Transactions of the SDPS:

Journal of Integrated Design and Process Science

20 (1), 2016, 7-32

DOI 10.3233/jid-2016-0001

http://www.sdpsnet.org

1092-0617/€27.50© 2016 – Society for Design and Process Science. All rights reserved. Published by IOS Press

Designing the Right Framework for Healthcare

Decision Support

Varadraj P. Gurupur a and Ronaldo Gutierrez

b

a Health Management and Informatics, University of Central Florida, Orlando, FL, USA

b Concordia Institute for Information Systems Engineering, Concordia University, Montreal, Quebec,

Canada

Abstract Many factors need to be taken into consideration while developing a decision support system for healthcare.

This mainly involves: a) adherence to statutory regulations, b) ease of use and access, and c) protecting patient data

from malicious use. Some of these requirements are intertwined creating a myriad of complexities. This leads to a

substantial increase in the level of complexity involved in designing and developing the decision support system. In

this paper we attempt to address some of these complexities to the reader and present a framework for a solutio n that

could be modified if required to deal with these aforementioned complexities.

Keywords: Environment-based design, framework, healthcare decision support, statutory regulation, patient data

1. Introduction

Today it is extremely important to study healthcare delivery infrastructure due to the increasingly

changing atmosphere of healthcare delivery in the United States. With the introduction of the Affordable

Care Act (Koh & Sebelius, 2010) and HITECH (Blumenthal, 2009), it has become increasingly important

for healthcare providers to adopt a healthcare delivery system that is not only affordable but also that

satisfies the criteria of meaningful use. While attempting to satisfy the aforementioned criteria physicians

also have to be mindful of financial return of investment and to balance usability and security of the

healthcare systems (Zhang & Liu, 2010).

Kovner, Knickman, Weisfeld, and Jonas (2011) have outlined the needs of a healthcare delivery system

in the United States. However, the authors feel that there is a need to perceive healthcare from a more global

perspective. In a more detailed literature Reid, Compton, Grossman, and Fanjiang (National Academy of

Engineering & Institute of Medicine, 2005) describe the engineering aspects of health care delivery

systems. The following features play a major role in a healthcare delivery system: a) protecting privacy and

security, b) satisfying the criteria of meaningful use, c) interoperability with other healthcare delivery

systems, d) incorporating necessary decision support systems and providing the necessary infrastructure to

allow the growth of a knowledge base that provides the necessary reasoning to provide decision support,

and e) ability to interact with the insurance providers to receive the necessary financial support, which

includes generation of the ICD 10 codes based on diagnosis and procedures. Some of the criteria for

evaluating the effectiveness and efficiency of healthcare decision support can be listed as follows: a)

accuracy of the healthcare decision, b) strength of the knowledge base of the expert system used for

 Corresponding author. Email: [email protected]

8 Gurupur & Gutierrez / Designing the Right Framework for Healthcare Decision Support

healthcare decision support (Hempelmann, Sakoglu, Gurupur, & Jampana, 2016), and c) usability of the

decision support system from a user’s perspective. The authors have discussed this topic in more detail in

Section 2.2.6. With the described features and criteria in mind, the necessary components of the healthcare

delivery system would be: i) patient interaction, ii) administrative processing, iii) knowledge base and

decision support, iv) XML generators and communication systems to interact with other healthcare delivery

systems.

While it is fairly straightforward to choose the components of healthcare delivery, identifying

components of healthcare decisions is a complex process. The complexity is mainly due to the fact that

requirements for healthcare decision support differs based on several factors such as: a) existing statutory

regulations, b) environment of healthcare delivery, c) needs of the patients and caregivers based on

demographics, level of education, geographic locations, methods used for communicating with the patients

which includes use of telemedicine, remote monitoring, and other such healthcare delivery systems.

However, based on the existing literature it may be a good idea to suggest that the necessary elements of

healthcare decisions are as follows: a) caregiver decisions, b) diagnostic decisions, c) choosing the right

healthcare provider, d) biomedical decisions for laboratories, radiology centers, and other such facilities,

and e) administrative decision support for non-clinical personnel. The need for the aforementioned

healthcare decisions is mainly due to the following prevailing circumstances: a) need for the reduction in

time associated with patient care, b) ease of access to individual healthcare data, and c) complexities

emerging from statutory regulations takes a toll on the administrative processes.

The purpose of designing the right framework is to provide a rostrum for the development of decision

support systems for healthcare. One of the key factors that challenge the development of the right decision

support system is assessing the critical need of decision support for that particular healthcare facility. The

critical need could be administrative, financial, patient support, or reduction in time. The first step towards

developing the right decision support would be identifying the critical need for developing the decision

support mechanism. Once this need has been identified, the software designers and architects would then

investigate their time and efforts in developing the right design and architecture to satisfy that critical need.

