In inhalation anesthesia life-support systems are used to provide gases to the patient and to monitor important parameters. These systems are used in dynamic and stressful situations where the information-load on the operators often is significant. This thesis presents a design concept of an anesthetic system. The design goal has been to keep the information-load on the operator low with the objective to minimize confusion and error. A number of contextual inquiries were made in the operating room during surgery at four hospitals in Sweden. The goal was to understand the actual use-situations when anesthetic systems are employed. In addition to these inquiries a number of interviews with clinicians were made. The result from the contextual inquiries and the interviews was a set of qualities-in-use; characterizations of the preferred use-qualities of the system. Based on these qualities-in-use the actual design concept was developed. The design concept is described in terms of sketches, scenarios and the qualities-in-use on which it was based. The thesis also includes a discussion on the advantages and disadvantages of the design concept.

<p>How can we develop usable and work process-oriented ICT systems for shared homecare?</p><p>Shared homecare involves different professionals, consists of mobile work and requires immediate and ubiquitous access to patient-oriented information, supporting an integrated view on the care process.</p><p>This thesis presents a new collaborative design method for user needs analysis and requirements specification in the context of health information systems development; the Multi-disciplinary Thematic Seminar (MdTS) method. The thesis also describes the MdTS method’s application and two different usability evaluations of the developed system.</p><p>The MdTS addresses a significant problem with health information technologies; they tend to support collaborative work of healthcare professionals poorly, sometimes leading to a fragmentation of workflow and disruption of healthcare processes. Based on human-computer interaction methods, MdTS implies a multiple-user needs analysis by thorough investigation of the entire interdisciplinary cooperative work and its transformation into technical specifications in order to develop appropriate information and communication technology (ICT) for the users’ differing work situations.</p><p>Application of the MdTS resulted in a prototype, the OLD@HOME Virtual Health Record (VHR), adapted to the specific demands in shared homecare. Through mobile devices each care professional accessed patient information in profession-specific views from an integrated platform.</p><p>This thesis provides an interesting case, illustrating how mobile ICT can support shared homecare, thereby bridging health and social care activities and improving knowledge about joint work processes.</p><p>Results from the usability evaluations were overall positive. Information needed at point of care was available on mobile devices and presented in an understandable manner. However, the evaluations also indicated that it is difficult to transfer results from one homecare setting to another due to differences in operational routines.</p><p>In conclusion, application of the MdTS method, in this study, succeeded in elicitation of correct user needs and in transferring correct requirements specifications to system developers for implementation.</p>

How can we develop usable and work process-oriented ICT systems for shared homecare? Shared homecare involves different professionals, consists of mobile work and requires immediate and ubiquitous access to patient-oriented information, supporting an integrated view on the care process. This thesis presents a new collaborative design method for user needs analysis and requirements specification in the context of health information systems development; the Multi-disciplinary Thematic Seminar (MdTS) method. The thesis also describes the MdTS method’s application and two different usability evaluations of the developed system. The MdTS addresses a significant problem with health information technologies; they tend to support collaborative work of healthcare professionals poorly, sometimes leading to a fragmentation of workflow and disruption of healthcare processes. Based on human-computer interaction methods, MdTS implies a multiple-user needs analysis by thorough investigation of the entire interdisciplinary cooperative work and its transformation into technical specifications in order to develop appropriate information and communication technology (ICT) for the users’ differing work situations. Application of the MdTS resulted in a prototype, the OLD@HOME Virtual Health Record (VHR), adapted to the specific demands in shared homecare. Through mobile devices each care professional accessed patient information in profession-specific views from an integrated platform. This thesis provides an interesting case, illustrating how mobile ICT can support shared homecare, thereby bridging health and social care activities and improving knowledge about joint work processes. Results from the usability evaluations were overall positive. Information needed at point of care was available on mobile devices and presented in an understandable manner. However, the evaluations also indicated that it is difficult to transfer results from one homecare setting to another due to differences in operational routines. In conclusion, application of the MdTS method, in this study, succeeded in elicitation of correct user needs and in transferring correct requirements specifications to system developers for implementation.

