A systems approach to a deeper understanding of a cancer care domain

http://jhi.sagepub.com/Health Informatics Journal

http://jhi.sagepub.com/content/10/3/205The online version of this article can be found at:

DOI: 10.1177/1460458204042234

2004 10: 205Health Informatics JournalOmnia Allam, Alex Gray, Steve McIntosh and David Morrey

A systems approach to a deeper understanding of a cancer care domain

Published by:

http://www.sagepublications.com

can be found at:Health Informatics JournalAdditional services and information for

http://jhi.sagepub.com/cgi/alertsEmail Alerts:

http://jhi.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://jhi.sagepub.com/content/10/3/205.refs.htmlCitations:

What is This?

- Sep 20, 2004Version of Record >>

at OAKLAND UNIV on June 15, 2014jhi.sagepub.comDownloaded from at OAKLAND UNIV on June 15, 2014jhi.sagepub.comDownloaded from

http://jhi.sagepub.com/

http://jhi.sagepub.com/content/10/3/205

http://www.sagepublications.com

http://jhi.sagepub.com/cgi/alerts

http://jhi.sagepub.com/subscriptions

http://www.sagepub.com/journalsReprints.nav

http://www.sagepub.com/journalsPermissions.nav

http://jhi.sagepub.com/content/10/3/205.refs.html

http://jhi.sagepub.com/content/10/3/205.full.pdf

http://online.sagepub.com/site/sphelp/vorhelp.xhtml



A systems approach to a deeper understandingof a cancer care domain

Omnia Allam, Alex Gray, Steve McIntosh and David Morrey

The article demonstrates the use of a holistic systems approach (soft systemsmethodology [SSM]) in the analysis of the cancer care domain to identify whetherthis creates a system more appropriate to the needs of cancer care teams withinthe NHS. It describes the current stage of a research project by the Departmentof Computer Science at Cardiff University in collaboration with Velindre NHSTrust, the South East Wales cancer centre. The aim of the project is to provideinformation effectively to cancer care teams by creating a system to extend thecurrent cancer network (the Information System for Clinical Organization [ISCO])to primary care. This extension will provide a communication bridge betweenprimary care and the cancer network. The article gives an overview of the project,followed by a detailed discussion and justification of the holistic approachadopted by the use of SSM, and concludes with a critical evaluation.

Keywordscancer care, ISCO, soft systems methodology

Introduction and aim

This research is carried out in collaboration with the Clinical Information Unit at VelindreNHS Trust, the South East Wales cancer centre. This hospital is the coordinating centre ofcancer care in South Wales. In addition to providing general cancer services it is also thecentre for Breast Test Wales, Cervical Screening Wales, the Welsh Blood Service and theWelsh Cancer Intelligence and Surveillance Unit.

The aim of this project is to investigate and determine the information needed tosupport cancer care teams whose members have diverse skills and work at different levels

205

Article

Copyright © 2004 SAGE Publications (London, Thousand Oaks, CA and New Delhi)Vol 10(3): 205–220 [1460-4582(200406)10:3;205–220; DOI: 10.1177/1460458204042234]www.sagepublications.com

Health Informatics Journal

at OAKLAND UNIV on June 15, 2014jhi.sagepub.comDownloaded from

www.sagepublications.com


in the healthcare spectrum (primary, secondary and tertiary); and to supply this infor-mation in an effective way to team members so that they are aware of the complete treat-ment requirements and can make more informed decisions on ways to progress thetreatment. This will involve identifying the information required by team members, deter-mining where it is available, and recommending how to create an improved spectrum ofinformation systems, based on the current system, which will provide this information inan effective form in the right place at the right time.

More information about the strategy of cancer care in South Wales and the existinginformation system (the Information System for Clinical Organization, ISCO) is given inAppendix A.

