The PROCAS (PRofiles Of CAre System) project is one of the third framework AIM projects (A2030), under project line 7: Regulatory Tools and Quality Assessment, whose objectives are to improve the quality and efficiency of medical treatment. These objectives will be realised by establishing a methodology for defining and developing what are termed "Profiles of Care" (PoC). These are sets of options for clinicians which provide acceptable ways of managing patients with similar medical conditions using good clinical practice.
The target of PROCAS is to construct explicit PoCs, with regard to a group of patients with similar conditions. PROCAS is limited to the medical diagnostic-therapeutic section of care. Nursing and para-medical care, supporting services and hotel services are excluded. PoCs are disease specific and can be used by doctors as a guide in the selection of the most effective strategy to manage each clinical problem.
The concept of the PROCAS project involves the linking of a specific health problem of a patient with a specific package of care. The latter is a list of optional diagnostic-therapeutic possibilities which play a role in the management of a disease. In the PROCAS project, these lists are called "potential health care plans" and may be connected with a symptom, sign or a diagnosis.
Clinical and medical work has been undertaken in order to build up the necessary data required for the PoC approach, in respect of the two clinical domains: cancer and cardiovascular diseases. Data from these exercises has been compared and reviewed by partners so as to develop a sound PoC model.
The sequence of clinical activities has been carefully identified to provide an orderly and acceptable approach capable of being implemented in a departmental information system.
Differences in approaches and nomenclature at different sites and different countries have been identified. Work was undertaken to establish a sound framework within which clinicians and medical teams at different sites could work relating particularly to procedures and common terminology.
The technical approach for PoCs required the early establishment of a prototype installed at different sites, under different organisational and technical circumstances. A PC system was developed to enable effective quality control of the medical process.
After an extensive review of the medical scope and of the user interface the consortium produced an advanced prototype (under Windows using Visual Basic and Microsoft Access) for effective clinical usage.
Validation and verification of the prototype is taking place in three hospitals: Istituto Scientifico H. San Raffaele in Milan, STICARES Cardiovascular Research Foundation, Zuiderziekenhuis in Rotterdam, and Centre Hospital Regional in Nice.
At a clinical level, the work is providing a valuable contribution to make medical reasoning explicit and to provide patient care which represents good clinical practice.
The PROCAS project has the main goal to develop computerised PoCs useful both for clinical management and quality assurance (QA).
The PoC concept is that the doctor's decision to "use" diagnostic or therapeutic procedures is linked to the patient's problems and the doctor's objectives.
PROCAS is a structured Order Entry system supporting locally current diagnostic-therapeutic management. The PoC approach tries to identify and standardise reproducible groups of health problems and working diagnoses for each disease, and associates them with corresponding objectives and procedures. Furthermore the clinical support is split into a series of decisional processes (from the initial problem to the final diagnosis).
Each step called Health Care Plan (HCP) contains "potential" procedures (identified by "clinical consensus") representing good clinical practice. The PoC software tracks the patient oriented flow of information and stores data generated by the clinical process. QA on clinical processes is performed through the comparison between observed and expected actions (process evaluation) and clinical management overviews. The first PoC tested in the PROCAS project is related to Breast Cancer. The clinical process is described by five different HCPs:
The actual work is related to testing the Breast Cancer PoC in different clinical environments to validate the PROCAS software and the QA process.
A second PoC was related to Prostate Cancer. Using these two PoCs clinical experimentation was performed retrospectively on 150 case notes to start the quality assurance process in a real clinical environment.
A key issue for effective collection and exchange of medical data, was the availability of a coding and classification system to reduce variability in terminology and clinical practice. Various options, already available on the market have been considered and experimental use of the READ, ICD-9-CM and ICD-10 classification systems has been implemented.
The PROCAS system provides three main areas of functionality.
The main functions related to the order entry system, involve an Admission module, and the Profile of Care creation module. By entering a diagnosis/problem and the specific objective, the system will lead the doctor through the Health Care Plan creation helping him to choose the procedures and investigation for this specific diagnostic step. The procedures performed during the previous steps are highlighted, thus avoiding a duplication request. Those procedures which should have already been ordered/performed in each step of the diagnostic/therapeutic path, are also summarised.
The discharge feature will fill in automatically the clinical abstract, taking the basic data from the Profile of Care, and allowing the doctor to enter the final modifications.
The Medical Audit activity is made possible by the production of different reports. A global view of the patient's profiles or a detailed view of a single profile of care, performing a sophisticated analysis between the potential and the effective health care plans, may be obtained.
The Database Administrator functions facilitate the definition of the hospital structure and the maintenance of the potential health care plans according to the specific requirements.
The PROCAS system supports medical reasoning by providing sets of options of treatment for specific stages of disease in oncology and cardiology. Representing good clinical practice it refers to the guidelines published in literature. The identification of the diagnostic steps and the associated procedures and therapies, may lead to an approach of resource management and control based on the monitoring of the clinical process.
Dr. Paolo Di Loreto Scientific Institute Hospitale San Raffaele Via Olgettina 26 20132 Milano Italy
Phone: +39-(2)-2643-2072 Fax: +39-(2)-2643.4704
Professor Ray Jackson Medical Advisors Limited Shepherds Cottage East Chiltington BN7 3AA Great Britain
Phone: +44-(1273)-890485 Fax: +44-(1273)-890394
Dr. Caspar M. B. Duwel STICARES Cardiovascular Research Foundation/Zuiderziekenhuis P.O. Box 52006 3007 LA Rotterdam The Netherlands
Phone: +31-(10)-4855177 Fax: +31-(10)-4854833
Dr. Fabrice Boulay Centre Hospital Regional Medical Information Dept. 5 Rue Pierre Devoluy F-06006 NICE
Phone +33.92.03.35.70 Fax +33.92.03.35.69
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