When care is moved from the hospital to the home the demands for high quality care still remain. For problems arising from the geographical separation of patients and professional caregivers, information and communication technology may offer important solutions. The overall aim of this thesis was to describe relevant requirements, to design and implement an IT-based system, and finally to evaluate the system’s influence on symptom control and support for both patients/next-of-kin and professional caregivers in advanced home healthcare. Of importance were needs in basic as well as advanced home healthcare, as were usability perspectives of both patients and professional caregivers. Requirement areas such as security, mobility, and responsibility, which should be considered when monitoring patients in the home, were identified. A prototype system for everyday assistance for diabetes patients was designed, and a system for frequent pain assessment for palliative home healthcare patients using a pain diary, digital pen and mobile Internet technology, was developed and evaluated through a qualitative content analysis approach. Twelve palliative cancer patients and six professional caregivers participated. The data collected included an ease-of-use questionnaire, and interviews with patients, spouses and professional caregivers. Patients expressed increased and improved contact with the caregivers, increased participation in their own care, a sense of increased security, and easiness in using the equipment in spite of severe illness and difficulties in comprehending the technology and system intervention. The professional caregivers showed a shifting outlook towards the pain assessment method; an initial cautious outlook due to low expectations of the patients’ abilities to use the pain assessment method and the caregivers’ own reluctance to use the system and change their way-of-working. Despite this, the professional caregivers experienced positive outcomes in terms of an increased awareness of pain, and positive patient influences including increased participation in their care, increased security and improved changes in pain treatment as a response to reported pain assessments. In conclusion, the networked digital pen system provided an effortless method for pain assessment and had positive influences on the care. The results imply that digital pen technology is suitable for the assessment of symptoms by palliative patients since these patients often have a limited capacity to handle technology due to their state of health. / On the day of the public defence date of the doctoral thesis the status of article III and IV was Submitted.

In medicine, data are produced from different sources and continuously stored in data depositories. Examples of these growing databases are quality registries. In Sweden, there are many cancer registries where data on cancer patients are gathered and recorded and are used mainly for reporting survival analyses to high level health authorities. In this thesis, a breast cancer quality registry operating in South-East of Sweden is used as the data source for newer analytical techniques, i.e. data mining as a part of knowledge discovery in databases (KDD) methodology. Analyses are done to sift through these data in order to find interesting information and hidden knowledge. KDD consists of multiple steps, starting with gathering data from different sources and preparing them in data pre-processing stages prior to data mining. Data were cleaned from outliers and noise and missing values were handled. Then a proper subset of the data was chosen by canonical correlation analysis (CCA) in a dimensionality reduction step. This technique was chosen because there were multiple outcomes, and variables had complex relationship to one another. After data were prepared, they were analyzed with a data mining method. Decision tree induction as a simple and efficient method was used to mine the data. To show the benefits of proper data pre-processing, results from data mining with pre-processing of the data were compared with results from data mining without data pre-processing. The comparison showed that data pre-processing results in a more compact model with a better performance in predicting the recurrence of cancer. An important part of knowledge discovery in medicine is to increase the involvement of medical experts in the process. This starts with enquiry about current problems in their field, which leads to finding areas where computer support can be helpful. The experts can suggest potentially important variables and should then approve and validate new patterns or knowledge as predictive or descriptive models. If it can be shown that the performance of a model is comparable to domain experts, it is more probable that the model will be used to support physicians in their daily decision-making. In this thesis, we validated the model by comparing predictions done by data mining and those made by domain experts without finding any significant difference between them. Breast cancer patients who are treated with mastectomy are recommended to receive radiotherapy. This treatment is called postmastectomy radiotherapy (PMRT) and there is a guideline for prescribing it. A history of this treatment is stored in breast cancer registries. We analyzed these datasets using rules from a clinical guideline and identified cases that had not been treated according to the PMRT guideline. Data mining revealed some patterns of non-compliance with the PMRT guideline. Further analysis with data mining revealed some reasons for guideline non-compliance. These patterns were then compared with reasons acquired from manual inspection of patient records. The comparisons showed that patterns resulting from data mining were limited to the stored variables in the registry. A prerequisite for better results is availability of comprehensive datasets. Medicine can take advantage of KDD methodology in different ways. The main advantage is being able to reuse information and explore hidden knowledge that can be obtained using advanced analysis techniques. The results depend on good collaboration between medical informaticians and domain experts and the availability of high quality data.

