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PubMed2005

General practice--chaos, complexity and innovation.

Primary health care (PHC) reforms focus on improving access to and effectiveness of general practice services, with greater emphasis on health promotion, prevention and chronic disease management, and integration with population health approaches. Currently, reforms are often based on scant evidence from the most accessible and easily known PHC domains and activities, yet most PHC is complex and poorly understood. Complexity theory is based on understanding patterns that are not predictable by traditional evidence and social knowledge, within a complex adaptive system. Complexity knowledge provides a way of understanding the general practitioner's role in PHC in self-organising local networks, with a capacity to generate new solutions integrated through historical and social connections. Complex systems provide a framework for an expanded knowledge base, debate and discussion of reforms and development of PHC goals and strategies.

Australia↗

PubMedDate not supplied

A computer expert system prototype for mechanically ventilated neonates development and impact on clinical judgment and information access capability of nurses.

A computer expert system is an alternative method of training and providing real-time clinical decision support for nurses to advance their practices from a novice to a proficient level. The purpose of this study was twofold: (1) to develop a prototype of a computer expert system for mechanically ventilated neonates (ES-MVN) and (2) to assess the impact of the ES-MVN on the clinical judgment and information access capability of nurses. Five steps used in developing the prototype are described in this article. The ES-MVN is a multimedia interactive consultation-based program that contains 2 major parts: the nursing diagnosis and the knowledge base on nursing care of mechanically ventilated neonates. A rule-based (Boolean frame) was chosen for the nursing diagnosis decision model. The prototype was developed on the Web server and a combination of computer applications operated in a Microsoft Windows environment. A quasi-experimental, 1-group pretest-posttest design was used to measure the efficacy of the ES-MVN in 16 neonatal intensive care unit registered nurses. Case simulations were used to test the nurses' clinical judgment performance. The results showed a significant increase in the nurses' performance scores of diagnoses and managed care after using the ES-MVN (t[15] = 17.21, P = .0001). The nurses' scores for perceptions of their information access capability and clinical judgment ability after receiving the ES-MVN were significantly higher than before installing the ES-MVN in the neonatal intensive care unit (ts[15] = 6.91 and = 17.53, Ps = .0001, respectively). The findings suggest the usefulness of the computer expert system as an effective tool to support nurses' clinical judgment in critical care situations and to provide access to information at the practice site.

Adult↗

PubMedDate not supplied

[Nephrology evidence and guidelines: current tools and several still open questions].

BACKGROUND: It is widely accepted that decision making should be based on evidence. Although nephrology is a relatively young discipline of internal medicine that should be quick to adopt evidence-based decision making policies, several problems are slowing the progress to an era of evidence-based nephrology. These problems may be identified as: a) an inadequate knowledge-base for problems related to the utilization of evidence-based research resources; b) the unavailability of adequate evidence sources in nephrology; and c) the small investment and funding for clinical research. METHODS: This review outlines the major problems of evidence-based nephrology and looks particularly at the strengths and weaknesses of study designs for evidence-based nephrology. The primary guidelines for evidence-based preparation are presented together with possible strategies to meet the challenge of adopting evidence-based policies in nephrology. CONCLUSIONS: This challenge is particularly important now; after several years of extraordinary basic science research, we face the problem of improving clinical practice by applying this same progress in basic science. This transition has failed because of the small investment provided for clinical research.

Evidence-Based Medicine↗

PubMed1992

Expertise, aptitude, and strategic remembering.

Second- and fourth-grade children were classified according to their knowledge of soccer (experts vs. novices) and IQ (high vs. low), and given 2 sort-recall tasks. One task included items related to the game of soccer and the other included items from familiar natural language categories. Previous research has shown that expertise in a subject can compensate for low levels of performance on text comprehension tasks. Our results, the first examining the effects of both expertise and intelligence on a strategic memory task, were that soccer expert children recalled more items on the soccer list but not on the nonsoccer list than soccer novice children. However, soccer expertise did not modify a significant effect of IQ level, with high-IQ children recalling more than low-IQ children for all contrasts. Interest in soccer was found to be related to expertise but did not contribute to differences in memory performance. The results demonstrate that the knowledge base plays an important role in children's memory, but that domain knowledge cannot fully eliminate the effects of IQ on sort-recall tasks using domain-related materials. That is, although rich domain knowledge seemed to compensate for low aptitude, in that low-aptitude experts performed at the level of high-aptitude novices, its effects were not strong enough to eliminate performance differences between high- and low-aptitude soccer experts.

Aptitude↗

PubMed1981

Relationship of physician continuity to type of health problems in primary care.

