Designing medical technology for resilience: integrating health economics and human factors approaches

Construction of the Digital Health Equity-Focused Implementation Research Conceptual Model - Bridging the Divide Between Equity-focused Digital Health and Implementation Research

Digital health implementations and investments continue to expand. As the reliance on digital health increases, it is imperative to implement technologies with inclusive and accessible approaches. A conceptual model can be used to guide equity-focused digital health implementations to improve suitability and uptake in diverse populations. The objective of this study is expand an implementation model with recommendations on the equitable implementation of new digital health technologies. The Digital Health Equity-Focused Implementation Research (DH-EquIR) conceptual model was developed based on a rigorous review of digital health implementation and health equity literature. The Equity-Focused Implementation Research for Health Programs (EquIR) model was used as a starting point and merged with digital equity and digital health implementation models. Existing theoretical frameworks and models were appraised as well as individual equity-sensitive implementation studies. Patient and program-related concepts related to digital equity, digital health implementation, and assessment of social/digital determinants of health were included. Sixty-two articles were analyzed to inform the adaption of the EquIR model for digital health. These articles included digital health equity models and frameworks, digital health implementation models and frameworks, research articles, guidelines, and concept analyses. Concepts were organized into EquIR conceptual groupings, including population health status, planning the program, designing the program, implementing the program, and equity-focused implementation outcomes. The adapted DH-EquIR conceptual model diagram was created as well as detailed tables displaying related equity concepts, evidence gaps in source articles, and analysis of existing equity-related models and tools. The DH-EquIR model serves to guide digital health developers and implementation specialists to promote the inclusion of health-equity planning in every phase of implementation. In addition, it can assist researchers and product developers to avoid repeating the mistakes that have led to inequities in the implementation of digital health across populations.

A knowledge framework for the design of built environment supportive of resilient internal logistics in hospitals

Internal logistics is crucial for hospitals, occurring within facilities that pose constraints and opportunities, demanding resilient performance (RP) to adapt to dynamic conditions and balance safety and efficiency pressures. However, the role of the built environment (BE) to support RP is not explicitly analysed in the hospital logistics literature, which is usually limited to discuss BE in terms of layout and routing issues. To address this gap, this study presents a knowledge framework of BE supportive of RP in internal hospital logistics. The framework was developed based on a study in a large teaching hospital, encompassing 11 service flows of people and supplies between an intensive care unit and other units. Data collection was based on 38 interviews, documents such as floor plans, and observations of logistics activities. Seven BE design principles developed in a previous study, concerned with RP in general but not focused on logistics, were adopted as initial themes for data analysis. Results of the thematic analysis gave rise to a knowledge framework composed of seven design prescriptions and 63 practical examples of BE supportive of RP in hospital internal logistics. The paper discusses how these prescriptions and examples are connected to resilience management. The framework is new in the context of internal hospital logistics and offers guidance to both BE and logistics designers.

Translating patient needs into medical device development: co-design of a photoprotection visor for Xeroderma Pigmentosum using qualitative interviews

INTRODUCTION

People with Xeroderma Pigmentosum (XP) have a heightened sensitivity to ultraviolet radiation (UVR) and are advised to wear photoprotective clothing including a visor covering the face and neck. Photoprotective visors are homemade and predominately worn by children with decreasing frequency as age increases. To improve upon the current design and efficacy we were tasked with developing a prototype visor to meet patients' needs.

METHODS

Adopting a codesign methodology, patients' experiences of wearing a visor and patient and carer views of emerging prototypes were explored during interviews. A thematic analysis was conducted in parallel with data collection and themes were interpreted into design cues; desirable attributes of a visor that would counteract the negative user experiences and meet the requirements described by patients and carers. The design cues guided the iterative development of prototypes by academic engineers.

RESULTS

Twenty-four interviews were conducted with patients and carers. Thematic analysis resulted in the following five themes: Being safe from UVR exposure; self-consciousness; temperature effects; acoustic difficulties; and material properties. The following design cues were developed from the themes respectively; materials and design with high UVR protection; ability to customise with own headwear; ventilation to reduce steaming up; acoustic functionality to enable hearing and speech; foldable, portable, and easy to put on and take off.

CONCLUSIONS

It is important to understand people's experiences of using medical devices to improve their safety, efficiency and user satisfaction. The user experience themes and design cues, informed the iterative development of low fidelity visor prototypes as part of a codesign process. These design cues and responses to the prototypes are guiding commercial manufacturing and regulatory approval. The visor can then be prescribed to patients, providing an equitable service of care.

