Delivery Workflow Research Articles

Incorporating systems-level stakeholder perspectives into the Design of Mobile Integrated Health Programs

ABSTRACT OBJECTIVES Despite early evidence of effectiveness, cost-savings, and resource optimization, mobile integrated health (MIH) programs have not been widely implemented in the United States. System, community, and organizational-level barriers often hinder evidence-based public health interventions, such as MIH programs, from being broadly adopted into real-world clinical practice. The objective of this study is to identify solutions to the barriers impeding the implementation of MIH through interviews with multilevel stakeholders. METHODS Using the CENTERing multi-level partner voices in Implementation Theory methodology, the study team recruited stakeholders to participate in semi-structured interviews that were recorded, transcribed, and open-coded. Stakeholders were asked to explore and propose solutions to established barriers to the implementation of MIH programs including poor understanding of the role of MIH, the absence of sustainable reimbursement for MIH programs, and its disruption of existing clinical workflows. The study team used the Consolidated Framework for Implementation Research to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes related to pragmatic solutions for overcoming barriers to the adoption of MIH. RESULTS Interviews with Department of Public Health officials, medical directors of MIH programs, non-physician MIH program leaders, community paramedics, health insurance officials, ambulatory physicians, hospital administrators, and hospital contract specialists (n = 18) elicited solutions to address barriers including 1) Developing a consistent identity for the MIH paradigm, 2) adopting an interdisciplinary approach to the development of efficient MIH workflows that utilize informatics to mimic existing clinical work, and 3) implementing capitated fee schedules that are cost-effective by targeting high-risk populations that are already a priority for payors. CONCLUSIONS An investigation of solutions to barriers that impede the translation of MIH models into sustainable practice elicited several unifying themes including the establishment of a cohesive identity for MIH to improve engagement and dissemination, the use of a strategic approach to program design that aligns with existing healthcare delivery workflows and collaboration with payors to promote a robust reimbursement structure. These findings may help accelerate the implementation of MIH programs into real clinical practice.

Program evaluation and healthcare process improvement focused on complex wheelchair procurement

ABSTRACT The operations of a specialty wheelchair (WC) seating center can influence the evaluation to delivery timeframe in days for a complex rehab technology (CRT) WC. Operations at one facility improved due to departmental process improvement (PI) project with evaluation of the delivery workflow and implementation of changes. A retrospective chart audit gathered baseline data on the evaluation to delivery timeframe in days of a CRT WC for 50 individuals prior to PI changes. Standard departmental workflow collected 745 individuals’ post-PI changes. The interventions took place from March 25, 2017, to April 5, 2018, and included defining and educating stakeholders on their roles and expectations, revisions of the electronic medical record, weekly and quarterly meetings with supplier leadership, paperwork completion goals, and follow-up paperwork centralization. Mean pre- and post-intervention evaluation to delivery timeframes in days was significantly different (162.2 versus 127.4 days, p < 0.0001). Overall, a reduction in the mean evaluation to delivery timeframe in days of CRT WC by 21.5% or 34.8 days occurred. Systematic change takes time as well as the commitment of all key players. PI changes resulted in evaluation to delivery timeframe reduction for patients to receive their CRT WCs.

Optimal Agent-Based Pickup and Delivery with Time Windows and Electric Vehicles

The traditional methods of transporting goods and people in urban areas using vehicles powered by internal combustion engines are major contributors to pollution. As a result, an increasing number of logistics companies are transitioning to electric vehicles (EVs) for daily operations, replacing traditional engines. This shift opens research avenues regarding the integration of EVs into delivery workflows and how this can contribute to greener cities. This study tackles the EV routing problem, focusing on balancing battery constraints and optimizing routes. We formulated the problem as a pickup and delivery with time windows, incorporating electric energy consumption constraints, and utilized consensus mechanisms in an agent-based simulation context. Our evaluation used 15 scenarios, capturing variations in vehicle configurations, order generation rates, and battery and freight capacities. We compared two order allocation strategies: “Closest Allocation” and “Negotiation” consensus-based allocation. The results confirmed that the consensus-based strategy outperformed the “Closest Allocation” in metrics such as remaining orders, orders not handled in time, total distance traveled, total recharging cost, and total number of recharges. These findings have significant implications for urban planners, logistic companies, and policymakers, demonstrating that an agent-based simulation context for electric vehicles using consensus-based strategies can enhance delivery efficiency and promote sustainability.

