMED-CT and public ontologies (e.g. Dublin Core) in order to count on a lingua franca to explore them. Discovery and analysis of CDS services based on machine interpretable models was performed reasoning over the ontologies built. Linked Services can be used effectively to expose CDS services to the Web of Data by building on current CDS standards. This allows building shared Linked Knowledge Bases to provide machine

Decisions at hand: a decision support system on handhelds.

Science.gov (United States)

Zupan, B; Porenta, A; Vidmar, G; Aoki, N; Bratko, I; Beck, J R

2001-01-01

One of the applications of clinical information systems is decision support. Although the advantages of utilizing such aids have never been theoretically disputed, they have been rarely used in practice. The factor that probably often limits the utility of clinical decision support systems is the need for computing power at the very site of decision making--at the place where the patient is interviewed, in discussion rooms, etc. The paper reports on a possible solution to this problem. A decision-support shell LogReg is presented, which runs on a handheld computer. A general schema for handheld-based decision support is also proposed, where decision models are developed on personal computers/workstations, encoded in XML and then transferred to handhelds, where the models are used within a decision support shell. A use case where LogReg has been applied to clinical outcome prediction in crush injury is presented.

Depression and Anxiety During Pregnancy: Evaluating the Literature in Support of Clinical Risk-Benefit Decision-Making.

Science.gov (United States)

Dalke, Katharine Baratz; Wenzel, Amy; Kim, Deborah R

2016-06-01

Depression and anxiety during pregnancy are common, and patients and providers are faced with complex decisions regarding various treatment modalities. A structured discussion of the risks and benefits of options with the patient and her support team is recommended to facilitate the decision-making process. This clinically focused review, with emphasis on the last 3 years of published study data, evaluates the major risk categories of medication treatments, namely pregnancy loss, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity. Nonpharmacological treatment options, including neuromodulation and psychotherapy, are also briefly reviewed. Specific recommendations, drawn from the literature and the authors' clinical experience, are also offered to help guide the clinician in decision-making.

PCA safety data review after clinical decision support and smart pump technology implementation.

Science.gov (United States)

Prewitt, Judy; Schneider, Susan; Horvath, Monica; Hammond, Julia; Jackson, Jason; Ginsberg, Brian

2013-06-01

Medication errors account for 20% of medical errors in the United States with the largest risk at prescribing and administration. Analgesics or opioids are frequently used medications that can be associated with patient harm when prescribed or administered improperly. In an effort to decrease medication errors, Duke University Hospital implemented clinical decision support via computer provider order entry (CPOE) and "smart pump" technology, 2/2008, with the goal to decrease patient-controlled analgesia (PCA) adverse events. This project evaluated PCA safety events, reviewing voluntary report system and adverse drug events via surveillance (ADE-S), on intermediate and step-down units preimplementation and postimplementation of clinical decision support via CPOE and PCA smart pumps for the prescribing and administration of opioids therapy in the adult patient requiring analgesia for acute pain. Voluntary report system and ADE-S PCA events decreased based upon 1000 PCA days; ADE-S PCA events per 1000 PCA days decreased 22%, from 5.3 (pre) to 4.2 (post) (P = 0.09). Voluntary report system events decreased 72%, from 2.4/1000 PCA days (pre) to 0.66/1000 PCA days (post) and was statistically significant (P PCA events between time periods in both the ADE-S and voluntary report system data, thus supporting the recommendation of clinical decision support via CPOE and PCA smart pump technology.

Sharing clinical decisions for multimorbidity case management using social network and open-source tools.

Science.gov (United States)

Martínez-García, Alicia; Moreno-Conde, Alberto; Jódar-Sánchez, Francisco; Leal, Sandra; Parra, Carlos

2013-12-01

Social networks applied through Web 2.0 tools have gained importance in health domain, because they produce improvements on the communication and coordination capabilities among health professionals. This is highly relevant for multimorbidity patients care because there is a large number of health professionals in charge of patient care, and this requires to obtain clinical consensus in their decisions. Our objective is to develop a tool for collaborative work among health professionals for multimorbidity patient care. We describe the architecture to incorporate decision support functionalities in a social network tool to enable the adoption of shared decisions among health professionals from different care levels. As part of the first stage of the project, this paper describes the results obtained in a pilot study about acceptance and use of the social network component in our healthcare setting. At Virgen del Rocío University Hospital we have designed and developed the Shared Care Platform (SCP) to provide support in the continuity of care for multimorbidity patients. The SCP has two consecutively developed components: social network component, called Clinical Wall, and Clinical Decision Support (CDS) system. The Clinical Wall contains a record where health professionals are able to debate and define shared decisions. We conducted a pilot study to assess the use and acceptance of the SCP by healthcare professionals through questionnaire based on the theory of the Technology Acceptance Model. In March 2012 we released and deployed the SCP, but only with the social network component. The pilot project lasted 6 months in the hospital and 2 primary care centers. From March to September 2012 we created 16 records in the Clinical Wall, all with a high priority. A total of 10 professionals took part in the exchange of messages: 3 internists and 7 general practitioners generated 33 messages. 12 of the 16 record (75%) were answered by the destination health professionals

EPIQR - a decision making tool for apartment building refurbishment

Energy Technology Data Exchange (ETDEWEB)

Caccavelli, D. [Centre Scientifique et Technique du Batiment, Cedex (France); Balaras, C. [National Observatory of Athens, Athens (Greece); Bluyssen, P. [TNO Building and Construction Research, Delft (Netherlands); Flourentzou, F. [Ecole Polytechnique Federale de Lausanne, Lausanne (France); Jaggs, M. [Building Research Establishment, Watford (United Kingdom); Wetzel, C. [Fraunhofer-Institut fur Bauphysik, Holzkirchen (Germany); Wittchen, K. [Danish Building Reasearch Institute, Hoersholm (Denmark)

1999-11-01

In a large majority of European countries, the amount of the maintenance and refurbishment works represents nearly 50% of the total amount spent in the building sector. New requirements are being added to the necessity of maintaining or re-establishing the building stock`s usage value. They are linked to the determination to reduce energy consumption, pollutant emissions, work site wastes, to improve the Indoor Environment Quality and all the modern conveniences inside apartment. Aware of this matter, the European Community has launched a two-year European research project, entitled EPIQR (Energy Performance, Indoor Environmental Quality, Retrofit) involving seven research institutions in the frame of the JOULE III programme. The purpose is to give architects and contracting authorities a multimedia tool to enable them to simultaneously grasp the whole process of apartment building refurbishment or retrofit. It has a number of functions: Assess the building`s degradation state based on a technical diagnosis after a standardised and complete inspection of the building; Prepare work proposals. These take into account not only the renovation of the building but also the improvement of the energy performance and IEQ; Estimate the costs corresponding to these works. A data base, containing the costs of 800 refurbishment works, provides a fast estimate of the total amount of the works being considered; Estimate the evolution of the degradation of the components if none of the works were to be carried out, as well as the refurbishment costs which would result. This paper provides an overview of the EPIQR methodology and the final deliverables of the project. (au)

Decision Analysis Technique

Directory of Open Access Journals (Sweden)

Hammad Dabo Baba

2014-01-01

Full Text Available One of the most significant step in building structure maintenance decision is the physical inspection of the facility to be maintained. The physical inspection involved cursory assessment of the structure and ratings of the identified defects based on expert evaluation. The objective of this paper is to describe present a novel approach to prioritizing the criticality of physical defects in a residential building system using multi criteria decision analysis approach. A residential building constructed in 1985 was considered in this study. Four criteria which includes; Physical Condition of the building system (PC, Effect on Asset (EA, effect on Occupants (EO and Maintenance Cost (MC are considered in the inspection. The building was divided in to nine systems regarded as alternatives. Expert's choice software was used in comparing the importance of the criteria against the main objective, whereas structured Proforma was used in quantifying the defects observed on all building systems against each criteria. The defects severity score of each building system was identified and later multiplied by the weight of the criteria and final hierarchy was derived. The final ranking indicates that, electrical system was considered the most critical system with a risk value of 0.134 while ceiling system scored the lowest risk value of 0.066. The technique is often used in prioritizing mechanical equipment for maintenance planning. However, result of this study indicates that the technique could be used in prioritizing building systems for maintenance planning

Computerized clinical decision support systems for chronic disease management: a decision-maker-researcher partnership systematic review.

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Roshanov, Pavel S; Misra, Shikha; Gerstein, Hertzel C; Garg, Amit X; Sebaldt, Rolf J; Mackay, Jean A; Weise-Kelly, Lorraine; Navarro, Tamara; Wilczynski, Nancy L; Haynes, R Brian

2011-08-03

The use of computerized clinical decision support systems (CCDSSs) may improve chronic disease management, which requires recurrent visits to multiple health professionals, ongoing disease and treatment monitoring, and patient behavior modification. The objective of this review was to determine if CCDSSs improve the processes of chronic care (such as diagnosis, treatment, and monitoring of disease) and associated patient outcomes (such as effects on biomarkers and clinical exacerbations). We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for potentially eligible articles published up to January 2010. We included randomized controlled trials that compared the use of CCDSSs to usual practice or non-CCDSS controls. Trials were eligible if at least one component of the CCDSS was designed to support chronic disease management. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of relevant outcomes. Of 55 included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements. Sixty-five percent (36/55) of trials measured impact on, typically, non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Factors of interest to decision makers, such as cost, user satisfaction, system interface and feature sets, unique design and deployment characteristics, and effects on user workflow were rarely investigated or reported. A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. Policy makers, healthcare administrators, and practitioners should be aware that the evidence of CCDSS effectiveness is limited, especially with respect to the small number and size of studies measuring patient outcomes.

Clinical decision support must be useful, functional is not enough

DEFF Research Database (Denmark)

Kortteisto, Tiina; Komulainen, Jorma; Mäkelä, Marjukka

2012-01-01

the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals. METHODS: The setting was a Finnish primary health care organization with 48......ABSTRACT: BACKGROUND: Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence...... professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics. RESULTS: The content of the guidance is a significant feature of the primary care professional...

Implications of caries diagnostic strategies for clinical management decisions

DEFF Research Database (Denmark)

Baelum, Vibeke; Hintze, Hanne; Wenzel, Ann

2012-01-01

-specificity) were calculated for each diagnostic strategy. RESULTS: Visual-tactile examination provided a true-positive rate of 34.2% and a false-positive rate of 1.5% for the detection of a cavity. The combination of a visual-tactile and a radiographic examination using the lesion in dentin threshold......OBJECTIVES: In clinical practice, a visual-tactile caries examination is frequently supplemented by bitewing radiography. This study evaluated strategies for combining visual-tactile and radiographic caries detection methods and determined their implications for clinical management decisions...... and cavitated lesions while the radiographic examination determined lesion depth. Direct inspection of the surfaces following tooth separation for the presence of cavitated or noncavitated lesions was the validation method. The true-positive rate (i.e. the sensitivity) and the false-positive rate (i.e. 1...

Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India.

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Tanderup, Malene; Reddy, Sunita; Patel, Tulsi; Nielsen, Birgitte Bruun

2015-09-01

As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.

The value of participatory development to support antimicrobial stewardship with a clinical decision support system

NARCIS (Netherlands)

Beerlage-de Jong, Nienke; Wentzel, Jobke; Hendrix, Ron; van Gemert-Pijnen, Lisette

2017-01-01

Background: Current clinical decision support systems (CDSSs) for antimicrobial stewardship programs (ASPs) are guideline- or expert-driven. They are focused on (clinical) content, not on supporting real-time workflow. Thus, CDSSs fail to optimally support prudent antimicrobial prescribing in daily

The value of participatory development to support antimicrobial stewardship with a clinical decision support system

NARCIS (Netherlands)

Beerlage-de Jong, Nienke; Wentzel, M.J.; Hendrix, Ron; van Gemert-Pijnen, Julia E.W.C.

