A consumer health decision support system (CDSS) is being developed at the South African Medical Research Council (MRC). It is a software program intended to help members of the public decide when they may be at risk of some common but serious illnesses like tuberculosis and hypertension. It would be ideal for a public health kiosk or e-health programs of the government. The program has been built as an expert system. Its knowledge base consists of rules which are used in assessing the risk of illness. The rules were given by medical experts who took part in the development of the CDSS. The study proposes a method for the evaluation of the rule base of the CDSS using FCA methods. It is important to evaluate the knowledge base of an expert system, because if its knowledge base is of broad scope and is accurate then it can be expected that the expert system will be good at giving advice and hence potentially useful. FCA is a mathematical framework which can be used to investigate causal relations in data. The study explored its utility in the evaluation of the CDSS knowledge base. FCA implications and the FCA formulation of the JSM method were two FCA methods that were selected. The FCA methods were used to generate rules from actual patient data, and these were compared to the rules initially given by the experts. The motivation to use FCA data analysis as well as experts’ knowledge in the development of the CDSS program is that FCA data analysis may discover some things that the experts may have overlooked. Or at least the experts can review their expertise against actual field data which has been analysed by FCA methods. A system like the CDSS cannot be built using FCA data analysis techniques only, involvement of experts is very important. The two FCA methods were chosen so as to compare their results, and it was also thought that they may perhaps complement each other. Preliminarily it was found that FCA implications and the FCA formulation of the JSM method can be used in the evaluation of the rule base of the CDSS. / Dissertation (MSc (Computer Science))--University of Pretoria, 2008. / Computer Science / unrestricted

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In this study, the continuous use of knowledge-based clinical decision support systems (KB-CDSS) is examined. KB-CDSS not only provides advice to clinicians, but also integrates guidelines with patient information and provides clinicians with tools that facilitate the application of guidelines in patient care. Studying KB-CDSS as a continuous application is important because continuity is a prerequisite to the success of KB-CDSS implementations and is considered as an important motivator for knowledge translation. Previous research in the area of health information systems (HIS) use has focused on the acceptance of these systems through the use of mostly information systems related constructs. Therefore, the theoretical models that explain the use of HIS have been limited and they obfuscated other phases of HIS such as continuous use. Moreover, extant research has not, to a large extent, considered the influence of KB-CDSS use on knowledge translation, the application of clinical guidelines in practice. This study seeks to fill these gaps in the literature by first integrating context-related factors with IS factors. This supports the study of antecedents of continuous use of KB-CDSS systems, exploring the relationship between continuous use and knowledge translation, and exploring changes in system dynamics (how usage patterns change with time). In order to achieve these research objectives, a literature review of healthcare and IS research was conducted, resulting in a comprehensive theoretical model that explains the antecedents of continuous use and its relationship to knowledge translation. To validate this model, data were collected from different sources, including: A questionnaire deployed to 118 physicians using the McMaster Pain Assistant KB-CDSS in three academic clinics in South Western Ontario, followed by five focus groups to further explain the context of using the systems and antecedents of its use, and the analysis of system use through data obtained from system logs and patient charts. The findings of this study show that: (i) Threats to physician professional identity surpasses intention to continue using KB-CDSS, thus influencing its use by physicians in the first six months; (ii) The relationships between factors influencing continuous system use change with time; (iii) System use has a strong relationship with knowledge translation after 6 months of use, but this relationship diminishes after 12 months of use; and (iv) How patients are affected by the system positively influences physician satisfaction with the system and hence their use of the system. This study helps in explaining the theory of physicians’ continuous use of KB-CDSS and how the antecedents of use change with time. Methodologically, this study has discovered several techniques that can be used to improve HIS research and physician acceptance of IS methods. Finally, in practice this study presents several suggestions for improving the development and deployment of KB-CDSS to enhance its use during the knowledge translation process. / Thesis / Doctor of Philosophy (PhD)