Investigation of intra-fractionated range guided adaptive proton therapy (RGAPT): II. Range-shift compensated on-line treatment adaptation and verification

We previously proposed range-guided adaptive proton therapy (RGAPT) that uses mid-range treatment beams as probing beams and intra-fractionated range measurements for online adaptation. In this work, we demonstrated experimental verification and reported the dosimetric accuracy for RGAPT. A STEEV phantom was used for the experiments, and a 3 × 3 × 3 cm3 cube inside the phantom was assigned to be the treatment target. We simulated three online range shift scenarios: reference, overshoot, and undershoot, by placing upstream Lucite sheets, 4, 0, and 8 that corresponded to changes of 0, 6.8, and −6.8 mm, respectively, in water-equivalent path length. The reference treatment plan was to deliver single-field uniform target doses in pencil beam scanning mode and generated on the Eclipse treatment planning system. Different numbers of mid-range layers, including single, three, and five layers, were selected as probing beams to evaluate beam range (BR) measurement accuracy in positron emission tomography (PET). Online plans were modified to adapt to BR shifts and compensate for probing beam doses. In contrast, non-adaptive plans were also delivered and compared to adaptive plans by film measurements. The mid-range probing beams of three (5.55MU) and five layers (8.71MU) yielded accurate range shift measurements in 60 s of PET acquisition with uncertainty of 0.5 mm while the single-layer probing (1.65MU) was not sufficient for measurements. The adaptive plans achieved an average gamma (2%/2 mm) passing rate of 95%. In contrast, the non-adaptive plans only had an average passing rate of 69%. RGAPT planning and delivery are feasible and verified by the experiments. The probing beam delivery, range measurements, and adaptive planning and delivery added a small increase in treatment delivery workflow time but resulted in substantial dose improvement. The three-layer mid-range probing was most suitable considering the balance of high range measurement accuracy and the low number of probing beam layers.

Towards a Regenerative Design Project Delivery Workflow: A Critical Review

Regenerative design (RD) is an approach to creating positive change in the built environment rather than reducing its negative impacts. RD focuses its design work on improving the relationship between humans, places, and ecosystems. It also proposes fundamental paradigm shifts that promise to address the urgent climatic and biodiversity crises. While it presents a systemic, holistic method of understanding the place and the interrelationships between economic, social, and natural systems with a participatory and collaborative approach to design, its design methodology needs a detailed definition of tools to help new practitioners and students develop RD projects successfully and promote its widespread implementation. In particular, a general project delivery workflow is needed. This paper undertook a comprehensive review to fill this gap, examining 150 references, including articles, books, reports, and theses related to RD. It selected and analysed 19 sources from 1994 to 2024 to analyse and extract their content referencing project delivery steps. This paper proposes a novel six-step project delivery workflow and a workflow diagram that creatively synthesises the proposed RD project delivery workflow. These practical and applicable contributions are helpful for design and building practitioners willing to start a regenerative project. Additionally, this research found links and overlaps between RD and circular building (CB), suggesting opportunities for mutual further development of RD and CB.

Comprehensive workflow evaluation to improve medication distribution to the emergency department in an academic medical center.