Background Current clinical decision support systems (CDSSs) for antimicrobial stewardship programs (ASPs) are guideline- or expert-driven. They are focused on (clinical) content, not on supporting real-time workflow. Thus, CDSSs fail to optimally support prudent antimicrobial prescribing in daily

Amsterdam wrist rules: A clinical decision aid

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Bentohami Abdelali

2011-10-01

Full Text Available Abstract Background Acute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures. Methods/Design This study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (≥18 years presenting with acute wrist trauma at the Emergency Department in the participating hospitals. This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated. In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study. Discussion Wrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are

OrderRex: clinical order decision support and outcome predictions by data-mining electronic medical records.

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Chen, Jonathan H; Podchiyska, Tanya; Altman, Russ B

2016-03-01

To answer a "grand challenge" in clinical decision support, the authors produced a recommender system that automatically data-mines inpatient decision support from electronic medical records (EMR), analogous to Netflix or Amazon.com's product recommender. EMR data were extracted from 1 year of hospitalizations (>18K patients with >5.4M structured items including clinical orders, lab results, and diagnosis codes). Association statistics were counted for the ∼1.5K most common items to drive an order recommender. The authors assessed the recommender's ability to predict hospital admission orders and outcomes based on initial encounter data from separate validation patients. Compared to a reference benchmark of using the overall most common orders, the recommender using temporal relationships improves precision at 10 recommendations from 33% to 38% (P < 10(-10)) for hospital admission orders. Relative risk-based association methods improve inverse frequency weighted recall from 4% to 16% (P < 10(-16)). The framework yields a prediction receiver operating characteristic area under curve (c-statistic) of 0.84 for 30 day mortality, 0.84 for 1 week need for ICU life support, 0.80 for 1 week hospital discharge, and 0.68 for 30-day readmission. Recommender results quantitatively improve on reference benchmarks and qualitatively appear clinically reasonable. The method assumes that aggregate decision making converges appropriately, but ongoing evaluation is necessary to discern common behaviors from "correct" ones. Collaborative filtering recommender algorithms generate clinical decision support that is predictive of real practice patterns and clinical outcomes. Incorporating temporal relationships improves accuracy. Different evaluation metrics satisfy different goals (predicting likely events vs. "interesting" suggestions). Published by Oxford University Press on behalf of the American Medical Informatics Association 2015. This work is written by US Government

The anatomy of clinical decision-making in multidisciplinary cancer meetings

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Soukup, Tayana; Petrides, Konstantinos V.; Lamb, Benjamin W.; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S. A.; Sevdalis, Nick

2016-01-01

Abstract In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable. The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision. This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons. We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis. The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001). Hawthorne effect is the main limitation of the study. The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core

A prospective cohort study of treatment decision-making for prostate cancer following participation in a multidisciplinary clinic.

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Hurwitz, Lauren M; Cullen, Jennifer; Elsamanoudi, Sally; Kim, Daniel J; Hudak, Jane; Colston, Maryellen; Travis, Judith; Kuo, Huai-Ching; Porter, Christopher R; Rosner, Inger L

2016-05-01

Patients diagnosed with prostate cancer (PCa) are presented with several treatment options of similar efficacy but varying side effects. Understanding how and why patients make their treatment decisions, as well as the effect of treatment choice on long-term outcomes, is critical to ensuring effective, patient-centered care. This study examined treatment decision-making in a racially diverse, equal-access, contemporary cohort of patients with PCa counseled on treatment options at a multidisciplinary clinic. A prospective cohort study was initiated at the Walter Reed National Military Medical Center (formerly Walter Reed Army Medical Center) in 2006. Newly diagnosed patients with PCa were enrolled before attending a multidisciplinary clinic. Patients completed surveys preclinic and postclinic to assess treatment preferences, reasons for treatment choice, and decisional regret. As of January 2014, 925 patients with PCa enrolled in this study. Surgery (54%), external radiation (20%), and active surveillance (12%) were the most common primary treatments for patients with low- and intermediate-risk PCa, whereas patients with high-risk PCa chose surgery (34%) or external radiation with neoadjuvant hormones (57%). Treatment choice differed by age at diagnosis, race, comorbidity status, and calendar year in both univariable and multivariable analyses. Patients preferred to play an active role in the decision-making process and cited doctors at the clinic as the most helpful source of treatment-related information. Almost all patients reported satisfaction with their decision. This is one of the first prospective cohort studies to examine treatment decision-making in an equal-access, multidisciplinary clinic setting. Studies of this cohort would aid in understanding and improving the PCa decision-making process. Published by Elsevier Inc.

The effect of high-fidelity patient simulation on the critical thinking and clinical decision-making skills of new graduate nurses.

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Maneval, Rhonda; Fowler, Kimberly A; Kays, John A; Boyd, Tiffany M; Shuey, Jennifer; Harne-Britner, Sarah; Mastrine, Cynthia

2012-03-01

This study was conducted to determine whether the addition of high-fidelity patient simulation to new nurse orientation enhanced critical thinking and clinical decision-making skills. A pretest-posttest design was used to assess critical thinking and clinical decision-making skills in two groups of graduate nurses. Compared with the control group, the high-fidelity patient simulation group did not show significant improvement in mean critical thinking or clinical decision-making scores. When mean scores were analyzed, both groups showed an increase in critical thinking scores from pretest to posttest, with the high-fidelity patient simulation group showing greater gains in overall scores. However, neither group showed a statistically significant increase in mean test scores. The effect of high-fidelity patient simulation on critical thinking and clinical decision-making skills remains unclear. Copyright 2012, SLACK Incorporated.

Improving Decision Making about Genetic Testing in the Clinic: An Overview of Effective Knowledge Translation Interventions.

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Légaré, France; Robitaille, Hubert; Gane, Claire; Hébert, Jessica; Labrecque, Michel; Rousseau, François

2016-01-01

Knowledge translation (KT) interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties. We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing. We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153) published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC) and Consumers and Communication. We retrieved 2473 unique trials of which we retained only 28 (1%). Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1) and educational outreach (n = 1). Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15), communication of DNA-based disease risk estimates (n = 7), personalized risk communication (n = 3) and mobile phone messaging (n = 1). Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective. More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations.

Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions.

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Haider, Adil H; Schneider, Eric B; Sriram, N; Dossick, Deborah S; Scott, Valerie K; Swoboda, Sandra M; Losonczy, Lia; Haut, Elliott R; Efron, David T; Pronovost, Peter J; Lipsett, Pamela A; Cornwell, Edward E; MacKenzie, Ellen J; Cooper, Lisa A; Freischlag, Julie A

2015-05-01

Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to illuminate clinicians' roles in propagating disparities. To determine whether clinicians' unconscious race and/or social class biases correlate with patient management decisions. We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012. We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses. Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision. In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 [95% CI, 0.29-0.49]) and social class (mean IAT D score

The potential of predictive analytics to provide clinical decision support in depression treatment planning.

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Kessler, Ronald C

2018-01-01

To review progress developing clinical decision support tools for personalized treatment of major depressive disorder (MDD). Over the years, a variety of individual indicators ranging from biomarkers to clinical observations and self-report scales have been used to predict various aspects of differential MDD treatment response. Most of this work focused on predicting remission either with antidepressant medications versus psychotherapy, some antidepressant medications versus others, some psychotherapies versus others, and combination therapies versus monotherapies. However, to date, none of the individual predictors in these studies has been strong enough to guide optimal treatment selection for most patients. Interest consequently turned to decision support tools made up of multiple predictors, but the development of such tools has been hampered by small study sample sizes. Design recommendations are made here for future studies to address this problem. Recommendations include using large prospective observational studies followed by pragmatic trials rather than smaller, expensive controlled treatment trials for preliminary development of decision support tools; basing these tools on comprehensive batteries of inexpensive self-report and clinical predictors (e.g., self-administered performance-based neurocognitive tests) versus expensive biomarkers; and reserving biomarker assessments for targeted studies of patients not well classified by inexpensive predictor batteries.

Numerical methods for optimizing the performance of buildings

DEFF Research Database (Denmark)

Pedersen, Frank

2008-01-01

The many different parties that influence design and control decisions for buildings, such as building owners, users, architects, consulting engineers, contractors, etx. may have different and to some extent conradicting requirements to buildings. Furthermore, national building regulations specif...

Getting data out of the electronic patient record: critical steps in building a data warehouse for decision support.

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Ebidia, A; Mulder, C; Tripp, B; Morgan, M W

1999-01-01

Health care has taken advantage of computers to streamline many clinical and administrative processes. However, the potential of health care information technology as a source of data for clinical and administrative decision support has not been fully explored. This paper describes the process of developing on-line analytical processing (OLAP) capacity from data generated in an on-line transaction processing (OLTP) system (the electronic patient record). We discuss the steps used to evaluate the EPR system, retrieve the data, and create an analytical data warehouse accessible for analysis. We also summarize studies based on the data (lab re-engineering, practice variation in diagnostic decision-making and evaluation of a clinical alert). Besides producing a useful data warehouse, the process also increased understanding of organizational and cost considerations in purchasing OLAP tools. We discuss the limitations of our approach and ways in which these limitations can be addressed.

Interim analysis: A rational approach of decision making in clinical trial.

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Kumar, Amal; Chakraborty, Bhaswat S

2016-01-01

Interim analysis of especially sizeable trials keeps the decision process free of conflict of interest while considering cost, resources, and meaningfulness of the project. Whenever necessary, such interim analysis can also call for potential termination or appropriate modification in sample size, study design, and even an early declaration of success. Given the extraordinary size and complexity today, this rational approach helps to analyze and predict the outcomes of a clinical trial that incorporate what is learned during the course of a study or a clinical development program. Such approach can also fill the gap by directing the resources toward relevant and optimized clinical trials between unmet medical needs and interventions being tested currently rather than fulfilling only business and profit goals.

Interim analysis: A rational approach of decision making in clinical trial

Directory of Open Access Journals (Sweden)

Amal Kumar

2016-01-01

Full Text Available Interim analysis of especially sizeable trials keeps the decision process free of conflict of interest while considering cost, resources, and meaningfulness of the project. Whenever necessary, such interim analysis can also call for potential termination or appropriate modification in sample size, study design, and even an early declaration of success. Given the extraordinary size and complexity today, this rational approach helps to analyze and predict the outcomes of a clinical trial that incorporate what is learned during the course of a study or a clinical development program. Such approach can also fill the gap by directing the resources toward relevant and optimized clinical trials between unmet medical needs and interventions being tested currently rather than fulfilling only business and profit goals.

