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Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM): Case Study


Abstract and Figures

Background Health information technology (HIT) and associated data analytics offer significant opportunities for tackling some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality: clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience. Objective In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and understanding among multidisciplinary teams. MethodsA 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context. Data were collected from over 700 hours of participant observations and 10 semistructured interviews. ResultsThe findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery of this journey and to capture requirements for the digital touchpoints of the connected health service. Conclusions Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation.
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Original Paper
Embedding the Pillars of Quality in Health Information Technology
Solutions Using “Integrated Patient Journey Mapping” (IPJM):
Case Study
Stephen McCarthy1, PhD; Paidi O'Raghallaigh1, PhD; Simon Woodworth1, PhD; Yoke Yin Lim2, MD; Louise C
Kenny3, PhD; Frédéric Adam1,4, PhD
1Department of Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland
2Cork University Maternity Hospital, Cork, Ireland
3Dept. of Women’s and Children’s Health, Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, United Kingdom
4INFANT SFI Centre, University College Cork, Cork, Ireland
Corresponding Author:
Stephen McCarthy, PhD
Department of Business Information Systems
Cork University Business School
University College Cork
Western Road
Cork, T12 K8AF
Phone: 353 21 490 ext 3214
Background: Health information technology (HIT) and associated data analytics offer significant opportunities for tackling
some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service
improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality:
clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that
both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience.
Objective: In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to
assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is
intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and
understanding among multidisciplinary teams.
Methods: A 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate
Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context.
Data were collected from over 700 hours of participant observations and 10 semistructured interviews.
Results: The findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing
an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed
connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery
of this journey and to capture requirements for the digital touchpoints of the connected health service.
Conclusions: Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation.
(JMIR Hum Factors 2020;7(3):e17416) doi: 10.2196/17416
health information technology; health care quality; data analytics; multidisciplinary research; mobile phone
JMIR Hum Factors 2020 | vol. 7 | iss. 3 | e17416 | p. 1 (page number not for citation purposes)
Prior Work
Significant investment continues to be directed toward service
reform strategies to deal with the sizable challenges facing health
care sectors [1]. These challenges include, but are not limited
to, an increasing demand for chronic care, shortages in skilled
medical labor, and an aging population [2,3]. In the United
Kingdom, the government pledged a £20.5 billion (US $27
billion) increase in the National Health Service’s budget between
2019 and 2024 to foster widespread performance improvements
across both primary and secondary care with the aim of tackling
these challenges [4]. This trend toward increased spending is
likely to continue into the future as nations across the globe
seek to deal with large-scale economic and demographic changes
Health care service redesign through the adoption of health
information technology (HIT) is being proposed as a means of
increasing both the efficiency and effectiveness of health care
services, reducing waiting times, and improving the standards
of patient care [5,6]. In particular, connected health has emerged
as a promising area of research for addressing some of the
current challenges [7-9]. This blends the physical and digital
realms by capturing real-time data from numerous connected
HIT devices (eg, smartphone apps, weighing scales, blood
pressure monitors, etc) to ensure that health care stakeholders
(eg, patients, carers, clinicians, etc) are provided with timely,
accurate, and pertinent information regarding the patient’s status
[8,10]. Combined with advanced data analytics, connected health
platforms can also contribute to the improvement of health
outcomes through targeted and early interventions [11]. For
instance, data analytics can provide clinicians with key insights
derived from patterns in large patient data sets, which can in
turn contribute to improved clinical decision making. This can
help reduce decision makers’reliance on gut feelingor intuition
by fostering a data-driven, evidence-based approach to clinical
decision making and decision support [12-14]. Connected health
platforms, combined with the use of smartphone apps, also offer
the possibility of deploying coaching on a broad scale to
improve adherence and outcomes for those affected by a variety
of conditions, such as diabetes [15-17].
However, Chen et al [18] noted that these targets can only be
achieved through appropriately designed interventions. This
requires inputs from all relevant stakeholders to design
connected health solutions that not only fit the needs of patients
[19] but also fit within the health care ecosystems and are viable
and sustainable in the long term [18]. The mapping tool that we
present in this paper is aimed specifically at eliciting and
channeling the opinions and preferences of a varied group of
stakeholders around the possible use of HIT across a medical
According to Doyle et al [20], there are 3 core pillars of health
care quality, which health care reform strategies (including those
involving connected health) must cater to, clinical effectiveness,
patient safety, and patient experience. Their contention has been
broadly supported by other researchers (for instance, the study
by Anhang et al [21]), with their paper receiving over a thousand
citations and many researchers adopting their 3-pillar
framework. The core argument in this stream of research is that
the relationship between patient experiences and other aspects
of care is symbiotic and critical. We agree with the view that
patient experiences are an integral aspect of care quality (even
if they may not be directly related to clinical processes and
outcomes [22]. We strongly agree that we need to understand
how patient experiences are associated with the effective use
of structures, the underlying health care processes, and the
occurrence of health outcomes. This knowledge ought to be
directed toward improving the efficiency and effectiveness of
care [21]. Thus, in this study, we adopted the 3 pillars of health
care quality by Doyle et al [20] as a guiding framework.
To date, health service reform initiatives have focused on
measures of clinical effectiveness and patient safety, with patient
experience receiving less attention [5,23]. It does not follow
that an efficient and compliant service will mean a good patient
experience. For instance, a patient might receive an appointment
quickly, but their overall experience may be poor if, for example,
they feel that their unique needs are not catered to. In most
cases, connected health solutions involve patients who directly
engage with apps, often in their homes or in the community.
Given the absence of direct supervision, it is critical that the
apps and devices are easy to use and that they promote
appropriate, accurate, and safe usage. Generally, connected
health solutions raise significant and new ethical concerns,
which need careful consideration [24]. Therefore, it is crucial
that their design considers all 3 central pillars of health care
quality (clinical effectiveness, patient safety, and patient
experience) in tandem [20,25]. Failure to consider these pillars
may mean that key requirements and constraints are overlooked,
leading to problems later—poor quality data, low utilization of
health care services, ineffective decisions by health care
professionals, or unethical use of data [20,26].
Although methods are available for exploring each pillar of
health care quality in isolation, to the best of our knowledge,
there is no single design tool currently in use that addresses all
3 pillars collectively, and more particularly in the context of
technology-intensive and multidisciplinary fields such as
connected health. This paper, goes some distance to address
this shortfall by presenting a design tool we developed called
Integrated Patient Journey Mapping (IPJM). This tool is
primarily aimed at supporting the analysis and design of
connected health apps. Inspired by the concept of journey
mapping, it allows researchers and practitioners to
simultaneously and explicitly consider the factors of clinical
effectiveness, patient safety, and patient experience in tandem.
The tool has primarily been validated through its use in a series
of projects. In this paper, we focus on its use in a project called
Learning to Evaluate Blood Pressure at Home(LEANBH) that
involves the development of a connected health app focused on
the investigation of preeclampsia, a disorder of pregnancy that
can lead to a variety of adverse outcomes.
The remainder of the paper is structured as follows: On the basis
of a review of existing literature, the Introduction section offers
a background to the development of the mapping tool in the
context of connected health and describes IPJM. The Methods
section explains the methods, while the Results section provides
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results from the LEANBH project on the use of IPJM in a
perinatal context. A discussion of the findings as they pertain
to academic and practitioner communities is outlined in the
Discussion section.
Connected Health and Data Analytics
Connected health has been defined as a novel, conceptual model
for health care management “where devices, services, or
interventions are designed around the patient’s needs, and
health-related data is shared, in such a way that the patient can
receive care in the most proactive and efficient manner possible”
[10]. Connected health aims to provide all actors involved in
the delivery of health care services with timely, accurate, and
pertinent information around the patient’s current state of
well-being [8,10,27,28]. This is made possible by the
development of information technology (IT) platforms that
seamlessly integrate numerous connected health devices, which
allow real-time management and monitoring of patients’
well-being across different settings [28-30]. This has been made
possible through the increasing availability of new wireless
networks (eg, Wi-Fi, Bluetooth, and 4G or 5G networks) that
enable high-speed seamless integration of connected health
devices and secure data repositories for storing health-related
Connected health platforms also enable health care actors to
take effective measures for managing the patient’s state of
well-being by analyzing health data from these devices [10,30].
Collected data from connected devices can be continuously
analyzed and shared to provide actors with key insights that
allow them to take effective action. For instance, feedback can
be derived from an analysis of a patient’s home-based blood
pressure readings or blood glucose levels taken from wearable
body sensors or connected devices that record patients’ vitals
[31,32]. In addition, rule-based systems can be employed to act
as early warning systemswhereby health care professionals are
notified when a patient’s vitals pass certain thresholds, as
detailed in the relevant clinical guidelines [33].
Connected health solutions and data analytics support a
proactive model of care in which all stakeholders are provided
with critical feedback at key touchpoints between the patient,
the connected health platform, and the health care service
[10,34]. At the same time, this provides a clear opportunity to
re-engineer relevant pathways to boost their effectiveness while
also leveraging leading-edge technology to reduce the
transaction cost or increase the throughput of key health care
services. However, the mapping of these touchpoints can be a
challenging task, given the complexity of the pathways as well
as the ubiquity and diversity of patient data in connected health
scenarios [35]. Existing modeling techniques often fail to
identify the ideal placement and configurations of connected
health solutions within the health care service network [35].