Approach to the project

The pilot study

A pilot interface that links a number of GPs’ systems with the ISCO information systemwas implemented and evaluated as a precursor to this project [1]. The main aim of thisrapid implementation was to assess the feasibility of the project’s goal to provide infor-mation across the different levels of the healthcare spectrum and to ensure that thebenefits of the required system would outweigh the cost. The outcome of the pilotdemonstrated a broad acceptance of the project aims by care team members at all levels;moreover, it showed positive awareness among the clinicians of the need to improve thecurrent information system with respect to the information given to care teams at alllevels. They certainly found the existing link between primary care and the cancer networkinefficient [2]; however, they could not express clearly how to improve it.

The current work

A detailed review of the ideas developed and tested in the pilot [1] was undertaken inthe initial phase so that it could be used as a starting point for further work toward deter-mining the information requirements to build an appropriate system.

Why is it important to define the information requirements?

A survey study by the British Computer Society [3] investigated the perception of why ITprojects fail.1 The survey involved detailed questioning of 38 members of the BCS, theAssociation of Project Managers and the Institute of Management. Managers were askedto share 50 points across at least three factors that they identified as the main causes offailure from their perspectives. Figures 1 and 2 show the number of times each factor wasmentioned and the score given to each one.

Managers were asked to identify the stage of the system development cycle at whichfailure could occur. Figure 1 demonstrates that all stages were selected, but failure at therequirements definition stage led the way by some distance as being the stage most likelyto cause failure.

Causes of failure once a project started were analysed in a separate question. Thisanalysis again had requirements as the prime cause. This demonstrates the perceived

Health Informatics Journal 10 (3)

206



importance of a good requirements definition in the successful creation of a new system.The top seven issues from this analysis are shown in Figure 2.

System development strategy

In this project it is important that the investigators appreciate the complexity of thesystem. This is due to the NHS’s structure. It is not a single organization but a loose confed-eration of thousands of GPs’ surgeries, pharmacies, hospitals and clinics. In this situationwe are dealing with different autonomous units interacting within the system in terms ofpeople, technology and process, all having different perspectives, roles and goals for theirinvolvement.

Although not simple, the computer aspects of a system are closed and predictable.The human aspects on the other hand are open and non-deterministic. Additionallypeople may react differently when examined singly against when they play a role in thewhole system. Therefore a holistic view was required. This recognizes that the whole isgreater than the sum of the parts, and the automatic assumption that computer solutionsare always appropriate should not be adopted from the outset [4].

In such a system, in order to identify the information requirements it is important thatan objective analysis is undertaken to determine them. This analysis must be conductedin an environment that avoids assumptions based on the ways things are currently done.

Allam et al. Understanding cancer care domain

207

Figure 1 Stages at which projects fail (source: [3])

0

10

20

30

40

50

60

70

80

Req

uire

men

ts d

efin

ition

Impl

emen

tatio

n

Use

r acc

epta

nce

test

ing

Pro

ject

pla

nnin

gP

roje

ct id

entif

icat

ion

Dev

elop

men

tP

roje

ct in

itiat

ion

Sys

tem

test

ing

Sys

tem

des

ign

Pro

ject

reso

urce

est

imat

ion

Use

r tra

inin

gP

roje

ct s

taff

train

ing

Frequency mentioned Importance



System analysis

Analysis is by definition:

A thorough study of a problem domain, the achievement of understanding of and thedocumentation of the characteristics of that domain and the problems (requiringsolution) that exist within that domain. [5]

Kovitz and Greenwich [6] divide analysis into two parts:

● Learning about the problem and the problem domain from the customer.

● Communicating this information to the rest of the development staff by writing therequirements document.

These definitions raise two main questions with respect to the project:

● What is the problem(s) which this project will try to solve? How should theproblem(s) be defined?

● How should the problem(s) be communicated between the users (GPs) and theISCO development team (computer scientists)?

