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City University, London
UOA 7 - Health Services Research
RA5a: Research environment and esteem
This submission describes health services and related research undertaken in health informatics and health policy. The staff are associated with the Centre for Health Informatics and the Centre for Allied Health Professions Research. The research is interdisciplinary with a strong emphasis on the adoption of a systemic approach.
2. Scope of Research Activities
The Centre for Health Informatics (CHI) was established at the beginning of 2005, evolving from the Centre for Measurement and Information in Medicine established in 1983. This change in name and focus aimed to enhance the marketability of the Centre and to provide a focus for the totality of health informatics and related activities across the institution, concentrating research in the mainstream areas of the emerging discipline.
CHI carries out a programme of interdisciplinary research involving the application of advanced information and communications science and technology (ICT), within a systems framework, to problems in medical and health-related research and clinical decision-making. Research is focused on four major areas of clinically-related activity: eHealth and telecare; high dependency medicine; laboratory medicine; and public health.
In these areas we are developing and applying methods and techniques that bring about more effective healthcare organisation and delivery. A particular focus is to research and develop systems that support the decision-making processes central to healthcare provision, including the provision of information to clinician, patient and manager, and enabling medical knowledge to be made available and managed more effectively. A key achievement in this area has been the development of the National electronic Library of Infection (NeLI), one of the specialist libraries of the National electronic Library for Health (NeLH), a single access point to best available evidence on infectious and communicable diseases and the National Resource in Infection Control developed for the Department of Health in response to recommendations from the National Audit Office. These national resources provide both a service to clinicians and a test-bed for research questions about the role of information delivery in decision-making. CHI’s research is of particular relevance in the current UK setting with the government’s evolving National Programme for IT, re-badged as Connecting for Health; a programme leading to a health service that is increasingly underpinned by ICT.
Applied health policy and health services research is undertaken within the Centre for Allied Health Professions Research (CAHPR) which provides a node for an extended network of multidisciplinary researchers across City University and beyond (see section 5). A prime research focus since 2001 has been the development of new professional roles in health care, and methods of working across professional, organisational and sectoral boundaries, with particular reference to primary and community care. More recently emphasis has begun to shift from primary and community care to the under-researched area of allied health professions policy and practice, formalised in the establishment of the UK’s first CAHPR in 2006 (see section 4).
3. Major Activity and Achievements
A wide range of methods and techniques are employed, spanning measurement, modelling and statistics; and, within CHI, techniques of artificial intelligence as well as computational science more widely. In terms of measurement, good quality data are needed for effective decision-making at clinical or policy level; a need that is still far from being met and thus an on-going research focus. Appropriate modalities of modelling can, at the clinical level, enhance understanding in changes in circulatory flow in the patient undergoing cardiac surgery. At the policy level modelling has been employed to help inform public health need and health service provision. A range of methods from computational science support more informative interpretation of patient data and assist in the processes of acquiring and managing medical knowledge, particularly that increasingly available from the web.