The fast-paced environment of the emergency department (ED), with frequent admissions, discharges, and transfers, poses a challenge for pharmacy departments to effectively distribute and store medications. The purpose of this study is to propose a unique workflow of patient-specific medication delivery to the ED from a hospital pharmacy to reduce the number of missing medications resulting in medication messages and redispenses. The medication delivery workflow proposed in this study consists of batching the preparation and distribution of patient-specific medications sent from the pharmacy to the ED in the 1 to 2 hours prior to their administration time. Chi-square analysis was completed to compare medication redispenses and "missing medication" messages before and after the intervention, with the significance level set at P < 0.05. The percentage of redispensed medications was effectively decreased following implementation of the workflow change from 21.6% to 9.2% (P < 0.001), with unit doses having the greatest reduction (25.8% vs 6.1%, P < 0.001). Benefits of this workflow change were also illustrated through a reduction in the percentage of missing-medication messages sent by nursing staff from 97.7% to 93.9% (P < 0.001). This study showed that implementation of standard, hourly batches of medications dispensed from the pharmacy to the ED resulted in a significant reduction in the total percentage of redispensed medications and missing-medication messages. The overall reduction in redispensed medications as a result of this innovative workflow change not only benefited nursing and pharmacy staff but can reduce medication waste and improve patient care through timely administration of medications.

Advancing the science of integrating multiple interventions by blending and bundling.

Cancer prevention and control research has produced a variety of effective interventions over the years, though most are single disease focused. To meet the Cancer Moonshot goal to reduce the cancer death rate by 50% by 2047, it may be necessary to overcome the limitations of siloed interventions that do not meet people's multiple needs and limitations in system capacity to deliver the increasing number of interventions in parallel. In this article, we propose integrating multiple evidence-based interventions as a potential solution. We define 2 types of integrated interventions, blended and bundled, and provide examples to illustrate each. We then offer a schematic and outline considerations for how to assemble blended or bundled interventions including looking at the intervention need or opportunity along the cancer continuum as well as co-occurring behaviors or motivations. We also discuss delivery workflow integration considerations including social-ecological level(s), context or setting, implementer, and intended beneficiary. Finally, in assembling integrated interventions, we encourage consideration of practice-based expertise and community and/or patient input. After assembly, we share thoughts related to implementation and evaluation of blended or bundled interventions. To conclude the article, we present multiple research opportunities in this space. With swift progress on these research directions, cancer prevention and control interventionists and implementation scientists can contribute to achieving the promise of the reignited Cancer Moonshot.

The Impact of COVID-19 Infection Control Measures on End-Stage Renal Disease Patients in a Community Hemodialysis Setting.

Several non-pharmaceutical infection control measures have been implemented at community-based hemodialysis centers to reduce the risk of Coronavirus Disease of 2019 (COVID-19) transmission,caused by the SARS-CoV-2 virus.However, there have been concerns that such measures may disrupt the routine and timely care required by patients, with adverse effects on their health outcomes.This cross-sectional study aims to determine the unintended consequences of COVID-19 infection control measures on hemodialysis patients. Electronic medical records were extracted from patients enrolled in community-based hemodialysis centers in Singapore.A baseline group prior of patients consisted of those enrolled in 2017, which was three years prior to the SARS-CoV-2-related pandemic (n = 548).This was compared with the study group of patients enrolled in 2019 (n = 426), just before the COVID-19 pandemic started.Medical records for these two groups were extracted from Januaryto July 2018 for the baseline group and from January to July 2020, respectively. Three regression models were built to study dialysis adherence, kidney disease biomarkers, and hospitalization episodes. There was no statistically significant difference in hospitalization and mortality outcomes, adherence to dialysis management, laboratory results for dialysis-related clearance, and anemia outcomes. There was a higher proportion of patients hospitalized for vascular access-related reasons in the study group as compared to the baseline group (OR 1.6, 95% CI: 1.10 to 2.29, P = 0.014).Patients in the study group had albumin levels 2.13% higher (95% CI: 0.88 to 3.39, P < 0.001) and alkaline phosphatase levels 7.3% lower (95% CI: 1.17 to 13.02, P = 0.020) than those in the baseline group. From this community-based hemodialysis study in Singapore, it was shown that the COVID-19 pandemic did not disrupt regular healthcare services for these patients.With strategies instituted fora coordinated health delivery workflow, ensuring sufficient capacity in the various healthcare delivery sites and overall pandemic preparedness, the patient clinical outcomes measures continued to be met with no adverse consequences noted.Some improvements in dialysis-related laboratory values and quality of care targets may be due to more stringent measures instituted to protect these vulnerable patients in the community.