In attempting to answer these questions in the pilot, no straightforward answer wasfound to identify the problem(s), mainly because the system involves people with differentperceptions, who may have conflicting ideas and/or objectives. This makes the task ofidentifying the information requirements harder as it has to cope with the diversity of


208

Figure 2 Reported cause of information systems project failure (source: [3])

0

10

20

30

40

50

60

70

80

Unc

lear

obj

ectiv

es a

nd re

quire

men

ts

Lack

of b

usin

ess

com

mitm

ent

Bus

ines

s re

quire

men

ts c

hang

ing

Poor

com

mun

icat

ions

Poor

qua

lity

stee

ring

grou

p

Poor

pro

ject

pla

nnin

g

Com

pany

and

pro

ject

pol

itics

Frequency mentioned Importance



views and objectives and combine these to achieve the common goal of identifying andpursuing the best treatment for the patient.

Ignoring the holistic view and looking at the required system from a traditional comput-ing point of view, we would develop an improved computerized interface to replace theexisting system based on letters that comprise the link between the GPs and the ISCOsystem (e.g. a referral letter is used by the GP to refer the patient to the acute hospital).This approach deals with the problems discovered in the initial analysis. However:

● There is a risk in implementing the problems inherent in the current system ratherthan thinking about the system in the wider context (the aim should be toimprove the system, not merely speed up the current process).

● It will provide a very specific solution, which cannot be used in a generic way.

Having recognized the dangers at this point, we faced a challenge with an associatedtradeoff, namely: either to accept the risk of undertaking a quick fix for the benefit of ashorter delivery time and initial user satisfaction by providing users with working softwarebased on an incomplete understanding of the domain; or to spend more time gaining adeeper understanding of the domain and providing explicit models of the perceivedreality. Such a fuller appreciation of the system is fundamental to successfully determinethe information requirements.

Both the problems are not understood, or not identified, and therefore the informationrequirements which are supposed to address these problems are inappropriate or, atworst, not known. [7]

This quotation identifies one of the fundamental difficulties in system design. The needto fully understand the domain is vital to the design of a suitable system.

The complexity of the NHS system, in addition to the previous factors shown in Figures1 and 2, led us to take a structured approach to understanding the nature of the domainand to making the existing assumptions explicit to the different stakeholders.

What we did

We decided that we should undertake this fuller analysis to be able to identify and addressthe fundamental causes of the existing problems, as this would lead to the developmentof a better solution in the new system.

Soft systems methodology (SSM) was chosen for the problem(s) analysis. This struc-tured approach is designed to deal with soft and fuzzy information in order to identifythe problem. (An outline description of SSM as perceived by the authors is included inAppendix B.) The systemic nature of this methodology supports an analysis of the cancercare system as a whole, not just the GP interface, with the aim to:

● Provide a sound understanding of the information requirements, and to supportthe design of a good infrastructure of the new system that extends the ISCOinformation system to primary care.

● Offer a solution that can be used in a generic way and is not disease specific.This allows flexibility and extendability of the system (the link between theprimary care and other areas of healthcare is essential to build an individualelectronic health record for each person to exist from birth to death).


209



How we did it

Exploring the current situation

This is based on the investigator’s wide knowledge of the domain, resulting from hermedical background and work as a hospital doctor for several years, together with theknowledge and experience gained from the pilot study and her recent training in IT. Thishelped in informing the construction of the presented root definition without the needto draw a rich picture of the situation.

Forming root definitions of relevant systems

The root definition shown in Figure 3 is a generic statement developed using SSM whichdescribes the cancer care system at an abstract level. It shows a compromise view of boththe medical professionals and the managers [8, 9]: presenting only one root definitionagreed by different stakeholders was an essential diplomatic solution at that stage.

Developing conceptual models

This root definition guided the development of the conceptual model shown in Figure 4.This is a model of the cancer care system at a generic level. It shows a logically derivedset of activities that must go into the system to be consistent with the description in theroot definition (Figure 3) and the logical dependencies between these activities.

This model has the submodel shown in Figure 5, which illustrates the set of activitiestackling the diagnosis and treatment of cancer. It shows us that:

● Activities 1–13 answer the question: how should we diagnose and treat cancer?

● Activities 14–17 all relate to performing the diagnosis and treatment of cancer.

● Activity 18 is the monitoring of the processes of diagnosis and treatment ofcancer.

