Supporting the systematic assessment of clinical processes: the MedFlow method.

OBJECTIVES: Healthcare is characterized by complex cooperation between highly specialized healthcare departments. This often leads to inefficient clinical processes. In order to improve these processes, a systematic assessment method is needed. Such methods are still missing. The objective of this paper is to propose and evaluate a method to support the systematic and semi-automatic assessment of clinical processes, with special focus on the quality of information logistics. METHODS: Criteria for the quality of information logistics were collected based on literature research and system analysis. Appropriate quality checks for these criteria were developed. An extended process modelling notation was developed. The method was evaluated in a pilot study. RESULTS: An own model integrates four sub-models with each concentrating on distinct process aspects (i.e., control flow, data flow, tool usage, organizational information). In order to assess the quality of a process, selected process details are combined in "views". Weak points are then detected by applying specific rule-sets on these views. Each rule-set represents a pattern of critical cross-points which are searched for in the appropriate view-matrix. The MedFlow method was evaluated in a first pilot study in radiological departments--applying quality checks for the detection of e.g. media cracks or testing the transcription of information objects. CONCLUSION: The MedFlow method is best used to assess clinical processes regarding their control flow and information handling. The latter directly influences the quality of communication and thus the quality of whole processes. However, this must be evaluated in further studies.

Gilbert's syndrome and Ramadan: exacerbation of unconjugated hyperbilirubinemia by religious fasting.

Gilbert's syndrome is a benign, often familial condition characterized by recurrent but asymptomatic jaundice. We report two cases of recurrent jaundice due to unconjugated hyperbilirubinemia in Muslim subjects during the fast of Ramadan. As the diagnosis of Gilbert's syndrome was not suspected, both patients were extensively investigated before the relationship to fasting was recognized and the correct diagnosis made. We conclude that the possible exacerbation of Gilbert's by fasting should be borne in mind in the evaluation of Muslim patients with jaundice.

Identification of spheroplast-like agents isolated from tissues of patients with Crohn's disease and control tissues by polymerase chain reaction.

Mycobacterium paratuberculosis has been isolated from tissue taken from patients with Crohn's disease and has been implicated in the etiology of this disease. On culture, the organisms appear initially as cell wall-deficient, spheroplast-like forms that are difficult to identify by conventional techniques. Here we examine 30 unidentified cultures by the polymerase chain reaction using primers specific for M. paratuberculosis, Mycobacterium tuberculosis, and Mycobacterium avium restriction fragment length polymorphism type A/I and also by a non-species-specific mycobacterial polymerase chain reaction. Six of these cultures, all from Crohn's disease, were shown to contain DNA from M. paratuberculosis. Cultures from both Crohn's disease and controls were found to contain mycobacterial DNA of unknown specific origin.

Sarcoidosis.

Sarcoidosis is a multisystem disorder of unknown cause characterized by non-caseating granuloma formation and evidence of enhanced cellular immune response at the site of involvement. Although the majority of patients have a self-limiting illness, a significant proportion develop severe chronic disability.

Detection of mycobacterial DNA in sarcoidosis and tuberculosis with polymerase chain reaction.

The cause of sarcoidosis is unknown. However, the histological similarity between the disorder and tuberculosis suggests that mycobacteria might contribute to the pathogenesis of sarcoidosis. We have used the polymerase chain reaction (PCR) to detect mycobacterial DNA in clinical samples from patients with sarcoidosis. 104 patients were included in the study (62 referred for possible tuberculosis and 20 for possible sarcoidosis, and 22 control patients who had undergone bronchoscopy for other reasons). Bronchoalveolar lavage samples, bronchial washings, and tissue specimens (1 from each patient) underwent assay by PCR as well as bacteriological, histological, and cytological examination. We used two PCR reactions: in the first the complex-specific insertion sequence IS986/IS6110 was used to specifically detect DNA from Mycobacterium tuberculosis complex bacteria; in the second, conserved sequences of the mycobacterial groEL gene were used to detect DNA from mycobacteria other than M tuberculosis. The PCR was more sensitive than culture for diagnosis of tuberculosis. However, the false-positive PCR rate for M tuberculosis was 9%. M tuberculosis DNA was found in half the sarcoidosis patients, and non-tuberculosis mycobacterial DNA in a further 20%. The findings that a significant proportion of the sarcoidosis patients in this study have mycobacteria in their lungs and that most of these mycobacteria belong to M tuberculosis complex suggest an aetiological role for mycobacteria in sarcoidosis.