The thesis investigates how the notion of ‘ontology’ has been used in the field of medical informatics and knowledge representation. Partly to investigate what an ‘ontology’ can be said to represent and what requirements we can have on a good ‘ontology’. The author studies the already existing medical terminologies and ‘ontologies’ to elucidate what theories they are based on. The terminological theories of Eugen Wüster and his legacy in medical informatics are studied. It is noted that terminological theories handling linguistic entities are not suited for describing and representing medical theories, since these are assumed to refer to the real world, which consists of more than linguistics entities. In order to find a metaphysical theory in accordance with the world view that medical theories describe, the author turn to the critical realism of Karl Popper, Roy Bhaskar and Ilkka Niiniluoto. These theories, taken together with the metaphysical theories regarding universals of David M Armstrong and Ingvar Johansson, are used as a basis to find out what an ‘ontology’ can be said to represent, and what criteria and requirements we can have on a good ‘ontology’. Among the requirements presented in the thesis are stability, interoperability and the requirement that a good ‘ontology’ must be in accordance with our best available theories. Finally, it is discussed how these requirements and criteria can come into conflict with one another, and how one should reason when handling these trade-offs. The author emphasises the importance of including the medical expertise in the process of creating ‘ontologies’, in order to produce as useful and relevant ‘ontologies’ as possible. / Avhandlingen undersöker hur begreppet ’ontology’ används inom den medicinska informatiken och kunskapsrepresentation. Dels ämnar avhandlingen att utreda vad en ’ontology’ kan sägas representera och dels vilka krav man kan ställa på en god ’ontology’. Utifrån historiska studier av redan existerande medicinska terminologier och ontologier studeras vilka teorier som ligger till grund för dessa. Bland annat studeras Eugen Wüsters teorier rörande terminologi och hur dennes efterföljare inom medicinsk informatik ser ut. Författaren konstaterar att terminologiska teorier som behandlar språkliga entiteter inte är lämpliga för att beskriva och representera medicinska teorier, då dessa antas handla om en verklighet bestående av mer än språkliga entiteter. För att hitta en metafysisk teori som stämmer överens med den världsbild som de medicinska teorierna beskriver, vänder sig författaren till Karl Poppers, Ilkka Niiniluotos och Roy Bhaskars syn på kritisk realism, vad det gäller vetenskapliga teorier. Detta tillsammans David M Armstrongs och Ingvar Johanssons metafysiska teorier rörande immanent realism och universalia, används som grund för att försöka analysera vad en ’ontology’ kan sägas representera, och vilka krav vi kan ställa på en god ’ontology’. Bland de krav som presenteras i avhandlingen finns stabilitet, interoperabilitet och kravet på att en god ’ontology’ ska vara i enlighet med de bästa tillgängliga vetenskapliga teorierna. Avslutningsvis diskuteras hur dessa krav kan komma i konflikt med varandra, och hur man bör resonera när man hanterar dessa ’trade-offs’. Författaren poängterar vikten av att man tar med medicinska expertisen i skapandeprocessen av ’ontologies’, för att man ska producera så användbara och relevanta ’ontologies’ som möjligt.

This thesis was one of the deliverables of StandIN. The purpose of StandIN was to propose a common framework including standards for technical interoperability. The goal of this thesis was to structure and analyze information about the knowledge- and adoption level of the standards among providers of healthcare information systems (HIS's). Moreover, it aimed to evaluate different aspect that might affect the adoption. The target group was providers of HIS's used in Swedish county councils and regions. The information was gathered through a survey and semi-structured interviews, and stored in an Excel database. From the database, Pivot tables and charts were created in order to show the knowledge- as well as adoption level of the different standards. The results were thereafter compared to theory about interoperability and standard adoption. It was clear that the knowledge level varied for the different standards. In addition, the adoption level was very low - except from CCOW and HL7 v2. Least adopted were domain-specific standards. The results also indicated a trend for only adopting parts of standards. Moreover, many providers stated that they performed specific integrations rather than followed common standards. This seemed to be due to the choice of standards being too wide, and the actual adoption not being consistent among the different providers. According to the providers, an introduction of a national framework based on uniform and consistent international standards was an awaited solution to the problem. A future extension of this thesis would be to perform a similar study involving the customers. The database could also be used to do clustered analyses of the adoption state in different county councils and regions. Moreover, it could be used to analyze the development of standard adoption over time. / Den här uppsatsen var ett utav delresultaten i StandIN, ett initiativ till att ta fram ett gemensamt ramverk med standarder för teknisk interoperabilitet. Den här uppsatsen syftade till att strukturera och analysera information om kunskaps- och tillämpningsnivån för de tilltänkta standarderna. Målgruppen var leverantörer av vårdinformationssystem som används i Sveriges landsting och regioner. Informationen samlades in genom en enkät samt semi-strukturerade intervjuer, och lagrades sedan i en Excel-databas. Pivot-tabeller och -diagram skapades för att visualisera kunskaps- och tillämpningsnivån, och resultaten jämfördes sedan med teori om interoperabilitet och standardtillämpning. Det var tydligt att kunskapsnivån skilde sig för de olika standarderna. Tillämpningsnivån var generellt sett väldigt låg, bortsett från CCOW och HL7 v2. Minst tillämpade var domänspecifika standarder. Det var också tydligt att centrala leverantörer inte tillämpade samma standarder, vilket troligtvis påverkar de kompletterande systemen. Många leverantörer gjorde snarare specifika integrationer, än följde gemensamma standarder. Anledningen var att valet av standarder var för brett, och att den faktiska tillämpningen av standarder inte var konsekvent mellan olika leverantörer. Enligt leverantörerna skulle ett nationellt ramverk med enhetliga och internationella standarder vara en efterlängtad lösning på problemet. En fortsättning på denna uppsats är att använda databasen till att göra klusteranalyser för tillämpningsnivån av standarder hos system i olika landsting och regioner. Databasen skulle också kunna användas till att analysera utvecklingen av kunskap och tillämpning över tid. / StandIN