Central Pillars of Health Care Quality
Quality improvement is the primary goal of all modern health
care service organizations, which strive for better patient health
care outcomes, service performance, and professional
development in the delivery of health care services [36].
According to Doyle et al [20], there are 3 central pillars that
constitute health care quality
Clinical Effectiveness
Clinical effectiveness concerns the improvement of the current
clinical practices and their related health care service outcomes
[25]. Clinical effectiveness can be improved through the
identification of nonvalue adding steps that fail to directly
improve the quality of patient care [37]. Workflow analysis can
help improve the effectiveness, efficiency, and efficacy of
clinical services based on an in-depth understanding of the status
quo [38,39]. For instance, workflow analysis can be undertaken
to investigate and identify potential variations in service delivery
and to identify issues such as bottlenecks and resource
Patient Safety
Patient safety aims to safeguard different dimensions of patient
well-being through regulation and proactive measures in practice
[25]. The health care sector is a highly regulated environment,
which demands that patient safety is taken into consideration
in service reform initiatives. Examples of the constraints that
ought to be considered when addressing patient safety include
medical protocols and clinical guidelines (eg, the National
Institute for Health and Care Excellence guidelines), ethical
standards (eg, the Hippocratic Oath), medical device certification
(eg, Food Drug Administration approval in the United States
and Conformité Européene (CE) Marking in the European
Union), and data protection (eg, General Data Protection
Regulation). These factors act as guide rails that aim to improve
patient safety [40].
Patient Experience
Patient experience centers on a patient’s “personal interpretation
of the service process and their interaction and involvement
with it during their journey or flow through a series of
touchpoints” [41]. Zomerdijk and Voss [42] state that
experiences are constructed based on the interpretation of
encounters and interactions designed by the service provider.
Although providers cannot directly offer an experience, they
can create the foundational basis on which stakeholders (eg,
customers, patients, and employees) can derive their own
experiences. Although operational service quality looks at
whether a service is delivered to its predefined specification,
patient experience is based on the patient’s feelings, judgments,
and perceptions of the benefits derived from the service [41,43].
Patient experience is a key factor in ensuring compliance with
recommendations as patients are much more likely to disregard
or abandon tools and practices if they contribute to a poor
experience. Patient experience must also be considered from
an ethical viewpoint where patients must be fully aware “of the
nature, scope, and granularity of data collected and what
information they are actually consenting to provide” [24].
However, although some methods for improving clinical
effectiveness and managing patient safety are relatively well
established in the health care sector (eg, process mapping,
service blueprinting, etc), methods for enhancing patient
experience are less entrenched, particularly within connected
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health [5,23,35]. The following section looks at journey mapping
as a patient-centric tool for designing health care service reform.
Journey Mapping
Journey maps have been used in several areas to offer pictorial
illustrations of complex processes or interactions that would
otherwise be difficult to apprehend. Howard [44] noted that
journey maps evolved from the field of service design when
designers sought to re-engineer or optimize the service delivery
of organizations or developed blueprints for new services (see
the study by Stickdorn and Schneider [45]).
In particular, journey maps can be used to depict the health care
service from the perspective of different actors, such as patients
[37,42,46]. In the case of the patient, they are based on mapping
consecutive touchpoints between the patient and the service,
the nexus of where patient experience is actively shaped
[23,42,47]. They see the relationship between the patient and
service organization as something emergent, dynamic, and
ubiquitous within the larger context and go beyond the more
static view provided by other service design methods [42].
Percival and McGregor [48], for instance, proposed a mapping
technique that includes a number of layers: staff roles, processes,
information creation or movement, HIT solutions, IT
infrastructure, patient needs or practice guidelines or policies,
and metrics. Journey maps incorporate both physical and
emotional aspects of the patient’s journey with the aim of
capturing and shaping the patient’s behavior, feelings,
motivations, and attitudes across the episodes of care, taking
into account such important factors as the environment or
context. They also help professionals to visually externalize
their disciplinary knowledge and collect multidisciplinary
insights. This promotes alignment but also empathy toward
patient groups by placing the patient at the heart of the modeling
process [49] and by creating a visually compelling story of the
patient’s experience [43].
User representations are developed to categorize and personify
different target groups through the description of fictional users,
that is, name, picture, personal background, and goals. User
personas involve creating representations of typical users to
help design teams to better understand and take account of the
mental models of these groups, that is, their expectations, prior
experience, and anticipated behavior [50]. LeRouge et al [50]
stated that user personas address the limitations of common
modeling tools such as Unified Modeling Language diagrams
by integrating the conceptual model of users, their cognitive
structures, and present behavior that drives health care thinking,
future behavior, and demand.
Journey maps can be combined with user personas in the
requirements gathering process to direct increased attention
toward patient experience. The added contribution of personas
to journey maps is that instead of being static representations
of demographic profiles, they offer dynamic views of customers
and users’ experiences in their interactions with current and
proposed products and services. The combined approach can
then be employed to make design decisions and evaluate design
solutions according to the unique needs of each persona. This
stimulates creativity among team members when trying to
address user needs and usability across numerous different
real-life scenarios [51]. Critically, a small number of personas
have been found to support the consideration of large, diverse
populations, making the concept particularly useful for health
care scenarios [52].
Developing Complex Apps
The area of HIT development has received considerable
attention over the last 40 years. This time has seen the
emergence of increasingly sophisticated platforms and
development environments. Recently, the availability of
cloud-based solutions, smart interconnected devices, and mobile
apps has unleashed the potential for connected health apps.
Unfortunately, these benefits can often be offset by the
complexity and cost of developing connected health apps. The
set of required development skills is becoming increasingly
specialized, as is the complexity of the project management of
the multidisciplinary teams required when developing such
solutions. Mapping tools might be a useful approach for building
cohesion within such teams, but at the same time, they must be
understandable by diverse groups and professions to ensure that
shared knowledge can be nurtured during the development
In the following section, we describe IPJM, a visual tool
developed to help design teams to meet these challenges and to
understand how to best reconcile the sometimes divergent
requirements arising out of the need for clinical effectiveness,
patient safety, and patient experience when designing connected
health solutions. IPJM is also intended to promote harmonious
team performance by negotiating and finding the right balance
between the somewhat competing needs of different groups.
This requires collaboration between different competencies on
multidisciplinary teams. It also requires the management of
conflict, which is likely to emerge from a comprehensive
consideration of all viewpoints [53-55]. As a result of using
IPJM, we hope that robust and high-quality designs will emerge
for the solutions being considered.
The IPJM tool was built using an ontology that conceptualizes
the journey of a patient along a medical pathway. The ontology
aims to promote a common vocabulary [56] among
multidisciplinary design teams based on the 3 core pillars of
health care quality. It captures the key elements of the journey:
the structure of elements, relationships between elements, and
implicit rules that govern the behavior of elements [57]. The
ontology depicted in Figure 1 is provided in the literature. In
addition, it has been validated through qualitative feedback from
a number of projects that involve the use of IPJM, including
the LEANBH project, which is described in the Methods section
of this paper.
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Figure 1. Integrated Patient Journey Map Ontology.
The ontology is split into 3 main areas: the patient persona, the
medical timeline, and the medical pathway. First, the patient
persona provides a characterization of a user group under
consideration (eg, an expectant mother who is at risk of
hypertension) and is inextricably linked to all other elements
of the ontology. The medical timeline adds a temporal aspect
to the episode of care by dividing it across a defined time frame
(eg, the weeks of a pregnancy). The medical pathway centers
on the consecutive events or steps in the episode of care [46]
and consists of 7 subcomponents that are defined and described
in Textbox 1. In particular, the medical pathway describes the
physical journey, the emotional journey, and the device
touchpoints associated with an episode of care. The physical
journey is further divided into tasks, and these tasks are further
subdivided into goals, constraints, and actors.
Textbox 1. Components of the medical pathway.
Physical journey: maps the movement of the patient across an episode of care as she moves from one touchpoint to another in different settings
(eg, patient’s home, general practitioner clinic, or emergency room) where the health care service is delivered and the patient experience is derived
Emotional journey: shows how the patient’s experience changes as she moves through the different touchpoints
Device touchpoints: lists the technological solutions utilized by the different actors (eg, doctor, general practitioner, and patient) at each touchpoint
Actors: lists the stakeholders involved in the delivery of the health care service (eg, hospital doctors, general practitioners, and nurses)
Task: details the tasks undertaken by each actor in the health care service delivery (eg, measuring the patient’s blood pressure and registering
Goals: comprises the desired outcomes that actors aim to deliver when carrying out tasks (eg, clinical, operational, and administrative goals)
Constraints: outlines the constraints such as treatment guidelines based on medical protocols, governance, safety, and clinical guidelines
In this way, the ontology provides the foundational basis for
IPJM by outlining the context in which the patient journeys
transpire. Going back to the underpinnings of the concept of
journey maps, the mapping tool (through the use of the ontology)
visualizes the journey of a persona facing a scenario. This can
sensitize designers and developers to the intricacies of individual
personas and scenarios and minimize the risk of designing for
normative situations that do not reflect the real situations of
actual patients. Commercial firms and public sector agencies
have used such ontologies very successfully in seeking to
develop interaction mechanisms with their customers and with
members of the public who need to access their services, such
as in the case of disabled people who have special mobility and
cognition needs [58].
IPJM can be used to show the as is and the to be comparison
between the existing medical pathway and the intended modified
pathway enhanced with technology, devices, apps, and other
new components and interactions. This ensures the tool’s
usefulness for negotiation and communication of the design of
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the proposed connected health solution, especially between
clinical specialists and designers or developers of the solutions.