Intensity-modulated radiation therapy (IMRT) for locally advanced paranasal sinus tumors: incorporating clinical decisions in the optimization process

International Nuclear Information System (INIS)

Tsien, Christina; Eisbruch, Avraham; McShan, Daniel; Kessler, Marc; Marsh, Robin C.; Fraass, Benedick

2003-01-01

Purpose: Intensity-modulated radiotherapy (IMRT) plans require decisions about priorities and tradeoffs among competing goals. This study evaluates the incorporation of various clinical decisions into the optimization system, using locally advanced paranasal sinus tumors as a model. Methods and Materials: Thirteen patients with locally advanced paranasal sinus tumors were retrospectively replanned using inverse planning. Two clinical decisions were assumed: (1) Spare both optic pathways (OP), or (2) Spare only the contralateral OP. In each case, adequate tumor coverage (treated to 70 Gy in 35 fractions) was required. Two beamlet IMRT plans were thus developed for each patient using a class solution cost function. By altering one key variable at a time, different levels of risk of OP toxicity and planning target volume (PTV) compromise were compared in a systematic manner. The resulting clinical tradeoffs were analyzed using dosimetric criteria, tumor control probability (TCP), equivalent uniform dose (EUD), and normal tissue complication probability. Results: Plan comparisons representing the two clinical decisions (sparing both OP and sparing only the contralateral OP), with respect to minimum dose, TCP, V 95 , and EUD, demonstrated small, yet statistically significant, differences. However, when individual cases were analyzed further, significant PTV underdosage (>5%) was present in most cases for plans sparing both OP. In 6/13 cases (46%), PTV underdosage was between 5% and 15%, and in 3 cases (23%) was greater than 15%. By comparison, adequate PTV coverage was present in 8/13 cases (62%) for plans sparing only the contralateral OP. Mean target EUD comparisons between the two plans (including 9 cases where a clinical tradeoff between PTV coverage and OP sparing was required) were similar: 68.6 Gy and 69.1 Gy, respectively (p=0.02). Mean TCP values for those 9 cases were 56.5 vs. 61.7, respectively (p=0.006). Conclusions: In IMRT plans for paranasal sinus tumors

Evaluation of RxNorm for Medication Clinical Decision Support.

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Freimuth, Robert R; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G

2014-01-01

We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS.

Designing a Clinical Framework to Guide Gross Motor Intervention Decisions for Infants and Young Children with Hypotonia

Science.gov (United States)

Darrah, Johanna; O'Donnell, Maureen; Lam, Joyce; Story, Maureen; Wickenheiser, Diane; Xu, Kaishou; Jin, Xiaokun

2013-01-01

Clinical practice frameworks are a valuable component of clinical education, promoting informed clinical decision making based on the best available evidence and/or clinical experience. They encourage standardized intervention approaches and evaluation of practice. Based on an international project to support the development of an enhanced service…

Clinical and genetic correlates of decision making in anorexia nervosa.

Science.gov (United States)

Tenconi, Elena; Degortes, Daniela; Clementi, Maurizio; Collantoni, Enrico; Pinato, Claudia; Forzan, Monica; Cassina, Matteo; Santonastaso, Paolo; Favaro, Angela

2016-01-01

Decision-making (DM) abilities have been found to be impaired in anorexia nervosa (AN), but few data are available about the characteristics and correlates of this cognitive function. The aim of the present study was to provide data on DM functioning in AN using both veridical and adaptive paradigms. While in veridical DM tasks, the individual's ability to predict a true/false response is measured, adaptive DM is the ability to consider both internal and external demands in order to make a good choice, in the absence of a single true "correct" answer. The participants were 189 women, of whom 91 were eating-disordered patients with a lifetime diagnosis of anorexia nervosa, and 98 were healthy women. All the participants underwent clinical, neuropsychological, and genetic assessment. The cognitive evaluation included a set of neuropsychological tasks and two decision-making tests: The Iowa Gambling Task and the Cognitive Bias Task. Anorexia nervosa patients showed significantly poorer performances on both decision-making tasks than healthy women. The Cognitive Bias Task revealed that anorexia nervosa patients employed significantly more context-independent decision-making strategies, which were independent from diagnostic subtype, handedness, education, and psychopathology. In the whole sample (patients and controls), Cognitive Bias Task performance was independently predicted by lifetime anorexia nervosa diagnosis, body mass index at assessment, and 5-HTTLPR genotype. Patients displayed poor decision-making functioning in both veridical and adaptive situations. The difficulties detected in anorexia nervosa individuals may affect not only the ability to consider the future outcomes of their actions (leading to "myopia for the future"), but also the capacity to update and review one's own mindset according to new environmental stimuli.

Energy simulation in building design

NARCIS (Netherlands)

Hensen, J.L.M.

1992-01-01

Design decision support related to building energy consumption and / or indoor climate, should be based on an integral approach of environment, building, heating, ventilating and airconditioning (HVAC) system and occupants. The tools to achieve this are now available in the form of computer

Medical Device Integrated Vital Signs Monitoring Application with Real-Time Clinical Decision Support.

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Moqeem, Aasia; Baig, Mirza; Gholamhosseini, Hamid; Mirza, Farhaan; Lindén, Maria

2018-01-01

This research involves the design and development of a novel Android smartphone application for real-time vital signs monitoring and decision support. The proposed application integrates market available, wireless and Bluetooth connected medical devices for collecting vital signs. The medical device data collected by the app includes heart rate, oxygen saturation and electrocardiograph (ECG). The collated data is streamed/displayed on the smartphone in real-time. This application was designed by adopting six screens approach (6S) mobile development framework and focused on user-centered approach and considered clinicians-as-a-user. The clinical engagement, consultations, feedback and usability of the application in the everyday practices were considered critical from the initial phase of the design and development. Furthermore, the proposed application is capable to deliver rich clinical decision support in real-time using the integrated medical device data.

Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection.

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Dobler, Claudia C; Bosnic-Anticevich, Sinthia; Armour, Carol L

2018-01-01

The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice. 20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically. The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk-benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances. In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection

Directory of Open Access Journals (Sweden)

Claudia C. Dobler

2018-03-01

Full Text Available The aim of the study was to explore the views of tuberculosis (TB physicians on treatment of latent TB infection (LTBI, focusing on decision making and communication in clinical practice. 20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically. The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk–benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances. In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Moab, Utah: Using Energy Data to Target Carbon Reductions from Building Energy Efficiency (City Energy: From Data to Decisions)

Energy Technology Data Exchange (ETDEWEB)

Strategic Priorities and Impact Analysis Team, Office of Strategic Programs

2017-11-01

This fact sheet "Moab, Utah: Using Energy Data to Target Carbon Reductions from Building Energy Efficiency" explains how the City of Moab used data from the U.S. Department of Energy's Cities Leading through Energy Analysis and Planning (Cities-LEAP) and the State and Local Energy Data (SLED) programs to inform its city energy planning. It is one of ten fact sheets in the "City Energy: From Data to Decisions" series.

Testing decision-making competency of schizophrenia participants in clinical trials. A meta-analysis and meta-regression.

Science.gov (United States)

Hostiuc, Sorin; Rusu, Mugurel Constantin; Negoi, Ionut; Drima, Eduard

2018-01-05

The process of assessing the decision-making capacity of potential subjects before their inclusion in clinical trials is a legal requirement and a moral obligation, as it is essential for respecting their autonomy. This issue is especially important in psychiatry patients (such as those diagnosed with schizophrenia). The primary purpose of this article was to evaluate the degree of impairment in each dimension of decision-making capacity in schizophrenia patients compared to non-mentally-ill controls, as quantified by the (MacCAT-CR) instrument. Secondary objectives were (1) to see whether enhanced consent forms are associated with a significant increase in decision-making capacity in schizophrenia patients, and (2) if decision-making capacity in schizophrenia subjects is dependent on the age, gender, or the inpatient status of the subjects. We systematically reviewed the results obtained from three databases: ISI Web of Science, Pubmed, Scopus. Each database was scrutinised using the following keywords: "MacCAT-CR + schizophrenia", "decision-making capacity + schizophrenia", and "informed consent + schizophrenia." We included 13 studies in the analysis. The effect size between the schizophrenia and the control group was significant, with a difference in means of -4.43 (-5.76; -3.1, p reasoning, and -0.05 (-0.9, -0.01, p = 0.022) for expressing a choice. Even if schizophrenia patients have a significantly decreased decision-making capacity compared to non-mentally-ill controls, they should be considered as competent unless very severe changes are identifiable during clinical examination. Enhanced informed consent forms decrease the differences between schizophrenia patients and non-mentally-ill controls (except for the reasoning dimension) and should be used whenever the investigators want to include more ill patients in their clinical trials. Increased age, men gender and an increased percentage of inpatients might increase the differential of decision

Potential Impact on Clinical Decision Making via a Genome-Wide Expression Profiling: A Case Report

Directory of Open Access Journals (Sweden)

Hyun Kim

2016-11-01

Full Text Available Management of men with prostate cancer is fraught with uncertainty as physicians and patients balance efficacy with potential toxicity and diminished quality of life. Utilization of genomics as a prognostic biomarker has improved the informed decision-making process by enabling more rationale treatment choices. Recently investigations have begun to determine whether genomic information from tumor transcriptome data can be used to impact clinical decision-making beyond prognosis. Here we discuss the potential of genomics to alter management of a patient who presented with high-risk prostate adenocarcinoma. We suggest that this information help selecting patients for advanced imaging, chemotherapies, or clinical trial.

Big Data as a Driver for Clinical Decision Support Systems: A Learning Health Systems Perspective

Directory of Open Access Journals (Sweden)

Arianna Dagliati

2018-05-01

Full Text Available Big data technologies are nowadays providing health care with powerful instruments to gather and analyze large volumes of heterogeneous data collected for different purposes, including clinical care, administration, and research. This makes possible to design IT infrastructures that favor the implementation of the so-called “Learning Healthcare System Cycle,” where healthcare practice and research are part of a unique and synergic process. In this paper we highlight how “Big Data enabled” integrated data collections may support clinical decision-making together with biomedical research. Two effective implementations are reported, concerning decision support in Diabetes and in Inherited Arrhythmogenic Diseases.

Using decision analysis to assess comparative clinical efficacy of surgical treatment of unstable ankle fractures.

Science.gov (United States)

Michelson, James D

2013-11-01

The development of a robust treatment algorithm for ankle fractures based on well-established stability criteria has been shown to be prognostic with respect to treatment and outcomes. In parallel with the development of improved understanding of the biomechanical rationale of ankle fracture treatment has been an increased emphasis on assessing the effectiveness of medical and surgical interventions. The purpose of this study was to investigate the use of using decision analysis in the assessment of the cost effectiveness of operative treatment of ankle fractures based on the existing clinical data in the literature. Using the data obtained from a previous structured review of the ankle fracture literature, decision analysis trees were constructed using standard software. The decision nodes for the trees were based on ankle fracture stability criteria previously published. The outcomes were assessed by calculated Quality-Adjusted Life Years (QALYs) assigned to achieving normal ankle function, developing posttraumatic arthritis, or sustaining a postoperative infection. Sensitivity analysis was undertaken by varying the patient's age, incidence of arthritis, and incidence or infection. Decision analysis trees captured the essential aspects of clinical decision making in ankle fracture treatment in a clinically useful manner. In general, stable fractures yielded better outcomes with nonoperative treatment, whereas unstable fractures had better outcomes with surgery. These were consistent results over a wide range of postoperative infection rates. Varying the age of the patient did not qualitatively change the results. Between the ages of 30 and 80 years, surgery yielded higher expected QALYs than nonoperative care for unstable fractures, and generated lower QALYs than nonoperative care for stable fractures. Using local cost estimates for operative and nonoperative treatment, the incremental cost of surgery for unstable fractures was less than $40,000 per QALY (the

Patient Perceptions of Illness Identity in Cancer Clinical Trial Decision-Making.

Science.gov (United States)

Palmer-Wackerly, Angela L; Dailey, Phokeng M; Krok-Schoen, Jessica L; Rhodes, Nancy D; Krieger, Janice L

2018-08-01

When patients are diagnosed with cancer, they begin to negotiate their illness identity in relation to their past and future selves, their relationships, and their group memberships. Thus, how patients view their cancer in relation to their other identities may affect how and why they make particular decisions about treatment options. Using the Communication Theory of Identity (CTI), the current study explores: (1) how and why illness identity is framed across identity layers in relation to one particular cancer treatment: participation in a cancer clinical trial (CT); and (2) how and why patients experience identity conflicts while making their treatment decisions. Semi-structured, in-depth interviews were analyzed for 46 cancer patients who were offered a CT. Results of a grounded theory analysis indicated that patients expressed separate identity frames (e.g., personal, relational, and communal), aligned identity frames (e.g., personal and communal), and identity conflicts (e.g., personal-personal). This study theoretically shows how and why patient illness identity relates to cancer treatment decision-making as well as how and why patients relate (and conflict) with the cancer communal identity frame. Practical implications include how healthcare providers and family members can support patient decision-making through awareness of and accommodating to identity shifts.

