On a daily basis critically ill paediatric patients are admitted in the Paediatric Critical Care Unit (PCCU). Some of these paediatric patients require cardiothoracic surgery and is mechanically ventilated post-operatively. Chapter one of this study gives an orientation to this research and explains that in order to prevent ventilator associated complications and high hospitalisation costs, the mechanically ventilated paediatric patient following cardiothoracic surgery should be extubated as soon as he/she is ready. Chapter two is dedicated to the available literature on this topic and indicates that literature on extubation criteria for the mechanically ventilated paediatric patient is minimal. The methodology of this study is discussed in detail in Chapter three. Chapter four gives a detailed explanation of the research findings and the researcher included the developed clinical pathway for the extubation of the paediatric patient following cardiothoracic surgery in a private hospital in Gauteng. The relevant clinical pathway functions as a guideline and evidence-based tool in the PCCU. Lastly Chapter five gives a summary of this study and a few recommendations are made. The researcher has included a personal reflection in this Chapter. / Dissertation (MCur)--University of Pretoria, 2014. / tm2015 / Nursing Science / MCur / Unrestricted

Electronic Medical Records (EMRs) are digital versions of paper charts, used to record the treatment of different patients in hospitals. Clinical pathways are used as guidelines for how to treat different diseases, determined by observing outcomes from previous treatments. Sequential pattern mining is a version of data mining where the data mined is organized in sequences. It is a common research topic in data mining with many new variations on existing algorithms being introduced frequently. In a previous report, the sequential pattern mining algorithm PrefixSpan was used to mine patterns in EMRs to verify or suggest new clinical pathways. It was found to only be able to verify pathways partially. One of the reasons stated for this was that PrefixSpan was too inefficient to be able to mine at a low enough support to consider some items. In this report CSpan is used instead, since it is supposed to outperform PrefixSpan by up to two orders of magnitude, in order to improve runtime and thereby address the problems mentioned in the previous work. The results show that CSpan did indeed improve the runtime and the algorithm was able to mine at a lower minimum support. However, the output was only barely improved. / Electronic Medical Records (EMRs) är digitala versioner av behandlingshistoriken för patienter på sjukhus. Clinical pathways används som riktlinjer för hur olika sjukdomar borde behandlas, vilka bestäms genom att observera utkomsten av tidigare behandlingar. Sequential pattern mining är en typ av data mining där datan som behandlas är strukturerad i sekvenser. Det är ett vanligt forskningsområde inom data mining där många nya variationer av existerande algoritmer introduceras frekvent. I en tidigare rapport användes sequential pattern mining algoritmen PrefixSpan på EMRs för att verifiera eller föreslå nya clinical pathways. Den kunde dock endast verifiera pathways delvis. En av anledningarna som nämndes för detta var att PrefixSpan var för ineffektiv för att kunna köras med en tillräckligt låg support för att kunna finna vissa åtgärder i en behandling. I den här rapporten används istället CSpan, eftersom den ska överprestera PrefixSpan med upp till två storleksordningar, för att förbättra körningstiden och därmed adressera problemen som nämns i den tidigare rapporten. Resultaten visar att CSpan förbättrade körningstiden och algoritmen kunde köras med lägre support. Däremot blev utdatan knappt förbättrad.

Despite the advantages of using NIV, healthcare professionals are not in agreement about precisely when to commence NIV (Elliott, Confalonieri& Nava 2002:1159; Lightowler, Wedzicha, Elliott&Ram 2003: [4]; Garpestad &Hill 2006:147), which adds to the underutilisation of NIV. The aim of this study was to collaboratively develop a clinical pathway for NIV. Two main objectives were identified, namely (i) to identify the components of a clinical pathway for NIV, and (ii) to develop a clinical pathway for NIV that can be implemented in the CCU. The research design utilised for this study was qualitative, contextual, explorative and descriptive in nature. The study consisted of three phases, namely Phase 1: Components of the clinical pathway, Phase 2: Literature control, and Phase 3: Development of the clinical pathway. The objectives of the study were met, and a clinical pathway for NIV was developed. / Dissertation (MCur)--University of Pretoria, 2011. / Nursing Science / unrestricted

