Realistic clinical examples play a major role in establishing requirements, and use cases, and we have developed and implemented several detailed scenarios during the project. A scenario in neurosurgery provided us with use cases in risk assessment and multidisciplinary service provision; one in orthopaedics allowed us to study decision-making in post-operative anti-coagulation and monitoring of quality of life and adverse events of patients at home. These and other use cases have been included in the main scenario which covers initial assessment, diagnosis, treatment and home-based follow-up of breast cancer patients. An illustrative fragment of the scenario follows.
Jane Smith, a 50 year old pre-menopausal lady is invited for routine breast cancer screening at her local screening centre. The centre computer selects the standard NHS Breast Screening Programme decision support and workflow pathway, though for some patients it may suggest a more restricted Royal College of Radiologists pathway which is preferred in some cases. Following mammography the images are uploaded to the screening service PACS, and a review request is sent to the radiological screening section. A specialist radiographer identifies a worrying feature which is corroborated by the NHSBSP decision support software which also flags a suspicious clinical and family history. JS is urgently referred to the breast cancer clinic at the local acute NHS trust where she is registered on the breast cancer assessment pathway and additional imaging and biopsy decisions are recommended by the decision support functions integrated into the Trust workflow management service. One week later Jane is seen by a consultant oncologist who confirms the presence of a small cancer and advises her of her treatment options and points her to NHS information and support services available to patients.
At home Jane and her partner visit the NHS Choices and HealthTalkOnline web sites, but a personal digital assistant also broadcasts a request for other relevant services, and gets responses offering quality of life and decision support services from a patient support charity, opportunities to participate in a current clinical trial by Cancer Research UK, and a commercial “patient diary” product which offers dietary and other personalised guidance to breast cancer patients during treatment and follow-up. Jane is subsequently admitted for treatment and is offered post-surgical tamoxifen for five years by her care team. She reviews the personalised pros and cons for this on the charity web site and decides to accept. She registers for the diary service which with her consent activates quality of life and monitoring services from other service providers as well. As well as capturing data for ongoing assessment and pharmaco-vigilance research the diary can, when appropriate, automatically alert Jane’s care team that pro-active contact with a patient may be desirable.
The scenario covers challenging use cases in which clinical, research and patient support services are distributed in time and space but need to be flexibly accessed and seamlessly coordinated in a patient-centred way.
The Safe and Sound service delivery platform exploits PROforma and LCC technologies (respectively OpenClinical and Open Knowledge software) to provide a range of options for controlling service delivery. At one extreme the services are managed entirely centrally (the orchestration model); at the other extreme an open peer to peer service model can be used (choreography); mixtures of the two can also be configured.
Details of the case study scenario can be found here