Improving Decision Making about Genetic Testing in the Clinic: An Overview of Effective Knowledge Translation Interventions.

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France Légaré

Full Text Available Knowledge translation (KT interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties.We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing.We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153 published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC and Consumers and Communication.We retrieved 2473 unique trials of which we retained only 28 (1%. Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1 and educational outreach (n = 1. Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15, communication of DNA-based disease risk estimates (n = 7, personalized risk communication (n = 3 and mobile phone messaging (n = 1. Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective.More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations.

Automated Modular Magnetic Resonance Imaging Clinical Decision Support System (MIROR): An Application in Pediatric Cancer Diagnosis.

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Zarinabad, Niloufar; Meeus, Emma M; Manias, Karen; Foster, Katharine; Peet, Andrew

2018-05-02

Advances in magnetic resonance imaging and the introduction of clinical decision support systems has underlined the need for an analysis tool to extract and analyze relevant information from magnetic resonance imaging data to aid decision making, prevent errors, and enhance health care. The aim of this study was to design and develop a modular medical image region of interest analysis tool and repository (MIROR) for automatic processing, classification, evaluation, and representation of advanced magnetic resonance imaging data. The clinical decision support system was developed and evaluated for diffusion-weighted imaging of body tumors in children (cohort of 48 children, with 37 malignant and 11 benign tumors). Mevislab software and Python have been used for the development of MIROR. Regions of interests were drawn around benign and malignant body tumors on different diffusion parametric maps, and extracted information was used to discriminate the malignant tumors from benign tumors. Using MIROR, the various histogram parameters derived for each tumor case when compared with the information in the repository provided additional information for tumor characterization and facilitated the discrimination between benign and malignant tumors. Clinical decision support system cross-validation showed high sensitivity and specificity in discriminating between these tumor groups using histogram parameters. MIROR, as a diagnostic tool and repository, allowed the interpretation and analysis of magnetic resonance imaging images to be more accessible and comprehensive for clinicians. It aims to increase clinicians' skillset by introducing newer techniques and up-to-date findings to their repertoire and make information from previous cases available to aid decision making. The modular-based format of the tool allows integration of analyses that are not readily available clinically and streamlines the future developments. ©Niloufar Zarinabad, Emma M Meeus, Karen Manias

Disciplined Decision Making in an Interdisciplinary Environment: Some Implications for Clinical Applications of Statistical Process Control.

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Hantula, Donald A.

1995-01-01

Clinical applications of statistical process control (SPC) in human service organizations are considered. SPC is seen as providing a standard set of criteria that serves as a common interface for data-based decision making, which may bring decision making under the control of established contingencies rather than the immediate contingencies of…

On algorithm for building of optimal α-decision trees

KAUST Repository

Alkhalid, Abdulaziz; Chikalov, Igor; Moshkov, Mikhail

2010-01-01

The paper describes an algorithm that constructs approximate decision trees (α-decision trees), which are optimal relatively to one of the following complexity measures: depth, total path length or number of nodes. The algorithm uses dynamic

Building capacity for evidence informed decision making in public health: a case study of organizational change.

Science.gov (United States)

Peirson, Leslea; Ciliska, Donna; Dobbins, Maureen; Mowat, David

2012-02-20

Core competencies for public health in Canada require proficiency in evidence informed decision making (EIDM). However, decision makers often lack access to information, many workers lack knowledge and skills to conduct systematic literature reviews, and public health settings typically lack infrastructure to support EIDM activities. This research was conducted to explore and describe critical factors and dynamics in the early implementation of one public health unit's strategic initiative to develop capacity to make EIDM standard practice. This qualitative case study was conducted in one public health unit in Ontario, Canada between 2008 and 2010. In-depth information was gathered from two sets of semi-structured interviews and focus groups (n = 27) with 70 members of the health unit, and through a review of 137 documents. Thematic analysis was used to code the key informant and document data. The critical factors and dynamics for building EIDM capacity at an organizational level included: clear vision and strong leadership, workforce and skills development, ability to access research (library services), fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management. With leadership, planning, commitment and substantial investments, a public health department has made significant progress, within the first two years of a 10-year initiative, towards achieving its goal of becoming an evidence informed decision making organization.

Uninformed Clinical Decisions Resulting From Lack of Adherence Assessment in Children with New Onset Epilepsy

Science.gov (United States)

Modi, Avani C.; Wu, Yelena P.; Guilfoyle, Shanna M.; Glauser, Tracy A.

2012-01-01

This study examined the relationship between non-adherence to antiepileptic drug (AED) therapy and clinical decision-making in a cohort of 112 children with newly-diagnosed epilepsy. AED adherence was monitored using electronic monitoring over the first six months of therapy. The primary outcome measure was rate of uninformed clinical decisions as defined by number of participants with AED dosage or drug changes to address continued seizures who demonstrated non-adherence prior to the seizure. Among the 52 (47%) participants who had an AED change for continued seizures, 30 (27% of the overall cohort) had imperfect medication adherence prior to their seizures. A quarter of children with new onset epilepsy had uninformed medication changes because adherence was not rigorously assessed in clinical practice. Results highlight the importance of routinely assessing medication adherence in this population. PMID:23159375

The MaSe decision support system: Development of an integrated information system for the selection of environmentally preferable materials and products in the building process

Energy Technology Data Exchange (ETDEWEB)

Strand, Sigrid Melby

2003-07-01

New building regulations and increased focus on building related environmental burdens have created a need for guidance to design more sustainable buildings. The main objective in this thesis is to develop a decision support system, to guide decision-makers to a better selection of building materials and products, based on environmental prioritisation. The system is focused on building materials and products, but the structure of the system can be adapted to other types of decision problems. No tool is found that satisfy the identified needs for a material selection system. By studying existing methods, however important information and possible solutions are gathered, that partly could be used in a new tool. Key decision makers with respect to material and product selection are the client, the architects, the technical consultants, and the contractors when they decide on specific brands. The user of the MaSe system first identifies the materials acceptable in the specific project, based on the technical requirements. These pre-selected materials are then scored and ranked through the procedures in the MaSe system. The alternative ranking is then the basis for the selection of construction elements, materials or products. Seeing the building and real estate industry as a part of our society, it is clear that the use of material resources and pollution are areas that need improvement. The MaSe system includes environmental aspects under the headlines Resources, Ecology and Human health. When selecting building materials, factors like recycling and reuse needs to be considered. Renewability, energy and waste are other aspects included in the Resource area. Toxic substances are clearly important when it comes to building materials. Factors to be included under the headline Ecology are global warming, acidification, and photochemical oxidant formation. The emissions of toxics to air, water and soil will have effect on human health. Aspects that should be included in

Sustainable Buildings in Interaction

DEFF Research Database (Denmark)

Elle, Morten

2007-01-01

The first attempts to build sustainable buildings in Denmark were typically located on the countryside. The basic idea was to create buildings that were independent of the technical infrastructure. District heating has, however, been the dominating solution to heating in buildings in Denmark......, and the focus on sustainable building have gradually turned from special houses on the countryside to normally looking houses in the urban fabric, integrated in the technical infrastructure. Some new built urban areas in Denmark will, however, not have to be supplied with district heating – these developments...... are going to consist of passive houses. The first sustainable buildings were built by their users, and the user – building interaction still play a decisive role for the performance of the present sustainable buildings. The users have to understand how the building functions. Urban design is essential...

A Survey on Turkish nursing students' perception of clinical learning environment and its association with academic motivation and clinical decision making.

Science.gov (United States)

Aktaş, Yeşim Yaman; Karabulut, Neziha

2016-01-01

Nursing education is a process that includes theoretical and practical learning and requires the acquisition of theoretical knowledge and skill. Nursing students need a good clinical practice environment in order to apply their knowledge and skills due to the fact that the clinical practice settings play an important role in the nursing profession. This study was carried out in an effort to explore nursing students' perception of the clinical learning environment and its association with academic motivation and clinical decision making. A descriptive survey design was used. This study was conducted in Giresun University in Turkey. Participants were second-, third- and fourth-year undergraduate students (n=222) in the Bachelor of Nursing Science Degree in the academic spring term of 2014-2015. The data was collected using the 'Clinical Learning Environment Scale', the 'Academic Motivation, and the 'The Clinical Decision Making in Nursing Scale'. Of the respondents in this study, 45% of the students were second class, 30.6% of the students were third class and 24.3% of the students were fourth class. There was a statistically significant positive correlation found between the clinical learning environment and the nursing students' academic motivation (r=0.182, pdecision making (r=0.082, p>.05). One of the prerequisites for the training of qualified students is to provide nursing students with a qualified clinical environment. It was found that nursing students' academic motivation increased as the quality of their clinical learning environment improved. Copyright © 2015 Elsevier Ltd. All rights reserved.

Barriers for an effective communication around clinical decision making: an analysis of the gaps between doctors' and patients' point of view.

Science.gov (United States)

Mira, José Joaquín; Guilabert, Mercedes; Pérez-Jover, Virtudes; Lorenzo, Susana

2014-12-01

There are doubts on whether patients feel that they have sufficient information for actively participating in clinical decisions. To describe the type of information that patients receive. To determine whether patients consider this information sufficient, and whether it contributes or not to improve clinical safety. To identify the barriers for patient participation in clinical decision making. Cross-sectional study with 764 patients and 327 physicians. Fourteen health centres belonging to three primary care districts and three hospitals in Spain. Just 35.1% (268) (95% CI 32.2, 39.1%) of patients preferred to have the last word in clinical decisions. Age (39 vs. 62%, P communication by the patients. Only 19.6% (64) (95% CI 15.4, 24.2%) of doctors considered that they could intervene to involve patients in the decisions. The majority of patients prefer the decisions to be made by their doctor, especially those with more severe illnesses, and older patients. Patients are not normally informed about medication interactions, precautions and foreseeable complications. The information provided by general practitioners does not seem to contribute enough to the patient involvement in clinical safety. © 2012 John Wiley & Sons Ltd.

Peripheral Exophytic Oral Lesions: A Clinical Decision Tree

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Hamed Mortazavi

2017-01-01

Full Text Available Diagnosis of peripheral oral exophytic lesions might be quite challenging. This review article aimed to introduce a decision tree for oral exophytic lesions according to their clinical features. General search engines and specialized databases including PubMed, PubMed Central, Medline Plus, EBSCO, Science Direct, Scopus, Embase, and authenticated textbooks were used to find relevant topics by means of keywords such as “oral soft tissue lesion,” “oral tumor like lesion,” “oral mucosal enlargement,” and “oral exophytic lesion.” Related English-language articles published since 1988 to 2016 in both medical and dental journals were appraised. Upon compilation of data, peripheral oral exophytic lesions were categorized into two major groups according to their surface texture: smooth (mesenchymal or nonsquamous epithelium-originated and rough (squamous epithelium-originated. Lesions with smooth surface were also categorized into three subgroups according to their general frequency: reactive hyperplastic lesions/inflammatory hyperplasia, salivary gland lesions (nonneoplastic and neoplastic, and mesenchymal lesions (benign and malignant neoplasms. In addition, lesions with rough surface were summarized in six more common lesions. In total, 29 entities were organized in the form of a decision tree in order to help clinicians establish a logical diagnosis by a stepwise progression method.