Le cancer du sein est une pathologie fréquente mais hétérogène. Il existe ainsi de multiples parcours de santé, dont l’optimisation est un des objectifs du 3ème Plan Cancer. Les parcours de santé ont été analysés sous 3 aspects : qualité, coût et impact psychosocial, à travers 2 études prospectives multicentriques. Des leviers d’efficience ont été identifiés : favoriser le dépistage du cancer du sein, s’inspirer de l’organisation des centres de lutte contre le cancer, mieux cibler les patientes tirant bénéfice d’une chimiothérapie adjuvante par l’accès à des outils innovants tels que les tests génomiques. Dans une 3ème étude prospective, la décision de chimiothérapie adjuvante était modifiée dans 18% des cas. La génomique entre en routine en sénologie. Les cliniciens doivent comprendre cette discipline. La dernière partie de cette thèse rapporte les travaux menés en génomique dans le cancer du sein, au stade de la recherche sur un gène codant pour une protéine à activité méthyltransférase, PRDM15, prometteuse dans les cancers du sein triple négatif exprimant les récepteurs aux androgènes. / Breast cancer is a frequent but heterogeneous disease. Therefore, there are multiple clinical pathways, of which the optimization is one of the objectives of the 3rd Plan Cancer. Three dimensions of the clinical pathways were analyzed through 2 multicenter prospective studies: quality, cost and psychosocial impact. Efficiency levers have been identified: to promote screening for breast cancer, to mimic the organization of comprehensive cancer centers, to better target patients benefiting from adjuvant chemotherapy by accessing tools innovations such as genomic tests. In a 3rd prospective study, the adjuvant chemotherapy decision was modified in 18% of the cases. Genomics enters routine in oncology. Clinicians must understand this discipline. The last part of this thesis reports the work carried out in genomics in breast cancer, at the stage of research on a gene coding for a protein with methyltransferase activity, PRDM15, promising in triple-negative breast cancers expressing androgen receptors.

Ständige Weiterentwicklungen von Behandlungsmöglichkeiten, die Technisierung der Medizin und die Liberalisierung des Gesundheitssystems führen auf Seiten der Versorger zu vermehrten Anstrengungen, die eigenen Geschäftsprozesse in Klinischen Pfaden zu dokumentieren, um auf dieser Basis eine medizinische und betriebswirtschaftliche Optimierung durchzuführen. Für die Entwicklung Klinischer Pfade ist die Einbeziehung Medizinischer Leitlinien unablässig, da sie für definierte Symptomkomplexe den aktuellen Stand der Forschung aggregieren. Gleichwohl sind sie Schulungsunterlagen, direkte Entscheidungshilfen oder Aufklärungsdokumente für Patienten und damit keinesfalls ausschließlich auf die Entwicklung Klinischer Pfade ausgerichtet. Dadurch geht die Leitlinien-getriebene Entwicklung Klinischer Pfade mit einem hohen interpretativen Aufwand auf Seiten der Anwender einher. Aus der Motivation diesen Prozess methodisch zu unterstützen, leitet sich die zentrale Forschungsfrage der Arbeit ab: Wie kann eine Methode gestaltet sein, die eine zielgerichtete Ableitung von Klinischen Pfaden aus Medizinischen Leitlinien zulässt? Dieser Frage nimmt sich die vorliegende Arbeit an und präsentiert einen referenzmodellbasierten Ansatz, diese bestehende methodische Lücke zu schließen. Das Lösungsartefakt setzt dabei direkt auf Seiten der Medizinischen Leitlinie an. Die Methode, kurz MAC, besteht aus drei Methodenfragmenten: dem Rollenmodell, in welchem die Aufgabenträgertypen und ihre Verantwortlichkeiten beschrieben werden, dem Produktfragment, welches den Entwurf einer Modellierungssprache zur Kodierung von Medizinischen Leitlinien und deren Wiederverwendung in Klinischen Pfaden auf Basis einer Referenzmodelladaption vorsieht, und dem Vorgehensmodell, in dem Handlungsanweisungen für die zuvor beschriebenen Aufgabenträgertypen spezifiziert sind. Die Arbeit leistet damit einen Beitrag zum Methodenspektrum der Wirtschaftsinformatik. Forschungsmethodisch ordnet sich die Arbeit in die gestaltungsorientierte Artefaktforschung (Design Science) ein.