In seeking to make a business case for new pathways, the map
can be used to demonstrate to relevant health care authorities
the potential impact of proposed changes.
IPJM Template
Building on this ontology, we iteratively designed and evaluated
the visual elements of a journey mapping tool called IPJM. An
example of a base template, constructed iteratively using the
ontological components, is shown in Figure 2. The patient
persona is situated on the left side of the template, the medical
pathway and its subcomponents are positioned in the center,
and the medical timeline is displayed horizontally on the top of
the template. Tasks, goals, constraints, and actors are listed
within the safety and governance component.
Figure 2. Base Integrated Patient Journey Map Template.
Each of these areas of the IPJM maps to the 3 core pillars of
health care quality previously outlined in the Background
section. For instance, the physical journey aims to provide
insights into the clinical effectiveness of the health care service
by plotting the sequence of steps involved in the delivery of
care. This, in turn, can be used to examine the steps to identify
those that do and do not add value to the health care service.
The emotional journey deals with patient experience. This is
based on the likely emotional response of the patient to
individual steps in the health care service. Finally, safety and
governance maps the aspects of patient safety based on the
responsibilities of different actors and their associated regulatory
The device touchpoint area caters for the connected health
context and maps the different connected devices and data
analytic solutions that are employed by actors when delivering
the service. For instance, one touchpoint between the patient
and the health care service could involve the use of a smartphone
app and a connected medical device for tracking and sharing
data on the patient’s state of well-being. Another touchpoint
could involve the use of data analytics by clinicians to gain
insights into the patient’s state of well-being, forecasting
potential health issues and intervening when required.
A design science approach was followed to ensure that there
was a rigorous basis for the construction of the tool [59]. A
description of the researchers’ approach to design science was
previously presented in a study by McCarthy et al [60].
Following O'Raghallaigh et al [56], the design science approach
consisted of 2 central activities: (1) identifying and generating
foundational abstract knowledgefrom academic and practitioner
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literature to guide, explain, and justify the design approach and
(2) using and refining abstract foundational knowledge in
developing and evaluating prototypes through engagement with
potential users of the tool. The approach thus sought to integrate
both design practices(construction of the artifact supported by
existing knowledge) with design science (generation of
knowledge through the construction and evaluation of the
artifact). For example, the initial version of the ontology was
developed from a scientific understanding of the academic
literature. On the other hand, the first version of the mapping
tool was largely developed through practice.
Prototypes of the IPJM tool were evaluated using different
techniques. Evaluation primarily focused on examining the use
of the tool by design teams during projects focused on increasing
health care quality (clinical effectiveness, patient safety, and
patient experience). In addition, the general evaluation looked
at IPJM as an analytical tool to support the collection of
requirements for connected health apps. In the case of the
LEANBH project, evaluation involved a multidisciplinary team
of stakeholders working together to populate IPJM templates
for 8 personas across diverse scenarios (such as white-coat
hypertension, chronic hypertension, gestational hypertension,
and preeclampsia). A separate template was used to map the
journey for each persona facing a scenario. Post-it notes were
used to fill in the components of the journey, and these were
positioned across the 4 areas of the template. This approach
allowed the journey to be easily modified by iteratively adding,
moving, or removing the post-it notes. Different colored markers
were used to connect and codify post-it notes and to indicate
where changes needed to be made to the journeys based on
discussion among the team members. Table 1 provides a
summary of the evaluation techniques used during the LEANBH
The following section outlines the in-depth case study of the
LEANBH project.
Table 1. Techniques used to evaluate the Integrated Patient Journey Mapping during the Learning to Evaluate Blood Pressure at Home project.
PurposeBrief descriptionData collection
Exploratory design of the model-
ing tool
Four full-day workshops involving a multidisciplinary group of stakeholders. The
workshops focused on deriving requirements for a connected health system that
would monitor the well-being of expectant mothers across different settings such as
the antenatal clinic, general practitioner’s practice, and an expectant mother’s home
Individual stakeholder’s subjec-
tive evaluation of IPJM
Semistructured interviews each lasting about 1 hour were conducted with the 10 in-
dividual team members to gain further in-depth insights into the IPJMatool. Interviews
were conducted with the principal investigator, project manager, 2 developers, a
funded investigator, data architect, clinical lead, clinical researcher, research nurse,
and the director of a commercial partner
Semistructured interviews
Evaluation of the prototype’s
ability to represent the current
best practices
A range of sources were used to ensure that IPJM considered clinical effectiveness,
patient safety, and patient experience goals. This involved analyzing best practices
around managing the patient pathway using sources such as the UK’s National Insti-
tute for Health and Care Excellence guidelines for managing hypertension during
pregnancy. In addition, information requirements were investigated based on the
Health Service Executive’s maternity health record in Ireland and Data Protection
Act guidelines around health care research
Analysis of supporting docu-
aIPJM: Integrated Patient Journey Mapping.
Case Study Approach
An in-depth case study approach [61] was undertaken to explore
the use of visual tools for embedding health care quality in the
design of connected health solutions. The in-depth case study
in question followed the guidelines provided in studies by Yin
[62,63]. It centered around the LEANBH project, a pilot research
project that provides remote health care monitoring for expectant
mothers to improve the detection and treatment of hypertension
during pregnancy.
The LEANBH Case Study
Hypertensive disorders in pregnancy (eg, preeclampsia and
gestational hypertension) are a major cause of maternal and
neonatal mortality and morbidity worldwide, accounting for
16% of maternal deaths in developed nations such as Ireland
and 25.7% of maternal deaths in the developing nations of Latin
America and the Caribbean [64]. In particular, preeclampsia is
a hypertensive disorder of pregnancy characterized by high
blood pressure (>140/90 mm Hg), the presence of protein in
urine, and other associated symptoms such as headaches and
edema, which can lead to serious complications during
pregnancy [65].
The LEANBH project was a collaborative effort that involved
organizations from academia, the health care sector, and the
industry. The multidisciplinary project team consisted of a
principal investigator, a project manager, a full-time and
part-time developer, an analyst, and a data architect (which
made up the information systems [IS] subgroup) and a clinical
lead, a clinical researcher, and a research nurse (which made
up the clinical subgroup). The primary goals of the project were
to increase clinical effectiveness, patient safety, and patient
experience in a perinatal care context. The project team was
tasked with building a connected health platform that integrates
several IT artifacts, including a smartphone app, a home blood
pressure monitor, and a urine analyzer for use by expectant
mothers. An electronic health record was included to capture
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vitals for use by clinicians. The project also aimed to develop
novel forecasting algorithms for predicting the likelihood of
gestational hypertension and preeclampsia.
The project was an observational study in which each patient
followed the standard pathway and had access to both the
standard care and the connected health platform. This simplified
the ethical approval process, which was mostly concerned with
providing complete and precise information to participants and
in eliciting their consent on recruitment. This was achieved by
creating a comprehensive patient information leaflet and
assigning a dedicated research nurse to recruiting patients and
training them in the use of the smartphone app, blood pressure
monitor, and urine analyzer. Ethical approval was granted by
both the University Clinical Research Ethical Committee and
the Health Service Executive via the Hospital’s Local
Information Governance Group Research and Audit Committee.
The authorization covered 2 rounds of recruitment of 50 patients
each: the first group was an initial low-risk group and the second
group was a more representative group of pregnant women,
including women with preeclampsia.
Data Gathering
Qualitative data were triangulated using 3 data gathering
techniques: participant observations, interviews, and project
documents. First, the lead author was granted exceptional access
to the live project setting, which allowed him to carry out over
700 hours of in-depth participatory observations in the field for
a period of 6 months (June 2015 to January 2016). Participant
observations allowed the lead author to gain rich insights into
peoples’ actions and directly observe events as they unfolded.
In addition, semistructured interviews, each lasting about 1
hour, were then conducted with the 10 individual team members
to gain further in-depth insights into the project. The interviews
provided rich accounts of the subjects’own words. Finally, the
lead author also had access to project documents throughout
the development phase, which included emails, reports, and
project management outputs. These documents offered a
concrete account of the phenomenon of interest.
Data Analysis
Content analysis [66] was used to organize data into common
themes and triangulate findings from interviews, project
documents, and participatory observations. The content analysis
centered on both reflection-in-action and reflection-on-action
[67], with clinicians and IT specialists asked to validate IPJM
and the individual journey maps. This hybrid approach was in
keeping with our use of the case study method, in an intrinsic
rather than an instrumental mode [68].
The journey map was first evaluated through
reflection-in-action, with participant observations by the lead
author using vignettes. As noted by Denzin and Lincoln [69],
“it is important to keep in mind that when conducting qualitative
research, the researcher is the main tool for analysis.” Vignettes
provided “a focused description of a series of events taken to
be representative, typical, or emblematic in the case” [70].
Vignettes were used in the first instance as many parameters
were emergent in our data analysis, and we wanted to stay as
close to the data as we could. This technique allowed the
researcher to produce, reflect, and learn from data around key
moments in the everyday life of the project [70,71]. Gaining
familiarity with the data, although arguably time consuming,
was a positive aspect of the data analysis process and helped
deliver a better artifact as well as a deeper understanding of its
The efficacy of the journey map was also validated through
reflection-on-action by analyzing interviews. To enhance the
rigor in our data analysis, we used the computerized software
provided by NVivo (QSR International) to analyze the interview
transcripts. The lead author identified the codes of interest,
including variables such as concepts and properties as well as
the relationship between these variables [70]. As part of the data
analysis and evaluation process, the researcher’s perception of
variables and relationships, otherwise referred to as theoretical
sensitivity, was influenced by a reading of literature. The lead
author continuously reread interview transcripts and used NVivo
to manage the coding inventory.