Engaging multisector stakeholders to identify priorities for global health innovation, change and research: an engagement methodology and application to prosthetics service delivery in Cambodia

PURPOSE

While innovation is known to catalyse solutions to global sustainable development challenges, lack of engagement from stakeholders during conceptualisation and development may influence the degree of success of implementation.

METHODS AND MATERIALS

This paper presents a complete and novel engagement methodology, developed from value led business modelling approaches, for working with multi-sector stakeholders. The methodology can be used to determine barriers and facilitators to clinical practice innovations or translational research, within a country-specific context. The approach has then been applied in the Cambodian prosthetics and orthotics sector to provide a practice-based exemplar application of the framework.

RESULTS

This approach seeks to ensure the suitability and sustainability of clinical practice and research programmes being implemented within a complex ecosystem. A theoretical basis, drawn from academic and business innovation sectors, has been consolidated and adapted for practical application to design, direct, and inform initiatives in low resource settings.

CONCLUSIONS

The methods presented provide a way to both develop and articulate the mission, vision, and goals of any proposed change, and to effectively communicate these with stakeholders in a way that engages the personal and professional values that exist in their ecosystem. It provides a structured process through which meaningful conversations can happen, and a basis for relationship management with key stakeholders; intrinsic to enable a sustained legacy from research and development.

Assessing the Social and Environmental Impact of Healthcare Technologies: Towards an Extended Social Return on Investment

Stroke is the third leading cause of death and disability overall worldwide. Upper limb impairment is a common consequence for stroke survivors, having negative impact on their quality of life. Robotic rehabilitation, through repetitive and monitored movements, can improve their status. Developed by a team of researchers at Politecnico di Milano, AGREE is an exoskeleton for upper limb rehabilitation at the stage gate between translational research and clinical validation. Since the cost of this device is particularly high, the present study aimed to provide a framework for assessing its value. The Social Return on Investment (SROI) method, able to grasp the economic, social and environmental impact of an activity, was applied, using expert opinions of a pool of clinical engineers and healthcare professionals from different Italian hospitals to obtain information. Environmental impacts were estimated through Life Cycle Assessment in terms of CO₂ emissions and incorporated in the analysis. Considering a 5-year period, the SROI for a single exoskeleton was 3.75:1, and the SROI for the number of exoskeletons projected to be sold was 2.868:1, thus resulting largely in value for money. This study provides a model for combining economic, social and environmental outcomes that, besides contributing to theory, could be useful for decision-making.

A three step protocol for the development of an innovative footwear (shoe and sensor based insole) to prevent diabetic foot ulceration

Background

The incidence of diabetic foot ulceration (DFU) is increasing worldwide. Therapeutic footwear is usually recommended in clinical practice for preventing foot ulcers in persons with diabetes. The project Science DiabetICC Footwear aims to develop innovative footwear to prevent DFU, specifically a shoe and sensor-based insole, which will allow for monitoring pressure, temperature, and humidity parameters.

Method

This study presents a three-step protocol for the development and evaluation of this therapeutic footwear, specifically: (i) a first observational study will specify the user requirements and contexts of use; (ii) after the design solutions were developed for shoe and insole, the semi-functional prototypes will be evaluated against the initial requirements; (iii) and a pre-clinical study protocol will enable the evaluation of the final functional prototype. The eligible diabetic participants will be involved in each stage of product development. The data will be collected using interviews, clinical evaluation of the foot, 3D foot parameters and plantar pressure evaluation. This three-step protocol was defined according to the national and international legal requirements, ISO norms for medical devices development, and was also reviewed and approved by the Ethics Committee of the Health Sciences Research Unit: Nursing (UICISA: E) of the Nursing School of Coimbra (ESEnfC).

Results

The involvement of end-users (diabetic patients) will enable the definition of user requirements and contexts of use to develop design solutions for the footwear. Those design solutions will be prototyped and evaluated by end-users to achieve the final design for therapeutic footwear. The final functional prototype will be evaluated in pre-clinical studies to ensure that the footwear meets all the requirements to move forward to clinical studies.

Discussion

The three-step study outlined in this protocol will provide the necessary insights during the product development, ensuring this new therapeutic footwear's main functional and ergonomic features for DFU prevention.