<p>Dagens elektroniska patientjournalsystem har begränsade möjligheter att på likartat sätt strukturera och lagra patientinformation. Det är en anledning till att det är problem med att utbyta patientjournaldata mellan olika system. Detta försvårar bland annat forskning och tillgänglighet till patientinformation. Brist på tillgänglighet minskar i sin tur möjligheten att ge en god vård oberoende av var patienten befinner sig.</p><p>Inom projektet openEHR har en idé med så kallade arketyper tagits fram som ett enhetligt sätt att strukturera utbytbar patientjournaldata för att möta framtida krav på patientjournaler och patientjournalsystem. Arketyper är formella modeller av kliniska informationsentiteter, exempelvis blodtryck. De byggs upp av restriktioner, struktur och termer med eventuella bindningar till medicinska terminologisystem. Dessutom kopplas medicinsk kunskap i arketyperna fri från journalsystemen.</p><p>Syftet med examensarbetet har varit att utveckla ett verktyg, en så kallad arketypeditor, som kan användas för att skapa och redigera arketyper. Utöver detta skulle möjligheterna undersökas att i verktyget implementera en koppling till medicinska terminologisystem. Utvecklingen har skett i en iterativ process med fokus på användbarhet och stabilitet. Det har även ingått att ta reda på syftet med en arketypeditor.</p><p>Resultatet är ett plattformsoberoende och stabilt verktyg som är utvecklat enligt användbarhetsprinciper med koppling till terminologisystemet Unified Medical Language System (UMLS). En arketypeditors syfte i ett bredare perspektiv är att lösa brister i dagens medicinska informationssystem som tas upp i denna rapport. Trots att openEHR-projektet är nytt finns det många tekniskt gångbara idéer, men det finns även problem som beror på för lite praktisk testning och tillämpning.</p> / <p>Present-day electronic health record systems have limited possibilities to structure and store patient information in a similarly manner. This causes problems with exchanging patient record data between different systems and it gives rise to problems with, among other things, research and patient information availability. Lack of availability will in turn decrease the possibility of giving good care irrespective of where the patient is located.</p><p>Within the openEHR project an idea with so called archetypes has been introduced as a uniform way to structure exchangeable patient record data in order to meet future requirements on electronic health records and systems. Archetypes are formal models of clinical information entities, for example blood pressure. They are constructed from constraints, structure and terms which may have bindings to medical terminology systems. Furthermore, medical knowledge in the archetypes is separated from the patient record systems.</p><p>The purpose of the thesis has been to develop a tool, a so called archetype editor, that can be used to create and edit archetypes. In addition, the possibilities of implementing a connection to medical terminology systems should be explored. The development has followed an iterative process with focus on stability and usability. Another task has also been to find out the purpose with an archetype editor.</p><p>The result is a platform-independent and stable tool, developed according to usability principles with a connection to the terminology system Unified Medical Language System (UMLS). An archetype editor’s purpose in a wider perspective is to solve shortcomings in medical information systems of today, which are brought up in this thesis. Although the openEHR project is new, there are many technically applicable ideas but also problems because of insufficient practical testing and application.</p>