● Activity 19 is the control action to ensure that diagnosis and treatment of cancerare carried out.

These are matters of interest to medical professionals.


210

Figure 3 A root definition describes the cancer care system at its abstract level

A system operated by healthcare professionals to improve the quality of life of thesuspected cancer patients by diagnosing and treating cancer while recognizing the

constraints of the health service environment.

C : suspected cancer patientsA : healthcare professionalsT : improve the quality of lifeW: diagnosing and treating cancer will improve the quality of lifeO : not specifiedE : health service environmental constraints



Critical evaluation

In applying SSM to this area the investigators have learned much. First, investigating thesystem only at the interface level and conducting a separate analysis at the primary careend would identify some of the GPs’ requirements with no reference as to what is happen-ing at the other end of the link (the cancer network). On the other hand, employing aholistic view as found in SSM allows us to explore the cancer care system as a whole, andrecognize the dependency and interactions between the processes in the system (thedeveloped model demonstrates that there is no linear relationship in these links). Repeti-tion of the same blood test at the same time by both the GP and the hospital is an exampleof a redundancy that exists in the current system. This is due to the slow interactionbetween primary care and the cancer network.

Second, SSM looks at the process unconstrained by the existing system. Comparingthe idealized processes of the model with reality forces the evaluation of the currentprocesses and the tackling of the problem from its root. A good example of this is the GPreferral action [10], which is a strong contender for automation if it is to meet the 2 weeksreferral goal stated by the minimum standards [11]. However, modelling the perceptionof this action raises different concerns from those found by a simple consideration of thedomain: is speed improvement all we need to meet this requirement? For instance:


211

Assess patientssymptoms and signs

Rejectdiagnosis of amalignancy

Assess the treatmentoptions

C

CA

Activityinformation

Activityinformation

CAActivityinformation

CC

CA

C

Determine how toassess treatment

options

Allocateactivities tohealthcareprofessionals

CA

C

Determine whether thequality of life improved by

diagnosing and treating cancer

Define healthcareprofessionals

Activity informationConstraints CControl action CA

A system operated by healthcare professionals toimprove the quality of life of the suspected cancerpatients by diagnosing and treating cancer whilerecognizing the healthcare service constraints.

Figure 4 A conceptual model of the system defined in Figure 3



● Does the GP know exactly to whom a particular patient should be referred?

● Do we have an appropriate referral system in place (e.g. an agreed referral letter)?

● And a far more fundamental question: is it appropriate from the system point ofview to have the existing boundaries between primary and secondary care thatcreate the need for a referral system?

Third, in addition to the gaining of a deeper understanding of the problem, raising thisdiscussion allows us to challenge the current assumptions by comparing the developedmodel against reality. For this comparison we used the following checklist for each activity:

● Is it done now?

● By whom?

● How?

● Is it monitored?

● How is it monitored?

● Judgement.

● Recommendation.


212

Figure 5 A submodel of the system shown in Figure 4

Activityinformation

2 Assess patientssymptoms and signs

16 Selectthe appropriatetreatment

10 Assess thetreatment options

9 Determine how toassess treatment

options

Constraints

Controlaction

7 Reject diagnosisof a malignancy



We found that everybody we interviewed assumes that the GP referral action is moni-tored. However, nobody is able to inform us who is monitoring the referral process, andwhat happens if a GP over-refers or under-refers the cancer patients. Through discussionand observation we found that this process does not exist at the network level. Few Trusts(if any) are monitoring GP referrals, and the monitoring criteria are not accessible fromoutside those Trusts.

Fourth, the model shows where the system boundaries cross the process boundaries.(Sometimes the activity is shared between both primary and secondary care, e.g. assess-ing patient symptoms and signs.) These ill-defined boundaries create a potential problemas the responsibilities are not clear. Comparing the developed model against reality canhelp in redefining roles and organizational structure to produce a more effective system.

Fifth, the precisely defined words used in both the root definition and the conceptualmodel offer a good communication medium between the users and the system develop-ment team. The use of English as the modelling language facilitates this communicationas there is no need to learn a specialized sublanguage suited to the domain.