Background: About 2% of the German population are affected by psoriasis. A growing number of cost-intensive systemic treatments are available. Surveys have shown high proportions of patients with moderate to severe psoriasis are not adequately treated despite a high disease burden. Digital therapy recommendation systems (TRS) may help implement guideline-based treatment. However, little is known about the acceptance of such clinical decision support systems (CDSSs). Therefore, the aim of the study was to access the acceptance of a prototypical TRS demonstrator. - Methods: Three scenarios (potential test patients with psoriasis but different sociodemographic and clinical characteristics, previous treatments, desire to have children, and multiple comorbidities) were designed in the demonstrator. The TRS demonstrator and test patients were presented to a random sample of 76 dermatologists attending a national dermatology conference in a cross-sectional face-to-face survey with case vignettes. The dermatologist were asked to rate the demonstrator by system usability scale (SUS), whether they would use it for certain patients populations and barriers of usage. Reasons for potential usage of the TRS demonstrator were tested via a Poisson regression with robust standard errors. Results: Acceptance of the TRS was highest for patients eligible for systemic therapy (82%). 50% of participants accepted the system for patients with additional comorbidities and 43% for patients with special subtypes of psoriasis. Dermatologists in the outpatient sector or with many patients per week were less willing to use the TRS for patients with special psoriasis-subtypes. Dermatologists rated the demonstrator as acceptable with an mean SUS of 76.8. Participants whose SUS was 10 points above average were 27% more likely to use TRS for special psoriasissubtypes. The main barrier in using the TRS was time demand (47.4%). Participants who perceived time as an obstacle were 22.3% less willing to use TRS with systemic therapy patients. 27.6% of physicians stated that they did not understand exactly how the recommendation was generated by the TRS, with no effect on the preparedness to use the system. - Conclusion: The considerably high acceptance and the preparedness to use the psoriasis CDSS suggests that a TRS appears to be implementable in routine healthcare and may improve clinical care. Main barrier is the additional time demand posed on dermatologists in a busy clinical setting. Therefore, it will be a major challenge to identify a limited set of variables that still allows a valid recommendation with precise prediction of the patient-individual benefits and harms.

The task of ensuring Patient Safety is, more than ever, central in Healthcare. The report “To Err is Human” [Kohn et al. 2000], was revealing alarming numbers of incidents, injuries and deaths caused by deficiencies in healthcare activities. The book initiated assessment and change of Healthcare methods and procedures. In addition, numerous reports to Swedish HSAN (Medical Responsibility Board) have shown a high rate of information and communication deficiencies in Healthcare has a direct or indirect cause of incidents, injuries and deaths. Despite numerous of new sophisticated tools for information management in recent years, e.g., tools such as Electronic Health Records (EHR) and Clinical Decision Support Systems (CDSS), the threats to Patient Safety have not been redeemed. Rather to the contrary. Underlying reasons for this paradox are twofold. Firstly, advancements in diagnosing techniques have given rise to increasing volumes of data at the same time as the number of patients has increased due to demographic changes and advancements in treatments. Secondly, the information processing systems are far from aligned to related workflow processes. In short, we do not at present have interoperability in our Healthcare systems. In this doctoral dissertation, we present an in-depth analysis of two different “HSAN-typical” cases, where Patient Safety was jeopardized by incomplete information flows and/or information breakdowns. The cases are mirroring the apprehension of Simplicity, that is, Occam´s Razor of Diagnostic Parsimony. A well-known protocol used in Healthcare and implemented in most (knowledge based) CDSS. This rule of thumb is the foundation for the well-known adage: “when you hear hoof beats, think horses, not zebras”. Hickam´s Dictum is one well known objection to the simplifications of Occam´s Razor stating "Patients can have as many diseases as they damn well please". Of course, this Dictum is harder to implement effectively! In the thesis we suggest a visualization tool Visual Incidence Anamneses (VIA) to provide middle out compromise between Ockham and Hickam but providing means to increase Patient Safety. The findings of our Study for the thesis have resulted in a number of Aspects and Principles as well as Core-principles for future CDSS design, That is, tools and methodologies that will support designing and validating Interoperability of Healthcare systems across patient-centric workflows. The VIA tool should be used as the initiating point in a patient (individual) centered workflow, quickly visualizing vital information such as symptoms, incidents and diagnoses, occurring earlier in the medical history, at different times, to ground further vital decisions on. The visualization will enable analysis of timelines and earlier diagnoses of the patient, using visually salient nodes for visualization of causalities in context. Furthermore, support for customization of the tool to the views of stakeholders, members of healthcare teams and empowerments of the patient, is crucial.