The objective of this study was to determine if the level of continuity of medical care was related to the type of health problems (chronic or acute) presented by patients at four family health centers during a one-year period. Patients with chronic diagnoses encountered significantly fewer physicians and had a higher mean Continuity Index than patients with acute illness diagnoses, even though these two groups made the same number of health center visits for their respective problems during this period. These findings indicate that the prioritizing of clinical problems (whether planned or fortuitous) with respect to the importance of providing continuous care may already be taking place at these health centers. These activities are appropriate if one accepts the premise that, other things being equal, longer illnesses are treated more effectively if there is a consistent knowledge base about a patient and his/her illness, and that this consistency of knowledge is related to the number of providers encountered by that patient.

Acute Disease↗

PubMed1995

A model for medical knowledge representation application to the analysis of descriptive pathology reports.

A new knowledge-representation system is presented, designed for medical knowledge-based applications and in particular for the analysis of descriptive medical reports. Knowledge is represented at two levels. A definitional level uses a concept-type hierarchy, a relation-type hierarchy, and a set of schematic graphs to define the concepts used and the relations between them, as well as different types of cardinality restrictions on these relations. A set of compositional hierarchies using the classic "has-part" relation as well as a new set-inclusion relation allows concept composition to be precisely defined. An assertional level allows the creation and manipulation of empirical data, in the form of graphs using the concepts, relations, and constraints defined at the definition level. The use of cardinality constraints in graph unification is considered in the context of descriptive medical discourse analysis.

Artificial Intelligence↗

PubMed1997

A survey of pediatric critical care nurses' knowledge of pain management.

BACKGROUND: Although nurses are accountable for pain management, it cannot be assumed that they are well informed about pain. Nurses' knowledge base underlies their pain management; therefore, it is important to measure their knowledge. OBJECTIVE: To measure pediatric critical care nurses' knowledge of pain management. METHOD: A descriptive, exploratory study was done. After a pilot study, an investigator-developed Pain Management Knowledge Test was distributed to 50 pediatric ICU nurses. Test responses were collected anonymously and coded by number. Item analysis was done, and descriptive statistics were calculated. Modified content analysis was used on requests for pain-related information. RESULTS: The test return rate was 38%. The overall mean score was 63%. Mean scores within test subsections varied from 50% to 92%. Other mean scores were 85% on a nine-item scale of drug-action items and 92% on a two-item scale of intervention items. However, no nurse recognized that cognitive-behavioral techniques can inhibit transmission of pain impulses; only 32% indicated that meperidine converts to a toxic metabolite, only 47% recognized nalbuphine as a drug that may cause signs and symptoms of withdrawal if given to a patient who has been receiving an opioid; and only 63% indicated that when a child states that the child has pain, pain exists. Thirteen nurses requested pain-related information, and all requests focused on analgesic medications. CONCLUSIONS: Testing nurses' knowledge of pain indicated gaps that can be addressed through educational interventions. Research is needed in which the test developed for this study is used as both pretest and posttest in an intervention study with pediatric critical care nurses or is modified for use with nurses in other clinical areas.

Adolescent↗

PubMed1993

An intelligent interactive simulator of clinical reasoning in general surgery.

We introduce an interactive computer environment for teaching in general surgery and for diagnostic assistance. The environment consists of a knowledge-based system coupled with an intelligent interface that allows users to acquire conceptual knowledge and clinical reasoning techniques. Knowledge is represented internally within a probabilistic framework and externally through a interface inspired by Concept Graphics. Given a set of symptoms, the internal knowledge framework computes the most probable set of diseases as well as best alternatives. The interface displays CGs illustrating the results and prompting essential facts of a medical situation or a process. The system is then ready to receive additional information or to suggest further investigation. Based on the new information, the system will narrow the solutions with increased belief coefficients.

Artificial Intelligence↗

PubMed2000

A coherent approach to health informatics education: results of the Dutch curriculum project.