Here the framework can play a pivotal role in aiding the software architects and designers in completing

their tasks.

The development of an effective framework involves a) covering all the areas of the critical need, b)

developing a structure of the knowledge base that can be rapidly expanded as needed, c) developing an

easily modifiable structure for modules that can be used in analysis of data received and knowledge

extracted from the knowledge base. This means that the framework must first assess the broad spectrum of

the needs, incorporate easily modifiable structures, and allow scalability of knowledge.

2. Related Work

The related work is introduced using four views. The first view in Section 2.1 represents the international

level including literature from the World Health Organization (WHO), the Organization for Economic Co-

operation and Development (OECD), and the US and Canada healthcare systems. The second view in

Section 2.2 considers healthcare decisions in the general context defined in the first view. The third view

in Section 2.3 defines healthcare decision support from an information technology’s perspective. The fourth

view in Section 2.4 introduces information technology’s frameworks that have been published in the

literature. As the views from Section 2.1 to Section 2.4 represent healthcare from different perspectives,

they have overlapping components.

2.1. Healthcare

Different organizations have attempted to define healthcare and its components. These organizations are

at different levels such as global (World Health Organization), specific countries’ organizations

(Organisation for Economic Co-operation and Development), nationwide (e.g., USA and Canada), regional

(states or provinces) and more micro levels (hospitals, clinics or home care).

Gurupur & Gutierrez / Designing the Right Framework for Healthcare Decision Support 9

The WHO (World Health Organization, 2013, p. xi) relates the world health to health coverage. The

WHO defines health coverage in terms of provision and access to high-quality health services, and financial

risk protection for people who need to use the services and overall society. In addition, health services

include methods for promotion, prevention, treatment, rehabilitation and palliation, encompassing health

care in communities, health centers and hospitals. Health services also mean taking action on social and

environmental determinants both within and beyond the health sector. Besides these components to define

healthcare, other important components are input and processes, outputs, outcomes, impact, social

determinants, and quantity, quality and equity of services. The World Health Organization (2013, p. 9)

defines inputs and processes such as health financing, health workforce, medicines, health products and

infrastructure, information and governance and legislation. The organization suggests outputs such as

service access and readiness (including medicines), service quality and safety, service utilization, financial

resources pooled, and crisis readiness. The defined outcomes are coverage of intervention, financial risk

protection and risk factor mitigation. The impact includes improved health status, improved financial well-

being, increased responsiveness, and increased health security. Based on the description of the WHO, there

is a sequential linear interaction between input and processes, outputs, outcomes and impact. The WHO

also suggests that the components interact during the sequence with quantity, quality and equity of services

and social determinants. Besides the previous framework, the World Health Organization (2013, p. 15) also

discusses a framework for measuring and monitoring the coverage of health services.

The Organization for Economic Co-operation and Development (OECD, 2015a, p. 13) defines health

using indicators of health status and health systems, where the goal of the latter is to improve the health

status of the population. The OECD (2015a, p. 13) uses a framework to assess the performance of health

systems including the main components such as demographic and economic context, and health expenditure

and financing, health care resources and activities (i.e., health workforce and health care activities), health

care system performance (i.e., quality of care, access to care, and health expenditure and financing), non-

medical determinants of health and health status. Between the components, the OECD indicates sequential

actions and feedback loops. The framework is based on the OECD Health Care Quality Indicators project

(Arah, Westert, Hurst, & Klazinga, 2006; Kelley & Hurst, 2006). As each country in the OECD has its own

regulations, but similar human needs, the scope in this paper is narrow down to the US and Canada for

practical purposes. Other international frameworks are discussed by The European Observatory on Health

Systems and Policies (2013).

The US Department of Health & Human Services defines healthcare in accordance with its strategic

plan (U.S. Department of Health & Human Services, 2016c), the Affordable Care Act (U.S. Department of

Health & Human Services, 2016a), the US National Healthcare Quality and Disparities reports (Agency for

Healthcare Research and Quality, 2015a, 2015b), and others ("Healthcare Research and Quality Act of

1999," 1999). Using these documents as bounding terms, the US Department of Health & Human Services

defines healthcare according to access to care (primary and preventive), access to information and data,

scientific knowledge, research networks, people (patients, consumers, providers, purchasers, practitioners,

policy makers, general authorities and educators), social security, private-public partnerships, health

insurance more affordable, technologies (e.g., information systems), facilities, equipment, methods, best

practices, healthcare outcomes, cost, utilization, and quality (safety, effectiveness, efficiency, and

competency) among others. A conceptual drawing of a four-level health care system by the National

Academy of Engineering and Institute of Medicine (2005, p. 20) in the US illustrates the environment,

organization, care team and patient’s categories; where each of them interact with the rest. The classification

includes the following components for each level. The environment is conformed of regulatory, market,

and policy framework including stakeholders such as public and private regulators, insurers, health care

purchasers, research funders, and others. The organization comprises infrastructure and resources referring

to hospitals, clinics, nursing, homes, etc.; where logically each of these entities has its own stakeholders.