Dosimetric and workflow impact of synthetic-MRI use in prostate high-dose-rate brachytherapy

Target and organ delineation during prostate high-dose-rate (HDR) brachytherapy treatment planning can be improved by acquiring both a postimplant CT and MRI. However, this leads to a longer treatment delivery workflow and may introduce uncertainties due to anatomical motion between scans. We investigated the dosimetric and workflow impact of MRI synthesized from CT for prostate HDR brachytherapy. Seventy-eight CT and T2-weighted MRI datasets from patients treated with prostate HDR brachytherapy at our institution were retrospectively collected to train and validate our deep-learning-based image-synthesis method. Synthetic MRI was assessed against real MRI using the dice similarity coefficient (DSC) between prostate contours drawn using both image sets. The DSC between the same observer's synthetic and real MRI prostate contours was compared with the DSC between two different observers' real MRI prostate contours. New treatment plans were generated targeting the synthetic MRI-defined prostate and compared with the clinically delivered plans using target coverage and dose to critical organs. Variability between the same observer's prostate contours from synthetic and real MRI was not significantly different from the variability between different observer's prostate contours on real MRI. Synthetic MRI-planned target coverage was not significantly different from that of the clinically delivered plans. There were no increases above organ institutional dose constraints in the synthetic MRI plans. We developed and validated a method for synthesizing MRI from CT for prostate HDR brachytherapy treatment planning. Synthetic MRI use may lead to a workflow advantage and removal of CT-to-MRI registration uncertainty without loss of information needed for target delineation and treatment planning.

APLUS: A Python library for usefulness simulations of machine learning models in healthcare

Despite the creation of thousands of machine learning (ML) models, the promise of improving patient care with ML remains largely unrealized. Adoption into clinical practice is lagging, in large part due to disconnects between how ML practitioners evaluate models and what is required for their successful integration into care delivery. Models are just one component of care delivery workflows whose constraints determine clinicians’ abilities to act on models’ outputs. However, methods to evaluate the usefulness of models in the context of their corresponding workflows are currently limited. To bridge this gap we developed APLUS, a reusable framework for quantitatively assessing via simulation the utility gained from integrating a model into a clinical workflow. We describe the APLUS simulation engine and workflow specification language, and apply it to evaluate a novel ML-based screening pathway for detecting peripheral artery disease at Stanford Health Care.

AAPM Task Group Report 306: Quality control and assurance for tomotherapy: An update to Task Group Report 148.

Since the publication of AAPM Task Group (TG) 148 on quality assurance (QA) for helical tomotherapy, there have been many new developments on the tomotherapy platform involving treatment delivery, on-board imaging options, motion management, and treatment planning systems (TPSs). In response to a need for guidance on quality control (QC) and QA for these technologies, the AAPM Therapy Physics Committee commissioned TG 306 to review these changes and make recommendations related to these technology updates. The specific objectives of this TG were (1) to update, as needed, recommendations on tolerance limits, frequencies and QC/QA testing methodology in TG 148, (2) address the commissioning and necessary QA checks, as a supplement to Medical Physics Practice Guidelines (MPPG) with respect to tomotherapy TPS and (3) to provide risk-based recommendations on the new technology implemented clinically and treatment delivery workflow. Detailed recommendations on QA tests and their tolerance levels are provided for dynamic jaws, binary multileaf collimators, and Synchrony motion management. A subset of TPS commissioning and QA checks in MPPG 5.a. applicable to tomotherapy are recommended. In addition, failure mode and effects analysis has been conducted among TG members to obtain multi-institutional analysis on tomotherapy-related failure modes and their effect ranking.