Relevant information at the right time can be critically important for clinicians when treating patients with cerebral palsy (CP). Gathering this information could be done through the usage of a clinical decision support system with a matching algorithm that finds relevant patients. The relevancy of this information for clinicians is determined by the relevancy of the matched patients. The aim of this thesis was therefore to investigate how an algorithm that matches similar patients with CP could be improved in terms of relevancy. The goal was also to explore the possibilities of domain knowledge and temporal aspects and how they could be combined and utilized in order to improve the matching algorithm. In this bachelor's thesis, we have conducted a literature study about the domain and a domain knowledge survey. The domain knowledge survey included gathering domain knowledge through contact with an expert in the area of CP. We also implemented an algorithm using intelligent similarity measurements based on validation from experts that could accurately match similar patients according to the domain knowledge gathered. The resulting algorithm is presented through a prototype of a CDSS, which allows clinicians to select and match patients through a GUI, and including features such as adjusting weight values for different attributes. The algorithm uses patient data retrieved from the CPUP database, which is specfic to patients with CP, to match with. From the CPUP database many temporal aspects could be concluded to be relevant for similarity assessment. Due to the limited scope of the thesis however, only the most important aspect was utilized. By treating this aspect as an attribute like the other domain knowledge based attributes, but with respect to other variables that affected it, a combination of temporal aspects and domain knowledge was done when identifying similar patients with CP. Using the prototype of the CDSS with the implemented algorithm could help clinicians make better informed decisions, and this leads to improved health care for children and patients with CP, which is why this thesis was important.

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The financial crisis that struck financial markets in 2008 was devastating for the global economy. The impact continues to be felt in the market - most recently in sovereign defaults. 1 There are many questions as to the origin of the crisis and how the same events may be prevented in the future. This dissertation explores two financial instruments: securitisation and credit default swaps (CDSs) and attempts to establish the role they played in the financial crisis. To fully understand the events that unfolded before and during the crisis, a sound theoretical understanding of these instruments is required. This understanding is important to discern the future of stable financial markets and to gain insight into some of the potential risks faced by financial markets. The South African perspective regarding securitisation, CDSs and the global financial crisis is an important field of study. The impact of the crisis on South Africa will be explored in this dissertation, as well as, the effect of the crisis on South Africa's securitisation market (which has proved healthy and robust over the first part of the new millennium despite the global slowdown of these instruments) and the CDS market. A key goal of this work is to establish whether or not CDSs have been used in South Africa to hedge the credit risk component of bonds linked to asset–backed securities (ABSs). This will provide an indication of the maturity of the South African credit risk transfer (CRT) market and how South Africa compares to more developed financial markets regarding complexity, regulation, sophistication and market sentiment. Through the exploration and understanding of these concepts, the efficacy of emerging economies to adapt to globalisation, and how welcome financial innovation has proved to be in emerging markets will be addressed. / Thesis (M.Com. (Risk management))--North-West University, Potchefstroom Campus, 2012.

The financial crisis that struck financial markets in 2008 was devastating for the global economy. The impact continues to be felt in the market - most recently in sovereign defaults. 1 There are many questions as to the origin of the crisis and how the same events may be prevented in the future. This dissertation explores two financial instruments: securitisation and credit default swaps (CDSs) and attempts to establish the role they played in the financial crisis. To fully understand the events that unfolded before and during the crisis, a sound theoretical understanding of these instruments is required. This understanding is important to discern the future of stable financial markets and to gain insight into some of the potential risks faced by financial markets. The South African perspective regarding securitisation, CDSs and the global financial crisis is an important field of study. The impact of the crisis on South Africa will be explored in this dissertation, as well as, the effect of the crisis on South Africa's securitisation market (which has proved healthy and robust over the first part of the new millennium despite the global slowdown of these instruments) and the CDS market. A key goal of this work is to establish whether or not CDSs have been used in South Africa to hedge the credit risk component of bonds linked to asset–backed securities (ABSs). This will provide an indication of the maturity of the South African credit risk transfer (CRT) market and how South Africa compares to more developed financial markets regarding complexity, regulation, sophistication and market sentiment. Through the exploration and understanding of these concepts, the efficacy of emerging economies to adapt to globalisation, and how welcome financial innovation has proved to be in emerging markets will be addressed. / Thesis (M.Com. (Risk management))--North-West University, Potchefstroom Campus, 2012.