The care team means frontline care providers including stakeholders such as health care professionals,

family members, and others. The patient is the person being served. The Institute of Medicine (2015c, p.

102) also illustrates the main components of healthcare and their interactions from the perspective of core

measures as levers for enhancing the impacts of the key determinant of health. The main categories in the

10 Gurupur & Gutierrez / Designing the Right Framework for Healthcare Decision Support

model are the determining factors, policies and programs, core measure set, strategic action and accelerated

results. Each of these categories has its own subcomponents that also interact with the subcomponents of

the other categories.

Although Canada and the US do not share the position of universal access policy in their respective

healthcare systems1, these countries have shared cultural and economic spheres, and common history of

medical care delivery (Maioni, 2015, pp. 61-77; Nadeau, Soroka, Maioni, Bélanger, & Pétry, 2015). Along

this stream, the health care systems in Canada is framed by the Canada Health Act (Health Canada, 2010a,

2012a). The act defines healthcare using the main terms such as Government of Canada, provinces,

Canadians and its well-being, health services, sickness, diseases, income groups, social, environmental and

occupational causes of disease, cooperative partnership of governments, health professionals, voluntary

organizations, and individual Canadians, continued access to quality health care without financial or other

barriers, Canada transfer health (cash contribution), extended health care services (i.e., nursing home

intermediate care services, adult residential care services, home care services, and ambulatory care

services), extra-billing, health care insurance plan, law of the province, hospitals, hospital services (e.g.,

meals, nursing, laboratory, drugs, operating room and other facilities, equipment and supplies), insured

health services, insured person, minister of health, physician services, resident, surgical-dental services,

user charge, consultation process, exceptions/limitations and regulations (Government of Canada, 2016).

In addition, the act indicates that each province throughout a fiscal year must satisfy the criteria of public

administration, comprehensiveness, universality, portability, and accessibility to get full cash contribution

from the government. The Canadian Academy of Health Sciences (CAHS) (2009, p. 18) developed a

framework and indicators to measure return on investment in health research. In this context, the main idea

is that research activity (i.e., global research, Canadian health research, and research capacity) produces

results (i.e., research results, knowledge pool, and consultation/collaboration) that influence decision

making in the health industry (i.e., product/drugs, services, databases, practitioners’ behavior,

clinical/manager’s guidelines, institutional policies and social care practices), other industries (i.e.,

product/services, built infrastructure, and work environment), government (i.e., resource allocation,

regulation, policy, intervention programs, and taxes and subsidies), research decision making (i.e., R&D

agendas/investment, issues/gaps, harder problems, and evidence problems), and the public and public

groups (i.e., advocacy groups, media coverage, general knowledge and confidence in data) that affect

healthcare (i.e., appropriateness, acceptability, accessibility, competence, continuity, effectiveness, and

safety in prevention, diagnosis/prognosis, treatment/palliation, and post-treatment for diseases, illness,

injury or progressive condition), health risk factors, and other health determinants (i.e., personal behavior,

social/cultural determinants, environmental determinants, and living and working conditions) contributing

to improving health, well-being and economic and social prosperity. The framework is described

considering five main categories 1) topic identification, selection, inputs and process, 2) primary outputs

dissemination, 3) secondary outputs, 4) adoption and 5) final outcomes. External influences are defined as

interests, traditions, technical limitations, and political dynamics. An alternative framework is presented by

the Canadian Institute for Health Information (CIHI) (2013). This framework includes as environment the

political, cultural, demographic and economic contexts. The main components of the health system in the

framework are inputs and characteristics (i.e., leadership and governance, health system resources, efficient

allocation of resources, adjustment to population needs, and health system innovation and learning

capacity), social determinants (i.e., structural factors influencing health, and biological material,

psychosocial and behavioral factors), outputs (access to comprehensive high-quality health services, person

center, safe, appropriate and effective, and efficient delivered), and outcomes (improve health status of

Canadians, improve health system responsiveness, and improve value for money). The Canadian Institute

for Health Information (CIHI) (2015, p. 31) also applies the previous framework logic to the hospital level.