During the project initiation phase, the project manager
organized 4-day-long participatory design workshops that aimed
to build a collective vision for the project and to gather
requirements for the connected health platform. These
workshops involved stakeholders from the IS and clinician
subgroups. During the workshops, the project manager
encouraged the groups to work together in utilizing IPJM to
map the physical and emotional journeys of pregnant women
across the touchpoints of the proposed connected health service.
In this way, IPJM provided a canvas for the groups to explore
an improved antenatal pathway, technical considerations of the
connected health platform, and the needs and capabilities of
different stakeholders (eg, expectant mothers, clinicians,
developers, nurses, midwives, and other health care
practitioners). The groups used markers and post-it notes to
dialogically work through potential challenges faced by personas
in engaging with the proposed service. Owing to delays in the
ethical approval process, the interdisciplinary team did not have
direct contact with expectant mothers during this time.
The project team used IPJM during successive workshops to
superimpose the journeys of fictional personas of different
expectant mothers who would use the connected health service.
In total, 8 fictional personas were identified by the team to
represent the different hypertensive disorders that can occur
during pregnancy and the medical scenarios that can occur. This
included Sheila, a 31-year-old first-time expectant mother at
risk of hypertension during pregnancy because of a family
history of preeclampsia (Figure 3). Her journey through the
standard antenatal pathway was now complemented with her
use of the proposed connected health solution. Other personas
included Denise, a 25-year-old expectant mother who developed
preeclampsia, and Fiona, a 29-year-old expectant mother who
developed gestational hypertension.
JMIR Hum Factors 2020 | vol. 7 | iss. 3 | e17416 | p. 8 (page number not for citation purposes)
Figure 3. Snapshot of a Completed IPJM.
The project manager viewed the use of fictional personas as
vital in that they acted as surrogates for real expectant mothers
in the participatory design phase. This gave a voice to
individuals who could not be physically present in the room.
As a result, IPJM helped to build a bridge between multiple
voices both inside and outside the design process, including the
missing voices of expectant mothers. Interestingly, these missing
voices often acted as the arbitrator during group discussions.
For example, when individuals disagreed on a point, they would
often revert to asking one another what the personas would
want. This challenged the siloed thinking of both the clinical
and IS subgroups. Individuals would often speak out on behalf
of one of the personas and assert how certain decisions would
affect the physical and emotional journey of this expectant
mother. One powerful example of this emerged during
discussions around the journey of Brenda, an expectant mother
who (due to the white-coat syndrome) is incorrectly diagnosed
with gestational hypertension and admitted to the hospital. The
group discussed the emotional impact that this event would
have on Brenda and challenged itself to come up with ways in
which the connected health platform could be designed to avoid
the unnecessary hospitalization of Brenda.
IPJM proved useful in helping individuals to build a deeper
understanding of the challenges faced by different users of the
proposed connected health platform. An example is the case of
an expectant mother, Denise, who had young children to care
for during her pregnancy. Denise’s journey generated
discussions around the challenges she would face if the
smartphone app forced her to take blood pressure readings at
strict time intervals, which could interfere with her childminding
obligations. This challenged the group’s prior assumptions.
They ended up altering the service to provide flexibility when
blood pressure readings could be recorded.
IPJM enabled the group to develop a common language around
the antenatal pathway. It became a powerful means of building
a shared understanding. For example, the IS subgroup faced a
steep learning curve to reach an understanding of the obstetrics
domain and the various health care settings in which the
connected health platform would be deployed. Similarly,
clinicians had limited knowledge of the technical aspects of the
connected health platform. IPJM challenged siloed knowledge
around the clinical and technology pathways and helped bridge
disciplinary boundaries. The synergies arising from this
confluence of disciplinary knowledge were essential for
highlighting IT and clinical challenges, both previously known
and unknown. As pointed out by the developer:
It was useful. It was only when I walked through the
journey map explaining how the [smartphone] app
would work that I realised that others had different
It also emerged that the IPJM tool was equally a means of
generating shared commitment among the groups. Individuals
later noted how participatory design activities using IPJM
allowed the group to leverage the full range of capabilities
possessed by the interdisciplinary group. As stated by the project
manager, these activities represented a significant milestone
Technical concerns and clinician concerns were
starting to be addressed as a unit as opposed to being
two separate entities... For the first time people
realised that the journey wasn’t a clinical journey, it
wasn’t a medical journey, but neither was it a
technological journey. It was all combined together.
In using IPJM, many individuals were largely unaware that they
were generating requirements for the proposed platform.
However, the analyst was able to capture requirements for the
platform from the discussions taking place as individuals worked
together in filling out the journey maps. The resultant journey
maps became a record of all relevant design knowledge. Owing
to the visual and instinctive nature of the journey maps,
individuals were able to handle the complexity of the medical
scenarios, whereas this would not have been possible if
JMIR Hum Factors 2020 | vol. 7 | iss. 3 | e17416 | p. 9 (page number not for citation purposes)
traditional modeling techniques had been used, as these require
a level of familiarity that some individuals did not possess.
Principal Findings
The findings suggest that IPJM can support multidisciplinary
teams in exploring connected health solutions that consider the
3 pillars of health care quality: patient experience, clinical
effectiveness, and patient safety [20]. It supports groups in
understanding and negotiating conflicting requirements that can
arise during transformational projects. This is achieved using
journey mapping and user personas for graphically externalizing
key domain knowledge. IPJM also promotes creative thinking
around service reform goals and fosters dialogue among
stakeholders, potentially leading to better solutions overall [72].
In addition, the ontology behind IPJM places constraints on
groups, although it also allows the modeling to be easily adapted
to different specialties, such as cardiology. The accessibility of
the IPJM tool means that it can become a valuable boundary
object [73,74], for discussions between multidisciplinary teams
of stakeholders. For instance, IPJM enables ideas to be shared,
interrogated, and visually externalized at both individual and
group levels [56]. The use of mediums such as post-it notes
means that the template is easy to use and modify as well.
Compared with other mapping tools, IPJM offers the possibility
to focus on the comparison between the as isand to beversions
of the pathway under study—this is a significant advantage in
projects that pursue specific improvement targets. Its reliance
on a visual grammar that does not require pre-existing
knowledge (unlike other systems analysis and design
approaches, such as Data Flow Diagrams or Value Stream
Mapping, which require substantial training before participants
can use them meaningfully) is also an advantage. The
comparison with other techniques, such as Patient Journey
Model architecture (PaJMa), the method proposed by Percival
and McGregor [48], for instance, shows that IPJM manages to
accumulate and represent a similarly broad variety of knowledge
but with greater economy and without passing on the complexity
of tasks and process steps onto the participants in the design
process or, generally, onto the readers of the documentation.
Both PaJMa and IPJM offer improvements over other mapping
tools by allowing analysts to consider a much broader range of
knowledge, but the use of personas in IPJM delivers a sharper
focus on human aspects, such as the human experience, of
patients, which is fundamental for connected health solutions
that entail a context of use where patients are alone when using
apps. In contrast to PaJMa, IPJM is likely to be more user
friendly and more flexible in the case of first-time digitalization
of medical pathways that involve mobile components that either
patients or clinicians will use remotely.
IPJM can be used as a cornerstone for modeling health care
service reform where stakeholders collaborate to derive an
understanding of and commitment to requirements [75,76].
Textbox 2 summarizes the benefits inherent in the use of IPJM
identified in its use during the LEANBH project.
Textbox 2. Strengths of Integrated Patient Journey Mapping.
Embeds pillars of quality: considers clinical effectiveness, patient safety, and patient experience in tandem
Externalizes knowledge: allows stakeholders to externalize their domain knowledge and build a shared understanding
Stimulates creativity: facilitates dialog between different stakeholders around developing creative solutions
Accessible: easy for multidisciplinary stakeholders to understand, use, and modify
Adaptable: can be adapted to the requirements of different contexts and specialties
Emancipatory: facilitates the alteration of medical pathways and the development of solutions for addressing their shortcomings
Educational: acts as a platform for communicating proposed changes, their impacts, and the intentions and ambitions of the teams
Beyond the benefits identified in Textbox 2, we argue that IPJM
can boost team cohesion during the execution of novel design
projects. Existing literature suggests that team cohesion is
essential to the performance of teams consisting of individuals
from diverse organizational and geographical backgrounds [77].
Team cohesion can be defined as the extent to which team
members are aligned in their shared understanding of and shared
commitment to project tasks, for example, the actions that
individuals and groups seek to perform based on agreed plans
[78,79]. Shared understanding involves a social process whereby
the divergent knowledge of individuals is transformed to
generate collaborative knowledge building [75,80]. Shared
understanding is required to explore design spaces and overcome
siloed thinking through the combination of existing knowledge
in new ways. Meanwhile, shared commitment goes beyond
shared understanding alone and requires team members to
commit time, effort, and resources in line with proposals that
have gained shared understanding [76,81].
Shared understanding and shared commitment are crucial to the
success of projects involving stakeholders from different
organizational and disciplinary backgrounds [54]. In the absence
of both shared understanding and shared commitment, the
perspectives and intentions of team members can become
increasingly fragmented, as individuals may not even be aware
of the intricacies of the issues around which they disagree [76].