Sixth, the SSM view of the human activity system (HAS) focuses on purpose. Acknow-ledging the human and cultural issues helps in providing an explicit, organized and defen-sible way of reconciling differences and/or conflicting perspectives within a completesystem. Even if the differences cannot be resolved it is useful to expose them and enablebetter understanding of the causes and allow the action required to be defined withrespect to this fuller understanding.

In our case, as there is no existing system to link primary care with the ISCO infor-mation system, the idealized processes included in the model provide a good and agreedbasis for the system design in our future work.

However, we also faced some barriers and constraints. First, although the reason forusing SSM is its ability to model different viewpoints, it was essential at the first stagesof modelling to develop a generic model reconciling the medical professionals’ andmanagers’ viewpoints (an agreement base at the beginning was an essential diplomaticsolution to gain their cooperation).

Second, there are difficulties in collecting information from the stakeholders mainly forpolitical reasons. They may believe that information is authority and they do not want tolose this authority; or they may claim perfectionism and not be ready to admit failure.

Third, the benefits of using SSM are not very clear to the users at this stage: they areinterested in a running software, not models or diagrams, no matter how good or prettythey are. In addition, there is a major difficulty in getting them to think in a conceptualway unconstrained by the existing reality: they often answer the ‘how’ not the ‘what’.

Fourth, SSM exposed the existing problems and provided recommendations for thesolution. The investigators cannot force the solution; the decision will be strategic andmanagerial.

How to take this model forward

This model is an agreed statement of the required cancer care system at its generic level.For the subsequent stages we will model different and/or conflicting viewpoints. Thesemodels will be used to develop a consensus primary task model (CPTM) which will beused to:


213



● Identify the problem(s) by recognizing the gap(s) between the model and reality.This drives recommendations for improvement by changing the process, bychanging the technology and/or by addressing people issues (e.g. competence,skills and authority).

● Provide a source of information acquired by converting the activity model to aninformation flow model as shown in Figure 6.

● Deliver the basis for the design as it provides the standards by presenting theidealized processes.

● Offer a communication medium between the users and the system developmentteam, which will enable users to understand concepts of the system beingdeveloped.

Conclusion

SSM provided an organized defensible approach to understanding the domain deeply andto demonstrating the concepts and assumptions explicitly. The use of SSM in modellinga complex situation is not new to health informatics. SSM has been used in many healthinformatics projects in order to gain a deeper understanding of the existing problems. Forexample a large teaching hospital in Melbourne, Australia is used as a case study todemonstrate the use of SSM to explore and define problems arising when knowledge isgenerated in searching for evidence-based healthcare [12]. Atkinson et al. [13] explainhow the soft and systemic approach employed in SSM may be used to create agendasfor strategic and operational decision making associated with integrated approaches tohealth informatics research and development.

The holistic view employed by SSM allowed us to investigate how to improve the cancercare system as a whole. We believe that this is the general aim of the stakeholders. Forinstance the success of diagnosing cancer in a shorter time, say within a few weeks, willbe lost if it takes the patient a year to be referred to the appropriate specialist because


214

Figure 6 Converting the activity model to an information flow model

What information needs to be available?

From what source?

In what form?

With what frequency?

In what form?

With what frequency?

To whom should it go?

What information would begenerated by doing this activity?

What information do I need to assesshow well I am doing the activity?

Activity?



other parts of the system are too slow or cause bottlenecks to occur. After all, the holisticsystem thinking approach of SSM is very natural to the medical profession, who are trainedto view the patient as a whole and not limit their view to the diseased organ.

Despite the limitations encountered, and although the model produced is still at a veryabstract level, it has helped in different ways to take the work forward to enhance thesystem development. From these factors, it can be concluded that the use of SSM hasbeen a success so far and will lead to the development of a better system.