This indicates the direction to adapt the framework to specific uses.

1 From the patient point of view, check the Department of Health & Human Services USA (2016) and Health Canada (2012b)

roadmaps to health.

Gurupur & Gutierrez / Designing the Right Framework for Healthcare Decision Support 11

2.2. Healthcare decisions

This section considers healthcare decisions in the general context defined in the first view. To achieve

this goal, this section answers the questions: 1) what are the components of healthcare decisions? 2) what

are the types of decisions to made in healthcare? 3) who are the stakeholders of healthcare decisions? 4)

who made the decisions of healthcare?, 5) how, when, and where to make the healthcare decisions? And

6) what are the criteria to evaluate the effectiveness and efficiency of healthcare decisions? The answers

to these questions are presented in Section 2.2.1 to Section 2.2.6 respectively.

2.2.1. What are the components of healthcare decisions?

Considering the concepts introduced in Section 2.1, healthcare decisions are at different level involving

different stakeholders, outcomes, and criteria. Decisions are at the global level, the national level (e.g.,

government and public), the industry level, and the patient level in hospitals, clinics or homes. The

composition and interactions of all these components and stakeholders make healthcare decisions complex.

Healthcare decisions are moving towards centralized decision-making structures (Health Canada, 2012a;

OECD, 2013). Subsequent developments in this paper provide more specific examples of healthcare

decisions and criteria to evaluate them.

2.2.2. What are the types of decisions to be made in healthcare?

There are several decisions that can be made in the healthcare system. The decisions happen at different

levels in different decentralized parts of the system, so understanding the truth of these highly complex

systems is not an easy task (Advisory Panel on Healthcare Innovation, 2015, p. 4; Carson, Nossal, & Dixon,

2015, pp. 1-13; Institute of Medicine, 2013b, pp. 2-4, 77-91). Some examples of decisions in healthcare

are: selecting and implementing the US nation-wide metric (Institute of Medicine, 2015c); identifying,

assessing, and managing health risk from sources such as water, air, diseases, toxic substances, consumer

products, workplace substances, food, drugs (pharmaceuticals), medical devices and pesticides (Health

Canada, 2000); deciding about vaccine programs (Public Health Agency of Canada, 2015); replacing earlier

treatment methods or providing new treatment options with new drug therapies (Health Canada, 2004);

defining and interpreting acts and regulations (Health Canada, 2005); innovating healthcare (Advisory

Panel on Healthcare Innovation, 2015); respecting privacy, information, sustainable development and

others (Health Canada, 2015c); improving diagnosis (National Academies of Sciences, Engineering, &

Medicine, 2015); scheduling and access (Institute of Medicine, 2015b); investing in global health systems

(Institute of Medicine, 2014d); evaluating design for complex global initiatives (Institute of Medicine,

2014b); balancing coverage and cost (Institute of Medicine, 2012); designing best care at lower cost

(Institute of Medicine, 2013a); answering questions regarding to geographic variation in healthcare

spending, utilization and quality (Institute of Medicine, 2013c); planning health professional education

(Institute of Medicine, 2010, 2014c); planning the nursing profession (Institute of Medicine, 2011b);

establishing transdisciplinary professionalism for improving health outcomes (Institute of Medicine,

2014a); building a better delivery system (National Academy of Engineering, 2010; National Academy of

Engineering & Institute of Medicine, 2005); planning computations technology for effective health care

(National Research Council, 2009); supporting cognitive engineering application in health care (National

Academy of Engineering, 2009); engineering a learning healthcare system (Institute of Medicine &

National Academy of Engineering, 2011); recommending strategies and priorities for information

technology at the centers for Medicare and Medicaid Services (National Research Council, 2012, pp. 111-

122); etc. Although the list of previous endeavors in healthcare decisions is not exhaustive, it shows the

broad variety of decisions to be made in healthcare.

2.2.3. Who are the stakeholders of healthcare decisions?

Considering the broad scope of decisions in health and healthcare systems, each of them implies several

and specific stakeholders. The Institute of Medicine (2013b, pp. 79-82) in the US suggests as stakeholders

12 Gurupur & Gutierrez / Designing the Right Framework for Healthcare Decision Support

people and institutions in the following categories: 1) patients, consumers, caregivers, and the public; 2)

health care professionals (physicians, nurses, pharmacists, and others); 3) hospitals and health care delivery

organizations; 4) payers; 5) public health agencies; 6) regulators; 7) communication professionals and the

media; 8) community-based organizations; 9) states (legislators, governors, executive agencies); and 10)

federal government (legislators, executive agencies).