IPJM provides team members with the opportunity to challenge
assumptions embedded in prebaked project proposals and
contribute diverse knowledge around the design of IT solutions.
This helps ensure that design efforts promote both a shared
understanding of users’ diverse needs and capabilities and a
shared commitment to the delivery of solutions that cater to
these needs. However, during the LEANBH project, not all
group members were equally committed to leveraging the tools
and to journey maps for modeling the problem domain and
gathering requirements. This is a key concern as there is a
possibility of a link between the involvement of stakeholders
JMIR Hum Factors 2020 | vol. 7 | iss. 3 | e17416 | p. 10 (page number not for citation purposes)
during the modeling process and their understanding of and
engagement with the project overall. Therefore, future versions
of the modeling tool need to consider how best to engage
practitioners from different backgrounds so that the entire team
rally around the journey maps and their validation.
The health care sector is currently facing the monumental
challenge of minimizing the costs associated with health care
delivery while simultaneously improving quality. Connected
health solutions can play a significant role in meeting this
challenge by transferring health care delivery to the least
expensive setting (ie, a patient’s home) in a way that does not
compromise quality. However, the successful design of
connected health solutions is far from a straightforward task,
and the success hinges on a quality-centric approach being
embodied during every step of the development lifecycle. At
this point in time, health care systems around the world are
seriously affected by their reliance on a one-to-one mode of
care delivery, where patients often wait for weeks and months
to see overstretched specialists. Crucially, connected health
apps can allow clinicians to better care for more patients by
giving them more frequent attention in a remote fashion and
without the need for face-to-face visits far more effectively [8].
It is here that the use of design tools such as IPJM can offer
significant value. This paper contributes theoretical and practical
insights into how visualization tools can be used to embed the
pillars of health care quality in the design of connected health
solutions. For instance, case study findings suggest that IPJM
can provide multidisciplinary teams with a canvas for designing
connected health solutions tripartite goals of clinical
effectiveness, patient safety, and patient experience. In
particular, IPJM can help ensure that patient experience is given
ample consideration when designing health care services, in
tandem with more traditional concerns such as resource
efficiency, waiting times, financial costs, and treatment efficacy.
In particular, IPJM can help bridge the gap, which is often
identified too late between the intended use of apps and the
observed system-in-use postimplementation. Such gaps often
lead to the occurrence of silent errors and require the complete
rethinking of apps and devices at considerable expense in time
and money, both of which are in short supply in the health care
sector [82].
Limitations and Future Research
However, IPJM is not without some limitations. For instance,
IPJM does not make explicit reference to key performance
indicators, such as throughput and waiting times, or other
metrics, such as productivity and cost-efficiency, although these
may be essential elements of the performance and success of
the services being designed. This clearly applies to the scenario
of a connected health solution being implemented to increase
the throughput of a medical pathway, to deliver cost savings,
and to improve visibility on patients’ conditions. Although
incorporating this element in the tool would be useful, there is
also a risk that increasing the level of detail may compromise
the overall accessibility and reliability of the maps. As a result,
it may be difficult to capture some of the inherent complexity
in health care systems, that is, when a patient is transferred from
a hospital during treatment. On the other hand, the tool can be
adapted according to the unique context in which it is to be used
to address any key elements that are missing. Its use within the
context of specific pathologies and medical specialties has the
potential to rapidly bring medical teams up a steep learning
curve toward developing connected health care apps.
Specifically, in the case of our research, we encountered other
limitations, although it may be unclear whether these were
circumstantial or if they were likely to also occur in other cases
and settings. We found it difficult at times to secure participation
from certain groupings in some meetings. For example,
clinicians sometimes found it difficult to commit time to use
IPJM, as they felt they were too busy and that the journey maps
were for the development team rather than for themselves.
Resolving these misconceptions is essential to producing maps
that are accurate and robust in the face of real-life scenarios.
Future research may also seek to develop a more interactive
version of IPJM to provide a more accessible view of the
patient’s journey. IPJM currently requires a large physical
display to ensure that all components are visible and legible.
During the project, we experimented with different display
dimensions and orientations before deciding on an A2 portrait
format. However, it may be necessary to consider whether
certain elements need to be reorganized so that the tool can be
displayed more easily across a variety of media and spatial
dimensions. A software program that would allow users to drill
down into subpathways and map components more effectively
could also be a useful extension.
Clearly, there are cognitive and presentational limitations that
apply to the mapping of macroservices, for instance, a national
or even transnational architecture for managing a certain
pathology or group of patients with dedicated needs. Although
the mapping of such a broad pathway might be desirable or
even essential as a communication tool for reaching a common
agreement, evidently difficulties will arise when attempting to
compile such a map where the need to be holistic and
comprehensive might be traded off against the necessity for
visual representations to remain comprehensible by most people
and therefore useful. Setting some boundaries that accommodate
both the need to capture the whole system as well as some of
its key components will be useful, although our research does
not provide clear avenues pertaining to how this may be
achieved. Weick [83] characterized the Bonini paradox (by
reference to Charles Bonini and his work on simulation,
published in 1963 [84]) as illustrative of situations where models
were proposed that were so complex in and of themselves that
it was no easier to understand them than it was to understand
the real world as observation could reveal it. We can hypothesize
that the Bonini paradox applies to journey maps and that die
hard attempts to capture a world without any ontological
boundaries would only yield theoretically excellent but
practically useless representations that would hamper design
efforts rather than help. The need for ontological boundaries,
such as those provided by the IPJM tool, is much needed and
is underresearched. Future research on this topic should explore
this new dimension.
JMIR Hum Factors 2020 | vol. 7 | iss. 3 | e17416 | p. 11 (page number not for citation purposes)
This publication has emanated from research conducted with the financial support of Science Foundation Ireland (Grant No.
Conflicts of Interest
None declared.
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HIT: health information technology
IS: information systems
IT: information technology
IPJM: Integrated Patient Journey Mapping
LEANBH: Learning to Evaluate Blood Pressure at Home
PaJMa: Patient Journey Model architecture
Edited by B Price; submitted 11.12.19; peer-reviewed by R Chan, S Chen; comments to author 16.03.20; revised version received
08.05.20; accepted 26.05.20; published 17.09.20
Please cite as:
McCarthy S, O'Raghallaigh P, Woodworth S, Lim YY, Kenny LC, Adam F
Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM):
Case Study
JMIR Hum Factors 2020;7(3):e17416
doi: 10.2196/17416
©Stephen McCarthy, Paidi O'Raghallaigh, Simon Woodworth, Yoke Yin Lim, Louise C Kenny, Frédéric Adam. Originally
published in JMIR Human Factors (, 17.09.2020. This is an open-access article distributed under
the terms of the Creative Commons Attribution License (, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Human Factors, is properly
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... If, on the one hand, digital technologies have facilitated connections between individuals that were unthinkable only a few years ago, on the other hand, they run the risk of a deterioration of interpersonal relationships. The development of caregiver/user communication skills, therefore, becomes necessary and must be emphasized in shared educational processes [32,33]. These paths are not easy, but they are indispensable and, although long, must begin as soon as possible in conjunction with the implementation of the telemedicine organizational model. ...
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Telemedicine has entered the daily lives of doctors, although the digital skills of healthcare professionals still remain a goal to be achieved. For the purpose of a large-scale development of telemedicine, it is necessary to create trust in the services it can offer and to favor their acceptance by healthcare professionals and patients. In this context, information for the patient regarding the use of telemedicine, the benefits that can be derived from it, and the training of healthcare professionals and patients for the use of new technologies are fundamental aspects. This consensus document is a commentary that has the aim of defining the information on and training aspects of telemedicine for pediatric patients and their caregivers, as well as pediatricians and other health professionals who deal with minors. For the present and the future of digital healthcare, there is a need for a growth in the skills of professionals and a lifelong learning approach throughout the professional life. Therefore, information and training actions are important to guarantee the necessary professionalism and knowledge of the tools, as well as a good understanding of the interactive context in which they are used. Furthermore, medical skills can also be integrated with the skills of various professionals (engineers, physicists, statisticians, and mathematicians) to birth a new category of health professionals responsible for building new semiotics, identifying criteria for predictive models to be integrated into clinical practice, standardizing clinical and research databases, and defining the boundaries of social networks and new communication technologies within health services.
... Research using co-design methods with young people with type 1 diabetes exposed a radically different view of technology than either their parents or practitioners, illustrating the need to involve target end-users in design (Pulman et al., 2013). This literature suggests HCD supports compassion in healthcare by creating methods and opportunities for inclusion in the design of technologies that address real and significant needs in people's lives (McCarthy et al., 2020;Majid et al., 2021) as well as promoting trust that empathy will be preserved and acceptance of new AI technologies in a healthcare space (Zhang et al., 2021). HCD to develop an electronic crutch for paralyzed people has been described as a humanitarian project designed with empathy for patients in mind (Sarkar et al., 2020). ...