Optimal Usability Test Procedure Generation for Medical Devices

Medical device usability testing offers many benefits, including finding medical device usage errors and providing safety to users. As usability testing becomes mandatory for medical devices, manufacturers are increasing the cost burden. In order to perform a high-quality usability test, it is important to implement a usability test procedure, but guidelines for this are lacking. In this paper, we propose a method to systematically design and implement a usability test procedure. We propose methods to reduce test time-costs and apply them to implement the final procedure. Next, by applying the proposed method to sinus surgical navigation system, it is shown that the total time was reduced by 21% compared to the usability summative test procedure previously used in the same system.

Methods for Early Assessment of the Societal Value of Health Technologies: A Scoping Review and Proposal for Classification

OBJECTIVES

Early assessments of health technologies help to better align and integrate their development and assessment. Such assessments can take many forms and serve different purposes, hampering users in their selection of the most appropriate method for a specific goal. The aim of this scoping review was to structure the large set of methods according to their specific goal.

METHODS

A scoping review was conducted using PubMed and reference lists of retrieved articles, to identify review studies with a methodological focus. From the included reviews, all individual methods were listed. Based on additional literature and examples, we extracted the specific goal of each method. All goals were clustered to derive a set of subclasses and methods were grouped into these subclasses.

RESULTS

Of the 404 screened, 5 reviews were included, and 1 was added when searching reference lists. The reviews described 56 methods, of which 43 (77%) were included and classified as methods to (1) explore the nature and magnitude of the problem, (2) estimate the nature and magnitude of the expected (societal) value, (3) identify conditions for the potential value to materialize, and (4) help develop and design the type of research that is needed.

CONCLUSIONS

The wide range of methods for exploring the societal value of health technologies at an early stage of development can be subdivided into a limited number of classes, distinguishing methods according to their specific objective. This facilitates selection of appropriate methods, depending on the specific needs and aims.

Design for resilient performance: Concept and principles

Resilient performance in socio-technical systems is usually described as stemming from people's self-organization and spur-of-the-moment actions and decisions. However, this is not exclusive with work system design ahead of time, with the deliberate intention of influencing resilient performance. This paper proposes a concept and principles of Design for Resilient Performance (DfRP), making explicit contributions that had been concealed and fragmented in the literature. Based on a literature review of influential human factors studies, 23 design principles were identified and set a basis for a Delphi study with 27 experts from nine countries. After three Delphi rounds, consensus was obtained and the DfRP concept was defined as well as seven design principles, namely: (i) there must be functional models of the system; (ii) make variations in performance visible; (iii) use the type of standardization that best fits the nature of the function; (iv) design slack resources and strategies; (v) design for acceptable performance even under degraded conditions; (vi) design must involve leveraging diverse perspectives; and (vii) design to support continuous learning at the individual and organisational level. The applicability of the principles is demonstrated through an exploratory case study of the rapid response team in a hospital. The principles of DfRP are contributions of prescriptive nature, which might give rise to more resilient socio-technical systems.

Coping with complexity in the COVID pandemic: An exploratory study of intensive care units

Although the COVID pandemic has challenged the resilience of health services in general, this impact has been most visible in intensive care units (ICUs). This paper presents an exploratory study of how ICUs in Brazil have coped with the complexity stemming from the pandemic. Five guidelines for coping with complexity were adopted as analytical framework. The guidelines were concerned with slack resources, diversity of perspectives, visibility, work-as-done, and unintended consequences. There were three main sources of data: (i) a survey with respondents from 33 ICUs, which indicated their agreement with 23 statements related to the use of the complexity guidelines; (ii) semistructured interviews with seven survey respondents and two public health officials; and (iii) 20 h of observations of the meetings of a municipal bed management committee. Seventy resilience practices were identified from these data sources. Most of these practices (n = 30) were related to the guideline on slack resources, which were commonly obtained from other hospital units. As for the survey data, the statement related to the availability of extra or standby human resources obtained the lowest score, reinforcing the key role of slack resources. Five lessons learned for coping with complexity in ICUs were drawn from our data; one lesson for each guideline. Furthermore, the survey questionnaire is a potential ICU assessment tool, which can be adapted to other health services.

The Built Environment Influence on Resilient Healthcare: A Systematic Literature Review of Design Knowledge

OBJECTIVE

The aim of this study was to develop built environment (BE) design knowledge to support resilient healthcare by systematically reviewing the evidence-based design (EBD) literature.

BACKGROUND

Although the EBD literature is vast, it has not made explicit its contribution to resilient healthcare, which is a key component of the highly complex health service.