The overall aim of this thesis was to develop, deploy and evaluate new IT-based methods for supporting treatment and assessment of treatment of advanced Parkinson’s disease. In this condition a number of different motor and non-motor symptoms occur in episodes of varying frequency, duration and severity. In order to determine outcome of treatment changes, repeated assessments are necessary. Hospitalization for observation is expensive and may not be representative for the situation at home. Paper home diaries have questionable reliability and storage and retrieval of results are problematic. Approaches for monitoring using wearable sensors are unable to address important non-motor symptoms. A test battery system consisting of both self-assessments of symptoms and motor function tests was constructed for a touch screen mobile phone. Tests are performed on several occasions per day during test periods of one week. Data is transmitted over the mobile net to a central server where summaries in different symptom dimensions and an overall test score per patient and test period are calculated. There is a web application that graphically presents the results to treating clinical staff. As part of this work, a novel method for assessment of spiral drawing impairment useful during event-driven sampling was developed. To date, the system has been used by over 100 patients in 10 clinics in Sweden and Italy. Evidence is growing that the test battery is useful, reliable and valid for assessment of symptoms during advanced Parkinson’s disease. Infusion of a levodopa/carbidopa gel into the small intestine has been shown to reduce variation in plasma drug levels and improve clinical response in this patient category. A pharmacokinetic-pharmacodynamic model of this intestinal gel infusion was constructed. Possibly this model can assist the process of individualization of dosage for this treatment through in numero simulations. Results from an exploratory data analysis indicate that severity measures during oral levodopa treatment may be factors to consider when deciding candidates for infusion treatment.

Dagens elektroniska patientjournalsystem har begränsade möjligheter att på likartat sätt strukturera och lagra patientinformation. Det är en anledning till att det är problem med att utbyta patientjournaldata mellan olika system. Detta försvårar bland annat forskning och tillgänglighet till patientinformation. Brist på tillgänglighet minskar i sin tur möjligheten att ge en god vård oberoende av var patienten befinner sig. Inom projektet openEHR har en idé med så kallade arketyper tagits fram som ett enhetligt sätt att strukturera utbytbar patientjournaldata för att möta framtida krav på patientjournaler och patientjournalsystem. Arketyper är formella modeller av kliniska informationsentiteter, exempelvis blodtryck. De byggs upp av restriktioner, struktur och termer med eventuella bindningar till medicinska terminologisystem. Dessutom kopplas medicinsk kunskap i arketyperna fri från journalsystemen. Syftet med examensarbetet har varit att utveckla ett verktyg, en så kallad arketypeditor, som kan användas för att skapa och redigera arketyper. Utöver detta skulle möjligheterna undersökas att i verktyget implementera en koppling till medicinska terminologisystem. Utvecklingen har skett i en iterativ process med fokus på användbarhet och stabilitet. Det har även ingått att ta reda på syftet med en arketypeditor. Resultatet är ett plattformsoberoende och stabilt verktyg som är utvecklat enligt användbarhetsprinciper med koppling till terminologisystemet Unified Medical Language System (UMLS). En arketypeditors syfte i ett bredare perspektiv är att lösa brister i dagens medicinska informationssystem som tas upp i denna rapport. Trots att openEHR-projektet är nytt finns det många tekniskt gångbara idéer, men det finns även problem som beror på för lite praktisk testning och tillämpning. / Present-day electronic health record systems have limited possibilities to structure and store patient information in a similarly manner. This causes problems with exchanging patient record data between different systems and it gives rise to problems with, among other things, research and patient information availability. Lack of availability will in turn decrease the possibility of giving good care irrespective of where the patient is located. Within the openEHR project an idea with so called archetypes has been introduced as a uniform way to structure exchangeable patient record data in order to meet future requirements on electronic health records and systems. Archetypes are formal models of clinical information entities, for example blood pressure. They are constructed from constraints, structure and terms which may have bindings to medical terminology systems. Furthermore, medical knowledge in the archetypes is separated from the patient record systems. The purpose of the thesis has been to develop a tool, a so called archetype editor, that can be used to create and edit archetypes. In addition, the possibilities of implementing a connection to medical terminology systems should be explored. The development has followed an iterative process with focus on stability and usability. Another task has also been to find out the purpose with an archetype editor. The result is a platform-independent and stable tool, developed according to usability principles with a connection to the terminology system Unified Medical Language System (UMLS). An archetype editor’s purpose in a wider perspective is to solve shortcomings in medical information systems of today, which are brought up in this thesis. Although the openEHR project is new, there are many technically applicable ideas but also problems because of insufficient practical testing and application.