The Snow ProjectMethods

April 2008

Johan G. Bellikaab

A Department of Computer Science, University of Tromsø B Norwegian Centre for Telemedicine, University Hospital of North Norway

Agenda

• Some historical quotes

• The Snow projects research question

• Overview of methods – “The tower of achievements”

• Outcome evaluation

• Finding the “correct” ICT solution

Hippocrates, 2400 years ago

“ . . . there is nothing remarkable in being right in the great majority of cases in the same district, provided the physician knows the signs and can draw the correct conclusions from them”

Source: Hippocrates, Prognosis, in Hippocratic Writings, G. Lloyd, Editor. 1983, Penguin. p. 170-185.

The father of medicine

Merwyn R. Greenlick (1992)

“... the probabilities that a physician faces with an individual patient in a given circumstance are specific to the characteristics of the population from which that patient comes. A physician who does not have data on these specific populations does not have all of the relevant knowledge necessary to treat the patient.”

Source: Greenlick, M.R., Educating physicians for population-based clinical practice. Jama, 1992. 267(12): p. 1645-8.

Professor Emeritus of Psychiatry and Public Health and Preventive Medicine,Oregon Health & Science University

Background• In 1999, infectious diseases were the second

leading cause of death (25%) worldwide1

• WHO has verified more than 1100 epidemic events worldwide over the last five years

• Nearly 40 diseases have emerged over the last generation2

• At the same time, there is a constant risk of a pandemic3

• The early warning system is weak

Source1: WHO. Report on infectious diseases: Removing Obstacles to Healthy Development. 1999 Soruce2: WHO. The world health report 2007: a safer future: global public health security in the 21st century. 2007.

Source3: World Health Organization. Responding to the avian influenza pandemic threat. 2005 http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_05_8-EN.pdf

The Snow approach: Peer-to-peer exchange of disease statistics data among primary care physicians and institutions involved in disease prevention

Snow research question:

Will exchange of information about occurrence of communicable diseases among GPs and organizations involved in Infectious disease prevention lead to changes in ”clinical practice” with regard to testing, diagnosing and treatment of such diseases among GPs?

What is ”clinical practice” for communicable diseases?Three potential decisions:

1. Treat on suspicion

2. Take a sample and wait for the lab result

3. Await further development and potentially have a new consultation later on

4. Combine 1 and 2

Medical informatics method Friedman’s tower of achievements (1995)

Model formulation

System development

System installation

Study of

effects

The phases involved in proving that a system actually leads to improvements consists of the following phases:

• a model formulation phase• a system development phase• a system installation in the work environment where it will normally be used

• and finally the study phase when the system is in production use with the aim of identifying the effects of the system on patient outcome

Friedman’s tower of achievements (1995)

Model formulation

System development

System installation

Study of

effects

The final step - system evaluation:“Does it help the patients?”

Method: Controlled studyIntervention areas: Users will receive information from the system.Control areas: We will only monitor the situations in these areas.

Alternative: Use data from the microbiology laboratory (and the GiLab project) to verify whether the system has any effect on laboratory use.

Answer the fundamental question: Compared to what?

Friedman’s tower of achievements (1995)

Model formulation

System development

System installation

Study of

effects

Model formulation:“a peer-to-peer approach to disease surveillance is better than the current hierarchical and centralized approach”

Friedman’s tower of achievements (1995)

Model formulation

System development

System installation

Study of

effects

System development:“Participatory design leads to user acceptance”

We therefore choose user involvement and agile software development methodology

If my “spine reaction” had been followed, we would probably have failed!

What does it take to achieve deployment?

Friedman’s tower of achievements (1995)

Model formulation

System development

System installation

Study of

effects

System validation:“Does it work” The pilot will show!

Snow design guidelines

• The participants must have some benefit from participating and using the system

• Surveillance and emergency response systems must be in regular use to work in an emergency situation

= Can disease surveillance data from the local patient population be used for diagnostic assistance?

What does it take to achieve deployment?

Questions?