Retrospective Analysis to Define Appropriate Physics FTE Support for Online Adaptive Radiotherapy Programs

<h3>Purpose/Objective(s)</h3> In 2019, ASTRO published an update to "Safety is No Accident", a comprehensive reference guide to promote safety in radiation oncology. Included in this report are staffing guidelines that provides a simple way to calculate physics and dosimetry staffing for individual centers. Since this publication, the use of online adaptive radiotherapy (ART) has been on the rise with RT delivery units (CT- and MR-based) being cleared for clinical use. While some centers have adopted the use of online ART delivery systems, it remains unclear how to properly define the staffing of full-time equivalent (FTE) employees for an ART program. Current staffing models rely on physics to lead the delivery of adaptive sessions, including contouring and plan evaluation/selection. Our hypothesis here is that ART programs are more demanding (in terms of physics FTE) than SRS/SBRT programs. <h3>Materials/Methods</h3> In-house software was developed to query treatment delivery logs from our institution's treatment delivery system. The system's daily machine logs contain detailed information for individual patient's treatment session including time-stamps for each step in the ART treatment delivery workflow. For this study, we identify time points for the following steps in the adaptive workflow: 1) patient session is started (when patient's identity is verified prior to treatment set up), 2) start of auto-contouring review (after acquisition of CBCT), 3) completion of contour review/editing (this marks the start of dose optimization/calculation), 4) start of treatment delivery, and 5) patient session is completed (required prior to removing patient from Linac). We use methodology by Batista et al to estimate per patient relative FTE factors for physicists using treatment session times. <h3>Results</h3> Machine logs from August 2021 to February 2022 were analyzed for this study. During this time, our clinic delivered over 450 online daily adaptive treatments for 26 unique patients. Treatment sites included prostate, GYN, lungs, breast, H&N, and abdomen. On average (± std. dev.), adaptive sessions took 37 ± 16 mins from start to end. Average contour review/edit time was 7.8 ± 5.5 mins. After contour approval, it took an average of 10.1 ± 3.4 mins for plan generation, evaluation, and selection to start of treatment delivery. Based on overall session times, we calculate a conservative estimate of relative FTE factor of 0.02 for physicists per number of adaptive cases per year (w/ 30 fx/pt, 45 min/session, and 2000 work-hours/yr ≈ 0.012 + 0.008 from [1] for IGRT-based planning/QA). <h3>Conclusion</h3> The clinical adoption of online ART will increase demand for physics support. To our knowledge, this is the first data-driven analysis to make recommendations of physics staffing for CBCT-based online ART programs. The relative FTE factor measured in this study should be confirmed using multi-center data.

Implementation Outcomes Assessment of a Digital Clinical Support Tool for Intrapartum Care in Rural Kenya: Observational Analysis.

BackgroundiDeliver, a digital clinical support system for maternal and neonatal care, was developed to support quality of care improvements in Kenya.ObjectiveTaking an implementation research approach, we evaluated the adoption and fidelity of iDeliver over time and assessed the feasibility of its use to provide routine Ministry of Health (MOH) reports.MethodsWe analyzed routinely collected data from iDeliver, which was implemented at the Transmara West Sub-County Hospital from December 2018 to September 2020. To evaluate its adoption, we assessed the proportion of actual facility deliveries that was recorded in iDeliver over time. We evaluated the fidelity of iDeliver use by studying the completeness of data entry by care providers during each stage of the labor and delivery workflow and whether the use reflected iDeliver’s envisioned function. We also examined the data completeness of the maternal and neonatal indicators prioritized by the Kenya MOH.ResultsA total of 1164 deliveries were registered in iDeliver, capturing 45.31% (1164/2569) of the facility’s deliveries over 22 months. This uptake of registration improved significantly over time by 6.7% (SE 2.1) on average in each quarter-year (P=.005), from 9.6% (15/157) in the fourth quarter of 2018 to 64% (235/367) in the third quarter of 2020. Across iDeliver’s workflow, the overall completion rate of all variables improved significantly by 2.9% (SE 0.4) on average in each quarter-year (P<.001), from 22.25% (257/1155) in the fourth quarter of 2018 to 49.21% (8905/18,095) in the third quarter of 2020. Data completion was highest for the discharge-labor summary stage (16,796/23,280, 72.15%) and lowest for the labor signs stage (848/5820, 14.57%). The completion rate of the key MOH indicators also improved significantly by 4.6% (SE 0.5) on average in each quarter-year (P<.001), from 27.1% (69/255) in the fourth quarter of 2018 to 83.75% (3346/3995) in the third quarter of 2020.ConclusionsiDeliver’s adoption and data completeness improved significantly over time. The assessment of iDeliver’ use fidelity suggested that some features were more easily used because providers had time to enter data; however, there was low use during active childbirth, which is when providers are necessarily engaged with the woman and newborn. These insights on the adoption and fidelity of iDeliver use prompted the team to adapt the application to reflect the users’ culture of use and further improve the implementation of iDeliver.

