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Using case-based reasoning to establish a continuing care information system of discharge planning
Expert Systems with Applications 26 (2004) 601–613 www.elsevier.com/locate/eswa
Using case-based reasoning to establish a continuing care information system of discharge planning Chun-Lang Changa,*, Bor-Wen Chengb, Jiun-Lin Sub a Department of Industrial Management, National Huwei Institute of Technology, 64 Wun-Hwa Rd. Huwei, Yunlin 632, Taiwan, ROC Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Touliu 640, Taiwan, ROC
b
Received 4 October 2003; revised 4 October 2003; accepted 1 December 2003
Abstract As family structure changes, population is aging and disease styles tend to be chronic, long-term care in Taiwan becomes problematic, needs to be addressed, and requires immediate solution. Presently, many medical care institutions in the country have assisted patients in discharge planning; however, the lack of a standard evaluation procedure in the process of discharge planning is disturbing for each hospital. Without it, there might be huge differences in the evaluation results. Moreover, the lack of support and the uncertainty of case eligibility standard in these institutions further affect the performance of continuing care services. This research adopted Case-Based Reasoning to establish a continuing care information system of discharge planning. With previously evaluated information of past cases, the similarity index is compared among new cases. In coordinate with Analytic Hierarchy Process, index weight is calculated to reason an old case that is most closely related to the condition of the new case. This information system can assist discharge-planning staff in accurately formulating a plan of action based on previous case-assessment experience and in obtaining valuable information that helps make decision. Through the implementation of the system, accumulation on knowledge and experience of continuing care models will help staff evaluate process of discharge planning to achieve a reasonable, standardized, and simplified procedure as a whole. This research will transform the evaluating experience of discharge-planning professionals into an assessment method with the application of computer reasoning to make the evaluation process of discharge planning convenient as well as to save more time for discharge-planning professionals to further understand the actual conditions of each case. On the other hand, this information system will provide dischargeplanning staff with a set of recommendations as references for making individual discharge plan. It is expected through this research that each hospital be provided with a blue print of improvement in case evaluation process and management. q 2004 Elsevier Ltd. All rights reserved. Keywords: Case-based reasoning; Analytic hierarchy process; Discharge planning; Continuing care
1. Background and objectives Long-term care management has become problematic, needs to be addressed, and requires immediate solutions in the modern society due to the changing family structure, aging population, and the tendency of chronic illnesses. According to the statistics from the Department of Health Executive Yuan, 2001 average life span of males and females in 1992 are 73.0 and 78.8, respectively, which are much longer than that in 1951, 53.38 for males and 56.33 for females. (Council for Economical Planning and Development, 2003) The above statistics indicates that our population characteristic has altered significantly, and * Corresponding author. Tel.: þ 886-5633-2800; fax: þ 886-5631-1548. E-mail address: [email protected] (C.-L. Chang). 0957-4174/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.eswa.2003.12.010
therefore, living and health care will be of equal importance due to the aging population in Taiwan. According to 2000 population census, among the total 2.2 million population in Taiwan-Fukin areas, nearly 2,70,000 of population currently needs long-term care services with elder population near 17,000. They account for 9.1% of the total population for senior citizens. With increasing demands on long-term cares, immediate development and establishment of a sound system cannot await. Furthermore, to effectively promote long-term care services, ‘Discharge Planning’ from the upper stream acute medical care system plays a key role. Nonetheless, successful deployment of ‘Discharge Planning’ requires resource integration within the executed medical care system as well as a complete structure and buildup of a sound information system of long-term cares.
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A comprehensive ‘Discharge Planning’ requires the upper end care plan assessment and satisfies individual needs of post-hospital cares in order to achieve continuous and complete cares. For cases that need long-term cares, their families must have been impacted by tremendous challenges they need to face socially, economically, and psychologically. Without a comprehensive continuing care plan, cases and their families cannot be discharged from the hospital free of worry. However, currently the medical care institutions that provide discharge planning emphasize mostly on the initial arrangement of the care plan and the executive method they use. It lacks a complete manage mechanism that involves assessment, communication and connection, education and development of continuing care institutions and units, and that involves case tracking and assistance, and providing the case available information. Nowadays, most of the continuing care models provided by each hospital do not fit the needs of the cases, their families, and continuing care institutes. Thereby the hospital is unable to implement after care services to be more systematic and standardized to attain continuing and complete cares with the cooperation of the three parties— the cases and their families, the continuing care institutes, and the staff of discharge planning. As such, the objectives of this research are as follows: 1. To locate important consideration factors as references to implement discharge planning when discharge-planning staff is formulating a plan in action. 2. To establish a continuing care information system of discharge planning to transform assessment experiences of discharge planners into the diagnosis method using computer reasoning, with the expectation to eliminate human errors and to reason, simplify, and standardize the overall evaluation process. 3. To draw up initial plans and to provide supporting suggestions to discharge planners (continuing care model: it includes continuing care institutes, medical care equipment and facilities, nursing and health education, consultation units, etc.). 4. To computerize the overall discharge planning process and to reinforce the formulation of discharge plans and its time efficiency upon implementation.
2. Literature review 2.1. Discharge planning Discharge planning is for both a health team (which includes physicians, nursing professionals, social workers, nutritionists, physical therapist, and occupational therapist) and families, through organized, planned, systematic decisions and actions, to ensure the continuum of posthospital health cares. It perceives intuitively the hidden risks, integrates long-term care resources, and under
consideration of human nature and quality medical, health, and living care, best utilizes resources at the most appropriate timing to locate the most suitable care place, and then safely transfer the case or the cared to another caring environment in search for the best solution. The definitions of discharge planning noted in past researches are listed below: 1. American Hospital Association, AHA (1983) define that discharge planning is a process of concentration, coordination, and technology integration, through the cooperation of medical care professionals, the cases and their families, to ensure all cases receive continuing cares after being discharged. It must reflect both inner and outer social, emotional, medical, and psychological needs of the cases and their families and provide assistance, and it must provide continuing cares, follow ups, and understand needs of the discharged cases. 2. Anderson and Helms (1995) claims that discharge planning is for each health team that also includes patients to safely transfer patients to another caring environment through organized and systematical decision actions and with coordination of health care resources. 3. Yu-Tse Dai. (1998) believe that discharging planning is instructing patients with plans and solving their problems as well once they are hospitalized and discharging patients from the hospital satisfied, free of worry, and well prepared in all aspects. Upon admitted to the hospital, the patients are continuously evaluated on what kind of care and resources they might need to maintain good health and quality life when returning to the society. During their inpatient stay, patients are provided with necessary health knowledge, self-care instructions, family consultation, improvement of living environment, available social information, etc. In addition, through the cooperation of medical care teams, patients, upon completion of necessary treatment, are assisted to successfully return to the society or transfer in time to other institute for continuing cares. 2.2. Referral service An effective plan of discharge planning must also include but not limited to the coordination and connection with the care institutes based on communities to extend and maintain treatment or cares of the case; this is ‘patient referral service’ (Mass, Buckwater, & Hardy, 1991) Referral has to be discussed with the cases and their families prior to their discharges in order for them to clearly know where and when to obtain health care resources needed. Also, for those who were discharged back to homes and communities, the professionals (public health nurses) in the referred institutions have the responsibility to keep tracking and evaluating and to respond appropriately depending on the changes of the needs. On the other hand,
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if the cases and their families are found not to utilize the referral resources as expected, the professionals need to evaluate reasons for that, and to conduct re-assessment and to introduce available resources again. Upon the achievement of the goal set, these nursing professionals can step out. (Clemen, Eigsti, & McGuire, 1983) The providence of service to any cases must be planned based on the content of their needs. In the process of ‘Discharge Planning’, complete control over the needs of the cases and their families must be through systematic need evaluation. Evaluation time is often for the professional in charge to complete the first care assessment within 48 h after case screening. However, need evaluation should not simply be limited to this first assessment. On the contrary, it should be conducted every time when the cases are cared. As far as the direction of evaluation is concerned, generally, three directions are involved, the case, the family, and the relevant social resources that influence cares, and they are inducted into eight aspects. (Huei-Tsi Chen et al., 2002) 1. Health: include current physical function of the case, disease development, and its future impact, etc. 2. Function hierarchy: current condition of self-care function and its development of the case, and the possibilities of becoming better or worse in the future. 3. Behavior: whether the case himself or herself has specific violent behavior history, and the abilities of the case and their families to handle relevant affairs such as medication administration and preparation and/or placement for special passageways. 4. Emotions: the condition of adjustment patients and their families need to make in accordance with the changes of the illness, such as the adjustment condition for physical function changes. 5. Economic/Finance: the condition of current cost of care and any financial aid needed for continuing cares. 6. Cognitive ability: conditions include the general cognitive ability of the case himself or herself, and that of the families towards illness-related care needs influenced by the diseases. 7. Resources for post-discharged care: the need assessment of the case in utilizing continuing care resources, such as the evaluation on safety appropriateness of the housing environment of the case and that on the usability of postdischarged care institutes. With regards to post-discharged community resources, professionals in charge need to have clear understanding on current available community resources to set up effective care plans. 8. Support system: include formal (families) and informal (friends) care support systems. Regarding case families, further understanding of the family power structure (who is the main caregiver, and who is the decision maker of care arrangement) is needed. In addition, further evaluation in the motivation and skills of the main caregiver and his or her general health condition is required.