METHOD

This review followed the steps recommended by the Preferred Reporting Items for Systematic reviews and Meta-Analyses method. After applying the inclusion and exclusion criteria, 43 journal papers were selected. The papers were analyzed in light of five guidelines for coping with complexity, allowing for the development of BE design knowledge that supports resilient healthcare.

RESULTS

The design knowledge compiled by the review was structured according to four levels of abstraction: five design-meta principles, corresponding to the five complexity guidelines, seven design principles, 21 design prescriptions, and 58 practical examples. The design knowledge emphasizes the interactions between the BE as physical infrastructure and the functions that it supports.

CONCLUSIONS

The design knowledge is expected to be useful not only to architects but also to those involved in the functional design of health services as they interact with the BE. Furthermore, our proposal provides a knowledge template that can be continuously updated based on the experience of practitioners and academic research.

Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective

BACKGROUND

Hospitals in various countries such as the Netherlands investigate and analyse serious adverse events (SAEs) to learn from previous events and attempt to prevent recurrence. However, current methods for SAE analysis do not address the complexity of healthcare and investigations typically focus on single events on the hospital level. This hampers hospitals in their ambition to learn from SAEs. Integrating human factors thinking and using a holistic and more consistent method could improve learning from SAEs.

AIM

This study aims to develop a novel generic analysis method (GAM) to: (1) facilitate a holistic event analysis using a human factors perspective and (2) ease aggregate analysis of events across hospitals.

METHODS

Multiple steps of carefully evaluating, testing and continuously refining prototypes of the method were performed. Various Dutch stakeholders in the field of patient safety were involved in each step. Theoretical experts were consulted, and the prototype was pretested using information-rich SAE reports from Dutch hospitals. Expert panels, engaging quality and safety experts and medical specialists from various hospitals were consulted for face and content validity evaluation. User test sessions concluded the development of the method.

RESULTS

The final version of the GAM consists of a framework and affiliated questionnaire. GAM combines elements of three methods for SAE analysis currently practised by Dutch hospitals. It is structured according to the Systems Engineering Initiative for Patient Safety model, which incorporates a human factors perspective into the analysis. These eases aggregated analysis of SAEs across hospitals and helps to consider the complexity of healthcare work systems.

CONCLUSION

The GAM is a valuable new tool for hospitals to learn from SAEs. The method can facilitate a holistic aggregate analysis of SAEs across hospitals using a human factors perspective, and is now ready for further extensive testing.

Embedding artificial intelligence in society: looking beyond the EU AI master plan using the culture cycle

The European Union (EU) Commission’s whitepaper on Artificial Intelligence (AI) proposes shaping the emerging AI market so that it better reflects common European values. It is a master plan that builds upon the EU AI High-Level Expert Group guidelines. This article reviews the masterplan, from a culture cycle perspective, to reflect on its potential clashes with current societal, technical, and methodological constraints. We identify two main obstacles in the implementation of this plan: (i) the lack of a coherent EU vision to drive future decision-making processes at state and local levels and (ii) the lack of methods to support a sustainable diffusion of AI in our society. The lack of a coherent vision stems from not considering societal differences across the EU member states. We suggest that these differences may lead to a fractured market and an AI crisis in which different members of the EU will adopt nation-centric strategies to exploit AI, thus preventing the development of a frictionless market as envisaged by the EU. Moreover, the Commission aims at changing the AI development culture proposing a human-centred and safety-first perspective that is not supported by methodological advancements, thus taking the risks of unforeseen social and societal impacts of AI. We discuss potential societal, technical, and methodological gaps that should be filled to avoid the risks of developing AI systems at the expense of society. Our analysis results in the recommendation that the EU regulators and policymakers consider how to complement the EC programme with rules and compensatory mechanisms to avoid market fragmentation due to local and global ambitions. Moreover, regulators should go beyond the human-centred approach establishing a research agenda seeking answers to the technical and methodological open questions regarding the development and assessment of human-AI co-action aiming for a sustainable AI diffusion in the society.

Implementing lateral flow devices in long-term care facilities: experiences from the Liverpool COVID-19 community testing pilot in care homes- a qualitative study

Introduction

Antigen-based lateral flow devices (LFDs) offer the potential of widespread rapid testing. The scientific literature has primarily focused on mathematical modelling of their use and test performance characteristics. For these tests to be implemented successfully, an understanding of the real-world contextual factors that allow them to be integrated into the workplace is vital. To address this gap in knowledge, we aimed to explore staff’s experiences of integrating LFDs into routine practice for visitors and staff testing with a view to understand implementation facilitators and barriers.