From the beginning a coherent approach to health informatics education has been aimed for in our project to develop learning materials. The features are the thematic approach of the contents, the interrelationship of the modules and the didactical approach embedded in the learning materials. Following results have been achieved. Learning materials have been developed for the following themes: healthcare policy and management, delivery of professional care (specific for nursing and allied health), more generic themes such as electronic patient record, clinical decision making, classification and coding of healthcare data and knowledge based systems. Software made available by private companies has been selected for use in the learning modules. In specific cases the available software products did not match the criteria to support the learning materials. In these cases model applications have been developed that can be considered as forerunners for systems in practical use. Already some companies have expressed interest to adapt our home grown products for use in clinical practice. The modules are based on a model curriculum that has been developed by Aarts et al in 1995. New developments in healthcare have prompted modification of the contents of a few modules. For example, a module has been redefined to cover the important issue of logistics in healthcare. The module on patient education has been adapted to take into account the resources available on the Internet. Also, new insights in the effectiveness of computer-based patient education have been taken into account. The module on informatics for disabled persons has been focussed on computer-based aids and is being linked to the EU-project "Impact" aimed at increasing knowledge about assistive technology. However, the model curriculum has proved to be reasonable robust as a base for our project to develop learning materials for health informatics.

Curriculum↗

PubMed1992

Redefining the science-practice relationship and professional training.

A revised conception of the relationship between psychological science and professional practice is proposed in the light of postmodern changes in perspectives on knowledge. Positivistic science, which has dominated the traditional interpretation of scientist-practitioner training, is considered from a constructivist point of view to be only one possible foundation of psychological knowledge. It is argued that the knowledge base of the profession should be derived with diverse methods and from multiple sources, including the knowledge of practice. The mutuality of science and practice is emphasized. An evolving framework for understanding the epistemology of practice, based on cognitive psychology, is presented. Emphasis on broadened choices of research methods, the development of reflective skills, and better linkage between teaching in the domains of research and practice are urged. Suggestions for research related to scientific training and the knowledge processes of practice are offered.

Forecasting↗

PubMed1996

Libraries and the R&D strategy: a way forward.

As guest editor for the December 1994 issue of Health Libraries Review, I chose the theme of Evidence-Based Practice. In my editorial I suggested that Evidence-based Practice offered tremendous opportunities for NHS librarians to demonstrate their skills in supporting a knowledge-based NHS, because many clinicians had complained that they did not have time, retrieval skills of knowledge of relevant information resources to be effective at finding scientific evidence. Librarians, on the other hand have advanced online searching skills, rapid document retrieval and delivery services, and up-to-date knowledge of the world's medical information resources and networks. These skills mean that librarians are not only well-placed to support clinicians in finding and sifting scientific evidence, but also in teaching clinicians how to search for and store information themselves. NHS librarians have not been slow to recognize these opportunities and innovative professional development programmes have appeared to help hone their skills, such as the Librarian of the 21st Century Programme in the Anglia and Oxford region. The success of NHS librarians in supporting evidence-based health care has led to their formal development in evidence-based medicine workshops for clinicians in a number of regions. In March 1996, as NHS Library Adviser. I was asked to prepare a paper for the R&D Board of the NHS Executive about how this library support could be formally integrated into the R&D Strategy. My paper was unanimously endorsed by the Board and later by the Central R&D Committee of the NHS Executive. It suggests principles of library provision in support of R&D and is reprinted below.

Databases, Factual↗

PubMed2002

[www.evidence.de--assessment and utilization of clinical guidelines by primary care physicians and internists].

BACKGROUND AND OBJECTIVE: Compared to the generation of new scientific results, implementation and utilization of evidence based knowledge is lacking far behind. Strengths and weaknesses of evidence- and HTML-based guidelines were evaluated in an academic network of primary care physicians to better understand the expectations and information needs of GPs. METHODS: Standardized survey of 72 primary care physicians (21% female, 79% male) regarding three network based issues: "frequency of guideline use", "reasons to use/not to use guidelines", "evaluation and overall judgement of guidelines". RESULTS: 62.9% of participating had used net based guidelines at least once, the percentage of more frequent users (> 2 times in two months) was 40.3%. Curiosity and non-specific interest as well as a concrete medical question were the main reasons for utilization of guidelines. The overall judgement of the guidelines was positive, however, only a minority of participating physicians viewed them as a concrete help in daily practice. CONCLUSION: Transformation of new scientific medical knowledge into daily primary care practice is only insufficiently developed. Netbased instruments of continuing medical education may serve as catalysts and should be further developed as well as evaluated.

Family Practice↗

PubMed2003

A research-based didactic model for education to promote culturally competent nursing care in Sweden.

As Sweden changes toward a multicultural society, scientific knowledge of transcultural nursing care becomes increasingly important. Earlier studies in Swedish nursing education have demonstrated a lack of knowledge base in transcultural nursing. Through an extensive review of the literature, a didactic model was developed to help facilitate the establishment of this body of knowledge in transcultural nursing. The article demonstrates how the model applies the content and structure of Leininger's theory of culture care diversity and universality and ethnonursing method in a 3-year nursing program in theory as well as clinical education. The model includes a written guide for faculty members, with references to scientific articles and documents to be used.