These methods and techniques have been applied successfully in a range of applications, including:
- Evaluating Home Telecare (Roudsari): examining, in this EU-funded project (REALITY), the impact of patients in a range of urban and rural settings collecting both clinical and quality-of-life data associated with the management of their chronic disease using hand-held computers. Evaluation has been addressed from the perspectives of the patient and their carers, healthcare professionals and health management;
- Provision of Policy Advice in relation to Screening for Diabetic Retinopathy (Carson/Roudsari): developing a prevalence model which has been used, with other data collection and analysis, to provide information at policy level on how to address the problem of assessing potential demand and costs of systematic retinopathy screening services in the context of NSF requirements;
- Artificial Pancreas (Hovorka): designing and developing a closed-loop, model-based schema for the administration of insulin to type 1 diabetic patients;
- High-Dependency Medicine (Weller): researching and implementing a wearable computer system for enhanced patient monitoring for anaesthetists and surgeons, enabling clinicians to simultaneously monitor many patients and supervise trainees whilst moving around the hospital performing other duties. It has an additional benefit for workforce management, especially with the initiative for nurse-anaesthetists;
- Infectious Diseases (Weinberg): developing and evaluating national Internet digital library resources together with associated training materials. Deliverables have been produced for NeLI, National Resource for Infection Control (www.nric.org.uk), Bugs and Drugs (www.antimicrobialresistance.org.uk) and Training in Infection (www.trainingininfection.org.uk), all available on the NeLI portal – www.neli.org.uk;
- Evaluation of eHealth Resources (Kostkova): including the WHO Resource Centre for National Public Health Laboratories project (http://www.who.int/labresources/), following on from WHO consultancy activity during 2001-3; and evaluation of Internet healthcare digital libraries and the impact of electronic health resources on patients, medical students and professionals and building virtual communities;
- Health Service Provision (Protti/Petchey): reviewing the proposed NHS information strategy for England prior to its release and the evaluation methodology used to monitor the local implementation of this national strategy;
- Health Information Systems (Kay/Roudsari): reviewing the development and emerging benefits of radio frequency identification (RFID) in healthcare, an overview of its many applications for improving patient care, and the necessary implementation and contextual considerations for achieving that goal;
- Laboratory Information Systems (Kay): researching and implementing the automated transmission of laboratory reports to general practitioners, hypertext advisory systems and handheld wireless computers. Work on electronic data interchange has driven the development of commercial systems, now used for the transfer of reports by every laboratory in the UK;
- Soft Systems Modelling (Carson): applied in a range of healthcare settings (including diabetes) to provide guidance on how the efficiency and effectiveness of service organisation and delivery might be enhanced (reported in four peer-reviewed journal papers);
- Evaluation of a Variety of Complex National and International Health Service Initiatives (all): using methods developed. These include the introduction of Personal Medical Services, the PCT-secondary care sector interface, home telecare for chronic conditions, and the development of community-based services for people with or affected by cancer and palliative care. The results of these evaluations have fed and continue to feed into the formation and evolution of national policy in these areas. Between 2001 and 2003, a multi-disciplinary Regional ‘Call-down’ Health Services Research Centre was co-hosted at City (with QMUL), funded by the London Region of the NHS Executive, which advised (among other things) on the shape of the public health workforce and its organisation (see section 5).
Complementing these applications studies, substantial methodological progress has also been made, including:
- Developing systems models (including soft systems methodology) to aid understanding of complex healthcare situations, particularly in the context of policy-making in relation to public health issues;
- Developing evaluation methods, including in-depth case studies, surveys, economic analysis, GIS (Geographic Information Systems) mapping and lexical analysis (readability scoring and concordancing), on-line evaluation of digital libraries;
- Developing evaluation methodology for home telecare applications;
- Developing the semantic web, web services, agent technologies, personalisation and customisation of web services, and XML-based secure interoperability.
This last development has resulted in the NeLI/National Resource for Infection Control project successfully implementing web services, infection disease ontology (with the HPA, PH Observatories), with ongoing investigation of the profiling and personalisation of the Internet portals. This has had a significant impact on user satisfaction (investigated using qualitative methods, online surveys) and traffic on the portals (now 13,000 unique users per month against 1000 in 2002). Piloting agent-driven document review system on NeLI in 2005 resulted in a 28% increase of reviewers recruited by agents. Public interventions in the area of antibiotic resistance using the Bugs and Drugs portal have been investigated using qualitative and quantitative methods and demonstrated a statistically significant change of knowledge and attitude amongst the public and medical students.
3.3 Overall Measures of Achievement
Research income since 2001 has amounted to more than £55,000 per member of academic staff per annum, secured from a range of agencies including Research Councils, EU, Government Departments, NHS, and the pharmaceutical and healthcare technology industries.