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Background Advances in artificial intelligence (AI) technologies, together with the availability of big data in society, creates uncertainties about how these developments will affect healthcare systems worldwide. Compassion is essential for high-quality healthcare and research shows how prosocial caring behaviors benefit human health and societies. However, the possible association between AI technologies and compassion is under conceptualized and underexplored. Objectives The aim of this scoping review is to provide a comprehensive depth and a balanced perspective of the emerging topic of AI technologies and compassion, to inform future research and practice. The review questions were: How is compassion discussed in relation to AI technologies in healthcare? How are AI technologies being used to enhance compassion in healthcare? What are the gaps in current knowledge and unexplored potential? What are the key areas where AI technologies could support compassion in healthcare? Materials and methods A systematic scoping review following five steps of Joanna Briggs Institute methodology. Presentation of the scoping review conforms with PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). Eligibility criteria were defined according to 3 concept constructs (AI technologies, compassion, healthcare) developed from the literature and informed by medical subject headings (MeSH) and key words for the electronic searches. Sources of evidence were Web of Science and PubMed databases, articles published in English language 2011–2022. Articles were screened by title/abstract using inclusion/exclusion criteria. Data extracted (author, date of publication, type of article, aim/context of healthcare, key relevant findings, country) was charted using data tables. Thematic analysis used an inductive-deductive approach to generate code categories from the review questions and the data. A multidisciplinary team assessed themes for resonance and relevance to research and practice. Results Searches identified 3,124 articles. A total of 197 were included after screening. The number of articles has increased over 10 years (2011, n = 1 to 2021, n = 47 and from Jan–Aug 2022 n = 35 articles). Overarching themes related to the review questions were: (1) Developments and debates (7 themes) Concerns about AI ethics, healthcare jobs, and loss of empathy; Human-centered design of AI technologies for healthcare; Optimistic speculation AI technologies will address care gaps; Interrogation of what it means to be human and to care; Recognition of future potential for patient monitoring, virtual proximity, and access to healthcare; Calls for curricula development and healthcare professional education; Implementation of AI applications to enhance health and wellbeing of the healthcare workforce. (2) How AI technologies enhance compassion (10 themes) Empathetic awareness; Empathetic response and relational behavior; Communication skills; Health coaching; Therapeutic interventions; Moral development learning; Clinical knowledge and clinical assessment; Healthcare quality assessment; Therapeutic bond and therapeutic alliance; Providing health information and advice. (3) Gaps in knowledge (4 themes) Educational effectiveness of AI-assisted learning; Patient diversity and AI technologies; Implementation of AI technologies in education and practice settings; Safety and clinical effectiveness of AI technologies. (4) Key areas for development (3 themes) Enriching education, learning and clinical practice; Extending healing spaces; Enhancing healing relationships. Conclusion There is an association between AI technologies and compassion in healthcare and interest in this association has grown internationally over the last decade. In a range of healthcare contexts, AI technologies are being used to enhance empathetic awareness; empathetic response and relational behavior; communication skills; health coaching; therapeutic interventions; moral development learning; clinical knowledge and clinical assessment; healthcare quality assessment; therapeutic bond and therapeutic alliance; and to provide health information and advice. The findings inform a reconceptualization of compassion as a human-AI system of intelligent caring comprising six elements: (1) Awareness of suffering (e.g., pain, distress, risk, disadvantage); (2) Understanding the suffering (significance, context, rights, responsibilities etc.); (3) Connecting with the suffering (e.g., verbal, physical, signs and symbols); (4) Making a judgment about the suffering (the need to act); (5) Responding with an intention to alleviate the suffering; (6) Attention to the effect and outcomes of the response. These elements can operate at an individual (human or machine) and collective systems level (healthcare organizations or systems) as a cyclical system to alleviate different types of suffering. New and novel approaches to human-AI intelligent caring could enrich education, learning, and clinical practice; extend healing spaces; and enhance healing relationships. Implications In a complex adaptive system such as healthcare, human-AI intelligent caring will need to be implemented, not as an ideology, but through strategic choices, incentives, regulation, professional education, and training, as well as through joined up thinking about human-AI intelligent caring. Research funders can encourage research and development into the topic of AI technologies and compassion as a system of human-AI intelligent caring. Educators, technologists, and health professionals can inform themselves about the system of human-AI intelligent caring.
... On the basis of administrators' feedback, we created user journey maps of their current workflow and a proposed workflow including MyCog Mobile. User journey maps are visual models of complex processes and interactions that can be used to represent health care services from the perspective of different stakeholders [55]. We focused on the broad tasks and interactions necessary for multiple users (patients, support staff, and clinicians) to complete a cognitive screening in a primary care setting. ...
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Background Annual cognitive screening in adults aged >65 years can improve early detection of cognitive impairment, yet less than half of all cases are identified in primary care. Time constraints in primary care settings present a major barrier to routine screening. A remote cognitive screener completed on a patient’s own smartphone before a visit has the potential to save primary care clinics time, encourage broader screening practices, and increase early detection of cognitive decline. Objective We described the iterative design and proposed the implementation of a remote cognitive screening app, MyCog Mobile, to be completed on a patient’s smartphone before an annual wellness visit. The research questions were as follows: What would motivate primary care clinicians and clinic administrators to implement a remote cognitive screening process? How might we design a remote cognitive screener to fit well with existing primary care workflows? What would motivate an older adult patient to complete a cognitive screener on a smartphone before a primary care visit? How might we optimize the user experience of completing a remote cognitive screener on a smartphone for older adults? Methods To address research questions 1 and 2, we conducted individual interviews with clinicians (n=5) and clinic administrators (n=3). We also collaborated with clinic administrators to create user journey maps of their existing and proposed MyCog Mobile workflows. To address research questions 3 and 4, we conducted individual semistructured interviews with cognitively healthy older adults (n=5) and solicited feedback from a community stakeholder panel (n=11). We also tested and refined high-fidelity prototypes of the MyCog Mobile app with the older adult interview participants, who rated the usability on the Simplified System Usability Scale and After-Scenario Questionnaire. Results Clinicians and clinic administrators were motivated to adopt a remote cognitive screening process if it saved time in their workflows. Findings from interviews and user journey mapping informed the proposed implementation and core functionality of MyCog Mobile. Older adult participants were motivated to complete cognitive screeners to ensure that they were cognitively healthy and saw additional benefits to remote screening, such as saving time during their visit and privacy. Older adults also identified potential challenges to remote smartphone screening, which informed the user experience design of the MyCog Mobile app. The average rating across prototype versions was 91 (SD 5.18) on the Simplified System Usability Scale and 6.13 (SD 8.40) on the After-Scenario Questionnaire, indicating above-average usability. Conclusions Through an iterative, human-centered design process, we developed a viable remote cognitive screening app and proposed an implementation strategy for primary care settings that was optimized for multiple stakeholders. The next steps include validating the cognitive screener in clinical and healthy populations and piloting the finalized app in a community primary care clinic.
... The reasons for undertaking patient journey mapping vary and have included improving the quality of care provided through understanding patient experiences with greater detail; better understanding the relationship that develops dynamically between patients and service organizations, and exploring the lived experiences of people from stigmatized or disadvantaged populations who may have additional challenges or barriers to accessing and remaining in contact with health services (Bearnot & Mitton, 2020;Lawrence et al., 2021;McCarthy et al., 2020;Richardson et al., 2007). ...
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Aim To identify how patient journey mapping is being undertaken and reported. Design A scoping review of the literature was undertaken using JBI guidance. Data Sources Databases were searched in July 2021 (16th–21st), including Ovid's Medline, Embase, Emcare and PsycINFO; Scopus; Web of Science Core Collection, the Directory of Open Access Journals; Informit and; ProQuest Dissertations and Theses Global. Review Methods Eligible articles included peer‐reviewed literature documenting journey mapping methodologies and studies conducted in healthcare services. Reviewers used Covidence to screen titles and abstracts of located sources, and to screen full‐text articles. A table was used to extract data and synthesize results. Results Eighty‐one articles were included. An acceleration of patient journey mapping research was observed, with 76.5% (n = 62) of articles published since 2015. Diverse mapping approaches were identified. Reporting of studies was inconsistent and largely non‐adherent with relevant, established reporting guidelines. Conclusion Patient journey mapping is a relatively novel approach for understanding patient experiences and is increasingly being adopted. There is variation in process details reported. Considerations for improving reporting standards are provided. Impact Patient journey mapping is a rapidly growing approach for better understanding how people enter, experience and exit health services. This type of methodology has significant potential to inform new, patient centred models of care and facilitate clinicians, patients and health professionals to better understand gaps and strategies in health services. The synthesised results of this review alert researchers to options available for journey mapping research and provide preliminary guidance for elevating reporting quality.
... Evolved from the field of service design, the method of journey mapping provides pictorial illustrations of the experience in complex processes or interactions from an individual's perspective regarding their relationship with surrounding organizations and services [39][40][41]. We modified journey mapping to develop the behavior mapping method to reflect the critical touchpoints when an individual interacts with surrounding organizations and services. ...
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Background Among rural Chinese patients with non-communicable diseases (NCDs), low socioeconomic status increases the risk of developing NCDs and associated financial burdens in paying for medicines and treatments. Despite the chronic disease medicine reimbursement policy of the local government in Nantong City, China, various barriers prevent patients from registering for and benefitting from the policy. This study aims to develop a behavior science-based intervention program for promoting the adoption of the policy and to evaluate the effectiveness of the program compared with usual practices. Methods Barriers and opportunities affecting stakeholders in adopting the policy were identified through contextual research and summarized through behavior mapping. The intervention is designed to target these barriers and opportunities through behavior science theories and will be evaluated through a 6-month cluster randomized controlled trial in Tongzhou District, Nantong, China. A total of 30 villages from two townships are randomized in a 1:1 ratio to either the intervention or the control arm (usual practices). Village doctors in the intervention arm (1) receive systematic training on policy details, registration procedures, and intervention protocol, (2) promote the policy and encourage registration, (3) follow up with patients in the first, third, and sixth months after the intervention, and (4) receive financial incentives based on performance. The primary outcome is policy registration rate and the secondary outcomes include the number of patients registering for the policy, medical costs saved, frequency of village doctor visits, and health measures such as blood pressure and glucose levels. Discussion This study is one of very few that aims to promote adoption of NCDs outpatient medication reimbursement policies, and the first study to evaluate the impact of these policies on patients’ financial and physical wellbeing in China. The simple, feasible, and scalable intervention is designed based on the theories of behavior science and is applicable to similar low-income regions nationwide where outpatient medical costs remain a financial burden for patients. Trial registration ClinicalTrials.gov, registered on 29 January 2021; Chinese Clinical Trial Registry, registered on 14 January 14 2021.
