ماتریس یکپارچه سازی جریان کار : یک چارچوب برای حمایت از توسعه سیستم اطلاعات جراحی

Design and technological development of surgical information systems for complex workspaces, such as the surgical theatre raise a variety of challenges for the designer. These challenges originate from the role of the designer within a multidisciplinary development team involving surgeons, technologists and designers. This role creates two needs: first, the analysis of surgical requirements and processes within the surgical workspace, and second, the sharing of the requirements and processes within a multidisciplinary development team. To address both the needs, this paper proposes a framework called the Workflow Integration Matrix (WIM). WIM uses theories of human behaviour in problem solving, especially the information processing paradigm. The proposed framework intends to provide evidence-based decision-making for the development of new surgical technologies.

Human-centred development of information systems for complex workspaces such as, the surgical theatres is a critical link to improve healthcare and patient safety (Taylor et al., 1996, Stead et al., 2000, Patel et al., 2001, Stone and McCloy, 2004 and Buckle et al., 2006). Here, the complexity of the surgical workspace is characterised by time critical decision-making tasks (Elstein et al., 1978 and Gordan et al., 1993), unpredictability of events (Hunink, 2005), low tolerance for errors (Reason, 2000) and importance of timely communication between members of the surgical team (Lingard et al., 2004). In this paper, we focus on supporting the development of surgical information systems, which provide real-time imaging and procedural support to the surgeon, to enhance surgical decision-making. The development of these systems is dependent on the knowledge of the surgical processes and requirements (Buckle et al., 2006 and Sanderson, 2006) and its structured communication between the members of a multidisciplinary development team (Cross, 1989, Milne, 2000 and Vink et al., 2006). While developing the surgical information system, if the surgical processes and requirements are analysed insufficiently or communicated inaccurately within a multidisciplinary development team, gaps will appear in the comprehension of the scope and the function of the system. This may lead to medical errors affecting patient's safety (Bogner, 1994). The multidisciplinary development team for the surgical information systems usually consists of surgeons, technology engineers and designers. Here the designer in the team is confronted with two main challenges: 1. Analysis of the requirements and processes based on surgical problem solving within the surgical workflow. 2. Facilitate communication of requirements, processes and possibilities between surgeons, technology engineers and designers of a multidisciplinary team? The first challenge necessitates analysis of the surgical workflow in order to identify the information processes and requirements within the surgical workspace. Similar to other complex workspaces, the technological development in a surgical workspace is critically dependent on the knowledge of problem-solving processes and the requirements related to it (Simon, 1969, Hollnagel and Woods, 1983, Rasmussen, 1986, Woods, 1986 and Vicente, 1999). Based on the theories of problem solving in complex workspaces (Simon, 1969, Dörner, 1996 and Badke-Schaub and Buerschaper, 2001), the term surgical workflow is defined as the surgical problem-solving process that is determined by the boundaries in terms of possibilities and limitations within the surgical workspace in the three surgical phases: before surgery (preoperative), during surgery (intra-operative) and after surgery (post-operative). Current surgical workflow analysis frameworks on modelling of surgical procedures for multi-modal image guided surgery (Jannin et al., 2003), XML based intra-operative surgical workflow framework (Neumuth et al., 2005) focus primarily on identification of the technological requirements and processes and do not fully consider analysing the surgical requirements. This leads to solutions that are influenced by the latest technological trends (Bainbridge, 1983) and are imposed rather than required by the surgeons (Patel et al., 2001). As stated by one of the surgeons ‘…This is impressive technology, but I don't see where exactly it supports my tasks…even if it is given for free I wouldn't install it in my hospital’. In order to avoid the technological push in the surgical workspace raises the need to develop a surgical workflow analysis framework, which is based on the knowledge of the surgical problem-solving process ( Jalote-Parmar et al., 2007a). The second challenge that confronts the designer is the communication of surgical processes, requirements and technological possibilities within a multidisciplinary team (Thomann and Caelen, 2007). During the product development process, there often exist communication gaps between surgeons (clients), designers and technology engineers (developers) (Barrett and Stanley, 1999 and Jalote-Parmar et al., 2007a). Sometimes communication is made difficult due to ad hoc approaches (Darlington and Culley, 2004), and lack of a common language to exchange multidisciplinary ideas (Green et al., 2004). Consequently, the important requirements are often randomly documented or not timely communicated, which gives a fragmented picture of the surgical requirements to the technologist. This leads to a biased technological development where the surgeons are unable to adapt the surgical information system to the surgical workspace (Patel et al., 2001). Cooper and Press (1995) have identified communication between development teams as the main requirement for successful design. Thus, raising the need to provide communication stages in the human-centred design process cycle, to facilitate exchange of surgical requirements, processes and possibilities. Existing surgical workflow analysis frameworks focus primarily on representing the technological processes (Jannin et al., 2003 and Neumuth et al., 2005) while disregarding the communication needs within the multidisciplinary teams. On the one hand, the frameworks do not allow the surgeons to view their own processes within the context that they understand; on the other hand, the frameworks do not allow the technologists to separate the complexities of the surgical processes into a set of manageable technological solutions. This is because the frameworks mainly incorporate the technological requirements at a high resolution therefore overlooking the overview of the surgical processes and requirements. The results of surgical workflow analyses need to provide an overview of the surgical processes and requirements and should be communicable to all members of the development team (Grudin and Pruitt, 2002). We propose that the designer can play an important role in bridging the communication gap while supporting human-centred development within a multidisciplinary team. Recent scholars have suggested that the design function is adopting a more prominent position in the product development effort (Von Stamm, 2003 and Perks et al., 2005). To bridge communications between surgeons and technologists requires the designer to accept a central role besides a traditional one in the product development (Jalote-Parmar et al., 2006) (see Figure 1).To meet the above two challenges this paper proposes a framework called Workflow Integration Matrix (WIM), which consists of two main components the current workflow and the future workflow. The current workflow allows the task decomposition of the three surgical phases. It is based upon the theory of human problem solving in complex environments (Simon, 1969) and is formulated by integrating results from empirical studies to established frameworks of cognitive task analysis (Rasmussen, 1986) and hierarchical task analysis (Annett and Duncan, 1967). The future workflow creates a bridge between the current surgical workflow and the future technological possibilities. It includes a task-based summary of the surgical and technological requirements to create alternate storyboards. WIM is integrated in the requirements analysis stage of the human-centred design cycle to facilitate communication between a multidisciplinary team. Recently, WIM has been implemented in a pan-European multidisciplinary development team to support the development of minimally invasive surgeries. Results indicate that WIM has been particularly useful in identifying and interfacing the surgical requirements with technological possibilities in the development of surgical information systems. The following sections of the paper explain the stages of development, implementation and validation of WIM. Addressing challenge 1, in Section 1 we will first explain the theoretical background of the term surgical workflow and the gaps in the existing surgical workflow frameworks. Section 2 explains the development of the component current workflow in WIM. We formulate this component, based on new data (study 1) and existing literature on task analysis frameworks. We first identified the task boundaries which determine the surgical problem-solving process. We then incorporated the task boundaries to a matrix to represent the current workflow. To address challenge 2: we conducted a second study (study 2) to identity the communication gaps between surgeons and technology engineers in the medical product development process. Section 3 builds upon the findings from the latter study, and explains the addition of future workflow component in WIM. Subsequently, communication stages are defined where WIM can be incorporated within the existing human-centred design cycle. Section 4 illustrates the validation of the WIM framework, which is based on the field application of WIM. The paper concludes with the benefits and limitations of the framework.

