Safe and Sound is building on several established programmes of research which have been carried out by the partners. This Grand Challenge project aims to pull this past work together in order to demonstrate the Safe and Sound "vision" (more at menu on right). Some new research issues also need to be explored as we articulate this integrated perspective.
Common healthcare model
A shared assumption of the partners is that healthcare services can be modelled as sets of interlocking guidelines and pathways that should be used in a coordinated fashion to guide an individual’s health care, capturing clinical data, pre-empting errors and/or recording adverse events. Versions of this perspective developed independently by each partner from their different points of view are informing the develoment of a common conceptual framework and requirements for practical knowledge services in the clinic.The team at Imperial Healthcare and the NHS Centre for Patient Safety and Service Quality has previously used systems analysis methods to examine the effectiveness of existing healthcare systems and suggest organisational interventions to improve patient safety. The Oxford University and Edinburgh University groups have focused on formal (machine interpretable) languages for modelling clinical processes, for describing care pathways and decisions and for defining quality standards that can be supported by computer-based services. A key task is to establish a healthcare process model that combines technical and clinical perspectives with quality and safety requirements.
Knowledge sharing
Despite the great promise of clinical decision support there is a major additional problem to be overcome. This concerns the routine dissemination of new clinical research and the ongoing maintenance of the knowledge base that decisions and care pathways critically depend upon. In the traditional view of knowledge dissemination a natural desire to defend quality of the knowledge base leads quickly to a centralised, even monolithic, repository of “approved” content. The tendency to centralise is also supported by the instincts of traditional systems engineers who are trained to establish and defend a system perimeter, within which only designated individuals with specific medical or technical expertise are permitted to make changes. Unfortunately the world of medical knowledge, particularly in the age of the world wide web, has no perimeter; the originators of new research and evidence lie largely outside the frontiers of any one provider. Instead of viewing openness as something to be suppressed, which is unachievable, we must make it work in our favour, using technologies and methods that give us better decisions as the global knowledge base increases. Identifying the requirements, necessary infrastructure, tools, technical standards and norms that will ensure integrity and safety in the open knowledge environments of the future is a key goal of the project.
Open, Peer to Peer Architectures
Traditionally, it was common for a clinical lifecycle (for example the detection, diagnosis, treatment and follow up of a certain disease that a particular patient has) to be localised with knowledge, actions and responsibilities centred upon a specific team of doctors working in a particular place. Medicine has now become distributed and service oriented. Knowledge can no longer be retained by a single group because it is obtained by specialists in many organisations. Actions are performed at numerous sites between which patients may move (expecting the context in which they are being treated to move with them). Responsibilities are shared, often between services which have little knowledge of each other's operation, and major issues of reliability and trust arise because we must increasingly use information that has been acquired, curated and deployed via services that operate across the Internet. Already such services are being combined in simple ways -- for instance when someone accesses several web diagnosis tools to provide multiple ‘opinions’ on a medical problem. As such services proliferate, we move towards an open, peer to peer architecture in which a wide variety of information providing services are available and medical knowledge that is trusted (in different ways for different tasks) is obtained by flexible service coordination rather than centralised management.
Technology assessment
It is now widely accepted that new clinical decision support systems are "complex" interventions. Assessments that focus solely on either technical criteria (like performance and scalability) or clinical criteria (such as patient morbidity and mortality) will not capture the user-centred, social, organizational and political factors that determine whether a system that works well in the lab will ultimately find a place in the clinic. Employed at the point of care, the services that we envisage will directly influence what, when and how each person’s care is delivered; the impact will be felt by doctors, nurses, and patients (among others) alike. Consequently there is an important requirement for sophisticated technology assessment to identify, assess, and (as far as possible) predict the key dimensions of that impact. Partners at Imperial College London's Centre for Patient Safety and Service Quality are developing the tools and techniques to meet this requirement.