Methods

Semi-structured interviews and thematic analysis.

Results

We identified two main themes and five subthemes. The main themes included: visitor-related testing factors and staff-related testing factors. Subthemes included: restoring a sense of normality, visitor-related testing challenges, staff-related testing challenges, and pre-pilot antecedent factors.

Conclusion

Our study demonstrates that the real-world implementation of LFDs to test visitors and staff faces significant challenges as a result of several contextual factors negatively affecting the work practice and environment. More comprehensive studies are needed to identify and inform effective implementation strategies to ensure that LFDs can be adopted in an agile way that better supports an already exhausted and morally depleted workforce.

Effects of User Characteristics on the Usability of a Home-Connected Medical Device (Smart Angel) for Ambulatory Monitoring: Usability Study

Background

The Smart Angel home medical device allows ambulatory surgery patients to monitor their own health by taking their blood pressure and oxygen levels and answering a health questionnaire from home. Currently, this device is a prototype in the design phase, and no usability evaluation has been performed. This preventive device must be usable by patients with different profiles; however, it is important to select patients carefully to ensure their safety when using the device. As such, it would be interesting to know how to select or exclude patients. However, the links between user characteristics and the usability of this home medical device remain unclear.

Objective

This study aims to better understand the links between certain characteristics of potential patients (ie, age, education, technophilia, and health literacy) and the usability (ie, effectiveness, efficiency, and satisfaction) of Smart Angel, as defined by the ISO 9241-11.

Methods

We conducted an experimental study involving 36 participants investigating the effects of 4 patient characteristics (ie, age, education, technophilia, and health literacy) on usability, measured in terms of effectiveness, efficiency, and satisfaction. A mixed methods approach (subjective vs objective) using a variety of standard instruments was adopted (direct observation, video analysis, and questionnaires). First, to help participants project themselves into the real use of the Smart Angel device, they watched a scenario in a video. Second, the participants completed a set of questionnaires to show the extent of their health literacy level (Newest Vital Sign [NVS] and the Health Literacy Survey [HLS]) and then operated Smart Angel devices. Efficiency (ie, handling time) and effectiveness (ie, number of handling errors) measures were collected by video analysis. Satisfaction measures were collected by a questionnaire (System Usability Scale [SUS]). The qualitative observational data were coded using inductive analysis by 2 independent researchers specialized in cognitive psychology and cognitive ergonomics.

Results

The results show a moderate and positive correlation between age and effectiveness (r=0.359; P=.03) and efficiency (r=0.357; P=.03). There is strong correlation between health literacy scored by the NVS and effectiveness (r=0.417; P=.01), efficiency (r=-0.38; P=.02), and satisfaction (r=0.45; P=.006). However, there is a weak correlation between technophilia and usability and no relationship between education level and usability.

Conclusions

Our results show that literacy level and age are 2 important factors to consider when selecting future users of the Smart Angel device to ensure patient safety. This study also serves as an example promoting mixed methodologies in assessments of medical device usability that cannot be performed under real-world conditions.

Research protocol for the validation of a new portable technology for real-time continuous monitoring of Early Warning Score (EWS) in hospital practice and for an early-stage multistakeholder assessment

INTRODUCTION

The real-time continuous monitoring of vital parameters in patients affected by multiple chronic conditions and/or COVID-19 can lead to several benefits to the Italian National Healthcare System (IT-NHS). The UBiquitous Integrated CARE (UBICARE) technology is a novel health digital platform at the validation stage in hospital setting. UBICARE might support the urgent need for digitalisation and early intervention, as well as minimise the face-to-face delivery of care in both hospital and community-based care settings. This research protocol aims to design an early-stage assessment of the multidimensional impact induced by UBICARE within the IT-NHS alongside technology validation in a hospital ward.

METHODS AND ANALYSIS

The targeted patients will be medium/high-risk hypertensive individuals as an illustrative first example of how UBICARE might bring benefits to susceptible patients. A mixed-method study will be applied to incorporate to the validation study a multistakeholder perspective, including perceived patient experiences and preferences, and facilitate technology adoption. First, semistructured interviews will be undertaken with a variety of stakeholders including clinicians, health managers and policy-makers to capture views on the likely technology utility, economic sustainability, impact of adoption in hospital practice and alternative adoption scenarios. Second, a monocentric, non-randomised and non-comparative clinical study, supplemented by the administration of standardised usability questionnaires to patients and health professionals, will validate the use of UBICARE in hospital practice. Finally, the results of the previous stages will be discussed in a multidisciplinary-facilitated workshop with IT-NHS relevant stakeholders to reconcile stakeholders' perspectives. Limitations include a non-random recruitment strategy in the clinical study, small sample size of the key stakeholders and potential stakeholder recruitment bias introduced by the research technique.