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Therefore, when staff of discharge planning is planning and executing referrals, he or she needs to assess the needs of the case and to understand what concerns the case in order to provide customized service to best suit each case. In this process, the case has every right to comprehend reasons for referral and any assistance available from continuing care resources. Otherwise, the case has the right to refuse the referral service. Insodoing, referral services are more meaningful and can be mutually beneficial. 2.3. Current long-term post-hospital care resources available in Taiwan At present, long-term post-hospital resources include the following: 1. Senior welfare institutions Senior welfare institutions are the full day care services provided by the institutions in which the elderly live. Services include medical care, nursing, physical therapy/rehabilitation, personal and living care, etc. (Wu & Ju, 1995). According to Senior Citizen Welfare Law, these institutions can be categorized as below: (a) Nurturing center: Private institutions that take care of patients who require long-term cares. (b) Caring institute: Senile Caring Centers, Senior Citizens’ Homes, Psychiatric Centers, etc. (c) Chronic disease hospital: Long-term medical care service providers to patients with chronic diseases that require the use of breathing machine, caring for bedsores, etc. 2. Community care resources Community care is to bring services to the community in which the elderly lives, enabling senior citizens to maintain their usual life styles in the community. For example, hospice and respite, and day time rehabilitation hospital for the aged, etc. (a) Day care: Applying to institutions for short time care during the day. (b) Nursing home: Institutes that are licensed by senior nursing professionals and are capable of providing 24-hour care services such as nursing skills and living cares. A nursing home can provide medical care services such as changing tracheotomy tube, changing urinary drainage catheter, changing stomach tube, feeding, body cleansing, and urine and/or bowel movement cleaning, dressing changing, etc. 3. Home care resources Home care is to bring services to the households of the elderly, namely the elderly can receive all services needed at home. It is known from the above that patients are overwhelmed by the various options of long-term care resources/facilities without any quality standard after discharged from the hospital. How to help patients find
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a post-hospital care center that fits individual needs and to ensure patients receive complete care services in a suitable environment plays a key role in the establishment of the continuing care system. 2.4. Challenges of implementing discharge planning Challenges of discharge planning during the process of its implementation in each hospital are inducted and organized as listed below: 1. The lack of support in continuing care 2. Since there is no effective measure to track patient information, it is necessary to establish an information system for discharge planning. 3. The lack of appropriate forms. Current evaluation form can only roughly assess the condition of the case and the caring ability of families. It cannot access current physical and mental condition of the case and the family situation. Lee (2001) note in the problems faced by the long-term care of the aged in Taiwan that three types of long-term care institutes are present, which are the chronic disease ward, nursing homes, and caring institutions. However, the eligibility standard of these institutions is not clear and definite, and the functions repetitive and implicit. As a result, case referrals and management of the institutes are rather challenging. Many caring institutes must provide long-term care service using acute illness wards. Insodoing, it does not promote economic efficiency; it wastes acute medical care resources and increases cost for long-term cares. Therefore, the case will not receive appropriate longterm cares. Jo (1999) proposes the following directions for future improvement in discharge planning: 1. Reinforce the public the awareness of discharge planning. 2. Persistently establish institutes that provide continuing referral services. 3. Set up related resource information on the web. 4. Organize a neutral executive team to assist cases with referral difficulties. It is indicated from the above organization of the references that discharge planning has to put emphasis not only on the upper-end of formulating plans, but also on the latter-end of tracking and management, which include (1) the evaluation, communication, tracking, the providence of information, connection of continuing care institutions; (2) tracking and assistance of continuing care received by patients, home care service provided, support equipment rented. Discharge planning needs to work hard on the latter end at present.
3. Research design 3.1. Research method This research adopted two measures to establish Continuing Care Information System, CCIS They are casebased reasoning, used as the foundation of research and development of the spindle system, and the other– analytic hierarchy process (AHP) – for calculating the evaluation dimension and as the weight of evaluation index. 3.1.1. Case-based reasoning, CBR Theory structure of CBR CBR is a set of new theory and research method divided from the domain of artificial intelligence in by Schank and Abelson (1977). Simply put, CBR process new problems using the problem-solving methods of the past. Its main spirit lies in how to systematically save and process previous problem-solving knowledge and experience to solve new or repetitive problems encountered to reduce mega volume of information and avoid repetitive process loads. Meanwhile, CBR enables experiences accumulations. Each problem solved, the new experience is saved. Regardless of its success or failure, the problem-solving process is considered as a new case and the result, successful or failed, was saved in the system as a decision support of the next problem or a warning of possible failure so as to be utilized in machine learning or human learning. (Zhun, 2001) Knowledge acquisition of CBR Regarding knowledge acquisition, Mechitov and Moshkovich (1995) believe that CBR matches the natural reasoning model of human, suitable for solving complicated and dynamic inquiries and providing solutions, especially more appropriate and effective for ill-defined areas in which no theory model can be proved and knowledge is incomplete. Its problem-solving procedures are to help solve current inquiry by conducting a search of past problem-solving measures and experience. CBR would save old and current successfully solved cases in case-base. Moreover, case-base could add in new cases from which problems were solved to enhance information sufficiency. 1. Retrieve: Similar cases are retrieved from case-base as references to provide new cases with recommendations. 2. Reuse: Save added knowledge and data into database for repetitive use. As cases increase, answers of questions become more accurate. 3. Revise: Suggest revising rules when needed to alter its processing method so that the result can better match the problem solved. 4. Retain: Ongoing accumulation and save of case data into case-base for inquiries and uses of new cases. The reasoning process procedures of CBR in this research are listed below, and its reasoning flow chart is
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with the highest similarity takes first priority, and thereafter assess whether it is appropriate for the new case. Kolodner (1993) propose the algorithm for CBR similarity, it is: Xn Wj £ simðfjinput ; fijhistory Þ j¼1 input history Xn Similarityðf ; fi Þ¼ W j¼1 j
as illustrated in Fig. 1. (Slade, 1991) 1. Input new case: Input current new case that awaits solution into this continuing care evaluation information system. The required input case information in this system is the evaluation index needed for evaluating continuing care models, for example, Barthel’s Score, conscious and economic condition, etc. 2. Analyze an inquiry: A case is consisted by many indexes. How to choose case index for important factors of case evaluation will have significantly impact on the completeness of the case and its assessment results. Therefore, this research, based on the questionnaire distribution at the first stage, investigated the evaluation experience of discharge-planning professionals at each medical institution nationwide to obtain important relevant evaluation index. 3. Assign index weight: According to the different level of importance of evaluation results among each index, expect the evaluation result to be more suitable for the use of the new case. This research adopted analytic hierarchy process (APA) for calculation. 4. Case selection: Case-base saved many data as references. It locates solution method for the most similar case by comparing similarity, and thereby assesses the appropriateness. 5. Similarity rule: Compare each attribute of the new case against that of the old ones in case-base. The case
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i j Wj n
case index each index weight number of index, i.e. key index for evaluation index fjinput the j number of index of input cases fijhistory the inumber of case and the j number of index in case -base simðfjinput ; fijhistory Þ : the similarity of the j number of index of the input case and the cases in case-base Similarityðf input ; fihistory Þ : the similarity of the i number of case in input cases and the case-base
6. Revise case: When the discharge plan of the selected similar case is not appropriate for the new case, revision can be performed through the professional knowledge of the staff of discharge planning to make it more appropriate.
Fig. 1. Reasoning flow chart of CBR.
