1. The Snow Project Methods April 2008 Johan G. Bellika ab A Department of Computer Science, University of Tromsø B Norwegian Centre for Telemedicine, University Hospital of North Norway

2. Agenda Some historical quotes The Snow projects research question Overview of methods –“The tower of achievements” Outcome evaluation Finding the “correct” ICT solution

3. Hippocrates, 2400 years ago “... there is nothing remarkable in being right in the great majority of cases in the same district, provided the physician knows the signs and can draw the correct conclusions from them” Source: Hippocrates, Prognosis, in Hippocratic Writings, G. Lloyd, Editor. 1983, Penguin. p. 170-185. The father of medicine

4. Merwyn R. Greenlick (1992) “... the probabilities that a physician faces with an individual patient in a given circumstance are specific to the characteristics of the population from which that patient comes. A physician who does not have data on these specific populations does not have all of the relevant knowledge necessary to treat the patient.” Source: Greenlick, M.R., Educating physicians for population-based clinical practice. Jama, 1992. 267(12): p. 1645-8. Professor Emeritus of Psychiatry and Public Health and Preventive Medicine, Oregon Health & Science University

5. Background In 1999, infectious diseases were the second leading cause of death (25%) worldwide 1 WHO has verified more than 1100 epidemic events worldwide over the last five years Nearly 40 diseases have emerged over the last generation 2 At the same time, there is a constant risk of a pandemic 3 The early warning system is weak Source1: WHO. Report on infectious diseases: Removing Obstacles to Healthy Development. 1999 Soruce2: WHO. The world health report 2007: a safer future: global public health security in the 21st century. 2007. Source3: World Health Organization. Responding to the avian influenza pandemic threat. 2005 http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_05_8-EN.pdf

6. The Snow approach: Peer-to-peer exchange of disease statistics data among primary care physicians and institutions involved in disease prevention

7. Snow research question: Will exchange of information about occurrence of communicable diseases among GPs and organizations involved in Infectious disease prevention lead to changes in ”clinical practice” with regard to testing, diagnosing and treatment of such diseases among GPs?

8. What is ”clinical practice” for communicable diseases? Three potential decisions: 1.Treat on suspicion 2.Take a sample and wait for the lab result 3.Await further development and potentially have a new consultation later on 4.Combine 1 and 2

9. Medical informatics method Friedman’s tower of achievements (1995) Model formulation System development System installation Study of effects The phases involved in proving that a system actually leads to improvements consists of the following phases: a model formulation phase a system development phase a system installation in the work environment where it will normally be used and finally the study phase when the system is in production use with the aim of identifying the effects of the system on patient outcome

10. Friedman’s tower of achievements (1995) Model formulation System development System installation Study of effects The final step - system evaluation: “Does it help the patients?” Method: Controlled study Intervention areas: Users will receive information from the system. Control areas: We will only monitor the situations in these areas. Alternative: Use data from the microbiology laboratory (and the GiLab project) to verify whether the system has any effect on laboratory use. Answer the fundamental question: Compared to what?

11. Friedman’s tower of achievements (1995) Model formulation System development System installation Study of effects Model formulation: “a peer-to-peer approach to disease surveillance is better than the current hierarchical and centralized approach”

12. Friedman’s tower of achievements (1995) Model formulation System development System installation Study of effects System development: “Participatory design leads to user acceptance” We therefore choose user involvement and agile software development methodology If my “spine reaction” had been followed, we would probably have failed! What does it take to achieve deployment?

13. Friedman’s tower of achievements (1995) Model formulation System development System installation Study of effects System validation: “Does it work” The pilot will show!

14. Snow design guidelines The participants must have some benefit from participating and using the system Surveillance and emergency response systems must be in regular use to work in an emergency situation = Can disease surveillance data from the local patient population be used for diagnostic assistance? What does it take to achieve deployment?

15. Questions?