Research output has been published in the medical, health informatics, health policy and other relevant disciplines to gain full coverage of the interdisciplinary health services research being undertaken. Publications include over 40 articles in peer-reviewed journals, over 55 contributions to peer-reviewed conference proceedings and six books and edited volumes.
Since 2001 24 research students have obtained their PhD degrees (plus 1 MPhil). Currently 18 research students are engaged on doctoral programmes in areas of eHealth and health policy directly related to health services research, maintaining a buoyant state of student recruitment and activity. Two recent PhD graduates are working in an internationally-leading Cambridge University team that is developing and clinically testing a wearable artificial pancreas. Another is a member of City’s Healthcare Education Development Unit engaged in major evaluation studies relating to good clinical practice.
4. Strategic Development
Strategy for both shorter and longer-term development is established through regular discussion amongst members of the CHI and CAHPR teams, in co-operation with clinical, public health, health management and other link partners as indicated below in relation to applications.
Development will continue across the broad areas of activity indicated. Specific clinical application areas will include:
- Management of Chronic Non-communicable Diseases. Telematic approaches to the management of chronic diseases, including diabetes, hypertension and asthma, focusing on patient support in the home environment. This will include the design and evaluation of web-based information/computer-aided learning systems and schemes of design and evaluation in relation to the collection of both clinical and health-status data from the patient in their home.
- High-Dependency Medical Applications. Advanced methods for the acquisition, processing and interpretation of data from patients in the high-dependency environment for the purposes of diagnosis, state prediction, management and prognosis.
- Laboratory Medicine. Application of ICT-based approaches (including RFID) to blood-tracking within the laboratory environment (supported by NHS Connecting for Health Evaluation funding of £150,000 from 2007).
- Infectious Diseases. Broad strategic development will continue to focus on the provision of Internet portals around infectious diseases to support patients, NHS professionals and organisation and delivery of healthcare. Specific research themes will include: further advances in Internet digital libraries in relation to service provision, stakeholder engagement and real-world evaluation; researching and developing the semantic web, healthcare ontologies and application of agent technologies for context search and personalisation of services; and further development of a general framework for evaluation of digital libraries and their impact on clinical care. Other related new EU-funded initiatives include: SeaLife (implementing a semantic web browser for life sciences – DG SANCO funded; £210,000, 2006-2009); and eBug aiming to develop, disseminate and evaluate educational packs and websites for children about antibiotics and hand hygiene to ten European countries (FP6) - £210,000, 2006-2009.
- Service Delivery and Organisation. Broad strategic development will continue to focus on multidisciplinary and multiple method evaluation of complex health policy and service delivery initiatives. While retaining and nurturing existing internal and external links with primary care and public health, linkage with the allied health professions (AHPs) is being enhanced via the recently established CAHPR. Strategic development will reflect the Centre’s aims to:
- monitor developments and trends in a dynamic health and social policy environment and anticipate issues which are likely to affect AHPs in the future;
- undertake research into AHP policy and practice, and disseminate research findings by various means, such as briefing papers, journal articles and conferences;
- develop close links and work in collaboration with governmental bodies, universities and colleges, professional organisations and NGOs, as well as AHPs themselves;
- influence the direction of policy and promote awareness among other health professionals, policymakers, the media and the general public of the nature and importance of the roles played by AHPs; and
- encourage and provide a focus for AHP research within the UK and help build research capacity within the Professions.
In keeping with the underlying philosophy of CHI, the applications-focused developments defined above will be complemented by relevant methodological development, including themes within modelling, evaluation and knowledge management.
eHealth: There will also be on-going development of an electronic healthcare simulator which enhances the research capability of CHI in the area of eHealth, focusing on issues relating to the NHS modernisation strategy. NHS organisations are at different levels of ICT development and technology specifications are not mature. Hence this laboratory simulation facility allows researchers, including NHS professionals and members of the healthcare industries, to explore eHealth scenarios which require stable networks and device connections to test their hypotheses relating to eHealth provision.