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7. Save case: Save feasible cases into case-base to enhance its completeness and to consolidate the self-learning mechanism of the system.3.1.2. Analytic hierarchy process Analytic Hierarchy Process (AHP) is a theory developed by Saaty (1980) and Hwang and Yoon (1981). It utilizes eigenvector to calculate the attribute weight. Its procedures are as follows: 1. Establish pairwise comparison matrix ½A among indexes according to the intensity scale of importance. 2. Calculate the maximum eigenvalue, lmax ; of pairwise comparison matrix ½A: 3. Obtain the eigenvector relative to lmax by replacing lmax for l in formula ðA 2 lIÞ ¼ 0: Deng and Tseng (1989a) note in ‘Inner Characteristics and Applications of Analytic Hierarchy Process’ that the application procedures and processing measures of eigenvector approach are: (1) establish pairwise comparison matrix, (2) calculate the weight of elements, and (3) consistency test. Below is the illustration, respectively: 1. Establish pairwise comparison matrix Based on a certain element in the previous hierarchy as evaluation criteria, perform pairwise comparison of level of importance among elements consisted in the next hierarchy. Next, compare the relative importance degree for each two elements and set up the ratio of relative level of importance. Therefore, this research must perform comparisons of relative level of importance of each two pair of indexes, which were acquired at the first stage, to complete the pairwise comparison matrix: 3 2 1 a12 … a1n 7 6 7 6 1 7 6 1 … a 2n 7 6a 7 6 12 A¼6 7 … … … … 7 6 7 6 5 4 1 1 … 1 a1n a2n 2. Calculate index weight Saaty (1997) and Hwang and Yoon (1981) believe that weight appropriateness can clearly and definitely reflect the difference of importance degree between each index, and further affect the ultimate results directly. Therefore, extra caution is needed when calculating the weight. According to pairwise comparison matrix, A ¼ ½aij ; calculate initial maximal eigenvalue, lmax; using right eigenvector approach and its relative principal eigenvector. Then, after normalization of the principal eigenvector, the priority vector of each index weight is represented. 3. Consistency test When decision-maker designs the pairwise comparison questionnaire, consistency is hard to achieve, and therefore, a consistency test is needed to examine whether the content filled in the questionnaires retrieved are
worthwhile using as references. If a questionnaire does not pass the consistency test, it indicates that the information of the questionnaire is inconsistent and the participant will be asked to re-complete it or the questionnaires invalid. 3.2. Research subject It has been simply six years since discharge planning was first launched by Department of Health of Executive Yuan in 1996 With only this short period of implementing time and the overall low level of computerization in general hospitals, this research selected an academic medical center as main source of collecting information when establishing the original characteristics (including information accuracy, completeness, consistency, and data volume) of system database. In addition, the proposed questionnaire participants of this research are the 108 institutions that were sponsored by Department of Health in 2001 to implement discharge planning. (Discharge Planning Process Standard, 2001) 3.3. Research structure This research is constituted by four major parts, as shown in Fig. 2, they are detailed as follows. 1. Part one: Locate evaluation index by interviews with professionals and organization of references; design the initial questionnaire. 2. Part two: Proceed to questionnaire distribution, retrieve and analysis, organization and identify important evaluation indexes. 3. Part three: Design analytic hierarchy process questionnaire for distribution to obtain weight for each evaluation dimension and index. Then, supporting with the comparison of case similarity and case-based reasoning to prepare for part 4. 4. Part four: Supporting by information of part 3 to establish continuing care information system of discharge planning. 3.4. System analyses and planning Generally, many important key factors need to be taken into consideration upon planning and designing a system from the perspective of demand If the decision-maker can consider thoroughly on system planning, risks would be lowered and obstacles eliminated when actually executing the system. This research collected information and organized the required focal points of evaluating ‘Continuing Care Information System of Discharge Planning’ as follows, and they are detailed from the needs of three different users:
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Fig. 2. Research structure.
(1) System administrator, (2) Staff of discharge planning, and (3) Case and families.
1. System administrator: (1) Maintenance of evaluation dimensions and indexes of the system. (2) Maintenance of case database. 2. Staff of discharge planning: (1) Screening and evaluation of continuing care model for individual case. (2) Arrangement for education of nursing, caring skills and common sense of hygiene. (3) Clinical department referral of case consultation. (4) Continuing follow-ups and management of case information. (5) Knowledge accumulation of discharge-planning professionals and its passing on. 3. Case and families: (1) Search for long-term care resources. (2) Brief introduction of information related to social welfare. (3) Inquiries of health and hygiene education information related to continuing care. After assessing demands of system users, this research planed to design the system into four major support systems to satisfy the needs of the system. They are, as shown in Fig. 3, case-based reasoning diagnosis system, case-base maintenance system, index maintenance system, and customer inquiry system, respectively. Furthermore, utilize
the method that combines reasoning mechanism and knowledge base to accumulate, create, and share the knowledge. Meanwhile, with the image presentation method of computer programming, assist each user to be able to operate each function more easily. Within continuing care information system of discharge planning, each sub-system has its specific function and its necessity on the aspect of system design. This research based on needs of different system users to design functions that determine, inquire, evaluate, save, revise, and feedback, and thereby enable users of each hierarchy to enter this system according to different terms of use and restrictions to achieve the objectives of knowledge creation, accumulation, and exploration. In the design, case-based reasoning diagnosis system is the spindle system and three other support systems (case-base maintenance system, index maintenance system, and customer inquiry system) the aids to enhance the comprehensiveness of knowledge interchange in this system. 1. Spindle System: Cased-Based Diagnosis System Using the mechanism of case-based reasoning to assist staff of discharge planning in providing suggestions when conducting continuing care assessment to break through the limitation of depending on the memory space of human brains and human errors in judgment. 2. Support System 1: Case-Base Maintenance System System maintainer can update the system and revise the information based on actual conditions for the diagnosis results to fit users’ needs better. Moreover, the suggestions made after evaluation will also satisfy
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Fig. 3. Hierarchy of continuing care information system of discharge planning.
the needs of the cases and their families better. When using case-base maintenance system, system administrator can make commands as inquire, add, revise, and delete in case-base according to actual needs in present. 3. Support System 2: Index Maintenance System It further deconstructs the existing recorded information in the system for the implicit data, which is originally saved in the system, to be utilized effectively and to be further transformed into the explicit data. Then, through the analysis and exploration of researchers, data ultimately become practical knowledge with referencing values to provide the hospital with digital data of another aspect. Index maintenance system, nonetheless, is the maintenance management of the related evaluation dimension and evaluation index weight required in the process of case searching. Regarding overall system maintenance, its objective is to make system operation more flexible, configurable, and to increase the selflearning ability of the system to fully utilize system capacity. 4. Support System 3: Customer Inquiry System This system is specifically designed to serve customers, hoping to provide the desired long-term care information and other related information of continuing care, such as social welfare act, knowledge of nursing and hygiene, and other relevant information, etc., to
make the effects of this system fully enjoyable to customers.