... On the other hand, there is also a technical challenge that must be met head on to assemble the multi-disciplinary teams that are required to properly specify and develop the applications that will realise the potential of connected health. Technologists, application developers, cloud services providers, medical experts, insurance providers, policymakers, parliamentarians and also of course, patients, will need to come together and undertake the vast Technology Assessment exercise that must underpin a rigorous and harmonious evolution from the current healthcare systems of the world to a global connected architecture to look after everyone equitably (McCarthy et al, 2016(McCarthy et al, , 2019. ...
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This paper explores the potential of connected health solutions to solve the problems currently facing healthcare systems around the world with a particular interest in their decision support capabilities. Leveraging three selected projects in which we have been involved in the area of maternal and child health, the paper proposes a blueprint for connected health decisions in a variety of settings, namely: home-based, community-based, ward-based scenarios as well as the specific scenario of low-income countries. This blueprint can be used to frame discussions on connected health solutions and discuss their decision support potential.
... McCarthy et al. (2020) proposed a hybrid personalized learning model based on advantages and monitored the implementation within four years. They found that advantage-based learning could identify and enhance students' strengths [19]. McNair et al. (2020) pushed personalized learning resources to students through digital textbooks, which effectively solved the solidification of learning content and rigid learning pace in a collaborative learning environment. ...
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The present work aims to construct knowledge systems of different specialties, provide personalized learning approaches for students, improve the teaching effectiveness of teachers and learning interests of students, and help students accurately diagnose their learning problems. First, the existing issues of students’ chemistry learning and knowledge systems are analyzed. Then, a personalized learning model is constructed based on the distributed computing method of the Internet of Things (IoT) and the clustering algorithm of deep learning (DL). This model realizes the effective classification of students by the DL algorithm according to the students’ learning data and designs diverse customized teaching contents in line with the performance of IoT. Finally, this model’s effectiveness is verified through the data analysis of 2019 chemistry students at M University. The research results indicate that 96.67% of students express satisfaction with the learning effect of the personalized learning model, and 100% of learners are satisfied with the various forms of teaching resources offered by this model. Besides, this model’s accuracy can reach 85% on the personalized learning platform based on IoT and DL algorithms. Compared with the latest research model, this model has a better performance in achievement prediction and customized recommendation. The test results of the actual effect demonstrate that the personalized learning system has achieved expected outcomes, significantly enhancing students’ understanding of knowledge with medium difficulty. In addition, learners are delighted with the model. They believe that the learning resources in the model can meet their learning needs, and they are willing to recommend the course to other learners actively. This model is of significant practical value to promote the development of IoT and DL technology in professional learning. This exploration innovatively stratifies learners’ level of understanding and provides personalized learning resources meeting the current cognitive competence of students to enhance learners’ knowledge and achieve personalized learning.
... In unsupervised learning, the data is labelless like most data in the real world. Hence, the unsupervised learning algorithm is particularly useful [20]. Unsupervised learning methods are divided into two categories: (1) one is a direct method based on the probability density function estimation: trying to find the distribution parameters in the feature space and classifying them. ...
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With people’s pursuit of music art, a large number of singers began to analyze the trend of music in the future and create music works. Firstly, this study introduces the theory of music pop trend analysis, big data mining technology, and related algorithms. Then, the autoregressive integrated moving (ARIM), random forest, and long-term and short-term memory (LSTM) algorithms are used to establish the image analysis and prediction model, analyze the music data, and predict the music trend. The test results of the three models show that when the singer’s songs are analyzed from three aspects: collection, download, and playback times, the LSTM model can predict well the playback times. However, the LSTM model also has some defects. For example, the model cannot accurately predict some songs with large data fluctuations. At the same time, there is no big data gap between the playback times predicted by the ARIM model image analysis and the actual playback times, showing the allowable error fluctuation range. A comprehensive analysis shows that compared with the ARIM algorithm and random forest algorithm, the LSTM algorithm can predict the music trend more accurately. The research results will help many singers create songs according to the current and future music trends and will also make traditional music creation more information-based and modern.
The simulated patient method is becoming an increasingly popular observational method to measure practice behavior in pharmacy practice and health services research. The simulated patient method involves sending a trained individual (simulated patient among other names), who is indistinguishable from a regular consumer, into a healthcare setting with a standardized scripted request. This method has come to be accepted as being well-suited for observing practice in the naturalistic setting and has also been used as an intervention when combined with feedback and coaching. This chapter presents an overview of the method, a brief history of its use, considerations for designing, implementing, and evaluating simulated patient studies, including ethical considerations, as well as methods of analysis and mixed-methods designs.
This chapter explores how pharmacy and health services researchers can use methods usually applied in the field of human-centered design as a complementary approach in their work. Human-centered design methods are increasingly being used by researchers as a complementary approach to address complex health challenges that have been difficult to resolve with traditional health services research methods alone. These methods can bring disciplines and perspectives together to unlock new ideas and opportunities. Human-centered design methods can be applied to the development of analog and digital patient experiences, health services, health messages, products and devices, processes, and physical environments. The overall aim of this chapter is to provide an introduction to human-centered design and its application in health research. Key literature and methods are highlighted to help readers identify opportunities for human-centered design within their own research and practice. The benefits and challenges of using these methods alongside conventional health services research methods are also discussed.
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Policymakers, academics, and industry players have been focused on determining whether connected health (CH) is a fad or a trend by looking at its sustainability. Although the significance of innovation in healthcare is gradually rising, a definitive identification and systematic comprehension of the core drivers, structure, content, and pattern of innovation in CH are missing. To bridge this gap, this study re-examines and analyses CH from the perspectives of its industrial chain and structure, to assess its future prospects and sustainability by focusing on how its structures and participants act in the ecosystem. This study involves an inductive theory building approach based on multi-stage, semi-structured interviews (n = 60 in total). The results indicate that the core drivers, constituents, and components of CH need to be identified and restructured. A valid discourse, which is missing in the current literature, should be proposed with regard to the sustainability of CH. A sustainable business model innovation (BMI) system and the methods employed to achieve sustainability are suggested to discover indicators for future success. This study enriches the current CH understanding from a technology perspective and suggests some implications for practitioners as well as policymakers to enhance sustainable development in the healthcare sector.
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This pilot study investigated factors influencing the application of connected health (CH) in Taiwanese remote areas. These factors cover issues of cost, infrastructure, technology, business sustainability, business model, collaboration, and communication. It aimed to explore the significance and to assess the feasibility of researching CH in Taiwan. A qualitative exploratory study was conducted by interviewing relevant stakeholders (n = 18). The majority were healthcare providers as most of them are the CH end users. Their feedback was essential in reflecting the effectiveness of CH products and services. Therefore, understanding their views is significant in the design of a successful and user-friendly interactive system. A theoretical framework on the introduction of innovations in healthcare was employed to guide data collection and thematic analysis. Additionally, stakeholders proposed strategies for enhancing the implementation of CH in remote areas. This pilot study also contributed to identifying future directions and information for conducting the multi-stage interviews for collecting the data more effectively. Although the results reveal that the study of CH is meaningful, there is an issue of business sustainability which is obscured by some barriers that need to be addressed. These barriers will be further investigated in the first-stage interview and second-stage interview in future research. The research findings also suggest that strategies and sustainability for CH implementation should be included from the planning phase to benefit all the stakeholders in the CH ecosystem.
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Background: This paper examines the development of the Connected Health research landscape with a view on providing a historical perspective on existing Connected Health research. Connected Health has become a rapidly growing research field as our healthcare system is facing pressured to become more proactive and patient centred. Objective: We aimed to identify the extent and coverage of the current body of knowledge in Connected Health. With this, we want to identify which topics have drawn the attention of Connected health researchers, and if there are gaps or interdisciplinary opportunities for further research. Methods: We used a systematic mapping study that combines scientific contributions from research on medicine, business, computer science and engineering. We analyse the papers with seven classification criteria, publication source, publication year, research types, empirical types, contribution types research topic and the condition studied in the paper. Results: Altogether, our search resulted in 208 papers which were analysed by a multidisciplinary group of researchers. Our results indicate a slow start for Connected Health research but a more recent steady upswing since 2013. The majority of papers proposed healthcare solutions (37%) or evaluated Connected Health approaches (23%). Case studies (28%) and experiments (26%) were the most popular forms of scientific validation employed. Diabetes, cancer, multiple sclerosis, and heart conditions are among the most prevalent conditions studied. Conclusions: We conclude that Connected Health research seems to be an established field of research, which has been growing strongly during the last five years. There seems to be more focus on technology driven research with a strong contribution from medicine, but business aspects of Connected health are not as much studied.