A framework for the oversight and local deployment of safe and high-quality prediction models.

Artificial intelligence/machine learning models are being rapidly developed and used in clinical practice. However, many models are deployed without a clear understanding of clinical or operational impact and frequently lack monitoring plans that can detect potential safety signals. There is a lack of consensus in establishing governance to deploy, pilot, and monitor algorithms within operational healthcare delivery workflows. Here, we describe a governance framework that combines current regulatory best practices and lifecycle management of predictive models being used for clinical care. Since January 2021, we have successfully added models to our governance portfolio and are currently managing 52 models.

Image-Guided Volumetric Modulated Arc Therapy for Total Body Irradiation: A Single Institution Experience

<h3>Purpose/Objective(s)</h3> The use of multi-isocentric volumetric mediated arc therapy (VMAT) for total body irradiation (TBI) improves dose uniformity and organ-at-risk avoidance and offers better patient comfort, but is limited by time-intensive planning and positioning errors at treatment delivery. We present a system that utilizes automated contouring and planning scripts run in widely-available software combined with image-guided delivery for an efficient simulation-to-treatment workflow. We hypothesize that this system will improve target dose coverage and normal tissue avoidance compared to conventional TBI. <h3>Materials/Methods</h3> Patients were simulated supine in both head-first and feet-first positions. Automated planning software scripts were used to co-register the two simulation scans into a single whole-body CT, to contour organs at risk and planning target volume (PTV), to divide the PTV into sub-targets with junction region overlap, and to place isocenters. Treatment was planned with VMAT for the entire body except for legs and feet, which were planned with conventional AP/PA fields. Image guidance was used for treatment delivery. Plans were evaluated for quality, planning time, delivery time, and setup accuracy. The dosimetric parameters of VMAT-TBI plans versus conventional AP/PA TBI plans were compared. <h3>Results</h3> Twelve patients were simulated and treated with VMAT-TBI: three pediatric patients and nine adult patients (age range: 9-59). Compared with conventional whole-body AP/PA technique, VMAT-TBI improved dose coverage to the whole body: PTV V₁₀₀ was improved from 71.4% ± 11.1% to 88.1% ± 2.6% (<i>P</i> < 0.001). Mean lung dose was reduced from 11.1 Gy ± 0.9 Gy to 9.3 Gy ± 1.0 Gy (<i>P</i> < 0.001). With a beam monitor unit (MU) rate of 200 MU/minute, mean lung dose rate was 15.5 centiGray (cGY)/minute. Robust planning and image-guided delivery reduced setup uncertainty. VMAT-TBI planning time was one working day. Total time on the treatment table was approximately one hour per fraction. All patients were able to complete the treatment course as prescribed. <h3>Conclusion</h3> A robust treatment planning technique and an image-guided delivery workflow were developed for VMAT-TBI. Planning efficiency was improved using automation with scripts, making planning time comparable to traditional TBI. Compared with classic AP/PA whole body fields, VMAT-TBI improved whole body prescription dose coverage and lung sparing. Time on treatment table was comparable to treatment time for traditional TBI, and patient comfort was improved due to ability to deliver treatment in the supine position. VMAT planning should be considered for all myeloablative transplant protocol patients being treated with TBI.