4. Questionnaire design and analysis 4.1. Phase 1-‘Questionnaire Design’ 1. Questionnaire design The produce of the content of the research questionnaire at this phase was mainly based on the eight aspects required in evaluating the case’s caring needs, proposed by Chen (2002). Then, through collecting evaluation forms of discharge planning from eight hospitals, organizing and compiling each assessment factors into the eight aspects to design the initial questionnaire of this research, namely the pretest questionnaire for professional interviews. Questionnaire content includes: eight evaluation dimensions and 36 evaluation indexes. 2. Questionnaire data collection This research selected the responsible person of five units related to discharge planning (including discharge planning affair professionals, social resource aid consultation professionals of the case, continuing care connection support professionals of the case,
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and academic discharge planning professionals) as pretest subjects. 3. Questionnaire results analysis After organizing the pretest results of professionals’ questionnaires, revisions were done in evaluation index that demonstrates ambiguity or cannot clearly and definitely express the behavioral meaning of the case that is intended to obtain. Meanwhile, footnotes and descriptions were added in the questionnaire items, which are difficult for participants to comprehend, for a better and clearer understanding. The professionals suggested revising the hierarchy structure to which evaluation index belongs so that each index can be placed in appropriate dimension. Furthermore, seven of the eight dimensions of evaluation need are left and the original 36 evaluation indexes were screened, revised, and combined into 29. 4.2. Phase 2-‘Questionnaire analysis’ 1. Questionnaire data collection The institutes to which the Department of Health sponsored financially to implement discharge-planning services in 2001 are the subjects that received this questionnaire at this stage. There are 108 institutes in total; 108 questionnaires sent. 2. Questionnaire results analysis The questionnaire results of phase 2 can be analyzed into two major parts: summary statistics analysis and reliability analysis. (1) Summary statistics analysis Summary statistics analysis was conducted using the retrieved 67 effective questionnaires. The statistical analysis results of need evaluation dimensions of continuing care of discharge planning is ranked according to the mean, as illustrated in Table 1. (2) Reliability analysis Although the Cronbach a value of the overall questionnaire and its each evaluation dimension are both higher than the suggested value, Cronbach a ¼ 0:6 (as illustrated in Table 2), it is found during dimensional reliability analysis Table 1 Dimensions of continuing care need assessment of discharge planningsorting by the mean Ranking of importance degree
Evaluation dimension
Mean
1 2 3 4 5 6 7
G Evaluation of medical care awareness E Evaluation of nursing care D Evaluation of support systems C Evaluation of main caregiver(s) B Evaluation of physical conditions A Evaluation of functional conditions F Evaluation of basic information
4.6433 4.6380 4.6161 4.4471 4.3953 4.2637 3.8881
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Table 2 Reliability of each evaluation dimension Evaluation dimension
Reliability (Cronbach a)
A Evaluation of functional conditions B Evaluation of physical conditions C Evaluation of main caregiver(s) D Evaluation of support systems E Evaluation of nursing care F Evaluation of basic information G Evaluation of medical care awareness
0.6859 0.8487 0.7140 0.6432 0.9232 0.6137 0.8605
that if deleting a certain evaluation index in the two evaluation dimensions—[A Evaluation of functional conditions] and [F Evaluation of basic information], its reliability Cronbach a value will increase a certain level. Therefore, three evaluation indexes, A3 (IADL measuring table), F1 (age of the case), and F4 (education background of the case), were deleted. Finally, the revised reliability values for [A Evaluation of functional conditions] and [F Evaluation of basic information] are 0.7786 and 0.6912, respectively. After screening the evaluation indexes that belong in each dimension using reliability analysis, i.e. to revise the complete hierarchy structure of the continuing care need assessment of discharge planning, the result is the threelayer analytic hierarchy structure figure as shown in Fig. 4, and AHP questionnaire of phase 3 is designed according to such structure. 4.3. Phase 3-‘analytic hierarchy process’ (AHP) 1. Questionnaire design After the research analyses in phase 1 (questionnaire design) and phase 2 (questionnaire analysis), the evaluation dimensions and their belonging evaluation indexes are completely revised, and an analytic hierarchy structure can be further organized, as the three-layer analytic hierarchy structure figure shown in Fig. 4. In addition, based on the evaluation dimensions and indexes, pairwise comparison was conducted to understand the relative importance degree between dimension and dimension, and between index and index, and thereby the ‘analytic hierarchy process (AHP)’ research questionnaire is designed. 2. Questionnaire data collection To achieve consistency of completing the questionnaire before and after, the subjects of the questionnaires are same as that in phase 2-the institutes to which Department of Health financially sponsored to implement discharge planning in 2001. There are 108 questionnaires being distributed.
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Fig. 4. Hierarchy structure of continuing care need evaluation of discharge planning.
3. Questionnaire results analysis This research adopted ‘MATLAB R12’ and ‘Microsoft Excel’ software as the supporting tools to compute the AHP questionnaire to calculate the maximum eigenvalue
of each pairwise comparison matrix, the weight of each factor, and the consistency test of the questionnaire. Table 3 is the evaluation dimension and index weight obtained by calculating the investigation list of AHP questionnaire.
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Table 3 Weight of the evaluation dimensions and indexes Evaluation dimension
Evaluation dimension weight
Evaluation index
Evaluation index weight
A Evaluation of functional conditions
0.126
B Evaluation of physical conditions
0.088
C Evaluation of main caregiver(s)
0.198
A1 Barthel’s Score A2 Karnfsky Scale (K Scale) B1 Consciousness B2 Emotions B3 Communications B4 Breathing B5 Skin B6 Nutrition C1 Main caregiver(s) C2 Assessment on learning health education of main caregiver(s) C3 Interaction of the case and families C4 Educational background of main caregiver(s) D1 Economic/Financial situation D2 Connection of community resources D3 Emphasis and support degree of the family to patient E1 Bedsores E2 Breathing machine E3 Passageway (nasal-gastric tube, tracheotomy tube, urinary drainage catheters) E4 Wounds E5 Mucus suctioning F1 Identification category of the case F2 Disease diagnosis of the case G1 Motives of learning self-care skills
0.0825 0.0435 0.0154 0.0098 0.0118 0.0244 0.0113 0.0153 0.0384 0.0595
D Evaluation of support systems
0.180
E Evaluation of nursing care
0.184
F Evaluation of basic information
G Evaluation of medical care awareness
0.073
0.151
G2 Condition explanation of physicians G3 Awareness of discharge planning of the case and families G4 Awareness of illness of the case and families
5. Verification of continuing care information system of discharge planning In order to verify the feasibility of Continuing Care Information System of Discharge Planning, this research adopted real discharged cases. Information saved in the system database is cases of ‘discharge planning in a selected medical center in 2002.’ Data includes division of neurology and pulmonary, with 141 and 123 numbers of data, respectively, 264 in total. In addition, cases adopted for system verification are those in 2001. There are 15 data being randomly selected each from division of neurology and pulmonary medicine for case-based reasoning diagnosis system to conduct diagnosis. The case verification of this system selected previously searched five cases as subjects of calculating reasoning accuracy of the system. The overall system verification results are illustrated in Table 4, from which
0.0708 0.0293 0.0532 0.0359 0.0909
0.0275 0.0527 0.0342
0.0244 0.0452 0.0382 0.0348 0.0606 0.0268 0.0331
0.0305
it is indicated that the average similarity of the previous five cases reasoned by the system is 0.8609 while the average accuracy of the system is 0.8089. These two figures indicate a high level of average accuracy of the average similarity for the old cases reasoned by this system. Therefore, it presents a high feasibility of this continuing care information system of discharge planning, and can be used as a supporting system in decision making of staff of discharge planning while drafting plans for cases. The definition of ‘accuracy’ in this research is: the care models of the system include five categories and 24 options, i.e. medical care supporting facility and equipment (12 items), referred continuing care institute (1 item), skills and education of health (8 items), rehabilitation instruction (1 item), consultation (2 item); compare the two care models of reasoned old and new case, count ratio of matched items, and then calculate it.
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Table 4 overall result of system verification Ranking of similarity
Average similarity
Standard deviation
Average accuracy
Standard deviation
1 2 3 4 5
0.9027 0.8756 0.8609 0.8414 0.8241
0.0653 0.0689 0.0695 0.0753 0.0771
0.8306 0.8181 0.8083 0.8097 0.7778
0.1252 0.1041 0.1182 0.1087 0.1028
Total Mean/Average
0.8609
0.0712
0.8089
0.1118
6. Conclusions This research obtained many findings through the process of planning, analysis, establishment, and verification of the comprehensive system. They are organized and inducted into the following four focal points as the final conclusions of this research: 1. Evaluate the relative weight of each evaluation dimension and evaluation index by distributing AHP questionnaire It is found through AHP questionnaire that the relative importance degree of major caregiver evaluation dimension is ranked first, nursing care evaluation dimension second, and then followed by dimensions of medical care awareness, functional condition, physical condition, and basic information assessment. Therefore, it is clearly understood that the most important factor for cases to consider for their initial discharge plans is the main caregiver evaluation dimension, coordinated with other important factors such as the required nursing care models by the cases, and condition of learning general hygiene of the families, condition of the support system of the case, etc. These consideration factors can be used as future references in discharge planning. 2. Assist discharge-planning staff in making discharge plans by utilizing the ‘Continuing Care Information System of Discharge Planning’ The utilization of the continuing care information system of discharge planning designed by this research enables fast reasoning of the current care model required by the case after discharged. When operating case-based reasoning diagnosis system, users simply need to input 26 items of evaluation index for analysis and reasoning. There will be five old cases in suggestion after evaluation, and the information of the previous five cases will be listed by the system as well to provide reference basis for discharge-planning professionals to make plans. 3. Conduct result evaluation of system verification to test system feasibility This research conducted system verification using 30 cases. The reasoning mean of case similarity is 0.8609, and that of accuracy, 0.8089, indicating a high level of verification results of this system, and thereby verifying
a high level of feasibility of the ‘Continuing Care Information System of Discharge Planning’ designed by this research to be the supporting system utilized by discharge -planning staff for making discharge plans. 4. Simplify the work process of discharge planning to uplift overall efficiency and to consolidate customer service data Applying the ‘Continuing Care Information System of Discharge Planning’, many procedures can be combined to reduce repetitive work. When the case completed the evaluation process, case data can be saved into system database for ‘Case-Base Maintenance System’ to conduct case administrations. Furthermore, dischargeplanning professionals can instruct cases and their families, through ‘Customer Inquiry System’, each type of health education and skills and to convey messages of continuing care resources. Insodoing, overall dischargeplanning work process will be more systematic, and thereby enhance overall job efficiency and able to fully provide information required by customers.