ETHICS AND DISSEMINATION

The Ethics Committee for Clinical Experimentation of Tuscany Region approved the protocol. Participation in this study is voluntary. Study results will be disseminated through peer-reviewed publications and academic conferences.

Sousa L, Marques IA, Costa P, Cortez S, Carneiro F, Cruz A, Salgueiro-Oliveira A. Development of an innovative double-chamber syringe for intravenous therapeutics and flushing: Nurses' involvement through a human-centred approach

BACKGROUND

In nursing practice, flushing the catheters pre and post-drug administration is considered an important clinical procedure to prevent complications, and requires the use of several syringes to comply with international standards of care. We envisioned an innovative double-chamber syringe that enables the filling and administration of both solutions. Following current international recommendations, the development of new medical devices should integrate Health Technology Assessment. The Human-centred design is usually used for that assessment purposes, as a method that actively include end-users in the devices development process.

METHOD

Application of the Human-Centred Design through the involvement of nurses in the initial stages of the device development in order to accomplish the initial stages of Technology Readiness Level. A multi-method approach was used, including literature/guidelines review, focus groups with end-users and expert panels.

RESULTS

The involvement of nurses enabled the definition of user requirements and contexts of use, as well as the evaluation of design solutions and prototypes in order to accomplish with usability and ergonomic features of the medical device.

CONCLUSIONS

Significant contributions were made regarding the final design solution of this innovative double-chamber syringe.

Resilience in the Surgical Scheduling to Support Adaptive Scheduling System

Operating Room (OR) managers frequently encounter uncertainties related to real-time scheduling, especially on the day of surgery. It is necessary to enable earlier identification of uncertainties occurring in the perioperative environment. This study aims to propose a framework for resilient surgical scheduling by identifying uncertainty factors affecting the real-time surgical scheduling through a mixed-methods study. We collected the pre- and post-surgical scheduling data for twenty days and a one-day observation data in a top-tier general university hospital in South Korea. Data were compared and analyzed for any changes related to the dimensions of uncertainty. The observations in situ of surgical scheduling were performed to confirm our findings from the quantitative data. Analysis was divided into two phases of fundamental uncertainties categorization (conceptual, technical and personal) and uncertainties leveling for effective decision-making strategies. Pre- and post-surgical scheduling data analysis showed that unconfirmed patient medical conditions and emergency cases are the main causes of frequent same-day surgery schedule changes, with derived factors that affect the scheduling pattern (time of surgery, overtime surgery, surgical procedure changes and surgery duration). The observation revealed how the OR manager controlled the unexpected events to prevent overtime surgeries. In conclusion, integrating resilience approach to identifying uncertainties and managing event changes can minimize potential risks that may compromise the surgical personnel and patients' safety, thereby promoting higher resilience in the current system. Furthermore, this strategy may improve coordination among personnel and increase surgical scheduling efficiency.

Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience

BACKGROUND

Traditional approaches to safety management in health care have focused primarily on counting errors and understanding how things go wrong. Resilient Health Care (RHC) provides an alternative complementary perspective of learning from incidents and understanding how, most of the time, work is safe. The aim of this review was to identify how RHC is conceptualised, described and interpreted in the published literature, to describe the methods used to study RHC, and to identify factors that develop RHC.

METHODS

Electronic searches of PubMed, Scopus and Cochrane databases were performed to identify relevant peer-reviewed studies, and a hand search undertaken for studies published in books that explained how RHC as a concept has been interpreted, what methods have been used to study it, and what factors have been important to its development. Studies were evaluated independently by two researchers. Data was synthesised using a thematic approach.

RESULTS

Thirty-six studies were included; they shared similar descriptions of RHC which was the ability to adjust its functioning prior to, during, or following events and thereby sustain required operations under both expected and unexpected conditions. Qualitative methods were mainly used to study RHC. Two types of data sources have been used: direct (e.g. focus groups and surveys) and indirect (e.g. observations and simulations) data sources. Most of the tools for studying RHC were developed based on predefined resilient constructs and have been categorised into three categories: performance variability and Work As Done, cornerstone capabilities for resilience, and integration with other safety management paradigms. Tools for studying RHC currently exist but have yet to be fully implemented. Effective team relationships, trade-offs and health care 'resilience' training of health care professionals were factors used to develop RHC.