Transitioning Broadcast to Cloud

<italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">We analyze the differences between on-premise broadcast and cloud-based online video delivery workflows and identify means needed for bridging the gaps between them. Specifically, we note differences in the ingest protocols, media formats, signal-processing chains, codec constraints, metadata, transport formats, delays, and means for implementing operations such as ad-splicing, redundancy, and synchronization. To bridge the gaps, we suggest specific improvements in cloud ingest, signal processing, and transcoding stacks. Cloud playout is also identified as a critically needed technology for convergence. Finally, based on all such considerations, we offer sketches of several possible hybrid architectures, with varying degrees of offloading of processing in the cloud, which are likely to emerge in the future</i> .

OpenBuildingControl: Digitizing the control delivery from building energy modeling to specification, implementation and formal verification

The current process for specifying, installing and commissioning building control sequences is largely manual and based on ambiguous natural language specifications. It lacks a formal end-to-end quality control and it has been shown not to deliver high performance sequences at scale. While high-performance HVAC control sequences enable significant reductions in energy consumption, errors in implementing the control logic are common even for less advanced sequences. To improve this situation, we present a digitized building control delivery workflow with formal end-to-end verification, a Control Description Language for the digital specification of building control sequences within this workflow, and software tools that enable digitization of this process. Using the process and tools introduced here, mechanical designers can customize, test and improve these sequences within annual energy simulation, store them in a library for use in other projects, and export them for bidding. Control providers can implement the sequences on existing control product lines through code generation. Commissioning providers can formally verify whether as-installed sequences conform to the digital design specification that was exported by the mechanical designer. Moreover, control product development teams can use the reference implementations of these libraries within their product testing to ensure that their products reproduce the behavior of the reference implementations. This paper presents this process, the language and the supporting software, together with examples of all of the above steps. The presented work has given rise to a new proposed standard, ASHRAE 231P, that will allow digitizing the building control delivery process through the standardization of a control-vendor independent format for exchanging control logic that we pioneered through the here presented work.

A longitudinal time and motion study quantifying how implementation of an electronic medical record influences hospital nurses’ care delivery

Aim backgroundMany health care services are implementing or planning to undergo digital transformation to keep pace with increasing Electronic Medical Record (EMR) functionality. The aim of this study was to objectively measure nursing care delivery before and following introduction of an EMR. Design and methodsAn extensive program of work to expand an EMR across our health service using a ‘big bang’ methodology was undertaken. The program incorporated digital care delivery workflows including physiological observations, clinical notes and closed loop medication management. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied to undertake a direct observational time and motion study of nurses’ work in a major Australian hospital immediately prior to and six months following the introduction of a full clinical EMR. ResultsTime and motion results were from observing approximately one week of nursing time pre (paper) to six months post (EMR) implementation. A non-significant 6.4% increase in the proportion of time spent on direct care was observed when using the EMR with a statistically significant increase in mean time per direct care task (2.5 min vs 3.9 min, p = 0.001). The proportion of time spent on medication-related activities did not significantly change although the average time per task rose from 2.0 to 2.9 min (p = 0.008). A significant reduction in proportion of time spent in transit and indirect care tasks when using the electronic workflows was reported. No statistically significant changes to the proportions of time spent on professional communication, direct care or documentation were observed. ConclusionsSuccessful EMR implementation is possible without adversely affecting allocation of nursing time. Our findings from deploying a large scale EMR across all healthcare craft groups and workflows have described for nurses that an EMR enables them to spend longer with patients per direct care episode and use their time on other activities more effectively.