Currently the facility simulates an electronic hospital environment in the laboratory. Subsequently, similar scenarios can be set up for GP practices, Social Services and cross-organisational connections. This in-house provision enables a range of research issues to be explored, for example relating to: electronic records in practice; data coding and extraction techniques; messaging protocols; and sources of information designed for patients. Initial funding for this initiative was provided from Research Capability Development funding. Industrial support has been provided by CSW (a major contributor to the NHS Connecting for Health programme).
Service Delivery and Organisation:Whilst the majority of future development will be application focused, methodological development is planned in relation to on-line surveys and systematic literature reviews, as a result of the recent recruitment of new research staff.
The interdisciplinary research programme benefits from collaboration with other individuals and groupings within City University. Co-operation with other departments of the School of Informatics and with the School of Engineering and Mathematical Sciences provides additional technical expertise in measurement and instrumentation, signal and image processing, and in software development and information science. Co-operation is also being expanded with members of City Community and Health Sciences, encompassing the St Bartholomew’s School of Nursing and Midwifery (particularly community nursing) and the Allied Health Professions. Co-operation is also in place with the City Health Economics Centre (particularly in relation to evaluation studies).
eHealth: There is also extensive research collaboration with a number of groupings in the primary and secondary healthcare sectors; hospitals and medical schools including St Bartholomew's Hospital and the Royal London Hospital (e.g. in relation to wearable technologies), Guy's, King's and St Thomas' School of Medicine (GKT) of King's College, University of London and the Royal Brompton Hospital (e.g. in relation to the artificial pancreas); and a number of primary care health centres (e.g. in relation to telecare of chronic diseases). City University is also continuing to develop its major strategic alliance with Queen Mary's, London University (QMUL), particularly in health-related areas which will impact on future health services research.
Internationally, current and recent research linkage with clinical, industrial and academic colleagues has spanned some 14 European countries (principally through EU-funded projects), as well as a research training co-tutelage agreement with the Università degli Studi di Padova, Italy in biomedical engineering, health informatics and related subjects, an institution with which research linkage with the MIM Centre and now CHI spans more than 20 years. The first two PhD students registered under this scheme graduated in 2005.
Most recently, CHI has established a research link with its counterpart at the University of New South Wales in Australia (UNSW). The Centre for Health Informatics at UNSW, led by Professor Enrico Coiera, undertakes internationally-leading research in evidence-based decision support, clinical communications and evaluation, assessing the effectiveness of new information and communications technologies in improving health outcomes and delivery, providing close correspondence with CHI. The linkage programme will offer opportunities for short exchange visits by members of staff and research students in both directions as part of planned collaborative research ventures. Thus, for example, research students registered at City University may have the opportunity of carrying out a portion of their research training at UNSW (paralleling the agreement with Padova).
Service delivery and organisation: Extensive external current and recent research collaboration includes: public health (QMUL); general practice/primary care (QMUL, University of Warwick Medical School, University College, London, National Primary Care Research & Development Centre, Manchester); social geography (QMUL); social anthropology (Brunel University); clinical communication (University of Birmingham). In varying permutations and combinations, this network has undertaken a series of multi-disciplinary and multi-method evaluations of national health policy/service delivery innovations, on behalf of the Department of Health, the NHS and the National Lottery. A national and international network of AHP academics, professionals and policy-makers has already begun to be created around CAHPR. Further development of this will be underpinned by a successful bid for ESRC funding for a seminar series, which is also supported by the Department of Health (July 2007).
6. Sustainability of the Research Environment
During the assessment period there has been significant change in the academic personnel within CHI through retirements and through the movement of Dr Roman Hovorka and his metabolic modelling research group to the University of Cambridge.
The research-active numbers currently in place are small. However, the University regards this area of health services research as being of strategic importance and has agreed to fund two new positions in CHI, one at professorial and one at senior lecturer level.