CONCLUSIONS

Although there was consistency in the conceptualisation of RHC, methods used to study and the factors used to develop it, several questions remain to be answered before a gold standard strategy for studying RHC can confidently be identified. These include operationalising RHC assessment methods in multi-level and diverse settings and developing, testing and evaluating interventions to address the wider safety implications of RHC amidst organisational and institutional change.

Work, resilience and sustainable futures

Purpose

This paper examines the relationship between work, resilience and sustainable futures for organisations and communities by considering the nature of work-related problems (WRPs) and the work-based research designed to investigate them. The authors explore the axis of work environment > work-related problem > resilience > sustainable futures as it might be impacted by work-based research.

Design/methodology/approach

The paper introduces two current real-world examples, one in Australia and one in Asia, of work-based research projects associated with higher education aimed at promoting resilience and sustainability, and discusses the research problems, questions, designs, methods, resilience markers and sustainability markers used by these projects.

Findings

Work-based research, when conducted rigorously using mixed methods, may contribute to increased resilience of organisations and communities and thereby seeks to promote more sustainable organisational and social futures.

Practical implications

Work-based research conducted in higher education seeks to investigate, address and solve WRP, even when such problems occur in unstable, changing, complex and messy environments.

Social implications

Resilience and sustainable futures are ambiguous and disputed terms, but if work-based research can be brought to bear on them, organisations and communities might better adapt and recover from challenging situations, thus reducing their susceptibility to shock and adversity.

Originality/value

While resilience and sustainability are commonly referred to in the research literature, their association to work, and specifically problems associated with work, have yet to be examined. This paper goes some of the way to addressing this need.

The Lean and Agile Multi-dimensional Process (LAMP) - a new framework for rapid and iterative evidence generation to support health-care technology design and development

Introduction: Health technology assessments (HTA) are tools for policymaking and resource allocation. Early HTAs are increasingly used in design and development of new technologies. Conducting early HTAs is challenging, due to a lack of evidence and significant uncertainties in the technology and the market. A multi-disciplinary approach is considered essential. However, an operational framework that can enable the integration of multi-dimensional evidence into commercialization remains lacking.Areas covered: We developed the Lean and Agile Multi-dimensional Process (LAMP), an early HTA framework, for embedding commercial decision-making in structured evidence generation activities, divided into phases. Diverse evidence in unmet needs, user acceptance, cost-effectiveness, and market competitiveness are being generated in increasing depth. This supports the emergence of design and value propositions that align technology capabilities and clinical and user needs.Expert opinion: We have been applying LAMP to working with medical device and diagnostic industry in the UK. The framework can be adapted to suit different technologies, decision needs, time scales, and resources. LAMP offers a practical solution to the multi-disciplinary approach. Methodologists drive the process by performing evidence generation and synthesis as and by enabling interactions between manufacturers, designers, clinicians, and other key stakeholders.

How to Ease the Pain of Taking a Diagnostic Point of Care Test to the Market: A Framework for Evidence Development

Bringing a diagnostic point of care test (POCT) to a healthcare market can be a painful experience as it requires the manufacturer to meet considerable technical, financial, managerial, and regulatory challenges. In this opinion article we propose a framework for developing the evidence needed to support product development, marketing, and adoption. We discuss each step in the evidence development pathway from the invention phase to the implementation of a new POCT in the healthcare system. We highlight the importance of articulating the value propositions and documenting the care pathway. We provide guidance on how to conduct care pathway analysis as little has been published on this. We summarize the clinical, economic and qualitative studies to be considered for developing evidence, and provide useful links to relevant software, on-line applications, websites, and give practical advice. We also provide advice on patient and public involvement and engagement (PPIE), and on product management. Our aim is to help device manufacturers to understand the concepts and terminology used in evaluation of in vitro diagnostics (IVDs) so that they can communicate effectively with evaluation methodologists, statisticians, and health economists. Manufacturers of medical tests and devices can use the proposed framework to plan their evidence development strategy in alignment with device development, applications for regulatory approval, and publication.

What do healthcare professionals need to turn risk models for type 2 diabetes into usable computerized clinical decision support systems? Lessons learned from the MOSAIC project

Background

To understand user needs, system requirements and organizational conditions towards successful design and adoption of Clinical Decision Support Systems for Type 2 Diabetes (T2D) care built on top of computerized risk models.