Development of a real-time clinical decision support system upon the Web MVC-based architecture for prostate cancer treatment.

Science.gov (United States)

Lin, Hsueh-Chun; Wu, Hsi-Chin; Chang, Chih-Hung; Li, Tsai-Chung; Liang, Wen-Miin; Wang, Jong-Yi Wang

2011-03-08

A real-time clinical decision support system (RTCDSS) with interactive diagrams enables clinicians to instantly and efficiently track patients' clinical records (PCRs) and improve their quality of clinical care. We propose a RTCDSS to process online clinical informatics from multiple databases for clinical decision making in the treatment of prostate cancer based on Web Model-View-Controller (MVC) architecture, by which the system can easily be adapted to different diseases and applications. We designed a framework upon the Web MVC-based architecture in which the reusable and extractable models can be conveniently adapted to other hospital information systems and which allows for efficient database integration. Then, we determined the clinical variables of the prostate cancer treatment based on participating clinicians' opinions and developed a computational model to determine the pretreatment parameters. Furthermore, the components of the RTCDSS integrated PCRs and decision factors for real-time analysis to provide evidence-based diagrams upon the clinician-oriented interface for visualization of treatment guidance and health risk assessment. The resulting system can improve quality of clinical treatment by allowing clinicians to concurrently analyze and evaluate the clinical markers of prostate cancer patients with instantaneous clinical data and evidence-based diagrams which can automatically identify pretreatment parameters. Moreover, the proposed RTCDSS can aid interactions between patients and clinicians. Our proposed framework supports online clinical informatics, evaluates treatment risks, offers interactive guidance, and provides real-time reference for decision making in the treatment of prostate cancer. The developed clinician-oriented interface can assist clinicians in conveniently presenting evidence-based information to patients and can be readily adapted to an existing hospital information system and be easily applied in other chronic diseases.

Effects of ventilation rate per person and per floor area on perceived air quality, sick building syndrome symptoms, and decision-making.

Science.gov (United States)

Maddalena, R; Mendell, M J; Eliseeva, K; Chan, W R; Sullivan, D P; Russell, M; Satish, U; Fisk, W J

2015-08-01

Ventilation rates (VRs) in buildings must adequately control indoor levels of pollutants; however, VRs are constrained by the energy costs. Experiments in a simulated office assessed the effects of VR per occupant on perceived air quality (PAQ), Sick Building Syndrome (SBS) symptoms, and decision-making performance. A parallel set of experiments assessed the effects of VR per unit floor area on the same outcomes. Sixteen blinded healthy young adult subjects participated in each study. Each exposure lasted four hours and each subject experienced two conditions in a within-subject study design. The order of presentation of test conditions, day of testing, and gender were balanced. Temperature, relative humidity, VRs, and concentrations of pollutants were monitored. Online surveys assessed PAQ and SBS symptoms and a validated computer-based tool measured decision-making performance. Neither changing the VR per person nor changing the VR per floor area, had consistent statistically significant effects on PAQ or SBS symptoms. However, reductions in either occupant-based VR or floor-area-based VR had a significant and independent negative impact on most decision-making measures. These results indicate that the changes in VR employed in the study influence performance of healthy young adults even when PAQ and SBS symptoms are unaffected. The study results indicate the importance of avoiding low VRs per person and low VRs per floor area to minimize decrements in cognitive performance. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Molecular and protein markers for clinical decision making in breast cancer: today and tomorrow.

Science.gov (United States)

Harbeck, Nadia; Sotlar, Karl; Wuerstlein, Rachel; Doisneau-Sixou, Sophie

2014-04-01

In early breast cancer (eBC), established clinicopathological factors are not sufficient for clinical decision making particularly regarding adjuvant chemotherapy since substantial over- or undertreatment may occur. Thus, novel protein- and molecular markers have been put forward as decision aids. Since these potential prognosis and/or predictive tests differ substantially regarding their methodology, analytical and clinical validation, this review attempts to summarize the essential facts for clinicians. This review focuses on those markers which are the most advanced so far in their development towards routine clinical application, i.e. two protein markers (i.e. uPA/PAI-1 and IHC4) and six molecular multigene tests (i.e. Mammaprint®, Oncotype DX®, PAM50, Endopredict®, the 97-gene genomic grade, and 76 gene Rotterdam signatures). Next to methodological aspects, we summarized the clinical evidences, in particular the main prospective clinical trials which have already been fully recruited (i.e. MINDACT, TAILORx, WSG PLAN B) or are still ongoing (i.e. RxPONDER/SWOG S1007, WSG-ADAPT). Last but not least, this review points out the key elements for clinicians to select one test among the wide panel of proposed assays, for a specific population of patients in term of level of evidence, analytical and clinical validity as well as cost effectiveness. Copyright © 2013 Elsevier Ltd. All rights reserved.

A programmable rules engine to provide clinical decision support using HTML forms.

Science.gov (United States)

Heusinkveld, J; Geissbuhler, A; Sheshelidze, D; Miller, R

1999-01-01

The authors have developed a simple method for specifying rules to be applied to information on HTML forms. This approach allows clinical experts, who lack the programming expertise needed to write CGI scripts, to construct and maintain domain-specific knowledge and ordering capabilities within WizOrder, the order-entry and decision support system used at Vanderbilt Hospital. The clinical knowledge base maintainers use HTML editors to create forms and spreadsheet programs for rule entry. A test environment has been developed which uses Netscape to display forms; the production environment displays forms using an embedded browser.

Development, implementation and evaluation of a clinical research engagement and leadership capacity building program in a large Australian health care service.

Science.gov (United States)

Misso, Marie L; Ilic, Dragan; Haines, Terry P; Hutchinson, Alison M; East, Christine E; Teede, Helena J

2016-01-14

Health professionals need to be integrated more effectively in clinical research to ensure that research addresses clinical needs and provides practical solutions at the coal face of care. In light of limited evidence on how best to achieve this, evaluation of strategies to introduce, adapt and sustain evidence-based practices across different populations and settings is required. This project aims to address this gap through the co-design, development, implementation, evaluation, refinement and ultimately scale-up of a clinical research engagement and leadership capacity building program in a clinical setting with little to no co-ordinated approach to clinical research engagement and education. The protocol is based on principles of research capacity building and on a six-step framework, which have previously led to successful implementation and long-term sustainability. A mixed methods study design will be used. Methods will include: (1) a review of the literature about strategies that engage health professionals in research through capacity building and/or education in research methods; (2) a review of existing local research education and support elements; (3) a needs assessment in the local clinical setting, including an online cross-sectional survey and semi-structured interviews; (4) co-design and development of an educational and support program; (5) implementation of the program in the clinical environment; and (6) pre- and post-implementation evaluation and ultimately program scale-up. The evaluation focuses on research activity and knowledge, attitudes and preferences about clinical research, evidence-based practice and leadership and post implementation, about their satisfaction with the program. The investigators will evaluate the feasibility and effect of the program according to capacity building measures and will revise where appropriate prior to scale-up. It is anticipated that this clinical research engagement and leadership capacity building

From Learning to Decision-Making: A Cross-Sectional Survey of a Clinical Pharmacist-Steered Journal Club

Directory of Open Access Journals (Sweden)

Sherine Ismail

2017-01-01

Full Text Available Journal clubs have been traditionally incorporated into academic training programs to enhance competency in the interpretation of literature. We designed a structured journal club (JC to improve skills in the interpretation of literature; however, we were not aware of how learners (interns, residents, clinical pharmacists, etc. would perceive it. We aimed to assess the perception of learners at different levels of pharmacy training. A cross-sectional design was used. A self-administered online survey was emailed to JC attendees from 2010–2014 at King Abdulaziz Medical City, Jeddah, Saudi Arabia. The survey questions included: introduction sessions, topic selection, JC layout, interaction with the moderator, and decision-making skills by clinical pharmacists. The response rate was 58/89 (65%; 52/54 (96% respondents believed that JC adds to their knowledge in interpreting literature. Topic selection met the core curriculum requirements for credentials exams for 16/36 (44.4%, while 16/22 (73% presenters had good to excellent interaction with the moderator. JC facilitated decision-making for 10/12 (83% of clinical pharmacists. The results suggest that clinical pharmacist-steered JC may serve as an effective tool to empower learners at different levels of pharmacy practice, with evidence-based principles for interpretation of literature and guide informed decision-making.

Exploring a Laboratory Model of Pharmacogenetics as Applied to Clinical Decision Making

Directory of Open Access Journals (Sweden)

David F. Kisor

2013-01-01

Full Text Available Objective: To evaluate a pilot of a laboratory model for relating pharmacogenetics to clinical decision making. Case Study: This pilot was undertaken and evaluated to help determine if a pharmacogenetics laboratory should be included in the core Doctor of Pharmacy curriculum. The placement of the laboratory exercise in the curriculum was determined by identifying the point in the curriculum where the students had been introduced to the chemistry of deoxyribonucleic acid (DNA as well as instructed on the chemistry of genetic variation. The laboratory included cytochrome P450 2C19 genotyping relative to the *2 variant. Twenty-four students served as the pilot group. Students provided buccal swabs as the source of DNA. Students stabilized the samples and were then provided instructions related to sample preparation, polymerase chain reaction, and gel electrophoresis. The results were reported as images of gels. Students used a reference gel image to compare their results to. Students then applied a dosing algorithm to make a "clinical decision" relative to clopidogrel use. Students were offered a post laboratory survey regarding attitudes toward the laboratory. Twenty-four students completed the laboratory with genotyping results being provided for 22 students (91.7%. Sixteen students were wild-type (*1/*1, while six students were heterozygous (*1/*2. Twenty-three students (96% completed the post laboratory survey. All 23 agreed (6, 26.1% or strongly agreed (17, 73.9% that the laboratory "had relevance and value in the pharmacy curriculum" Conclusion: The post pilot study survey exploring a laboratory model for pharmacogenetics related to clinical decision making indicated that such a laboratory would be viewed positively by students. This model may be adopted by colleges to expand pharmacogenetics education.   Type: Case Study

Professional autonomy in 21st century healthcare: nurses' accounts of clinical decision-making.

Science.gov (United States)

Traynor, Michael; Boland, Maggie; Buus, Niels

2010-10-01

Autonomy in decision-making has traditionally been described as a feature of professional work, however the work of healthcare professionals has been seen as steadily encroached upon by State and managerialist forces. Nursing has faced particular problems in establishing itself as a credible profession for reasons including history, gender and a traditional subservience to medicine. This paper reports on a focus group study of UK nurses participating in post-qualifying professional development in 2008. Three groups of nurses in different specialist areas comprised a total of 26 participants. The study uses accounts of decision-making to gain insight into contemporary professional nursing. The study also aims to explore the usefulness of a theory of professional work set out by Jamous and Peloille (1970). The analysis draws on notions of interpretive repertoires and elements of narrative analysis. We identified two interpretive repertoires: 'clinical judgement' which was used to describe the different grounds for making judgements; and 'decision-making' which was used to describe organisational circumstances influencing decision-making. Jamous and Peloille's theory proved useful for interpreting instances where the nurses collectively withdrew from the potential dangers of too extreme claims for technicality or indeterminacy in their work. However, their theory did not explain the full range of accounts of decision-making that were given. Taken at face value, the accounts from the participants depict nurses as sometimes practising in indirect ways in order to have influence in the clinical and bureaucratic setting. However, a focus on language use and in particular, interpretive repertoires, has enabled us to suggest that despite an overall picture of severely limited autonomy, nurses in the groups reproduced stories of the successful accomplishment of moral and influential action. Copyright © 2010 Elsevier Ltd. All rights reserved.