7. Suggestions This research simply focused on providing recommendations and assistance when the discharge -planning professional is drafting the individual plan for the case. However, it does not consider other relevant information network of procedures regarding the overall discharge planning process. Neither did it take into account the actual needs of the patients and their families. Therefore, it is recommended for future researchers to further expand the scope based on these two aspects, which are described in general below: 1. Establish an overall discharge planning information network Utilizing the function of inner networking in the hospital to transfer documents of case information, to promote communications among each department, and thereby reduce waste of time in document transfer and trivial office jobs. Then, in cooperation with outer networking, connect with continuing care institutes and provide discharged patients and their families with related caring knowledge and inquiring service of
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medical care information to make the overall care system of discharge planning more sound and complete. 2. Consider from the aspect of the cases and their families to set up discharge plans The discharge plans made for individual cases are the responsibility of the professional nursing staff in the hospital or the discharge-planning staff. Even better, a team, consisted of other related medical care professionals (including nutritionist, social workers, attending physicians, etc), is organized to provide postdischarged services. However, in most cases, discharge plans are considered from the angle of medical care or its relevant without further understanding the problems and challenges that the cases and their families will face after discharged. For instance, the problems of meal preparation at home, self-changing clothing, getting up and out of bed, using the restroom, etc, or shopping, taking a walk, or other recreational activities. In this case, it is problematic whether the discharge plan made by these medical care professionals truly fits the need of the case. Therefore, this research suggests further discussion and exploration on this direction in order to better understand the real needs of the case and families to provide a care model that fits. References Department of Health Executive Yuan, ROC, (2001), Discharge Planning Process Standard. Council for Economical Planning and Development Executive Yuan, ROC, (2003). Table of World Population Estimates. Wu, S.-C., & Ju, Z.-M. (1994). Public attitudes towards long-term care arrangement of the elderly-findings of society condition investigation in Taiwan area in 1994. China Magazine, 14, 369–382.
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Lee, S.-D., et al. (2001). Long-Term Care. Yi-Hsient Publishing Co. Ltd. Jo, X.-H. (1999). Initial exploration on discharge planning results of neurosurgeon ward in a selected hospital. Cheng-Keng Nursing, 10(4), 1–7. Chen, H.-T., et al. (2002). Long-Term Care Practical Affairs. Young-Da Publishers. Jun-Hsien Zhun., (2001). Using protocol analysis and deductive case-based reasoning to establish the decision models of financial statement experts. Graduate School of Information Management Department in National Kaohsiung First University of Science and Technology. Master thesis. Deng, Z.-Y., & Tseng, G.-H. (1989). Characteristics and applications of analytic hierarchy process (AHP). China Statistical Journal, 27(6), 5–22. Dai, Y.-T., Chang, D.-R., & Lo, M.-F. (1998). Discharge planning in taiwan area—result analysis of the trial plan. Tzu Chi Medical Journal, 10(1), 61– 68. American Hospital Association, (1983). Introduction to discharge planning for hospital IL: American Hospital Association. Anderson, M. A., & Helms, L. B. (1995). Communication between continuing care organization. Research in Nursing and Health, 18(1), 49– 57. Clemen, S. A., Eigsti, D. G., & McGuire, S. L. (1983). Comprehensive family and community health nursing. Taipei: Nan Shan Tang. Hwang, C. L., & Yoon, K. (1981). Multiple Attribute Decision Making: Method and Applications. New york: Springer-Verlag. Kolodner, J. L. (1993). Case-Based Reasoning. Morgan Kaufmann Publishers Inc.. Mass, M., Buckwater, K. C., & Hardy, M. (1991). Nursing diagnoses and interventions for the elderly. California: Addison-Wesley Nursing. Mechitov, A. I., & Moshkovich, H. M. (1995). Knowledge acquisition tool for case-based reasoning system. Expert Systems with Application, 9(2), 201– 212. Saaty, T. L. (1980). The Analytic Hierarchy Process. New York: McGrawHill. Schank, R. C., & Abelson, R. P. (1977). Scripts, Plans, Goals and Understanding. New Jersey, USA: Erlbaum Hillsdale. Slade, S. (1991). Case-based reasoning: a research paradigm. AI Magazine, 4(1), 42–55.
Using case-based reasoning to establish a continuing care information system of discharge planning Chun-Lang Changa,*, Bor-Wen Chengb, Jiun-Lin Sub a Department of Industrial Management, National Huwei Institute of Technology, 64 Wun-Hwa Rd. Huwei, Yunlin 632, Taiwan, ROC Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Touliu 640, Taiwan, ROC
b
Received 4 October 2003; revised 4 October 2003; accepted 1 December 2003
Abstract As family structure changes, population is aging and disease styles tend to be chronic, long-term care in Taiwan becomes problematic, needs to be addressed, and requires immediate solution. Presently, many medical care institutions in the country have assisted patients in discharge planning; however, the lack of a standard evaluation procedure in the process of discharge planning is disturbing for each hospital. Without it, there might be huge differences in the evaluation results. Moreover, the lack of support and the uncertainty of case eligibility standard in these institutions further affect the performance of continuing care services. This research adopted Case-Based Reasoning to establish a continuing care information system of discharge planning. With previously evaluated information of past cases, the similarity index is compared among new cases. In coordinate with Analytic Hierarchy Process, index weight is calculated to reason an old case that is most closely related to the condition of the new case. This information system can assist discharge-planning staff in accurately formulating a plan of action based on previous case-assessment experience and in obtaining valuable information that helps make decision. Through the implementation of the system, accumulation on knowledge and experience of continuing care models will help staff evaluate process of discharge planning to achieve a reasonable, standardized, and simplified procedure as a whole. This research will transform the evaluating experience of discharge-planning professionals into an assessment method with the application of computer reasoning to make the evaluation process of discharge planning convenient as well as to save more time for discharge-planning professionals to further understand the actual conditions of each case. On the other hand, this information system will provide dischargeplanning staff with a set of recommendations as references for making individual discharge plan. It is expected through this research that each hospital be provided with a blue print of improvement in case evaluation process and management. q 2004 Elsevier Ltd. All rights reserved. Keywords: Case-based reasoning; Analytic hierarchy process; Discharge planning; Continuing care
1. Background and objectives Long-term care management has become problematic, needs to be addressed, and requires immediate solutions in the modern society due to the changing family structure, aging population, and the tendency of chronic illnesses. According to the statistics from the Department of Health Executive Yuan, 2001 average life span of males and females in 1992 are 73.0 and 78.8, respectively, which are much longer than that in 1951, 53.38 for males and 56.33 for females. (Council for Economical Planning and Development, 2003) The above statistics indicates that our population characteristic has altered significantly, and * Corresponding author. Tel.: þ 886-5633-2800; fax: þ 886-5631-1548. E-mail address: [email protected] (C.-L. Chang). 0957-4174/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.eswa.2003.12.010
therefore, living and health care will be of equal importance due to the aging population in Taiwan. According to 2000 population census, among the total 2.2 million population in Taiwan-Fukin areas, nearly 2,70,000 of population currently needs long-term care services with elder population near 17,000. They account for 9.1% of the total population for senior citizens. With increasing demands on long-term cares, immediate development and establishment of a sound system cannot await. Furthermore, to effectively promote long-term care services, ‘Discharge Planning’ from the upper stream acute medical care system plays a key role. Nonetheless, successful deployment of ‘Discharge Planning’ requires resource integration within the executed medical care system as well as a complete structure and buildup of a sound information system of long-term cares.