Methods

The holistic and evidence-based CEHRES Roadmap, used to create eHealth solutions through participatory development approach, persuasive design techniques and business modelling, was adopted in the MOSAIC project to define the sequence of multidisciplinary methods organized in three phases, user needs, implementation and evaluation. The research was qualitative, the total number of participants was ninety, about five-seventeen involved in each round of experiment.

Results

Prediction models for the onset of T2D are built on clinical studies, while for T2D care are derived from healthcare registries. Accordingly, two set of DSSs were defined: the first, T2D Screening, introduces a novel routine; in the second case, T2D Care, DSSs can support managers at population level, and daily practitioners at individual level. In the user needs phase, T2D Screening and solution T2D Care at population level share similar priorities, as both deal with risk-stratification. End-users of T2D Screening and solution T2D Care at individual level prioritize easiness of use and satisfaction, while managers prefer the tools to be available every time and everywhere. In the implementation phase, three Use Cases were defined for T2D Screening, adapting the tool to different settings and granularity of information. Two Use Cases were defined around solutions T2D Care at population and T2D Care at individual, to be used in primary or secondary care. Suitable filtering options were equipped with “attractive” visual analytics to focus the attention of end-users on specific parameters and events. In the evaluation phase, good levels of user experience versus bad level of usability suggest that end-users of T2D Screening perceived the potential, but they are worried about complexity. Usability and user experience were above acceptable thresholds for T2D Care at population and T2D Care at individual.

Conclusions

By using a holistic approach, we have been able to understand user needs, behaviours and interactions and give new insights in the definition of effective Decision Support Systems to deal with the complexity of T2D care.

Electronic supplementary material

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Embedded deep learning in ophthalmology: making ophthalmic imaging smarter

Deep learning has recently gained high interest in ophthalmology due to its ability to detect clinically significant features for diagnosis and prognosis. Despite these significant advances, little is known about the ability of various deep learning systems to be embedded within ophthalmic imaging devices, allowing automated image acquisition. In this work, we will review the existing and future directions for 'active acquisition'-embedded deep learning, leading to as high-quality images with little intervention by the human operator. In clinical practice, the improved image quality should translate into more robust deep learning-based clinical diagnostics. Embedded deep learning will be enabled by the constantly improving hardware performance with low cost. We will briefly review possible computation methods in larger clinical systems. Briefly, they can be included in a three-layer framework composed of edge, fog, and cloud layers, the former being performed at a device level. Improved egde-layer performance via 'active acquisition' serves as an automatic data curation operator translating to better quality data in electronic health records, as well as on the cloud layer, for improved deep learning-based clinical data mining.

HEALTH TECHNOLOGY ASSESSMENT METHODS GUIDELINES FOR MEDICAL DEVICES: HOW CAN WE ADDRESS THE GAPS? THE INTERNATIONAL FEDERATION OF MEDICAL AND BIOLOGICAL ENGINEERING PERSPECTIVE

Objectives:

Current health technology assessment (HTA) methods guidelines for medical devices may benefit from contributions by biomedical and clinical engineers. Our study aims to: (i) review and identify gaps in the current HTA guidelines on medical devices, (ii) propose recommendations to optimize the impact of HTA for medical devices, and (iii) reach a consensus among biomedical engineers on these recommendations.

Methods:

A gray literature search of HTA agency Web sites for assessment methods guidelines on devices was conducted. The International Federation of Medical and Biological Engineers (IFMBE) then convened a structured focus group, with experts from different fields, to identify potential gaps in the current HTA guidelines, and to develop recommendations to fill these perceived gaps. The thirty recommendations generated from the focus group were circulated in a Delphi survey to eighty-five biomedical and clinical engineers.

Results:

Thirty-two panelists, from seventeen countries, participated in the Delphi survey. The responses showed a strong agreement on twenty-seven of thirty recommendations. Some uncertainties remain about the methods to accurately assess the effectiveness and safety, and interoperability of a medical device with other devices or within the clinical setting.

Conclusions:

As medical devices differ from drug therapies, current HTA methods may not accurately reflect the conclusions of their assessment. Recommendations informed by the focus group discussions and Delphi survey responses aimed to address the perceived gaps, and to provide a more integrated approach in medical device assessments in combining engineering with other perspectives, such as clinical, economic, patient, human factors, ethical, and environmental.