CHI has been highly successful in ensuring the sustainability of its research by making two part-time professorial appointments of high international standing (Professors Denis Protti and Jonathan Kay).
Health services research benefits from the vibrant research culture which City University seeks to support and develop further by means of a range of University-wide research initiatives. These include university research studentships, a scheme from which CHI has benefited. Half-day research seminars are held, complementing the Departmental seminar programme, with those focusing on health informatics and related topics providing opportunities for CHI research students to present their research to a wider University audience and explore the possibilities for co-operation with other groupings in Health Sciences. Comprehensive induction and ongoing training programmes are attended by all full-time research students. Research students are also strongly encouraged and supported to participate in relevant national and international conferences to provide further peer review and support.
University training is also provided for principal investigators and contract research staff which, in relation to health services research, has been taken up by our staff on themes including research funding, publishing, research supervision and project management. This activity has benefited from the availability of Research Capability Funding.
7. Impact on Health and Healthcare
Major contributions to health and healthcare over the assessment period include:
- Development of electronic library resources in relation to infectious diseases, now adopted by NeLH;
- Development of closed loop, model-based schema for insulin administration to diabetic patients (artificial pancreas); this research by Dr Hovorka and colleagues had reached the stage of preliminary clinical testing before the move to Cambridge (currently undergoing clinical trialling at Addenbrooke’s Hospital, Cambridge);
- Provision of advice to North Central London Strategic Health Authority relating to diabetic screening programmes, impacting on Department of Health policy;
- Application of evaluation methodology in home telecare (EU-funded REALITY project), the results of which are now impacting on health policy (e.g. NHS PASA national framework agreement for telecare – contract CM/RSC/05/4376); this project also benefited from co-operation with the City Health Economics Centre;
- Enhancement of patient care and safety through enhanced monitoring methods and improved prediction of potential trauma (e.g. by means of neuro-fuzzy control in the estimation of clinical parameters in ventilated COPD patients (as reported in the Proceedings of the IEEE EMBS Conference, Lyon 2007); by means of artificial neural networks to enable rapid diagnosis and assessment of the state of patients with chest pain (as reported in the Proceedings of MEDSIP 04, Sliema 2004, ISBN 0-86431-439-7); and through advanced non-linear techniques – fractals and chaos - in ongoing cooperation with Budapest University of Technology and Economics supported by the Hungarian State Eötvös Scholarship scheme);
- Development of new and enhanced roles for Allied Health Professionals, e.g. supplementary prescribing and first-line care (i.e. without medical referral).
- Development of mathematical modelling methodology for application in simulation, dose prediction studies and decision support systems, of particular relevance in the context of managing chronic diseases such as diabetes;
- Development of systems modelling frameworks that aid the understanding of complex medical problems in which decision support is needed – of particular relevance in the context of public health and health policy;
- Development of evaluation methodologies of particular relevance in the context of home-based monitoring of chronic disease, telecare more generally, and digital libraries/information systems (including new funding from NHS Direct Online for “Evaluation of NHS Direct DiTV”, £317,000 from 2007); and
- Developing evaluation methods that integrate in-depth case studies, surveys, economic analysis, GIS (Geographic Information Systems) mapping and lexical analysis (readability scoring and concordancing). A number of these methods have found uptake on the NeLI portal and in the WHO Labresources project.
The following indicators are measures of the esteem relating to members of academic staff:
Prof Ewart Carson
- Elected Fellow, International Academy of Medical and Biological Engineering (2006);
- Elected Fellow, Institute of Electrical and Electronic Engineers;
- Recipient of Career Achievement Award, Engineering in Medicine and Biology Society, Institute of Electrical and Electronic Engineers (2005);
- Chairman (2001) and Executive Team Member (2002-to date), Institution of Engineering and Technology (IET) Professional Network on Healthcare Technologies;
- Technical Board Member (2002-2008), International Federation for Automatic Control (IFAC) (Responsibility for Biological and Ecological Systems);
- Vice Chairman (2002-2008), IFAC Technical Committee on Modelling & Control in Biomedical Systems;
- Associate Editor, Computer Methods and Programs in Biomedicine;
- College Member, EPSRC (2001-2005).