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A comprehensive ‘Discharge Planning’ requires the upper end care plan assessment and satisfies individual needs of post-hospital cares in order to achieve continuous and complete cares. For cases that need long-term cares, their families must have been impacted by tremendous challenges they need to face socially, economically, and psychologically. Without a comprehensive continuing care plan, cases and their families cannot be discharged from the hospital free of worry. However, currently the medical care institutions that provide discharge planning emphasize mostly on the initial arrangement of the care plan and the executive method they use. It lacks a complete manage mechanism that involves assessment, communication and connection, education and development of continuing care institutions and units, and that involves case tracking and assistance, and providing the case available information. Nowadays, most of the continuing care models provided by each hospital do not fit the needs of the cases, their families, and continuing care institutes. Thereby the hospital is unable to implement after care services to be more systematic and standardized to attain continuing and complete cares with the cooperation of the three parties— the cases and their families, the continuing care institutes, and the staff of discharge planning. As such, the objectives of this research are as follows: 1. To locate important consideration factors as references to implement discharge planning when discharge-planning staff is formulating a plan in action. 2. To establish a continuing care information system of discharge planning to transform assessment experiences of discharge planners into the diagnosis method using computer reasoning, with the expectation to eliminate human errors and to reason, simplify, and standardize the overall evaluation process. 3. To draw up initial plans and to provide supporting suggestions to discharge planners (continuing care model: it includes continuing care institutes, medical care equipment and facilities, nursing and health education, consultation units, etc.). 4. To computerize the overall discharge planning process and to reinforce the formulation of discharge plans and its time efficiency upon implementation.
2. Literature review 2.1. Discharge planning Discharge planning is for both a health team (which includes physicians, nursing professionals, social workers, nutritionists, physical therapist, and occupational therapist) and families, through organized, planned, systematic decisions and actions, to ensure the continuum of posthospital health cares. It perceives intuitively the hidden risks, integrates long-term care resources, and under
consideration of human nature and quality medical, health, and living care, best utilizes resources at the most appropriate timing to locate the most suitable care place, and then safely transfer the case or the cared to another caring environment in search for the best solution. The definitions of discharge planning noted in past researches are listed below: 1. American Hospital Association, AHA (1983) define that discharge planning is a process of concentration, coordination, and technology integration, through the cooperation of medical care professionals, the cases and their families, to ensure all cases receive continuing cares after being discharged. It must reflect both inner and outer social, emotional, medical, and psychological needs of the cases and their families and provide assistance, and it must provide continuing cares, follow ups, and understand needs of the discharged cases. 2. Anderson and Helms (1995) claims that discharge planning is for each health team that also includes patients to safely transfer patients to another caring environment through organized and systematical decision actions and with coordination of health care resources. 3. Yu-Tse Dai. (1998) believe that discharging planning is instructing patients with plans and solving their problems as well once they are hospitalized and discharging patients from the hospital satisfied, free of worry, and well prepared in all aspects. Upon admitted to the hospital, the patients are continuously evaluated on what kind of care and resources they might need to maintain good health and quality life when returning to the society. During their inpatient stay, patients are provided with necessary health knowledge, self-care instructions, family consultation, improvement of living environment, available social information, etc. In addition, through the cooperation of medical care teams, patients, upon completion of necessary treatment, are assisted to successfully return to the society or transfer in time to other institute for continuing cares. 2.2. Referral service An effective plan of discharge planning must also include but not limited to the coordination and connection with the care institutes based on communities to extend and maintain treatment or cares of the case; this is ‘patient referral service’ (Mass, Buckwater, & Hardy, 1991) Referral has to be discussed with the cases and their families prior to their discharges in order for them to clearly know where and when to obtain health care resources needed. Also, for those who were discharged back to homes and communities, the professionals (public health nurses) in the referred institutions have the responsibility to keep tracking and evaluating and to respond appropriately depending on the changes of the needs. On the other hand,
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if the cases and their families are found not to utilize the referral resources as expected, the professionals need to evaluate reasons for that, and to conduct re-assessment and to introduce available resources again. Upon the achievement of the goal set, these nursing professionals can step out. (Clemen, Eigsti, & McGuire, 1983) The providence of service to any cases must be planned based on the content of their needs. In the process of ‘Discharge Planning’, complete control over the needs of the cases and their families must be through systematic need evaluation. Evaluation time is often for the professional in charge to complete the first care assessment within 48 h after case screening. However, need evaluation should not simply be limited to this first assessment. On the contrary, it should be conducted every time when the cases are cared. As far as the direction of evaluation is concerned, generally, three directions are involved, the case, the family, and the relevant social resources that influence cares, and they are inducted into eight aspects. (Huei-Tsi Chen et al., 2002) 1. Health: include current physical function of the case, disease development, and its future impact, etc. 2. Function hierarchy: current condition of self-care function and its development of the case, and the possibilities of becoming better or worse in the future. 3. Behavior: whether the case himself or herself has specific violent behavior history, and the abilities of the case and their families to handle relevant affairs such as medication administration and preparation and/or placement for special passageways. 4. Emotions: the condition of adjustment patients and their families need to make in accordance with the changes of the illness, such as the adjustment condition for physical function changes. 5. Economic/Finance: the condition of current cost of care and any financial aid needed for continuing cares. 6. Cognitive ability: conditions include the general cognitive ability of the case himself or herself, and that of the families towards illness-related care needs influenced by the diseases. 7. Resources for post-discharged care: the need assessment of the case in utilizing continuing care resources, such as the evaluation on safety appropriateness of the housing environment of the case and that on the usability of postdischarged care institutes. With regards to post-discharged community resources, professionals in charge need to have clear understanding on current available community resources to set up effective care plans. 8. Support system: include formal (families) and informal (friends) care support systems. Regarding case families, further understanding of the family power structure (who is the main caregiver, and who is the decision maker of care arrangement) is needed. In addition, further evaluation in the motivation and skills of the main caregiver and his or her general health condition is required.
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Therefore, when staff of discharge planning is planning and executing referrals, he or she needs to assess the needs of the case and to understand what concerns the case in order to provide customized service to best suit each case. In this process, the case has every right to comprehend reasons for referral and any assistance available from continuing care resources. Otherwise, the case has the right to refuse the referral service. Insodoing, referral services are more meaningful and can be mutually beneficial. 2.3. Current long-term post-hospital care resources available in Taiwan At present, long-term post-hospital resources include the following: 1. Senior welfare institutions Senior welfare institutions are the full day care services provided by the institutions in which the elderly live. Services include medical care, nursing, physical therapy/rehabilitation, personal and living care, etc. (Wu & Ju, 1995). According to Senior Citizen Welfare Law, these institutions can be categorized as below: (a) Nurturing center: Private institutions that take care of patients who require long-term cares. (b) Caring institute: Senile Caring Centers, Senior Citizens’ Homes, Psychiatric Centers, etc. (c) Chronic disease hospital: Long-term medical care service providers to patients with chronic diseases that require the use of breathing machine, caring for bedsores, etc. 2. Community care resources Community care is to bring services to the community in which the elderly lives, enabling senior citizens to maintain their usual life styles in the community. For example, hospice and respite, and day time rehabilitation hospital for the aged, etc. (a) Day care: Applying to institutions for short time care during the day. (b) Nursing home: Institutes that are licensed by senior nursing professionals and are capable of providing 24-hour care services such as nursing skills and living cares. A nursing home can provide medical care services such as changing tracheotomy tube, changing urinary drainage catheter, changing stomach tube, feeding, body cleansing, and urine and/or bowel movement cleaning, dressing changing, etc. 3. Home care resources Home care is to bring services to the households of the elderly, namely the elderly can receive all services needed at home. It is known from the above that patients are overwhelmed by the various options of long-term care resources/facilities without any quality standard after discharged from the hospital. How to help patients find
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a post-hospital care center that fits individual needs and to ensure patients receive complete care services in a suitable environment plays a key role in the establishment of the continuing care system. 2.4. Challenges of implementing discharge planning Challenges of discharge planning during the process of its implementation in each hospital are inducted and organized as listed below: 1. The lack of support in continuing care 2. Since there is no effective measure to track patient information, it is necessary to establish an information system for discharge planning. 3. The lack of appropriate forms. Current evaluation form can only roughly assess the condition of the case and the caring ability of families. It cannot access current physical and mental condition of the case and the family situation. Lee (2001) note in the problems faced by the long-term care of the aged in Taiwan that three types of long-term care institutes are present, which are the chronic disease ward, nursing homes, and caring institutions. However, the eligibility standard of these institutions is not clear and definite, and the functions repetitive and implicit. As a result, case referrals and management of the institutes are rather challenging. Many caring institutes must provide long-term care service using acute illness wards. Insodoing, it does not promote economic efficiency; it wastes acute medical care resources and increases cost for long-term cares. Therefore, the case will not receive appropriate longterm cares. Jo (1999) proposes the following directions for future improvement in discharge planning: 1. Reinforce the public the awareness of discharge planning. 2. Persistently establish institutes that provide continuing referral services. 3. Set up related resource information on the web. 4. Organize a neutral executive team to assist cases with referral difficulties. It is indicated from the above organization of the references that discharge planning has to put emphasis not only on the upper-end of formulating plans, but also on the latter-end of tracking and management, which include (1) the evaluation, communication, tracking, the providence of information, connection of continuing care institutions; (2) tracking and assistance of continuing care received by patients, home care service provided, support equipment rented. Discharge planning needs to work hard on the latter end at present.