Against the background of increasing multidisciplinarity as well as the focus on quality, transparency and economic efficiency of medical services, clinical pathways (CPs) have been established as a promising tool at the organizational level in recent years. They are primarily intended to ensure an adequate description of the care processes and to manage the balance between best treatment practice and economic viability. CPs standardize the internal care services by explicating the institution-specific knowledge with regard to recommendations for action, service portfolio, organizational structures, infrastructure, etc. of a specific service provider. The development of hospital information systems (HIS) has so far been characterized by an evolutionary development of modules in the field of laboratory, radiology, nursing and picture archiving systems as well as in the area of administrative systems. As one result of this development, the HIS usually comprises a heterogeneous network of software systems of different types and manufacturers. However, the actual control of patients by means of evidence-based processes and integration of CPs into HIS was not addressed until the recent years, when HIS manufacturers started developing modules for CP modeling and workflow support. The objective of this thesis is to provide a holistic methodical support for the description of clinical pathways and their integration into a hospital information system to finally improve the compliance of daily care to standard process definitions. Therefore, conceptual models provide an adequate mean to describe and communicate complex matters in a comprehensible form as well as to configure IT systems due to their semi-formal nature. Hence, a first research thread investigates the question, how clinical pathways can be described adequately using conceptual models. This results in an iterative design of adequate modeling languages for clinical pathways. A second research thread further investigates the question, how conceptual models of clinical pathways can be used to configure process-oriented application systems in health care. This thread therefore describes the design of a model-based method, that enables a consecutive transformation of CPs into technical (workflow) specifications, based on the principles of the Model-Driven Architecture.

Against the background of increasing multidisciplinarity as well as the focus on quality, transparency and economic efficiency of medical services, clinical pathways (CPs) have been established as a promising tool at the organizational level in recent years. They are primarily intended to ensure an adequate description of the care processes and to manage the balance between best treatment practice and economic viability. CPs standardize the internal care services by explicating the institution-specific knowledge with regard to recommendations for action, service portfolio, organizational structures, infrastructure, etc. of a specific service provider. The development of hospital information systems (HIS) has so far been characterized by an evolutionary development of modules in the field of laboratory, radiology, nursing and picture archiving systems as well as in the area of administrative systems. As one result of this development, the HIS usually comprises a heterogeneous network of software systems of different types and manufacturers. However, the actual control of patients by means of evidence-based processes and integration of CPs into HIS was not addressed until the recent years, when HIS manufacturers started developing modules for CP modeling and workflow support. The objective of this thesis is to provide a holistic methodical support for the description of clinical pathways and their integration into a hospital information system to finally improve the compliance of daily care to standard process definitions. Therefore, conceptual models provide an adequate mean to describe and communicate complex matters in a comprehensible form as well as to configure IT systems due to their semi-formal nature. Hence, a first research thread investigates the question, how clinical pathways can be described adequately using conceptual models. This results in an iterative design of adequate modeling languages for clinical pathways. A second research thread further investigates the question, how conceptual models of clinical pathways can be used to configure process-oriented application systems in health care. This thread therefore describes the design of a model-based method, that enables a consecutive transformation of CPs into technical (workflow) specifications, based on the principles of the Model-Driven Architecture.:A. Synopsis of the Doctoral Dissertation B. Agility in Medical Treatment Processes C. Domain Specific Modeling Language - CPmod D. BPMN4CP - Version 1.0 E. BPMN4CP - Version 2.0 F. BPMN4CP - Version 2.1 G. MDA in Health Care IS Development H. Transforming Clinical Pathways into Care Workflows I. CDA Templates - Utilizing the MediCUBE

