Abstract
It is well described that hospitals have problems with sustaining high quality of care
and expedient introduction of new medical knowledge. Clinical practice guidelines (CPGs)
have been promoted as a remedy to deal with these problems. It is, however, also well
described that application and compliance with CPGs in most areas of clinical practice are
deficient. Computerization of CPGs has been brought forward as a method to disseminate and
to support application of CPGs. Until now, CPG-computerization has focused on development
of formal expressions of CPGs. The developed systems have, however, not gained any
extensive application in clinical practice. The basic assumption in this thesis is that the scanty
penetration is due to an inappropriate design process when designing computerized CPGs for
clinical work practice.
This thesis examines the application of guidance within areas where CPG compliance
is known to be prominent in order to determine demands on clinical guidance and
characteristic features of applied guidance. The contributions of this thesis fall in two main
areas:
• An analysis of how guidance is applied in clinical practice, within areas where
CPG compliance is known to be high. The analysis focuses on the emergence
of general clinical work practice demands on guidance
• An analysis of guidance demands from clinical work practice and business
strategy, focusing on implications for the design of computerised CPGs.
In my research, I have applied observation studies, interviews, workshops and
collection of guiding artefacts and CPGs as methods for obtaining data. In the analysis of data,
a grounded theory approach was applied. Further prototyping was applied to validate and
refine the findings, and finally two clinicians validated the results.
The empirical basis of the thesis is comprised by fieldwork in three oncology
departments and a case study of advanced life support. Although close to all patients within
oncology are treated according to a CPG, I found limited application of physical CPGs and
web-based CPG portals. However, I found comprehensive application of activity specific preprinted
forms and standard order sets embedded in the work practice and presenting guidance
at the point of care. I have conceptualised the forms and standard order sets as second order
guiding artefacts. Second order guiding artefacts were transformed from primary guiding
artefacts (protocols and CPGs) according to a standard operating procedure. Based on a
participatory design approach, prototypes for computerization of CPGs have been developed
and applied for clarification of demands on computerized CPGs.
The clinicians in my studies expressed a desire to have computerised CPGs, although
it was a prerequisite that they should be easy to apply and not demand interruptions in clinical
work.
Based on my research, I found that computerized clinical guidance should be:
• Activity specific
• Present at the point of care
• Embedded in work practice
• Flexible
• A source for coordination
• Automated when feasible
• Designed in a way that provides room for local adaptations of guidance
• Designed with focus on specific business strategic aims
Further, based on my findings, I will suggest that design of computerized CPGs should
be based on: 1) scrutinization of the clinical work practice, 2) articulation of the business
strategic aims, and 3) analysis and formalization of CPGs. This will imply orchestration of
design teams with competencies from a wide array of disciplines such as health practice,
business management, knowledge management and information systems.
and expedient introduction of new medical knowledge. Clinical practice guidelines (CPGs)
have been promoted as a remedy to deal with these problems. It is, however, also well
described that application and compliance with CPGs in most areas of clinical practice are
deficient. Computerization of CPGs has been brought forward as a method to disseminate and
to support application of CPGs. Until now, CPG-computerization has focused on development
of formal expressions of CPGs. The developed systems have, however, not gained any
extensive application in clinical practice. The basic assumption in this thesis is that the scanty
penetration is due to an inappropriate design process when designing computerized CPGs for
clinical work practice.
This thesis examines the application of guidance within areas where CPG compliance
is known to be prominent in order to determine demands on clinical guidance and
characteristic features of applied guidance. The contributions of this thesis fall in two main
areas:
• An analysis of how guidance is applied in clinical practice, within areas where
CPG compliance is known to be high. The analysis focuses on the emergence
of general clinical work practice demands on guidance
• An analysis of guidance demands from clinical work practice and business
strategy, focusing on implications for the design of computerised CPGs.
In my research, I have applied observation studies, interviews, workshops and
collection of guiding artefacts and CPGs as methods for obtaining data. In the analysis of data,
a grounded theory approach was applied. Further prototyping was applied to validate and
refine the findings, and finally two clinicians validated the results.
The empirical basis of the thesis is comprised by fieldwork in three oncology
departments and a case study of advanced life support. Although close to all patients within
oncology are treated according to a CPG, I found limited application of physical CPGs and
web-based CPG portals. However, I found comprehensive application of activity specific preprinted
forms and standard order sets embedded in the work practice and presenting guidance
at the point of care. I have conceptualised the forms and standard order sets as second order
guiding artefacts. Second order guiding artefacts were transformed from primary guiding
artefacts (protocols and CPGs) according to a standard operating procedure. Based on a
participatory design approach, prototypes for computerization of CPGs have been developed
and applied for clarification of demands on computerized CPGs.
The clinicians in my studies expressed a desire to have computerised CPGs, although
it was a prerequisite that they should be easy to apply and not demand interruptions in clinical
work.
Based on my research, I found that computerized clinical guidance should be:
• Activity specific
• Present at the point of care
• Embedded in work practice
• Flexible
• A source for coordination
• Automated when feasible
• Designed in a way that provides room for local adaptations of guidance
• Designed with focus on specific business strategic aims
Further, based on my findings, I will suggest that design of computerized CPGs should
be based on: 1) scrutinization of the clinical work practice, 2) articulation of the business
strategic aims, and 3) analysis and formalization of CPGs. This will imply orchestration of
design teams with competencies from a wide array of disciplines such as health practice,
business management, knowledge management and information systems.
| Original language | English |
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| Place of Publication | København |
|---|---|
| Publisher | Faculty of Science, University of Copenhagen |
| Number of pages | 125 |
| Publication status | Published - 2010 |