2.2.4. Who make the decisions of healthcare?

Based on the Institute of Medicine (2008, pp. 21-22), healthcare decisions are made by multiple people,

individually or collaboratively, in multiple contexts for multiple purposes. The institute adds that “Decision

makers are likely to be the consumer choosing among health plans, patients or the patients’ caregivers

making treatment choices, payers or employers making health care coverage and reimbursement decisions,

professional medical societies developing practice guidelines or clinical recommendations, regulatory

agencies assessing new drugs or devices, and public programs developing population-based health

interventions. Every decision maker needs credible, unbiased, and understandable evidence on the

effectiveness of health care services”.

2.2.5. How/when/where to make the healthcare Decision?

Providing direct answer to this question requires to break down healthcare decisions and to find the

relevant stakeholders, information (e.g., evidence), outcomes, and criteria. For practical purposes the

example of setting priorities for evidence based assessment in healthcare is used. Under this consideration,

the Institute of Medicine (2008, pp. 57-77) in the US recommends the appointment of an independent

Priority Setting Advisory Committee (PSAC) to develop and implement a process for a national clinical

assessment program. The institute complements that the committee should ensure a balance of expertise

and interests with minimal bias due to conflict of interest in order to adhere the process to principles of

consistency, efficiency, objectivity, responsiveness, and transparency. As a result, the institute indicates

that the process should be open, predictable, and explicitly defined, with fully documented standards and

simple and effective procedures to preserve the available resources. The highest priorities topics should

consider: 1) how well the topic reflects the clinical questions of patients and clinicians, and 2) the potential

for the topics to have a strong impact on clinical and other outcomes that matter the most to patients”

(Institute of Medicine, 2008, p. 57). Depending on the type of question to made a decision and the

timeframe, the Institute of Medicine (2008, pp. 90-92, 102-104) indicates that there are specific types of

evidences that can represent different level of quality for the answer.

2.2.6. What are the criteria to evaluate the effectiveness and efficiency of healthcare decisions?

Considering the big picture of healthcare, several indicators are used to evaluate the effectiveness and

efficiency of healthcare decisions. Health decisions are evaluated in the World Health Statistics using

criteria such as life expectancy and mortality, cause-specific mortality and morbidity, infectious diseases,

health services coverage, risk factors, health systems (i.e., workforce, infrastructure and technologies, and

essential medicines), health expenditures, health inequities, and demographic and socioeconomic context

(World Health Organization, 2015). The OECD (2015a) organized the criteria to evaluate the effectiveness

and efficiency of healthcare decisions in terms of health status (i.e., life expectancy and mortality), risk

factors to health, access to care, quality of care, health workforce, health care activities, pharmaceutical

spending, pharmaceutical sector, non-medical determinants of health, health expenditure and financing,

ageing and long-term care, and demographic and socioeconomic context. The Agency for Healthcare

Research and Quality (2015b) in the US evaluates healthcare decisions around concepts of access to care,

quality of care (i.e., processes of care, outcomes of care, patient perception of care, and infrastructure),

disparities in care, and the NQS (National Quality Strategy) priorities. More specifically, the agency uses

metrics such as access to health care, patient safety, person and family centered care, care coordination,

effective treatment, healthy living, care affordability, and priority populations. In Canada, the main

Gurupur & Gutierrez / Designing the Right Framework for Healthcare Decision Support 13

indicators to evaluate healthcare decisions are health status, health system responsiveness, value for money,

and equity in health status and responsiveness (Canadian Institute for Health Information (CIHI), 2015, p.

29). CIHI (2015, pp. 66-68) defines more specifically subcomponents of the indicators. It can be understood

that despite of difference approaches to finance healthcare systems, several countries share similar

indicators to evaluate the effectiveness and efficiency of healthcare decisions.

2.3. Healthcare decision support

As healthcare decisions happen at different levels in healthcare, healthcare decision support can play a

role in each of them. This section links healthcare decisions to healthcare decision support answering the

questions: 1) what are the components of healthcare decisions support? 2) what are the types of decisions

for healthcare decision support? 3) who are the stakeholders for healthcare decision support? 4) who uses

healthcare decision support?, 5) how, when, and where to support healthcare decisions? and 6) what are

the criteria to evaluate the effectiveness and efficiency of healthcare decision support? The answers to these

questions are presented in Section 2.3.1 to Section 2.3.6 respectively. Considering the big scope of

healthcare and healthcare decision support, some questions are only partially answered with specific

examples from the literature. This strategy is used for practical purposes and to control the limitation of

space in the paper, but it i