A Shared Information Technology-Business-Health Model: Lessons for Healthcare Leaders on Integrating Technology from Investment

Objective: Technology is rapidly shifting our day-to-day existence, education, social relationships, health care and business. Psychiatric leaders have slowly explored telepsychiatric services – but few have an approach to technology in general–due to competing clinical, educational and research demands. Technology has typically been added on, rather than integrated, to institutional functions. Method: This narrative review used a literature search of Medline, PsycNET, PsycINFO, Embase, Cochrane, SpringerLink, Scopus, ABI/Inform, Business Source Complete, and Web of Science, using subject headings and keywords along with a manual search of reference lists of articles published by November 2020. The keywords explored four areas: 1) business; 2) service delivery; 3) system change; and 4) technology. Articles were reviewed by title/abstract, full text review and review of references. They were included if they discussed integration of technology into health care and compared literature from medicine/health, psychiatry/behavioral health, business, technology, leadership and health care administration. The goal was to explore how medicine/psychiatry has integrated technology compared to business, and apply business approaches to health care and training. Results: From a total of 2,710 potential references, two authors found 327 eligible for full text review and found 69 papers directly relevant to the concepts. Business and medicine/psychiatry have similarities/differences from both historical and contemporary views. Many health care systems and companies lack a strategic plan for technology and focus only on short-term due to administrative demands. Clinical informatics is a rapidly expanding area and would be central to this process. It has started to facilitate patient-centered care as defined by quality, affordable, and timely health care. While in principle information systems use integrative approaches, electronic health records, electronic means of communications with patients and staff, behavioral health indicators and related digital advances are often added to existing systems rather than integrated. Effective businesses use integrative approaches to share domain knowledge and streamline practices to link information technology (IT) with research and development, production, financing and marketing management. A case example highlights the IT strategy and business leaders’ comments in shifting to straight through processing (STP) from the banking industry for investments. It also exemplifies a model of shared IT-business understanding, which improves performance via efficiency, quality of data/information processing/integration and managerial teamwork. Conclusion: When it is integrated into health care service delivery workflow, evaluated and quality improved, IT facilitates the translation of strategic planning into organizational change. Incremental versus strategically innovative approaches to technological integration for care, education and administration are considered. Successful implementation requires a needs and impact assessment for patients, staff, clinicians and leaders across all levels of the organization. Benefits to the mission, limited disruptions of core operational workflow and reasonable costs reduce the likelihood of failure.

Transition From Manual to Automated Planning and Delivery of Volumetric Modulated Arc Therapy Stereotactic Radiosurgery: Clinical, Dosimetric, and Quality Assurance Results

PurposeProperly planned single isocenter volumetric modulated arc therapy (VMAT) radiosurgery plans exhibit high quality and efficiency. We report here the largest clinical experience to date, to our knowledge, comparing manual planning with a new automated platform designed to standardize and simplify radiosurgery planning and delivery processes. MethodsWe treated 693 patients with single isocenter VMAT radiosurgical plans generated by either our conventional manual (mVMAT) or a recently implemented automated (HyperArcTM) technique. All plans targeted the gross tumor volume without margin. Radiochromic film was used for patient-specific quality assurance (PSQA). We evaluated local control and toxicity data for a subgroup of 107 patients having 377 metastatic tumors that were treated with HyperArc. ResultsThe median Radiation Therapy Oncology Group (RTOG) conformity index was 1.14 and was not different between the 2 techniques. The median Paddick gradient index was 5.42 for HyperArc versus 7.09 for mVMAT (P < .001). The median mean brain doses were 4.6% and 5.1% for HyperArc and mVMAT, respectively (P = .04). The PSQA for both techniques met clinical criteria, but 97% of the HyperArc plans satisfied the gamma tolerance limit recommended by the American Association of Physicists in Medicine Task Group No. 218, compared with 94% of the mVMAT plans (P = .02). The median treatment-planning times were not significantly different. The median treatment times were 10.5 and 11.4 minutes for HyperArc and mVMAT, respectively (P < .001). The Kaplan-Meier estimate of local control was 90.1% at 1 year. ConclusionsHyperArc produces high-quality radiosurgical plans that are at least as good as mVMAT plans created by an expert manual planner with easier planning and more efficient delivery workflow. A less experienced planner can produce very high-quality radiosurgical plans even for patients with more than 10 targets. The use of a single-isocenter technique for multiple targets with no PTV margin did not compromise clinical outcomes, and 1-year local control for treated targets remained congruent with historical series.