La tesi vuole porre l’attenzione su uno dei dilemmi dei moderni sistemi sanitari: garantire buoni servizi di cura a costi contenuti. La tesi affronta tale questione attraverso l’implementazione del modello value-based (cfr. medicina basata sul valore), dove per “valore” si intende il risultato di salute conseguito per risorse impiegate. L’obiettivo della tesi è quello di dedurre, attraverso tre differenti punti di analisi, le condizioni e i fattori che stanno inducendo le aziende sanitarie a migliorare i loro modelli di erogazione di cura al fine di incrementare il valore per i pazienti. Nello specifico, la tesi focalizza l’attenzione sui processi sanitari (cfr. operations management) mettendo in risalto le modalità con cui le aziende sanitarie tendono a ridisegnare i processi sanitari per rispondere meglio ai bisogni dei pazienti.La tesi tocca diverse prospettive del modello teorico del value-based. I primi due capitoli analizzano la creazione di valore e le condizioni di implementazione analizzando il fenomeno dalla prospettiva aziendale. Al contrario, l’ultimo capitolo punta ad analizzare tale questione dalla prospettiva del paziente. La tesi da spunti su come le aziende sanitarie debbano intraprendere tali cambiamenti operativi e supportare l’implementazione del modello value-based attraverso tre differenti prospettive: percorsi clinici, efficienza operativa, prospettiva del paziente. / The current thesis tries to shed a light on one of the dilemmas concerning healthcare systems: delivering good care at affordable costs. Therefore, this thesis addresses the issues related to the implementation of the value-based healthcare theory, where “value” is the clinical outcome achieved per resources used. The scope of the thesis is to deduce, through three different viewpoints of analysis, the conditions and drivers that are leading healthcare organizations to enhance their healthcare delivery system in order to create more value for patients. In particular, the thesis stresses the perspective of healthcare operations highlighting how providers tend to redesign healthcare processes to better meet patients’ needs. The thesis touches on different perspectives with regard to the value-based theoretical model. The first two chapters analyze value creation and the conditions of its implementation, looking at these phenomena from the provider’s point of view. In contrast, the last chapter aims to analyze this issue from the patient’s perspective. The thesis makes suggestions on how healthcare organizations should undertake operational changes and deals with value-based healthcare implementation through three different fronts: clinical pathways, operational efficiency, patient’s perspective.

Les deux dernières décennies ont été marquées par une augmentation significative des données collectées dans les systèmes d'informations. Cette masse de données contient des informations riches et peu exploitées. Cette réalité s’applique au secteur de la santé où l'informatisation est un enjeu pour l’amélioration de la qualité des soins. Les méthodes existantes dans les domaines de l'extraction de processus, de l'exploration de données et de la modélisation mathématique ne parviennent pas à gérer des données aussi hétérogènes et volumineuses que celles de la santé. Notre objectif est de développer une méthodologie complète pour transformer des données de santé brutes en modèles de simulation des parcours de soins cliniques. Nous introduisons d'abord un cadre mathématique dédié à la découverte de modèles décrivant les parcours de soin, en combinant optimisation combinatoire et Process Mining. Ensuite, nous enrichissons ce modèle par l’utilisation conjointe d’un algorithme d’alignement de séquences et de techniques classiques de Data Mining. Notre approche est capable de gérer des données bruitées et de grande taille. Enfin, nous proposons une procédure pour la conversion automatique d'un modèle descriptif des parcours de soins en un modèle de simulation dynamique. Après validation, le modèle obtenu est exécuté pour effectuer des analyses de sensibilité et évaluer de nouveaux scénarios. Un cas d’étude sur les maladies cardiovasculaires est présenté, avec l’utilisation de la base nationale des hospitalisations entre 2006 et 2015. La méthodologie présentée dans cette thèse est réutilisable dans d'autres aires thérapeutiques et sur d'autres sources de données de santé. / During the last two decades, the amount of data collected in Information Systems has drastically increased. This large amount of data is highly valuable. This reality applies to health-care where the computerization is still an ongoing process. Existing methods from the fields of process mining, data mining and mathematical modeling cannot handle large-sized and variable event logs. Our goal is to develop an extensive methodology to turn health data from event logs into simulation models of clinical pathways. We first introduce a mathematical framework to discover optimal process models. Our approach shows the benefits of combining combinatorial optimization and process mining techniques. Then, we enrich the discovered model with additional data from the log. An innovative combination of a sequence alignment algorithm and of classical data mining techniques is used to analyse path choices within long-term clinical pathways. The approach is suitable for noisy and large logs. Finally, we propose an automatic procedure to convert static models of clinical pathways into dynamic simulation models. The resulting models perform sensitivity analyses to quantify the impact of determinant factors on several key performance indicators related to care processes. They are also used to evaluate what-if scenarios. The presented methodology was proven to be highly reusable on various medical fields and on any source of event logs. Using the national French database of all the hospital events from 2006 to 2015, an extensive case study on cardiovascular diseases is presented to show the efficiency of the proposed framework.