Appendix A: the strategy of cancer care in South Wales

In the majority of cases, patients are referred to the cancer centre initially by their GP, whorefers a suspected cancer patient to the acute hospital. This is in accord with referralguidelines and protocols adopted by specific tumour site professional groups [14]. Theaim is to get the health complaint thoroughly investigated. If the diagnosis of a malig-nancy is established, a comprehensive management plan (individually tailored for eachpatient) is set up by a multidisciplinary team (MDT), comprising specialist doctors, nursesand other professions allied to medicine (e.g. a pharmacist, a dietician and a socialworker), and the patient is transferred to the cancer centre (CC). The GP must be informedof the diagnosis within 24 hours of the patient being informed [11]. At this stage thepatient’s main contact is usually the cancer centre. At the moment continuing contactwith the GP is also essential. Indeed, GP participation is currently important if palliativecare support is needed.

Figure 7 illustrates the information flow occurring in this process. It shows the infor-mation flow links that must currently occur between GP, MDT, CC and the palliative care(PC) team in the treatment of cancer patients.


215

Figure 7 Management of a cancer patient information flow

GP

GP

GP

GP

CC

CC

PC

GP: General practitionerMDT: Multidisciplinary teamCC: Cancer centrePC: Palliative care

GP database systemISCO information systemCommunication letters

Initial medical complaint

Malignancy suspicion

Malignant disease management

Involvement of palliative care

Confirm diagnosis

Referral

Inform

GP

GP

GP

GP

CC

CC

CC

PC

MDT



The existing information system

At the moment the ISCO [15], developed and used by Velindre Hospital since 1991, offersmultiprovider electronic case notes of cancer patients in certain areas of South Wales.2

These notes are currently available to clinicians in secondary and tertiary healthcare inaddition to palliative care, but are not available electronically to primary care. Primary careis largely excluded because of the gap that exists between GPs’ information systems andhospital-based clinicians’ information systems, and the separate systems of the cliniciansproviding palliative care.

This leads to a heterogeneous collection of autonomous systems, which are difficultto link into a single system [16].

The need for the GP–ISCO link

The information need of primary care in this area is defined as an important issue in theCancer Service Information Framework [14] published by the National Assembly for Walesin April 2000.

The Cancer Development Plan of the Cancer Services Co-ordinating Group (CSCG)published in December 2002 states [17]:

Patients often present to their GP with non-specific symptoms, which would notnecessarily indicate a diagnosis of cancer. This presents a clear challenge to primarycare as under-referral may delay the time to diagnosis with possible detrimental effecton outcome. Over-referral may swamp outpatient clinics and increase waiting time.Development in information and communication technology will provide thecommunication bridge between primary and secondary care; this will maximize thebenefits and result in earlier diagnosis.

There is a strong belief in the medical world that an efficient communication link acrossthe whole spectrum of cancer care is essential in order to avoid confusion and conflicts,and to provide the highest standard of care [2, 9, 18].

All these factors created the motivation and encouraged the investigators to take stepsto fill the gap between the GPs and the cancer network presented by the ISCO system.

Appendix B: soft system methodology (SSM)

SSM is a structured approach to help in understanding the real world by defining problemswhich are not clear-cut but fuzzy and ill-structured. It is a practical methodology thatadopts systems theory and views the organization in its wider context. This holistic viewincludes human activity systems (which acknowledge the fact that people in organizationsare pursuing purposeful activity) as well as the technical aspects. SSM recognizes thatthere are different valid viewpoints: the central focus of the methodology is the searchfor a relevant view(s) which the analyst aims to extract through a debate on the mainpurpose of the organization. This Weltanschauung will be used in the following stagesto form the basis for analysing the system requirements. (Weltanschauung is a Germanword that has no real English equivalent; the nearest is ‘world view’.) The strength of SSMcomes from not having any predetermined ideas of the solution, and the use of thismethodology gives a better understanding of the problem situation.

The authors’ perception of the methodology is shown in Figure 8.


216



How does SSM work?

Find out about the problem situation

At this stage the analyst gathers different views regarding the situation. It is important toreveal as wide a range of views as possible; even if the differences cannot be resolved itis useful to expose them.