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In recent years, we have witnessed an increasing trend towards the conduct of Information Systems Development (ISD) projects in distributed environments, whereby ISD team members are geographically, spatially and organizationally dispersed. This has been driven by the desire of organizations to expand their pool of development resources and to gain access to diverse sources of expertise, irrespective of location or organizational affiliation. While these benefits are impressive, the conduct of distributed ISD projects is far from a routine undertaking. This is reflected more broadly in the high rate of ISD project failure recorded across different industry sectors and organizational settings over the past twenty years. In particular, the effectiveness of distributed ISD teams is often inhibited by deep seated social and task-related differences between team members. For instance, distributed ISD project team members typically come from diverse backgrounds which can create social challenges around the alignment of structures, identities, and cultures, as well as task-based challenges related to the delivery of project outcomes. In light of these challenges, literature suggests that cohesion is a key determinant of team performance. However, a competing set of literature asserts that conflict is essential for exploiting diverse knowledge. These contrasting bodies of literature highlight an opportunity to explore the factors which affect the tension between both cohesion and conflict in distributed ISD projects and the impact these have on team performance. The dissertation therefore seeks to explore how cohesion and conflict co-exist and co-evolve through distributed ISD project team interactions, and how this impacts team performance. The dissertation presents a within-case and cross-case analysis of three distributed ISD projects. Each in-depth case study is characterised by inherent aspects of complexity or ‘wickedness’ which created unique challenges around the need for both cohesion and conflict. For instance, the distributed ISD projects were undertaken in emergent areas (i.e. connected health), and the team members in each case had not worked together before. In order to explore this emerging research area, theory building is undertaken by the researcher to describe and explain the factors which affect cohesion and conflict in distributed ISD project team interactions. The theoretical framework co-evolved through empirical insights from the in-depth case studies as well as logical propositions from seminal literature. Discussions of case study findings are structured according to the concepts developed in the theoretical framework, as well as their underlying relationships. These emergent theoretical insights are also used to guide discussions around both team performance and distributed ISD project team leadership later in the dissertation. The dissertation presents a number of unique contributions. Firstly, the dissertation develops a novel theoretical framework for describing and explaining how the interplay between different factors shape team interactions in distributed ISD projects. This contribution can help deepen scholars’ understanding of the complex and dynamic nature of team interactions in distributed ISD projects. Secondly, the dissertation contributes insights into how shared understanding and shared commitment among the team can be affected by these factors. In particular, findings presented from the in-depth case studies suggest that shared understanding and shared commitment may evolve in ways which are often unexpected. Thirdly, novel contributions are made by considering the relationship between cohesion, conflict and team performance. For instance, findings from the cross-case analysis suggests that cohesion and conflict are both needed to maximise team performance in distributed ISD projects. In particular, findings suggest that cohesion and conflict are appropriate for realising different perspectives of ISD project team performance. Lastly, the dissertation contributes insights into how team leaders can respond to social and task-based factors in distributed ISD projects. The dissertation puts forward a new style of team leadership called ‘agitation’. This theoretical contribution expands on existing literature by considering how team leaders embed constructive conflict into team member interactions in order to challenge social and task-related differences. Finally, the dissertation puts forward the concept of ‘leadership intelligence’ to contribute insights into how leaders can develop the sensitivity to know when to promote and suppress different leadership styles over the course of a project, and indeed even during an individual interaction. The structure of the dissertation is as follows: Chapter 1 provides a high-level introduction to the dissertation and sets out the structure of the remaining chapters as well as how they relate to each other. Chapter 2 presents a review of existing literature across the key areas of study and identifies areas which the dissertation will aim to investigate. Chapter 3 then outlines the first stage of theoretical development undertaken by the researcher which uses logical propositions from literature to investigate the relationship between concepts. Meanwhile, Chapter 4 presents an overview of the paradigm choice, research method, research strategy, and research process. Chapters 5-8 then investigate each research question in turn based on in-depth case study findings from three distributed ISD projects. Each case study is used to support theory building through empirical insights from a within-case analysis. Chapter 9 then provides a cross-case analysis of the research questions drawing on further empirical insights from across the three in-depth case studies. Chapter 10 draws the dissertation to a close with a conclusion.
Conference Paper
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Agile distributed Information Systems Development (ISD) is an innately social process in which distributed team members must continuously interact to develop new IT solutions. Existing literature suggests that shared understanding and shared commitment are essential for the effective functioning of agile distributed ISD project teams; however, the factors that shape the emergence of these two phenomena remain elusive. In this paper, we seek to develop a framework for investigating the interplay of factors that shape shared understanding and shared commitment during agile distributed ISD project team interactions. We draw on in-depth case study findings from an agile distributed ISD project called the "CHP project" which involved team members from diverse backgrounds such as academia, healthcare, and industry. The study reveals that shared understanding and shared commitment in agile distributed project teams are shaped by the dynamic interplay between macro-level (contextual) and micro-level (localised) factors. In particular, we find that diverse macro-level structures, identities, and cultures interplay with the micro-level vision, approach, and means of the project to impact shared understanding and shared commitment. Empirical findings also suggest that the absence of shared understanding and shared commitment can sometimes be constructive as conflict allows team members to air differences of opinion.
Conference Paper
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The field of Connected Health (CH) has emerged in response to growing demands for improved connectivity to deliver patient-centred care through innovative healthcare management systems. As a result, there is a growing need to develop new healthcare delivery models and new ways of thinking about how information and communication technology can support healthcare delivery. This paper examines the role of software engineering in CH and presents the CH Delivery Framework as a first step to encapsulate key factors software engineers need to consider.
Conference Paper
Distributed ISD projects are often typified by deep-seated differences between team members from diverse organizational and professional backgrounds. Consequently, literature suggests that cohesion is crucial for aligning the efforts of a distributed ISD team; however, a competing body of literature also asserts that conflict is essential for capitalizing on diverse knowledge flows. Team leaders can therefore face a conundrum around how to balance the paradoxical need for both cohesion and conflict. In this paper, we develop a theoretical framework to analyze case study findings from the ‘CDSS project’, a distributed ISD project undertaken in an Intensive Care Unit (ICU). We find evidence that distributed ISD leaders must adopt a ‘paradox mindset’, one which embraces both cohesion and conflict. Based on these findings, we also put forward the concept of ‘leadership intelligence’ which describes the simultaneous enactment of a diverse set of leadership styles for balancing constructive cohesion and conflict.
Under current law, national health spending is projected to grow 5.5 percent annually on average in 2017-26 and to represent 19.7 percent of the economy in 2026. Projected national health spending and enrollment growth over the next decade is largely driven by fundamental economic and demographic factors: changes in projected income growth, increases in prices for medical goods and services, and enrollment shifts from private health insurance to Medicare that are related to the aging of the population. The recent enactment of tax legislation that eliminated the individual mandate is expected to result in only a small reduction to insurance coverage trends.
This paper explores what the barriers and enablers are for the creation of shared understanding during a co-design process in industry. Knowing the barriers and enablers provides knowledge about how actors within a collaborative design project deal with their mutual differences. This is important since it influences both the effectiveness and quality of the design process. In order to provide more insight in the nature of the barriers and enablers, they are categorized in two different ways. First, we distinguished three organizational levels: the actor, project and company level. Second, the barriers and enablers were clustered according to their content. The results show that the clusters of barriers and enablers all concerned a different type of interface. Within each interface barriers and enablers on the three different organizational levels exist. This means that the effectiveness of creating shared understanding is not only dependent on face-to-face communication, but also on project management and project organization.
Introduction LEANBH (Learning to Evaluate and manage ANtenatal Blood pressure at Home) is a prospective, observational, non-interventional cohort, pilot study of a novel connected health solution aimed at empowering women to self-manage blood pressure (BP) monitoring in pregnancy. Hypertension in pregnancy affects around 5–8% of all pregnancies and misdiagnosis or poorly managed BP in pregnancy negatively affects maternal and neonatal outcomes. Objectives The primary objective of this study was to assess the feasibility and acceptability of home blood pressure monitoring (HBPM) and to compare these BP readings taken at home using the LEANBH architecture to those taken in healthcare settings (hospital and general practice). Patients, materials and methods Healthy primigravida with low risk singleton pregnancies were recruited from Cork University Maternity Hospital, Ireland. Women were equipped with a Microlife WatchBP Home Monitor, an Urisys 1100® Urine Analyzer and the mobile app developed for use throughout pregnancy as part of the Leanbh project. Participants were encouraged to submit BP and urine readings from home as frequently as possible and especially prior to an antenatal visit. All women attended their planned healthcare visits as usual. Mean arterial pressure (MAP) was calculated from the BP readings uploaded to a LEANBH platform throughout pregnancy and analysed using SPSS version 2.0 Mann–Whitney test. Results 51 women volunteered with 46 of them completing the study. 27 women were equipped with the devices with 5 subsequently withdrawing from this group while 24 women were recruited into the control group. A total of 1381 home BP readings and 983 healthcare setting BP readings were recorded with 972 paired (home vs healthcare setting) MAP available for analysis. The Mann–Whitney test performed showed statistical significance between the home vs healthcare setting MAP with a P value <0.05. A user error rate of 3.8% was noted among the HBPM group. Conclusion BP taken at home was significantly lower than that taken in a health care setting, suggesting that the incidence of white coat hypertension in this cohort is under reported. The low error rate suggests that HPBM is easy to use. A large randomized control trial is planned to fully evaluate the utility of this technology solution.