3. Research design 3.1. Research method This research adopted two measures to establish Continuing Care Information System, CCIS They are casebased reasoning, used as the foundation of research and development of the spindle system, and the other– analytic hierarchy process (AHP) – for calculating the evaluation dimension and as the weight of evaluation index. 3.1.1. Case-based reasoning, CBR Theory structure of CBR CBR is a set of new theory and research method divided from the domain of artificial intelligence in by Schank and Abelson (1977). Simply put, CBR process new problems using the problem-solving methods of the past. Its main spirit lies in how to systematically save and process previous problem-solving knowledge and experience to solve new or repetitive problems encountered to reduce mega volume of information and avoid repetitive process loads. Meanwhile, CBR enables experiences accumulations. Each problem solved, the new experience is saved. Regardless of its success or failure, the problem-solving process is considered as a new case and the result, successful or failed, was saved in the system as a decision support of the next problem or a warning of possible failure so as to be utilized in machine learning or human learning. (Zhun, 2001) Knowledge acquisition of CBR Regarding knowledge acquisition, Mechitov and Moshkovich (1995) believe that CBR matches the natural reasoning model of human, suitable for solving complicated and dynamic inquiries and providing solutions, especially more appropriate and effective for ill-defined areas in which no theory model can be proved and knowledge is incomplete. Its problem-solving procedures are to help solve current inquiry by conducting a search of past problem-solving measures and experience. CBR would save old and current successfully solved cases in case-base. Moreover, case-base could add in new cases from which problems were solved to enhance information sufficiency. 1. Retrieve: Similar cases are retrieved from case-base as references to provide new cases with recommendations. 2. Reuse: Save added knowledge and data into database for repetitive use. As cases increase, answers of questions become more accurate. 3. Revise: Suggest revising rules when needed to alter its processing method so that the result can better match the problem solved. 4. Retain: Ongoing accumulation and save of case data into case-base for inquiries and uses of new cases. The reasoning process procedures of CBR in this research are listed below, and its reasoning flow chart is
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with the highest similarity takes first priority, and thereafter assess whether it is appropriate for the new case. Kolodner (1993) propose the algorithm for CBR similarity, it is: Xn Wj £ simðfjinput ; fijhistory Þ j¼1 input history Xn Similarityðf ; fi Þ¼ W j¼1 j
as illustrated in Fig. 1. (Slade, 1991) 1. Input new case: Input current new case that awaits solution into this continuing care evaluation information system. The required input case information in this system is the evaluation index needed for evaluating continuing care models, for example, Barthel’s Score, conscious and economic condition, etc. 2. Analyze an inquiry: A case is consisted by many indexes. How to choose case index for important factors of case evaluation will have significantly impact on the completeness of the case and its assessment results. Therefore, this research, based on the questionnaire distribution at the first stage, investigated the evaluation experience of discharge-planning professionals at each medical institution nationwide to obtain important relevant evaluation index. 3. Assign index weight: According to the different level of importance of evaluation results among each index, expect the evaluation result to be more suitable for the use of the new case. This research adopted analytic hierarchy process (APA) for calculation. 4. Case selection: Case-base saved many data as references. It locates solution method for the most similar case by comparing similarity, and thereby assesses the appropriateness. 5. Similarity rule: Compare each attribute of the new case against that of the old ones in case-base. The case
605
i j Wj n
case index each index weight number of index, i.e. key index for evaluation index fjinput the j number of index of input cases fijhistory the inumber of case and the j number of index in case -base simðfjinput ; fijhistory Þ : the similarity of the j number of index of the input case and the cases in case-base Similarityðf input ; fihistory Þ : the similarity of the i number of case in input cases and the case-base
6. Revise case: When the discharge plan of the selected similar case is not appropriate for the new case, revision can be performed through the professional knowledge of the staff of discharge planning to make it more appropriate.
Fig. 1. Reasoning flow chart of CBR.
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7. Save case: Save feasible cases into case-base to enhance its completeness and to consolidate the self-learning mechanism of the system.3.1.2. Analytic hierarchy process Analytic Hierarchy Process (AHP) is a theory developed by Saaty (1980) and Hwang and Yoon (1981). It utilizes eigenvector to calculate the attribute weight. Its procedures are as follows: 1. Establish pairwise comparison matrix ½A among indexes according to the intensity scale of importance. 2. Calculate the maximum eigenvalue, lmax ; of pairwise comparison matrix ½A: 3. Obtain the eigenvector relative to lmax by replacing lmax for l in formula ðA 2 lIÞ ¼ 0: Deng and Tseng (1989a) note in ‘Inner Characteristics and Applications of Analytic Hierarchy Process’ that the application procedures and processing measures of eigenvector approach are: (1) establish pairwise comparison matrix, (2) calculate the weight of elements, and (3) consistency test. Below is the illustration, respectively: 1. Establish pairwise comparison matrix Based on a certain element in the previous hierarchy as evaluation criteria, perform pairwise comparison of level of importance among elements consisted in the next hierarchy. Next, compare the relative importance degree for each two elements and set up the ratio of relative level of importance. Therefore, this research must perform comparisons of relative level of importance of each two pair of indexes, which were acquired at the first stage, to complete the pairwise comparison matrix: 3 2 1 a12 … a1n 7 6 7 6 1 7 6 1 … a 2n 7 6a 7 6 12 A¼6 7 … … … … 7 6 7 6 5 4 1 1 … 1 a1n a2n 2. Calculate index weight Saaty (1997) and Hwang and Yoon (1981) believe that weight appropriateness can clearly and definitely reflect the difference of importance degree between each index, and further affect the ultimate results directly. Therefore, extra caution is needed when calculating the weight. According to pairwise comparison matrix, A ¼ ½aij ; calculate initial maximal eigenvalue, lmax; using right eigenvector approach and its relative principal eigenvector. Then, after normalization of the principal eigenvector, the priority vector of each index weight is represented. 3. Consistency test When decision-maker designs the pairwise comparison questionnaire, consistency is hard to achieve, and therefore, a consistency test is needed to examine whether the content filled in the questionnaires retrieved are
worthwhile using as references. If a questionnaire does not pass the consistency test, it indicates that the information of the questionnaire is inconsistent and the participant will be asked to re-complete it or the questionnaires invalid. 3.2. Research subject It has been simply six years since discharge planning was first launched by Department of Health of Executive Yuan in 1996 With only this short period of implementing time and the overall low level of computerization in general hospitals, this research selected an academic medical center as main source of collecting information when establishing the original characteristics (including information accuracy, completeness, consistency, and data volume) of system database. In addition, the proposed questionnaire participants of this research are the 108 institutions that were sponsored by Department of Health in 2001 to implement discharge planning. (Discharge Planning Process Standard, 2001) 3.3. Research structure This research is constituted by four major parts, as shown in Fig. 2, they are detailed as follows. 1. Part one: Locate evaluation index by interviews with professionals and organization of references; design the initial questionnaire. 2. Part two: Proceed to questionnaire distribution, retrieve and analysis, organization and identify important evaluation indexes. 3. Part three: Design analytic hierarchy process questionnaire for distribution to obtain weight for each evaluation dimension and index. Then, supporting with the comparison of case similarity and case-based reasoning to prepare for part 4. 4. Part four: Supporting by information of part 3 to establish continuing care information system of discharge planning. 3.4. System analyses and planning Generally, many important key factors need to be taken into consideration upon planning and designing a system from the perspective of demand If the decision-maker can consider thoroughly on system planning, risks would be lowered and obstacles eliminated when actually executing the system. This research collected information and organized the required focal points of evaluating ‘Continuing Care Information System of Discharge Planning’ as follows, and they are detailed from the needs of three different users:
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Fig. 2. Research structure.
(1) System administrator, (2) Staff of discharge planning, and (3) Case and families.