Decision analysis in the clinical neurosciences

NARCIS (Netherlands)

D.W.J. Dippel (Diederik)

1994-01-01

textabstractDiagnostic and therapeutic choice in neurology can fortunately be made without formal decision support in the majority of cases. in many patients a diagnosis and treatment choice are relatively easy to establish. This study however, concerns the application of a decision support

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

Science.gov (United States)

Aydon, Laurene; Hauck, Yvonne; Zimmer, Margo; Murdoch, Jamee

2016-09-01

The aim of this study was to identify factors that influence nurse's decisions to question concerning aspects of medication administration within the context of a neonatal clinical care unit. Medication error in the neonatal setting can be high with this particularly vulnerable population. As the care giver responsible for medication administration, nurses are deemed accountable for most errors. However, they are recognised as the forefront of prevention. Minimal evidence is available around reasoning, decision making and questioning around medication administration. Therefore, this study focuses upon addressing the gap in knowledge around what nurses believe influences their decision to question. A critical incident design was employed where nurses were asked to describe clinical incidents around their decision to question a medication issue. Nurses were recruited from a neonatal clinical care unit and participated in an individual digitally recorded interview. One hundred and three nurses participated between December 2013-August 2014. Use of the constant comparative method revealed commonalities within transcripts. Thirty-six categories were grouped into three major themes: 'Working environment', 'Doing the right thing' and 'Knowledge about medications'. Findings highlight factors that influence nurses' decision to question issues around medication administration. Nurses feel it is their responsibility to do the right thing and speak up for their vulnerable patients to enhance patient safety. Negative dimensions within the themes will inform planning of educational strategies to improve patient safety, whereas positive dimensions must be reinforced within the multidisciplinary team. The working environment must support nurses to question and ultimately provide safe patient care. Clear and up to date policies, formal and informal education, role modelling by senior nurses, effective use of communication skills and a team approach can facilitate nurses to

Temporal characteristics of decisions in hospital encounters: a threshold for shared decision making? A qualitative study.

Science.gov (United States)

Ofstad, Eirik H; Frich, Jan C; Schei, Edvin; Frankel, Richard M; Gulbrandsen, Pål

2014-11-01

To identify and characterize physicians' statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings. Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital. Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters. Clinical decisions related to a patient-physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients. In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

MULTI-PERSON DECISION FOR SUSTAINABLE DESIGN ON IBS FLOOR SYSTEM SELECTION

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Christiono Utomo

2013-05-01

Full Text Available Selecting a design solution (choice problem is one of the natures of design decision. If the problem is more complex and involves multi participants, decision aid is necessary. This paper discusses the nature of group judgment and negotiation on multi-criteria decision-making methodologies. It presents a conceptual model of negotiation support in a multi-person decision on building floor system selection. Decision technique (AHP was applied for decision process in a satisfying options and game theory for coalition formation. An n-person cooperative game is represented by a set of all players. The proposed coalition formation model enables each agent to select individually or coalition. It improves the value of building system decision. It further emphasizes the importance of performance evaluation in the design process and value-based decision. The support model can be extended to an automated negotiation and in different building system selection with proper  modification. Keywords: Multi-person, design decision, IBS, floor system selection.

Decisive management in selecting locations for development of construction projects

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Szafranko, E.; Pawłowicz, J. A.

2017-08-01

The location of an investment project is one of the most important decisions in the construction and land development business. The shape of a new building and aspects of its future use depend on making a good choice of a land plot where it will be constructed. There are many characteristics involved descriptions of land available for development. On the one hand, different buildings (with different envisaged use) fit differently to a given location. Residential homes, for example, require a location which will ensure a peaceful lifestyle, with places for walks and recreation, situated in a relatively quite setting. On the other hand, close proximity to schools, shops or a health clinic is another important consideration. Industrial buildings should be localized so as not to be a nuisance to others, and their location should facilitate efficient transport of raw materials and ready products. Yet other requirements are defined for public buildings. It is therefore evident that the characteristics included in an evaluation of the location of a planned building can be highly diverse and their diversity makes the evaluation difficult. Selection of a location can be supported by a variety of methods. For instance, an evaluation can rely on assigning points which indicate the fulfillment of certain criteria. This approach generates a complex evaluation in the form of tables and maps of usefulness. Another possibility is to make an assessment of the criteria that a given land parcels should satisfy in order to develop a specific type of a building. Having combined these two sets of information, we can create a system or a model for the management of land resources, which will easily help to support decision making processes pertaining to the choice of a location. This article shows a model approach for a specific building.

[Which research is needed to support clinical decision-making on integrative medicine? Can comparative effectiveness research close the gap?].

Science.gov (United States)

Witt, Claudia M; Huang, Wen-jing; Lao, Lixing; Berman, Brian M

2013-08-01

In clinical research on complementary and integrative medicine, experts and scientists have often pursued a research agenda in spite of an incomplete understanding of the needs of end users. Consequently, the majority of previous clinical trials have mainly assessed the efficacy of interventions. Scant data is available on their effectiveness. Comparative effectiveness research (CER) promises to support decision makers by generating evidence that compares the benefits and harms of best care options. This evidence, more generalizable than evidence generated by traditional randomized clinical trials (RCTs), is better suited to inform real-world care decisions. An emphasis on CER supports the development of the evidence base for clinical and policy decision-making. Whereas in most areas of complementary and integrative medicine data on CER is scarce, available acupuncture research already contributes to CER evidence. This paper will introduce CER and make suggestions for future research.

Multimorbidity, service organization and clinical decision making in primary care: a qualitative study.

Science.gov (United States)

Bower, Peter; Macdonald, Wendy; Harkness, Elaine; Gask, Linda; Kendrick, Tony; Valderas, Jose M; Dickens, Chris; Blakeman, Tom; Sibbald, Bonnie

2011-10-01

Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.

Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

Science.gov (United States)

Boehler, Margaret L; Schwind, Cathy J; Markwell, Stephen J; Minter, Rebecca M

2017-01-01

Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

Building of fuzzy decision trees using ID3 algorithm

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Begenova, S. B.; Avdeenko, T. V.

2018-05-01

Decision trees are widely used in the field of machine learning and artificial intelligence. Such popularity is due to the fact that with the help of decision trees graphic models, text rules can be built and they are easily understood by the final user. Because of the inaccuracy of observations, uncertainties, the data, collected in the environment, often take an unclear form. Therefore, fuzzy decision trees becoming popular in the field of machine learning. This article presents a method that includes the features of the two above-mentioned approaches: a graphical representation of the rules system in the form of a tree and a fuzzy representation of the data. The approach uses such advantages as high comprehensibility of decision trees and the ability to cope with inaccurate and uncertain information in fuzzy representation. The received learning method is suitable for classifying problems with both numerical and symbolic features. In the article, solution illustrations and numerical results are given.

Workshop on using natural language processing applications for enhancing clinical decision making: an executive summary.

Science.gov (United States)

Pai, Vinay M; Rodgers, Mary; Conroy, Richard; Luo, James; Zhou, Ruixia; Seto, Belinda

2014-02-01

In April 2012, the National Institutes of Health organized a two-day workshop entitled 'Natural Language Processing: State of the Art, Future Directions and Applications for Enhancing Clinical Decision-Making' (NLP-CDS). This report is a summary of the discussions during the second day of the workshop. Collectively, the workshop presenters and participants emphasized the need for unstructured clinical notes to be included in the decision making workflow and the need for individualized longitudinal data tracking. The workshop also discussed the need to: (1) combine evidence-based literature and patient records with machine-learning and prediction models; (2) provide trusted and reproducible clinical advice; (3) prioritize evidence and test results; and (4) engage healthcare professionals, caregivers, and patients. The overall consensus of the NLP-CDS workshop was that there are promising opportunities for NLP and CDS to deliver cognitive support for healthcare professionals, caregivers, and patients.

Clinical Performance and Management Outcomes with the DecisionDx-UM Gene Expression Profile Test in a Prospective Multicenter Study

Directory of Open Access Journals (Sweden)

Kristen Meldi Plasseraud

2016-01-01

Full Text Available Uveal melanoma management is challenging due to its metastatic propensity. DecisionDx-UM is a prospectively validated molecular test that interrogates primary tumor biology to provide objective information about metastatic potential that can be used in determining appropriate patient care. To evaluate the continued clinical validity and utility of DecisionDx-UM, beginning March 2010, 70 patients were enrolled in a prospective, multicenter, IRB-approved study to document patient management differences and clinical outcomes associated with low-risk Class 1 and high-risk Class 2 results indicated by DecisionDx-UM testing. Thirty-seven patients in the prospective study were Class 1 and 33 were Class 2. Class 1 patients had 100% 3-year metastasis-free survival compared to 63% for Class 2 (log rank test p=0.003 with 27.3 median follow-up months in this interim analysis. Class 2 patients received significantly higher-intensity monitoring and more oncology/clinical trial referrals compared to Class 1 patients (Fisher’s exact test p=2.1×10-13 and p=0.04, resp.. The results of this study provide additional, prospective evidence in an independent cohort of patients that Class 1 and Class 2 patients are managed according to the differential metastatic risk indicated by DecisionDx-UM. The trial is registered with Clinical Application of DecisionDx-UM Gene Expression Assay Results (NCT02376920.

Genetic Stratification in Myeloid Diseases: From Risk Assessment to Clinical Decision Support Tool

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Yishai Ofran

2014-10-01

Full Text Available Genetic aberrations have become a dominant factor in the stratification of myeloid malignancies. Cytogenetic and a few mutation studies are the backbone of risk assessment models of myeloid malignancies which are a major consideration in clinical decisions, especially patient assignment for allogeneic stem cell transplantation. Progress in our understanding of the genetic basis of the pathogenesis of myeloid malignancies and the growing capabilities of mass sequencing may add new roles for the clinical usage of genetic data. A few recently identified mutations recognized to be associated with specific diseases or clinical scenarios may soon become part of the diagnostic criteria of such conditions. Mutational studies may also advance our capabilities for a more efficient patient selection process, assigning the most effective therapy at the best timing for each patient. The clinical utility of genetic data is anticipated to advance further with the adoption of deep sequencing and next-generation sequencing techniques. We herein suggest some future potential applications of sequential genetic data to identify pending deteriorations at time points which are the best for aggressive interventions such as allogeneic stem cell transplantation. Genetics is moving from being mostly a prognostic factor to becoming a multitasking decision support tool for hematologists. Physicians must pay attention to advances in molecular hematology as it will soon be accessible and influential for most of our patients.

Decision theory and the evaluation of risks and benefits of clinical trials.

Science.gov (United States)

Bernabe, Rosemarie D C; van Thiel, Ghislaine J M W; Raaijmakers, Jan A M; van Delden, Johannes J M

2012-12-01

Research ethics committees (RECs) are tasked to assess the risks and the benefits of a clinical trial. In previous studies, it was shown that RECs find this task difficult, if not impossible, to do. The current approaches to benefit-risk assessment (i.e. Component Analysis and the Net Risk Test) confound the various risk-benefit tasks, and as such, make balancing impossible. In this article, we show that decision theory, specifically through the expected utility theory and multiattribute utility theory, enable for an explicit and ethically weighted risk-benefit evaluation. This makes a balanced ethical justification possible, and thus a more rationally defensible decision making. Copyright © 2012 Elsevier Ltd. All rights reserved.

Free and open source enabling technologies for patient-centric, guideline-based clinical decision support: a survey.