The knowledge of the surgical workflow is a primary requirement for the development of a surgical information system. The surgical processes and requirements related to the surgical workflow have to be critically analysed, validated and prioritised before communicating within a multidisciplinary development team. At the same time, a connection has to be made between the current and future workflows to facilitate the reflection of requirements and possibilities between teams. Aiming to support the central role of the designer in facilitating human-centred development of surgical information systems the contribution of this paper is two fold. Firstly, the proposed framework provides the means for a better understanding of the surgical problem-solving processes in the surgical workspace. Designers, surgeons and technology engineers can apply this framework to analyse the surgical processes and requirements related to the current surgical workflow. Secondly, as a result of the interviews we have outlined some criticalities connected with communication within multidisciplinary development teams, especially between surgeons and technologists. To facilitate the communication of requirements within the multidisciplinary team, we have proposed two solutions: (a) the addition of a future workflow component in WIM to provide a reflective space between the current surgical workflow and the proposed solutions, and (b) the integration of WIM in the human-centred design cycle to facilitate verification, prioritisation and communication of requirements and possibilities. The validation study conducted after 15 months of application of WIM in the development of surgical information system within a multidisciplinary team showed promising results. The results indicate that both surgeons and technologists find WIM helpful as a structured framework for exchanging information of surgical processes and requirements. Additionally, as a practical application, WIM is being used by several technologists for developing user-centred surgical information systems in augmented reality (Kalkofen et al., 2006). WIM framework is currently being applied by several designers and students to assist them in developing workflow driven system for clinicians (Jalote-Parmar et al., in press). Of course, any single method or solution will definitely not suffice in meeting all the challenges of supporting the problem-solving development in a complex workspace, with time critical decision-making tasks, unpredictability of events and low tolerance for errors. Studies indicate certain limitations in WIM allowing scope for further development in the area of improving detailed exchange of technological possibilities. Furthermore, WIM requires a further elaboration in analysing cognitive processes especially during the surprise states. Future studies in this regard will focus on the study of mental models during real-time task performances and their role in (medical) problem solving (Rasmussen, 1986). Research on cognitive processes reveals that the use of information provided to the surgeons change as a function of their background, developmental level and expertise. Though standardisation is necessary, it has its limitations. The question remains as to which extent and to which particular level the surgical information systems can be flexibly adapted for specific surgeons, situations and conditions (Patel et al., 2001; Jalote et al., 2007b). Such research is crucial for an effective use of technological innovations in information systems and provides the scope for future research in extending the proposed framework.