Prof Jonathan Kay
- Recipient of EU eHealth “Best Practice” Award (2003);
- Chairman, Information Group of the Academy of Medical Royal Colleges;
- Invited speaker, Healthcare Computing Conference (2007).
Dr Patty Kostkova
- Chairman, International Workshops on Healthcare Digital Libraries (e.g. HDL2003, HDL2005);
- Editor, Health Informatics Journal Special Issue on Healthcare Digital Libraries (2006);
- Member, Public education and professional education sub-committees of DH Specialist Advisory Committee in Antimicrobial Resistance (SACAR);
- Invited Speaker, 1st European Workshop on Semantic Web Applications in Biomedicine, Hungary (2004);
- Invited Speaker, NHS Direct Online (UK), BCAS, SACAR & APUA International Workshop on "What can professionals and the public do about antimicrobial resistance and prescribing?" (London);
- Invited Speaker, Workshop on Educational Campaigns Regarding Antibiotic Resistance, organised by ESAC (Brussels), KTL (Helsinki), Cancer Research (London), Charles University (Prague), Czech Academy of Science (Prague) and Health Canada (Canada);
- Consultant, European Centre for Disease Prevention and Control, Stockholm (working on the mapping of microbiological and public health expertise in the EU).
Prof Roland Petchey
- Principal investigator on the evaluation of two major Lottery initiatives in cancer and palliative care, with publications and invited presentations of the results in a range of international media (e.g. 8th International Conference on The Social Context of Death, Dying and Disposal, Bath, September 2007; UICC World Cancer Congress, Washington DC, July 2006; European Health Management Association Annual Conference, Budapest, June 2006).
Prof Denis Protti
- Who’s Who in Healthcare Award for Technology/Health Informatics (2004);
- Chairman of the International Advisory Group to the Welsh Minister of Health and Social Care (2006);
- Author of 14 World View Reports on IT in Healthcare commissioned by NHS Connecting for Health (2005);
- Founder Member of COACH – Canada’s Health Informatics Organisation.
Prof Abdul Roudsari
- Council Member and Member of Standards Working Group, UK Council for Health Informatics Professions (since 2003);
- Vice-Chair, UK Health Informatics Society (since 2004);
- Elected Member, NHS Connecting for Health Faculty of Health Informatics Management Board;
- Member, National Occupational Standards for Health Informatics, National Reference Group (Project run by NHS Health and Social Care Information Centre);
- Editorial Board Member, International Journal of Health Geographics (since 2002);
- Special Session Organiser (Intelligent e-health applications in medicine) and Proceedings Editor, European Symposium on Intelligent Technologies, Hybrid Systems and their Implementation on Smart Adaptive Systems (EUNITE-2002), Albufeira, Portugal (2002).
Prof Julius Weinberg
- Lead, National electronic Library for Infection (invited by the DoH to develop the National Resources in Infection Control);
- Expert Advisor, House of Lords Select Committees on Science and Technology Inquiries (Fighting Infection; and Pandemic Influenza);
- Invited Debater, European Conference on Microbiology and Infectious Disease;
- Non-Executive Director, NE Thames Strategic Health Authority.
Dr Peter Weller
- Executive Team Member, IET Professional Network on Healthcare Technologies (since 2004);
- Advisory Board Member for Critical Reviews in Biomedical Engineering (since 2006);
- Invited Keynote Speaker, European Society for Computing and Technology in Anaesthesia and Intensive Care conference, ESCTAIC’05, Aalborg, Denmark, 2005;
- Invited Speaker, Cardiovascular Faraday meeting, Hammersmith Hospital, November 2005;
- Elected to IET Technical and Professional Services Board, 2007.