A PRACTICE-BASED EVIDENCE APPROACH FOR CLINICAL DECISION SUPPORT Hamzah Bin Osop BComp. (National University of Singapore) MSc. in Information Systems (Nanyang Technological University) Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Electrical Engineering and Computer Science School Science and Engineering Faculty Queensland University of Technology November 2018 To my wife and parents Keywords Clinical data warehouse, clinical decision support system, decision-making, eHealth, electronic health records, electronic medical records, evidence-based practice, patient health records, practice-based evidence A Practice-Based Evidence Approach for Clinical Decision Support i Abstract Dynamic and complex patient care needs are creating an increasing demand for useful tools that support well-informed clinical decision making by healthcare professionals. Here, we introduce a new Practice-Based Evidence (PBE) approach to clinical decision making that builds on existing healthcare ICT infrastructure. In general, Practice-Based Evidence is defined as the use of current best evidence that is drawn from actual clinical practice settings to make specific decisions about individual patient care needs. An example is healthcare professionals collaborating to form research networks where valuable clinical data gathered during routine clinical practices are accumulated and shared. Such PBE approach has been proposed as a complement to Evidence-Based Practice (EBP) due to limitations of outcomes from randomised controlled trials. Instead of accumulating clinical data via research networks, our newly proposed PBE approach strategises an ICT architecture that exploits Electronic Health Records (EHRs) and a Clinical Decision Support System (CDSS) to provide automated support for decision making, customising it to individual patients. Currently, huge volumes of digital data are being generated by healthcare information systems. These data have the potential to be highly useful for decision making support. However, the healthcare information systems usually run on proprietary software and databases, resulting in a ‘diverse and disparate’ systems environment. This inhibits sharing of information across different information systems and ultimately to healthcare professionals. As such, we contend that an effective and efficient healthcare delivery requires an integrated, data-driven, information sharing approach. Our PBE approach to decision making support has three key components, (1) a data integration architecture, (2) Electronic Health Records as a key source of evidence, and (3) a Clinical Decision Support System as a tool to assist in decision making. To evaluate the effectiveness of our PBE approach, we assessed its potential to integrate multiple sources of data and provide comprehensive information that could be used in a decision support tool to assist healthcare professionals in making well- ii Feasibility of Practice-Based Evidence for Clinical Decision Support informed decisions. To do this, a study in three stages was conducted with IT professionals and doctors in a public hospital. The first stage of the study used interviews to elicit the hospital’s current Information and Communication Technology (ICT) architecture. Content analysis of the interview data revealed the clinical information systems in use and informed the design of a suitable data integration architecture, effectively a clinical data warehouse. The second stage of the study used a survey to identify doctors’ perceptions regarding the benefits of using EHR systems and the usefulness of EHR data for clinical decision making. The outcome from this stage of the study helped to identify the practical value and suitability of electronic health records as a source of evidence to inform decisions. The third and final stage consisted of a field test and a focus group discussion to evaluate the feasibility of our Practice-Based Evidence approach to clinical decision making, implemented through a prototype Clinical Decision Support System developed specifically for this research. Anonymised inpatient data was used as the source of evidence for our prototype CDSS. The system was able to provide several significant patient-centric statistics, one being the prediction of probable length of stay which illustrates how our PBE approach provides healthcare professionals with useful data that supports decision making. Outcomes from a qualitative thematic analysis of the focus group discussion revealed an overall positive perception regarding the feasibility and potential of our PBE approach to assist healthcare professionals with decision making. This thesis contributes to the body of knowledge within the healthcare ICT domain in several aspects. First, the conceptualisation of our PBE approach to decision making identifies key components essential for its implementation. Second, it identifies the use of EHR as alternative evidence for PBE approach, based on the general perception among doctors in Singapore regarding the potential of data in EHRs to assist with decision making. Third, it presents a data warehouse architecture that supports PBE adoption, which is based on an existing IT infrastructure design of a public hospital in Singapore. Fourth, it evaluates the PBE approach to decision making through the use of a prototype CDSS and anonymised patient health records, representing a case study of a potential real world application. A Practice-Based Evidence Approach for Clinical Decision Support iii Table of Contents Keywords ................................................................................................................................................. i Abstract ................................................................................................................................................... ii Table of Contents ................................................................................................................................... iv List of Figures ..................................................................................................................................... viii List of Tables .......................................................................................................................................... x List of Abbreviations ............................................................................................................................. xi Statement of Original Authorship ....................................................................................................... xiii Acknowledgements .............................................................................................................................. xiv Publications Arising from this Thesis ................................................................................................... xv INTRODUCTION ....................................................................................................... 1 1.1 Background .................................................................................................................................. 1 1.2 Research Context ......................................................................................................................... 5 1.3 Purposes ....................................................................................................................................... 6 1.3.1 Aims & Objectives ........................................................................................................... 6 1.3.2 Research Questions .......................................................................................................... 8 1.4 Significance, Scope and Definitions ............................................................................................ 9 1.4.1 Research Significance, Scope and Limitation .................................................................. 9 1.4.2 Methodology................................................................................................................... 11 1.4.3 Research Plan ................................................................................................................. 13 1.5 Research Contribution ............................................................................................................... 13 1.6 Thesis Outline ............................................................................................................................ 17 LITERATURE REVIEW ......................................................................................... 19 2.1 Background ................................................................................................................................ 19 2.2 Chronic Disease Prevalence in General Cases ........................................................................... 21 2.3 ICT Adoption in Healthcare....................................................................................................... 26 2.4 Evidence-based Practice ............................................................................................................ 29 2.4.1 Evolution of Evidence-based Practice ............................................................................ 30 2.4.2 Benefits of Evidence-based Practice............................................................................... 33 2.4.3 Effectiveness of Evidence-based Practice Limited by Evidence ...................................