Science.gov (United States)

Leong, T Y; Kaiser, K; Miksch, S

2007-01-01

Guideline-based clinical decision support is an emerging paradigm to help reduce error, lower cost, and improve quality in evidence-based medicine. The free and open source (FOS) approach is a promising alternative for delivering cost-effective information technology (IT) solutions in health care. In this paper, we survey the current FOS enabling technologies for patient-centric, guideline-based care, and discuss the current trends and future directions of their role in clinical decision support. We searched PubMed, major biomedical informatics websites, and the web in general for papers and links related to FOS health care IT systems. We also relied on our background and knowledge for specific subtopics. We focused on the functionalities of guideline modeling tools, and briefly examined the supporting technologies for terminology, data exchange and electronic health record (EHR) standards. To effectively support patient-centric, guideline-based care, the computerized guidelines and protocols need to be integrated with existing clinical information systems or EHRs. Technologies that enable such integration should be accessible, interoperable, and scalable. A plethora of FOS tools and techniques for supporting different knowledge management and quality assurance tasks involved are available. Many challenges, however, remain in their implementation. There are active and growing trends of deploying FOS enabling technologies for integrating clinical guidelines, protocols, and pathways into the main care processes. The continuing development and maturation of such technologies are likely to make increasingly significant contributions to patient-centric, guideline-based clinical decision support.

Development of a real-time clinical decision support system upon the web mvc-based architecture for prostate cancer treatment

Directory of Open Access Journals (Sweden)

Liang Wen-Miin

2011-03-01

Full Text Available Abstract Background A real-time clinical decision support system (RTCDSS with interactive diagrams enables clinicians to instantly and efficiently track patients' clinical records (PCRs and improve their quality of clinical care. We propose a RTCDSS to process online clinical informatics from multiple databases for clinical decision making in the treatment of prostate cancer based on Web Model-View-Controller (MVC architecture, by which the system can easily be adapted to different diseases and applications. Methods We designed a framework upon the Web MVC-based architecture in which the reusable and extractable models can be conveniently adapted to other hospital information systems and which allows for efficient database integration. Then, we determined the clinical variables of the prostate cancer treatment based on participating clinicians' opinions and developed a computational model to determine the pretreatment parameters. Furthermore, the components of the RTCDSS integrated PCRs and decision factors for real-time analysis to provide evidence-based diagrams upon the clinician-oriented interface for visualization of treatment guidance and health risk assessment. Results The resulting system can improve quality of clinical treatment by allowing clinicians to concurrently analyze and evaluate the clinical markers of prostate cancer patients with instantaneous clinical data and evidence-based diagrams which can automatically identify pretreatment parameters. Moreover, the proposed RTCDSS can aid interactions between patients and clinicians. Conclusions Our proposed framework supports online clinical informatics, evaluates treatment risks, offers interactive guidance, and provides real-time reference for decision making in the treatment of prostate cancer. The developed clinician-oriented interface can assist clinicians in conveniently presenting evidence-based information to patients and can be readily adapted to an existing hospital

The utility of observational studies in clinical decision making: lessons learned from statin trials.

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Foody, JoAnne M; Mendys, Phillip M; Liu, Larry Z; Simpson, Ross J

2010-05-01

Contemporary clinical decision making is well supported by a wide variety of information sources, including clinical practice guidelines, position papers, and insights from randomized controlled trials (RCTs). Much of our fundamental understanding of cardiovascular risk factors is based on multiple observations from major epidemiologic studies, such as The Seven Country Studies and the US-based Framingham Heart Study. These studies provided the framework for the development of clinical practice guidelines, including the National Cholesterol Education Program Adult Treatment Panel series. The objective of this article is to highlight the value of observational studies as a complement to clinical trial data for clinical decision making in real-world practice. Although RCTs are still the benchmark for assessing clinical efficacy and safety of a specific therapeutic approach, they may be of limited utility to practitioners who must then adapt the lessons learned from the trial into the patient care environment. The use of well-structured observational studies can improve our understanding of the translation of clinical trials into clinical practice, as demonstrated here with the example of statins. Although such studies have their own limitations, improved techniques for design and analysis have reduced the impact of bias and confounders. The introduction of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines has provided more uniformity for such studies. When used together with RCTs, observational studies can enhance our understanding of effectiveness and utility in real-world clinical practice. In the examples of statin observational studies, the results suggest that relative effectiveness of different statins and potential impact of switching statins should be carefully considered in treating individual patients by practicing physicians.

A qualitative study of decision-making on Phase III randomized clinical trial participation in paediatric oncology

DEFF Research Database (Denmark)

Ingersgaard, Marianne Vie; Tulstrup, Morten; Schmiegelow, Kjeld

2018-01-01

AIM: To explore parents' and adolescents' motives for accepting/declining participation in the ALL2008 trials and adolescents' involvement in the decision-making process. BACKGROUND: Children and adolescents with acute lymphoblastic leukaemia treated on the Nordic Society of Paediatric Haematology...... the adolescents' decision. There were no differences between motivations of preferences held by parents of children or adolescents, respectively. Decisions were based on subjective values attributed to cure contra toxicity and individual preferences for either standard or experimental treatment. The possibility....... FINDINGS: Adolescents and parents emphasized the importance of adolescents' active participation in decisions regarding enrolment into clinical trials. A majority of adolescents were either final or collaborative decision-makers. Parents stated that in case of disagreement, they would overrule...

Numerical methods for optimizing the performance of buildings

OpenAIRE

Pedersen, Frank

2008-01-01

The many different parties that influence design and control decisions for buildings, such as building owners, users, architects, consulting engineers, contractors, etx. may have different and to some extent conradicting requirements to buildings. Furthermore, national building regulations specify requirements to (among others) the energy performance and quality of the indoor climate.

How Qualitative Research Informs Clinical and Policy Decision Making in Transplantation: A Review.

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Tong, Allison; Morton, Rachael L; Webster, Angela C

2016-09-01

Patient-centered care is no longer just a buzzword. It is now widely touted as a cornerstone in delivering quality care across all fields of medicine. However, patient-centered strategies and interventions necessitate evidence about patients' decision-making processes, values, priorities, and needs. Qualitative research is particularly well suited to understanding the experience and perspective of patients, donors, clinicians, and policy makers on a wide range of transplantation-related topics including organ donation and allocation, adherence to prescribed therapy, pretransplant and posttransplant care, implementation of clinical guidelines, and doctor-patient communication. In transplantation, evidence derived from qualitative research has been integrated into strategies for shared decision-making, patient educational resources, process evaluations of trials, clinical guidelines, and policies. The aim of this article is to outline key concepts and methods used in qualitative research, guide the appraisal of qualitative studies, and assist clinicians to understand how qualitative research may inform their practice and policy.

Sustainable Buildings

DEFF Research Database (Denmark)

Tommerup, Henrik M.; Elle, Morten

The scientific community agrees that: all countries must drastically and rapidly reduce their CO2 emissions and that energy efficient houses play a decisive role in this. The general attitude at the workshop on Sustainable Buildings was that we face large and serious climate change problems...

Trail Blazing or Jam Session? Towards a new Concept of Clinical Decision-Making

OpenAIRE

Risør, Torsten

2016-01-01

Manuscript. Published version available at http://dx.doi.org/10.1080/13648470.2016.1239695 Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to ‘trail blazing’; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image....

Development and Pilot Testing of a Decision Aid for Genomic Research Participants Notified of Clinically Actionable Research Findings for Cancer Risk.

Science.gov (United States)

Willis, Amanda M; Smith, Sian K; Meiser, Bettina; Ballinger, Mandy L; Thomas, David M; Tattersall, Martin; Young, Mary-Anne

2018-02-17

Germline genomic testing is increasingly used in research to identify genetic causes of disease, including cancer. However, there is evidence that individuals who are notified of clinically actionable research findings have difficulty making informed decisions regarding uptake of genetic counseling for these findings. This study aimed to produce and pilot test a decision aid to assist participants in genomic research studies who are notified of clinically actionable research findings to make informed choices regarding uptake of genetic counseling. Development was guided by published literature, the International Patient Decision Aid Standards, and the expertise of a steering committee of clinicians, researchers, and consumers. Decision aid acceptability was assessed by self-report questionnaire. All 19 participants stated that the decision aid was easy to read, clearly presented, increased their understanding of the implications of taking up research findings, and would be helpful in decision-making. While low to moderate levels of distress/worry were reported after reading the booklet, a majority of participants also reported feeling reassured. All participants would recommend the booklet to others considering uptake of clinically actionable research findings. Results indicate the decision aid is acceptable to the target audience, with potential as a useful decision support tool for genomic research participants.

Building capacity for evidence informed decision making in public health: a case study of organizational change

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Peirson Leslea

2012-02-01

Full Text Available Abstract Background Core competencies for public health in Canada require proficiency in evidence informed decision making (EIDM. However, decision makers often lack access to information, many workers lack knowledge and skills to conduct systematic literature reviews, and public health settings typically lack infrastructure to support EIDM activities. This research was conducted to explore and describe critical factors and dynamics in the early implementation of one public health unit's strategic initiative to develop capacity to make EIDM standard practice. Methods This qualitative case study was conducted in one public health unit in Ontario, Canada between 2008 and 2010. In-depth information was gathered from two sets of semi-structured interviews and focus groups (n = 27 with 70 members of the health unit, and through a review of 137 documents. Thematic analysis was used to code the key informant and document data. Results The critical factors and dynamics for building EIDM capacity at an organizational level included: clear vision and strong leadership, workforce and skills development, ability to access research (library services, fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management. Conclusion With leadership, planning, commitment and substantial investments, a public health department has made significant progress, within the first two years of a 10-year initiative, towards achieving its goal of becoming an evidence informed decision making organization.

Can a patient smart card improve decision making in a clinical setting?.

Science.gov (United States)

Bérubé, J; Papillon, M J; Lavoie, G; Durant, P; Fortin, J P

1995-01-01

In the health field, clinical information is the raw material for the clinician delivering health services. Therefore, the clinical information available to the physician is often incomplete or even non¿existent upon consultation. Furthermore, the reconstruction of the medical history, which is the most important source of data for the clinician to establish a diagnosis and initiate a treatment, suffers from many constraints. The smart card, like the one used in Quebec's project, could ease the physician's decision-making by allowing fast access to accurate and pertinent data. The smart card is a major asset in the present health system.

Computer-based Monitoring for Decision Support Systems and Disaster Preparedness in Buildings

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Alan Vinh

2009-04-01

Full Text Available The operation of modern buildings can support a vast amount of static and real-time data. Static information such as building schematics is vital for security and rescue purposes. There is a need for building managers and for first responders to be notified of designated building alerts in real-time so that actions can be performed promptly. The capability to monitor building devices and to keep the first responder community updated with the latest building information during emergency situations, as well as the ability to remotely control certain building devices and processes, can be realized today. This paper describes the various challenges encountered in the research area of building interoperability and proposes methods and insights for developing a standards framework to enable communication between building information systems and first responder information systems. Having a standards framework in place will assist in the development and deployment of commercial products in support of building interoperability.

Assessment of the sunk-cost effect in clinical decision-making.

Science.gov (United States)

Braverman, Jennifer A; Blumenthal-Barby, J S

2012-07-01

Despite the current push toward the practice of evidence-based medicine and comparative effectiveness research, clinicians' decisions may be influenced not only by evidence, but also by cognitive biases. A cognitive bias describes a tendency to make systematic errors in certain circumstances based on cognitive factors rather than evidence. Though health care providers have been shown in several studies to be susceptible to a variety of types of cognitive biases, research on the role of the sunk-cost bias in clinical decision-making is extremely limited. The sunk-cost bias is the tendency to pursue a course of action, even after it has proved to be suboptimal, because resources have been invested in that course of action. This study explores whether health care providers' medical treatment recommendations are affected by prior investments in a course of treatment. Specifically, we surveyed 389 health care providers in a large urban medical center in the United States during August 2009. We asked participants to make a treatment recommendation based on one of four hypothetical clinical scenarios that varied in the source and type of prior investment described. By comparing recommendations across scenarios, we found that providers did not demonstrate a sunk-cost effect; rather, they demonstrated a significant tendency to over-compensate for the effect. In addition, we found that more than one in ten health care providers recommended continuation of an ineffective treatment. Copyright © 2012 Elsevier Ltd. All rights reserved.