Purpose:The thesis will shed light on the overall need of CDSSs in the Swedish health care system,  and  it  will  also  present  a  specific  efficiency  problem  that  could  be  solved  by implementing a CDSS. The need for a CDSS is where an implementation would improve patient outcome, by delivering the right care at the right time, and where the CDSS could reduce the cost of the delivered care. A better understanding of the current need could help eliminate the existing empirical gap and ultimately lead to better and more efficient health care in Sweden. The research question was formulated as: Where within Swedish health care can a need for increased efficiency be met through the implementation of a realistic CDSS system? Design and methodology: The  thesis  is  a  case  study  where qualitative data, collected through a literature review and interviews, was used to answer the research question. The methodology used was tailored to the unique setting of the research and in accordance to the purpose of the study. The method was divided into five phases. (1) Finding an area of focus, such as a specific diagnosis, within the health care system where the need for a CDSS system is deemed high. (2) Mapping the care chain of the identified area of interest. (3) Developing hypotheses concerning where in the care chain challenges could be solved using a clinical decision support system. (4) Confirming or rejecting the proposed hypotheses through interviews with relevant experts. (5) Presenting the specific efficiency problem that could be solved using a CDSS and a presentation of the design of said CDSS. Findings: The efficiency problem that could be solved using a CDSS was identified to be within the area of heart failure treatment. There were a multitude of areas of improvement found along the care chain and a number of them could be solved by developing and using specific CDSSs. A CDSS that could help physicians, within the primary care system, to identify patients that  could benefit from  being  assessed  by  cardiology specialist was  proposed  as  the  most beneficial  CDSS  system.  The  proposed  CDSS  would  be  both  beneficial  and  realistically implementable. / Syftet med uppsatsen är att belysa det övergripande behovet av kliniska beslutsstödssystem inom den svenska vården och slutligen finna det mest trängande behovet. En bättre förståelse för detta behov kan hjälpa att minska det existerande empiriska gapet och slutligen leda till en bättre och mer effektiv vård i Sverige. Forskarfrågan formulerades som uppdraget att finna ett behov för ökad effektivitet inom svensk sjukvård, som kan lösas genom implementering av ett realistiskt kliniskt beslutsstöd. Design och metodologi: Uppsatsen är en casestudie där kvalitativ data, samlad genom en litteraturstudie samt intervjuer, användes för att besvara forskningsfrågan. Metodologin som brukades var anpassad efter den unika naturen för forskningen, samt i enighet med syftet av studien. Metoden delades in i fem faser. (1) Finna ett fokusområde, exempelvis en specifik diagnos, där behovet av ett kliniskt beslutsstöd bedömdes högt. (2) Kartlägga vårdkedjan för den identifierade diagnosen. (3) Utveckla hypoteser angående var inom vårdkedjan som  utmaningar skulle kunna lösas med ett kliniskt beslutsstöd. (4) Bekräfta eller förkasta ypoteserna genom intervjuer med relevanta experter. (5) Presentera problemet med det mest trängande behovet efter ett kliniskt beslutsstöd och hur ett sådans skulle utformas. Fynd: Effektivitetsproblemet som kunde lösas bäst via ett kliniskt beslutsstöd identifierades att vara inom området hjärtsviktsbehandling. Det fanns flertalet områden med utvecklingspotential som urskiljdes ur vårdkedjan för hjärtsviktspatienter, och vissa av dessa utmaningar kunde lösas genom utveckling och implementering av specifika kliniska beslutsstöd. Det kliniska beslutsstöd som skulle lösa det mest trängande behovet inom vården idag föreslås vara ett system som hjälper läkare inom vårdcentralerna att identifiera patienter som skulle gagnas av en remiss till en kardiolog. Det föreslagna kliniska beslutsstödet skulle vara både fördelaktigt för vårdpersonal samt patienter samt är realistiskt implementerbart.