Express the situation

It is up to the analyst’s style and the nature of the situation to express the situation discov-ered. There is no prescribed method of doing this; however, there is a tendency to drawrich picture diagrams of the situation. This description usually shows people involved,problem areas, controlling bodies and sources of conflict. This helps in problem identifi-cation, not in the process of recommending solutions [19], and informs the constructionof root definitions.

Root definitions of relevant systems

Root definitions (RDs) do not exist in reality; the equivalent in real-world terminologymight be business objectives or mission statements. At this stage we move from the realworld to systems thinking about the real world (Figure 9). In this intellectual process theanalyst forms a kind of hypothesis or a set of assumptions about relevant systems in orderto capture the root purpose of the organization. This technique is useful to define preciselywhat human activity system (HAS) is to be dealt with and what problem is to be tackled.

The root definition is a concise, tightly constructed description of a human activitysystem which states what the system is. [20]

Each RD will derive from a particular view of reality to describe a transformation process(T) and the belief or Weltanschauung (W) that makes the transformation processmeaningful. To ensure that the RD is well formed and the words used are precisely


217

Figure 8 The authors’ perception of the methodology in this context

Define rootdefinitions of

relevant systems

Find out aboutthe problem

situation

Express the situation

Map currentinformation

provision andcompare against

requirements

Define changes:desirable,feasible

Maporganizational

structureProvide

communicationmedia

Compare to achieveaccomodation

of views

Real world

Systems thinking about the real world

Compare

Develop conceptual models



defined, its components are checked using the mnemonic CATWOE: ‘CATWOE must bea test of the structure and words chosen in the RD’ [7].

● Customer: the beneficiary or victim affected by the activities.

● Actor: the agent who carries out the transformation process.

● Transformation process: the change taking place, ‘the core of the RD’ [21].

● Weltanschauung: the assumptions or beliefs that make the RD meaningful.

● Owner: a wider system decision taker with authority over the system defined, i.e.the sponsor or the controller.

● Environmental constraints: the significant features of the wider system of whichthe problem situation is a part.

Develop conceptual model (CM)

The conceptual model represents an explicit way of thinking about the problem situation.It demonstrates what the system must do in order to be the one defined in the RD, byshowing a logically derived set of activities that must go into the system as well as thelogical dependencies between these activities.

The CM is not a model of the situation but a model of concepts relevant to the situ-ation. Each model is relevant to the situation but none of them is a representation of it:therefore it cannot be validated by testing against the real world. However, testing theCM against the formal system model (FSM) determines if it is well enough structured tobe a model of the HAS [7]. The FSM considers the following features:

● Purpose. Does the model derived achieve the purpose defined? This questiondetermines the degree of defensibility of the model.

● Connectivity. As the model represents a system and not just an aggregate, theactivities need to have the complete logical connection.

● Hierarchy. This system is located at some position within a systems hierarchyextending from wider systems to subsystems.

● Measures of performance. This information is required to monitor variousactivities in the model.

● Decision-taking process (controller). The control subsystem ensures that if theseactivities exist in the real world, then they would work together to achieve thedefined purpose.


218

Figure 9 Systems thinking about the real world [22]

The realworld

Description ofor relevant to

some aspects ofthe real world

Set ofassumptions



● Resources. Does the implied authority of the controller cover the total resourcesavailable to the activities?

● Boundary. Does this represent authority within the system boundary?

How the CM could be used

The following examples demonstrate some of the several ways of using the models:

● To compare against reality in order to: use them as a source of informationrequirements; make recommendations for desirable and feasible changes;redefine roles and organizational structures.

● To form a single model reconciling the many perspectives representing a ‘taken-to-be’ description of the organization.

● To provide a communication medium between the customers and the system’sdesigners and programmers.

Notes1 Success was defined as delivering to the sponsor everything specified, to the quality agreed on,

within the time and cost laid out at the start.2 A separate project by the Cancer Information Framework (CIF) is concerned with extending the ISCO

system to become the Cancer Network System for Wales (CaNISC: Cancer Network InformationSystem Cymru).