INTEGRATED FRAMEWORK FOR ENHANCING EARTHQUAKE RISK MITIGATION DECISIONS

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Temitope Egbelakin

2015-12-01

Full Text Available The increasing scale of losses from earthquake disasters has reinforced the need for property owners to become proactive in seismic risk reduction programs. However, despite advancement in seismic design methods and legislative frameworks, building owners are found unwilling or lack motivation to adopt adequate mitigation measures that will reduce their vulnerability to earthquake disasters. Various theories and empirical findings have been used to explain the adoption of protective behaviours including seismic mitigation decisions, but their application has been inadequate to enhance building owners’ protective decisions. A holistic framework that incorporates the motivational orientations of decision-making, coupled with the social, cultural, economic, regulatory, institutional and political realms of earthquake risk mitigation to enhance building owners’ decisions to voluntarily implement adequate mitigation measures, is proposed. This framework attempts to address any multi-disciplinary barriers that exist in earthquake disaster management, by ensuring that stakeholders involved in seismic mitigation decisions work together to foster seismic rehabilitation of EPBs, as well as illuminate strategies that will initiate, promote and sustain the adoption of long-term earthquake mitigation. .

The Interface of Clinical Decision-Making With Study Protocols for Knowledge Translation From a Walking Recovery Trial.

Science.gov (United States)

Hershberg, Julie A; Rose, Dorian K; Tilson, Julie K; Brutsch, Bettina; Correa, Anita; Gallichio, Joann; McLeod, Molly; Moore, Craig; Wu, Sam; Duncan, Pamela W; Behrman, Andrea L

2017-01-01

Despite efforts to translate knowledge into clinical practice, barriers often arise in adapting the strict protocols of a randomized, controlled trial (RCT) to the individual patient. The Locomotor Experience Applied Post-Stroke (LEAPS) RCT demonstrated equal effectiveness of 2 intervention protocols for walking recovery poststroke; both protocols were more effective than usual care physical therapy. The purpose of this article was to provide knowledge-translation tools to facilitate implementation of the LEAPS RCT protocols into clinical practice. Participants from 2 of the trial's intervention arms: (1) early Locomotor Training Program (LTP) and (2) Home Exercise Program (HEP) were chosen for case presentation. The two cases illustrate how the protocols are used in synergy with individual patient presentations and clinical expertise. Decision algorithms and guidelines for progression represent the interface between implementation of an RCT standardized intervention protocol and clinical decision-making. In each case, the participant presents with a distinct clinical challenge that the therapist addresses by integrating the participant's unique presentation with the therapist's expertise while maintaining fidelity to the LEAPS protocol. Both participants progressed through an increasingly challenging intervention despite their own unique presentation. Decision algorithms and exercise progression for the LTP and HEP protocols facilitate translation of the RCT protocol to the real world of clinical practice. The two case examples to facilitate translation of the LEAPS RCT into clinical practice by enhancing understanding of the protocols, their progression, and their application to individual participants.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A147).

Emerging medical informatics with case-based reasoning for aiding clinical decision in multi-agent system.

Science.gov (United States)

Shen, Ying; Colloc, Joël; Jacquet-Andrieu, Armelle; Lei, Kai

2015-08-01

This research aims to depict the methodological steps and tools about the combined operation of case-based reasoning (CBR) and multi-agent system (MAS) to expose the ontological application in the field of clinical decision support. The multi-agent architecture works for the consideration of the whole cycle of clinical decision-making adaptable to many medical aspects such as the diagnosis, prognosis, treatment, therapeutic monitoring of gastric cancer. In the multi-agent architecture, the ontological agent type employs the domain knowledge to ease the extraction of similar clinical cases and provide treatment suggestions to patients and physicians. Ontological agent is used for the extension of domain hierarchy and the interpretation of input requests. Case-based reasoning memorizes and restores experience data for solving similar problems, with the help of matching approach and defined interfaces of ontologies. A typical case is developed to illustrate the implementation of the knowledge acquisition and restitution of medical experts. Copyright © 2015 Elsevier Inc. All rights reserved.

A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision-Making.

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Ranieri, Veronica F; Barratt, Helen; Rees, Geraint; Fulop, Naomi J

2018-01-23

To describe the influences on clinical academic physicians' postdoctoral career decision-making. Thirty-five doctoral trainee physicians from University College London took part in semi-structured interviews in 2015 and 2016. Participants were asked open-ended questions about their career to-date, their experiences undertaking a PhD, and their career plans post-PhD. The interviews were audio-recorded and transcribed. Thematic analysis was used to generate, review, and define themes from the transcripts. Emerging differences and similarities in participants' reasons for pursuing a PhD were then grouped to produce typologies to explore how their experiences influenced their career decision-making. Participants described four key reasons for undertaking a PhD, which formed the basis of the four typologies identified. These reasons included: to pursue a clinical academic career; to complete an extensive period of research to understand whether a clinical academic career was the desired path forward; to improve clinical career prospects; and to take a break from clinical training. These findings highlight the need to target efforts at retaining clinical academic physicians according to their reasons for pursuing a PhD and their subsequent experiences with the process. Those responsible for overseeing clinical training must be well-informed of the long-term benefits of training academically-qualified physicians. In light of current political uncertainty, universities, hospitals, and external agencies alike must increase their efforts to inspire and assuage early-career clinical academic physicians' fears regarding their academic future.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A clinical decision-making algorithm for penicillin allergy.

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Soria, Angèle; Autegarden, Elodie; Amsler, Emmanuelle; Gaouar, Hafida; Vial, Amandine; Francès, Camille; Autegarden, Jean-Eric

2017-12-01

About 10% of subjects report suspected penicillin allergy, but 85-90% of these patients are not truly allergic and could safely receive beta-lactam antibiotics Objective: To design and validate a clinical decision-making algorithm, based on anamnesis (chronology, severity, and duration of the suspected allergic reactions) and reaching a 100% sensitivity and negative predictive value, to assess allergy risk related to a penicillin prescription in general practise. All patients were included prospectively and explorated based on ENDA/EAACI recommendations. Results of penicillin allergy work-up (gold standard) were compared with results of the algorithm. Allergological work-up diagnosed penicillin hypersensitivity in 41/259 patients (15.8%) [95% CI: 11.5-20.3]. Three of these patients were diagnosed as having immediate-type hypersensitivity to penicillin, but had been misdiagnosed as low risk patients using the clinical algorithm. Thus, the sensitivity and negative predictive value of the algorithm were 92.7% [95% CI: 80.1-98.5] and 96.3% [95% CI: 89.6-99.2], respectively, and the probability that a patient with true penicillin allergy had been misclassified was 3.7% [95% CI: 0.8-10.4]. Although the risk of misclassification is low, we cannot recommend the use of this algorithm in general practice. However, the algorithm can be useful in emergency situations in hospital settings. Key messages True penicillin allergy is considerably lower than alleged penicillin allergy (15.8%; 41 of the 259 patients with suspected penicillin allergy). A clinical algorithm based on the patient's clinical history of the supposed allergic event to penicillin misclassified 3/41 (3.7%) truly allergic patients.

Clinical reasoning and population health: decision making for an emerging paradigm of health care.

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Edwards, Ian; Richardson, Barbara

2008-01-01

Chronic conditions now provide the major disease and disability burden facing humanity. This development has necessitated a reorientation in the practice skills of health care professions away from hospital-based inpatient and outpatient care toward community-based management of patients with chronic conditions. Part of this reorientation toward community-based management of chronic conditions involves practitioners' understanding and adoption of a concept of population health management based on appropriate theoretical models of health care. Drawing on recent studies of expertise in physiotherapy, this article proposes a clinical reasoning and decision-making framework to meet these challenges. The challenge of population and community-based management of chronic conditions also provides an opportunity for physiotherapists to further clarify a professional epistemology of practice that embraces the kinds of knowledge and clinical reasoning processes used in physiotherapy practice. Three case studies related to the management of chronic musculoskeletal pain in different populations are used to exemplify the range of epistemological perspectives that underpin community-based practice. They illustrate the link between conceptualizations of practice problems and knowledge sources that are used as a basis for clinical reasoning and decision making as practitioners are increasingly required to move between the clinic and the community.

Why do we do as we do? Factors influencing clinical reasoning and decision-making among physiotherapists in an acute setting.

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Holdar, Ulrika; Wallin, Lars; Heiwe, Susanne

2013-12-01

Despite the current movement for health-care to become more informed by evidence, knowledge on effective implementation of evidence-based practice is scarce. To improve research application among physiotherapists, the process of implementation and clinical reasoning needs to be scrutinized. The aim of this study was to identify various experiences of factors that influence the physiotherapist's clinical reasoning in specialist care. A phenomenographic approach was chosen. Eleven physiotherapists at two acute care hospitals in nn. Data was obtained by observations and interviews. Phenomenographic data analysis identified various experiences of clinical decision-making. The Ethical Review Board of the nn approved the study. The observations and the interviews enabled identification of various experiences that influenced clinical decision-making. The physiotherapists' clinical reasoning was perceived to be constrained by contextual factors. The physiotherapists collected current information on the patient by using written and verbal information exchange and used this to generate an inner picture of the patient. By creating hypotheses that were accepted or rejected, they made decisions in advance of their interventions. The decisions were influenced by the individual characteristics of the physiotherapist, his/her knowledge and patient perceptions. Clinical reasoning is a complex and constantly evolving process. Contextual factors such as economy and politics are not easily changed, but factors such as the patient and the physiotherapist as a person are more tangible. Copyright © 2013 John Wiley & Sons, Ltd.

Building a semantic web-based metadata repository for facilitating detailed clinical modeling in cancer genome studies.

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Sharma, Deepak K; Solbrig, Harold R; Tao, Cui; Weng, Chunhua; Chute, Christopher G; Jiang, Guoqian

2017-06-05

Detailed Clinical Models (DCMs) have been regarded as the basis for retaining computable meaning when data are exchanged between heterogeneous computer systems. To better support clinical cancer data capturing and reporting, there is an emerging need to develop informatics solutions for standards-based clinical models in cancer study domains. The objective of the study is to develop and evaluate a cancer genome study metadata management system that serves as a key infrastructure in supporting clinical information modeling in cancer genome study domains. We leveraged a Semantic Web-based metadata repository enhanced with both ISO11179 metadata standard and Clinical Information Modeling Initiative (CIMI) Reference Model. We used the common data elements (CDEs) defined in The Cancer Genome Atlas (TCGA) data dictionary, and extracted the metadata of the CDEs using the NCI Cancer Data Standards Repository (caDSR) CDE dataset rendered in the Resource Description Framework (RDF). The ITEM/ITEM_GROUP pattern defined in the latest CIMI Reference Model is used to represent reusable model elements (mini-Archetypes). We produced a metadata repository with 38 clinical cancer genome study domains, comprising a rich collection of mini-Archetype pattern instances. We performed a case study of the domain "clinical pharmaceutical" in the TCGA data dictionary and demonstrated enriched data elements in the metadata repository are very useful in support of building detailed clinical models. Our informatics approach leveraging Semantic Web technologies provides an effective way to build a CIMI-compliant metadata repository that would facilitate the detailed clinical modeling to support use cases beyond TCGA in clinical cancer study domains.