Cultural Diversity↗

PubMedDate not supplied

The development of personal computer-based medical consultation system for diagnosis of congenital malformation syndromes using MUMPS.

This paper describes a medical consultation system for diagnosis of congenital malformation syndromes. The system consists of a personal computer, NEC PC-98XL (MS-DOS), using SP-MUMPS for the retrieval of knowledge data, and BASIC for the input/output of image data. This system displays pictorial knowledge and is designed so users can build up the knowledge base, as needed, by adding knowledge from medical literature and records of patients actually treated.

Congenital Abnormalities↗

PubMed1984

[Computer-assisted diagnosis and its application in pancreatic diseases].

The medical expert system CADIAC-2 based on fuzzy logic supports diagnostic decisions in the field of internal medicine. A medical knowledge base contains nosological descriptions of diseases. Given patient data, diagnostic decisions are made on the basis of the medical knowledge stored. Reasonings for the established diagnoses or diagnostic hypotheses are presented as well as plans for further examinations on the patient. Unexplained symptoms, signs or test results are also indicated. The usefulness of CADIAC-2 is demonstrated in a case study involving 38 patients with various pancreating diseases.

Diagnosis, Computer-Assisted↗

PubMed2004

Knowledge acquisition, synthesis, and validation: a model for decision support systems.

BACKGROUND: Decision tools such as clinical decision support systems must be built on a solid foundation of nursing knowledge. However, current methods to determine the best evidence do not include a broad range of knowledge sources. As clinical decision support systems will be designed to assist nurses when making critical decisions, methods need to be devised to glean the best possible knowledge. AIMS: This paper presents a comprehensive knowledge development process to develop a nursing clinical decision support system. DISCUSSION: The Nurse Computer Decision Support Project (N-CODES) is developing a prototype for a prospective decision support system. The prototype is being constructed on rules and cases generated by the best available evidence. To accommodate the range of decisions made in practice, different types of evidence are necessary. The process incorporates procedures to uncover, evaluate, and assimilate information to develop the knowledge domain for a clinical decision support systems. Both formal and practice-based knowledge are included. The model contains several innovative approaches including the use of clinical experts and a network of practicing clinicians. CONCLUSION: These strategies will assist scientists and practitioners interested in determining the best evidence to support clinical decision support systems.

Decision Making↗

PubMed2004

Prospective evaluation of an internet-linked handheld computer critical care knowledge access system.

INTRODUCTION: Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs. METHODS: Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators. RESULTS: Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3-126.8), with medical software accessed less often (median 9/month, IQR 3.7-13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15-40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources (P = 0.018). Benefits and barriers to use of this technology were identified. CONCLUSION: An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.

Academic Medical Centers↗

PubMedDate not supplied

Increasing prostate cancer awareness in African American men.

PURPOSE/OBJECTIVES: To describe the knowledge base of African American men regarding prostate cancer and evaluate the immediate effects of an educational intervention on short-term knowledge acquisition. DESIGN: Prospective one group pretest/post-test. SETTING: Church meetings, Salvation Army senior meetings, health fairs, and senior citizens' meetings in the African American community of a large midwestern city. SAMPLE: Convenience sample of 75 African American men (ages 23-88) who completed a pre- and postintervention questionnaire regarding knowledge and awareness of prostate cancer. METHOD: The questionnaire was based on patient education material from the American Cancer Society. The instrument consisted of seven statements related to prostate cancer incidence, risk factors, and detection. Following completion of the preintervention questionnaire, the investigator provided subjects with information on prostate cancer. Subjects were retested. MAIN RESEARCH VARIABLES: Knowledge and awareness of prostate cancer including incidence, risk factors, and detection in African American men. FINDINGS: Correct responses increased from 23% (preeducation) to 64% (posteducation). The three most frequently missed questions on the pretest related to urinary frequency as an early sign of prostate cancer incidence of prostate cancer in African American men, and increased risk among African American men for prostate cancer when compared to Caucasian men. These items remained the three most frequently missed questions on the post-test. CONCLUSIONS: An educational intervention had a positive effect on short-term knowledge and awareness of prostate cancer in African American men. Additional research is necessary to assess long-term retention of information and what effect, if any, increased knowledge has on health behavior. IMPLICATIONS FOR NURSING PRACTICE: Continued efforts are warranted to encourage this high-risk group to participate in prostate screenings. To influence health behavior, patient education and information regarding the incidence and mortality of prostate cancer is critical in this high-risk population.

Adult↗