References1 Allam O, Gray W A, Jones W, Bater A, Morrey D. Designing an information interface to support

sharing of information in cancer care. In Proceedings of the 7th International Symposium of HealthInformatics Management Research (ISHIMR 2002). Sheffield: Sheffield University, 2002.

2 Personal communication, Dr Glyn Elwyn, Director of Research, CAPRICORN Research Network,Croesnewydd Hall, Wrexham Technology Park, Wrexham LL13 7YP. http://www.capricorn.uk.net

3 Taylor A. IT projects sink or swim. The Computer Bulletin Professional Practice. The British ComputerSociety, 2000. http://www.bcs.org.uk 2003 February.

4 Avison D E, Fitzgerald G. Information Systems Development: Methodologies, Techniques and Tools2nd edn. New York: McGraw-Hill, 2000.

5 Bray I K. An Introduction to Requirements Engineering. London: Addison-Wesley, 2002.6 Kovitz B, Greenwich C T. Practical Software Requirements. A Manual of Content and Style.

Manning, 1999.7 Wilson B. Soft Systems Methodology: Conceptual Model Building and its Contribution. New York:

Wiley, 2001.8 Personal communication, Dr Andrew Champion, Assistant Director of Cancer Services, Cancer

Services Co-ordinating Group, NHS Wales.9 Personal communication, Dr Jane Hanson, Cancer Services Co-ordinating Group, NHS Wales.

10 Department of Health. A Policy Framework for Commissioning Cancer Service: A Report by theExpert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. 1995.http://www.doh.gov.uk 2003 February.

11 Cancer Services Co-ordinating Group (CSCG). All Wales Minimum Standards. NHS Wales, 2000.12 Fennessy G. Knowledge management in evidence based healthcare: issues raised when specialist

information services search for the evidence. Health Informatics Journal 2001; 7; 4–7.13 Atkinson C, Eldabi T, Paul R, Pouloudi A. Integrated approaches to health informatics research and

development. Logistic Information Management 2002; 15 (2); 138–52.


219



14 Griffiths Jayne. Cancer Service Information Framework: A Strategic Report by the Cancer ServicesCo-ordinating Group. NHS Wales, 2000.

15 Velindre NHS Trust. ISCO Information System for Clinical Organisation. Internal document 1999.Submission by Velindre Hospital, Velindre Road, Cardiff CF14 2TL.

16 Morrey D, Jones W, Bater A, Howells D, Finlay I. Implementation of a multi-provider clinicalinformation system to co-ordinate palliative care. In Proceeding with Healthcare Computing. London:British Computer Society Health Informatics Group, 1999.

17 Cancer Services Co-ordinating Group (CSCG). Cancer Service Strategic Development Plan2003/04–2007/08. NHS Wales, 2002.

18 Personal communication, Professor Ilora Finlay, Department of Palliative Medicine, University ofWales College of Medicine.

19 Avison D E, Wood Harper A T. Multiview: An Exploration in Information System Development.Maidenhead: McGraw-Hill, 1990.

20 Checkland P. Systems Thinking, Systems Practice. Chichester: Wiley, 1981.21 Smyth D S, Checkland P B. Using a system approach: the structure of root definitions. Journal of

Applied System Analysis 1976; 5; 1.22 Brian Wilson and Associates. Workshop: Soft Systems Approach to Management Problem Solving.

Department of Computer Science, Cardiff University, 2002.

Correspondence to: Omnia Allam


220

Omnia AllamComputer Science Department, Cardiff University, Queen’s Buildings, NewportRoad, PO Box 916, Cardiff CF24 3XF, UKEmail: [email protected]

Alex GrayComputer Science Department, Cardiff University, UKEmail: [email protected]

Steve McIntoshComputer Science Department, Cardiff University, UKEmail: [email protected]

David MorreyVelindre NHS Trust, Velindre Hospital, UKEmail: [email protected]



Documents

A systems approach to a deeper understanding of a cancer care domain