Ständige Weiterentwicklungen von Behandlungsmöglichkeiten, die Technisierung der Medizin und die Liberalisierung des Gesundheitssystems führen auf Seiten der Versorger zu vermehrten Anstrengungen, die eigenen Geschäftsprozesse in Klinischen Pfaden zu dokumentieren, um auf dieser Basis eine medizinische und betriebswirtschaftliche Optimierung durchzuführen. Für die Entwicklung Klinischer Pfade ist die Einbeziehung Medizinischer Leitlinien unablässig, da sie für definierte Symptomkomplexe den aktuellen Stand der Forschung aggregieren. Gleichwohl sind sie Schulungsunterlagen, direkte Entscheidungshilfen oder Aufklärungsdokumente für Patienten und damit keinesfalls ausschließlich auf die Entwicklung Klinischer Pfade ausgerichtet. Dadurch geht die Leitlinien-getriebene Entwicklung Klinischer Pfade mit einem hohen interpretativen Aufwand auf Seiten der Anwender einher. Aus der Motivation diesen Prozess methodisch zu unterstützen, leitet sich die zentrale Forschungsfrage der Arbeit ab: Wie kann eine Methode gestaltet sein, die eine zielgerichtete Ableitung von Klinischen Pfaden aus Medizinischen Leitlinien zulässt? Dieser Frage nimmt sich die vorliegende Arbeit an und präsentiert einen referenzmodellbasierten Ansatz, diese bestehende methodische Lücke zu schließen. Das Lösungsartefakt setzt dabei direkt auf Seiten der Medizinischen Leitlinie an. Die Methode, kurz MAC, besteht aus drei Methodenfragmenten: dem Rollenmodell, in welchem die Aufgabenträgertypen und ihre Verantwortlichkeiten beschrieben werden, dem Produktfragment, welches den Entwurf einer Modellierungssprache zur Kodierung von Medizinischen Leitlinien und deren Wiederverwendung in Klinischen Pfaden auf Basis einer Referenzmodelladaption vorsieht, und dem Vorgehensmodell, in dem Handlungsanweisungen für die zuvor beschriebenen Aufgabenträgertypen spezifiziert sind. Die Arbeit leistet damit einen Beitrag zum Methodenspektrum der Wirtschaftsinformatik. Forschungsmethodisch ordnet sich die Arbeit in die gestaltungsorientierte Artefaktforschung (Design Science) ein.:Teil A - Zusammenfassung Abbildungsverzeichnis Tabellenverzeichnis Abkürzungsverzeichnis 0 Einleitung 0.1 Hintergrund 0.2 Gegenstand und Motivation 0.3 Forschungsdesign 0.3.1 Wissenschaftstheoretische Positionierung 0.3.2 Forschungsziel 0.3.3 Forschungsmethode 1 Aufbau der Arbeit 1.1 Publikation P1: Konzeptuelle Modellierung im klinischen Umfeld 1.2 Publikation P2: Reference Modeling in Health Care – State-of-the-art and Proposal for the Construction and Application of a Reference Model 1.3 Publikation P3: From Clinical Practice Guideline to Clinical Pathway – Issues of Reference Model-Based Approach 1.4 Publikation P4: Anforderungen an eine Methode zur Ableitung Klinischer Pfade aus Medizinischen Leitlinien 1.5 Publikation P5: Methode zur Ableitung Klinischer Pfade aus Medizinischen Leitlinien 2 Fazit 2.1 Beitrag der Arbeit 2.2 Kritische Würdigung und weiterer Forschungsbedarf Literaturverzeichnis Anhang A Teil B - Einzelpublikationen