1. System administrator: (1) Maintenance of evaluation dimensions and indexes of the system. (2) Maintenance of case database. 2. Staff of discharge planning: (1) Screening and evaluation of continuing care model for individual case. (2) Arrangement for education of nursing, caring skills and common sense of hygiene. (3) Clinical department referral of case consultation. (4) Continuing follow-ups and management of case information. (5) Knowledge accumulation of discharge-planning professionals and its passing on. 3. Case and families: (1) Search for long-term care resources. (2) Brief introduction of information related to social welfare. (3) Inquiries of health and hygiene education information related to continuing care. After assessing demands of system users, this research planed to design the system into four major support systems to satisfy the needs of the system. They are, as shown in Fig. 3, case-based reasoning diagnosis system, case-base maintenance system, index maintenance system, and customer inquiry system, respectively. Furthermore, utilize
the method that combines reasoning mechanism and knowledge base to accumulate, create, and share the knowledge. Meanwhile, with the image presentation method of computer programming, assist each user to be able to operate each function more easily. Within continuing care information system of discharge planning, each sub-system has its specific function and its necessity on the aspect of system design. This research based on needs of different system users to design functions that determine, inquire, evaluate, save, revise, and feedback, and thereby enable users of each hierarchy to enter this system according to different terms of use and restrictions to achieve the objectives of knowledge creation, accumulation, and exploration. In the design, case-based reasoning diagnosis system is the spindle system and three other support systems (case-base maintenance system, index maintenance system, and customer inquiry system) the aids to enhance the comprehensiveness of knowledge interchange in this system. 1. Spindle System: Cased-Based Diagnosis System Using the mechanism of case-based reasoning to assist staff of discharge planning in providing suggestions when conducting continuing care assessment to break through the limitation of depending on the memory space of human brains and human errors in judgment. 2. Support System 1: Case-Base Maintenance System System maintainer can update the system and revise the information based on actual conditions for the diagnosis results to fit users’ needs better. Moreover, the suggestions made after evaluation will also satisfy
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Fig. 3. Hierarchy of continuing care information system of discharge planning.
the needs of the cases and their families better. When using case-base maintenance system, system administrator can make commands as inquire, add, revise, and delete in case-base according to actual needs in present. 3. Support System 2: Index Maintenance System It further deconstructs the existing recorded information in the system for the implicit data, which is originally saved in the system, to be utilized effectively and to be further transformed into the explicit data. Then, through the analysis and exploration of researchers, data ultimately become practical knowledge with referencing values to provide the hospital with digital data of another aspect. Index maintenance system, nonetheless, is the maintenance management of the related evaluation dimension and evaluation index weight required in the process of case searching. Regarding overall system maintenance, its objective is to make system operation more flexible, configurable, and to increase the selflearning ability of the system to fully utilize system capacity. 4. Support System 3: Customer Inquiry System This system is specifically designed to serve customers, hoping to provide the desired long-term care information and other related information of continuing care, such as social welfare act, knowledge of nursing and hygiene, and other relevant information, etc., to
make the effects of this system fully enjoyable to customers.
4. Questionnaire design and analysis 4.1. Phase 1-‘Questionnaire Design’ 1. Questionnaire design The produce of the content of the research questionnaire at this phase was mainly based on the eight aspects required in evaluating the case’s caring needs, proposed by Chen (2002). Then, through collecting evaluation forms of discharge planning from eight hospitals, organizing and compiling each assessment factors into the eight aspects to design the initial questionnaire of this research, namely the pretest questionnaire for professional interviews. Questionnaire content includes: eight evaluation dimensions and 36 evaluation indexes. 2. Questionnaire data collection This research selected the responsible person of five units related to discharge planning (including discharge planning affair professionals, social resource aid consultation professionals of the case, continuing care connection support professionals of the case,
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and academic discharge planning professionals) as pretest subjects. 3. Questionnaire results analysis After organizing the pretest results of professionals’ questionnaires, revisions were done in evaluation index that demonstrates ambiguity or cannot clearly and definitely express the behavioral meaning of the case that is intended to obtain. Meanwhile, footnotes and descriptions were added in the questionnaire items, which are difficult for participants to comprehend, for a better and clearer understanding. The professionals suggested revising the hierarchy structure to which evaluation index belongs so that each index can be placed in appropriate dimension. Furthermore, seven of the eight dimensions of evaluation need are left and the original 36 evaluation indexes were screened, revised, and combined into 29. 4.2. Phase 2-‘Questionnaire analysis’ 1. Questionnaire data collection The institutes to which the Department of Health sponsored financially to implement discharge-planning services in 2001 are the subjects that received this questionnaire at this stage. There are 108 institutes in total; 108 questionnaires sent. 2. Questionnaire results analysis The questionnaire results of phase 2 can be analyzed into two major parts: summary statistics analysis and reliability analysis. (1) Summary statistics analysis Summary statistics analysis was conducted using the retrieved 67 effective questionnaires. The statistical analysis results of need evaluation dimensions of continuing care of discharge planning is ranked according to the mean, as illustrated in Table 1. (2) Reliability analysis Although the Cronbach a value of the overall questionnaire and its each evaluation dimension are both higher than the suggested value, Cronbach a ¼ 0:6 (as illustrated in Table 2), it is found during dimensional reliability analysis Table 1 Dimensions of continuing care need assessment of discharge planningsorting by the mean Ranking of importance degree
Evaluation dimension
Mean
1 2 3 4 5 6 7
G Evaluation of medical care awareness E Evaluation of nursing care D Evaluation of support systems C Evaluation of main caregiver(s) B Evaluation of physical conditions A Evaluation of functional conditions F Evaluation of basic information
4.6433 4.6380 4.6161 4.4471 4.3953 4.2637 3.8881
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Table 2 Reliability of each evaluation dimension Evaluation dimension
Reliability (Cronbach a)
A Evaluation of functional conditions B Evaluation of physical conditions C Evaluation of main caregiver(s) D Evaluation of support systems E Evaluation of nursing care F Evaluation of basic information G Evaluation of medical care awareness
0.6859 0.8487 0.7140 0.6432 0.9232 0.6137 0.8605
that if deleting a certain evaluation index in the two evaluation dimensions—[A Evaluation of functional conditions] and [F Evaluation of basic information], its reliability Cronbach a value will increase a certain level. Therefore, three evaluation indexes, A3 (IADL measuring table), F1 (age of the case), and F4 (education background of the case), were deleted. Finally, the revised reliability values for [A Evaluation of functional conditions] and [F Evaluation of basic information] are 0.7786 and 0.6912, respectively. After screening the evaluation indexes that belong in each dimension using reliability analysis, i.e. to revise the complete hierarchy structure of the continuing care need assessment of discharge planning, the result is the threelayer analytic hierarchy structure figure as shown in Fig. 4, and AHP questionnaire of phase 3 is designed according to such structure. 4.3. Phase 3-‘analytic hierarchy process’ (AHP) 1. Questionnaire design After the research analyses in phase 1 (questionnaire design) and phase 2 (questionnaire analysis), the evaluation dimensions and their belonging evaluation indexes are completely revised, and an analytic hierarchy structure can be further organized, as the three-layer analytic hierarchy structure figure shown in Fig. 4. In addition, based on the evaluation dimensions and indexes, pairwise comparison was conducted to understand the relative importance degree between dimension and dimension, and between index and index, and thereby the ‘analytic hierarchy process (AHP)’ research questionnaire is designed. 2. Questionnaire data collection To achieve consistency of completing the questionnaire before and after, the subjects of the questionnaires are same as that in phase 2-the institutes to which Department of Health financially sponsored to implement discharge planning in 2001. There are 108 questionnaires being distributed.
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Fig. 4. Hierarchy structure of continuing care need evaluation of discharge planning.
3. Questionnaire results analysis This research adopted ‘MATLAB R12’ and ‘Microsoft Excel’ software as the supporting tools to compute the AHP questionnaire to calculate the maximum eigenvalue
of each pairwise comparison matrix, the weight of each factor, and the consistency test of the questionnaire. Table 3 is the evaluation dimension and index weight obtained by calculating the investigation list of AHP questionnaire.
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Table 3 Weight of the evaluation dimensions and indexes Evaluation dimension
Evaluation dimension weight
Evaluation index
Evaluation index weight
A Evaluation of functional conditions
0.126
B Evaluation of physical conditions
0.088
C Evaluation of main caregiver(s)
0.198
A1 Barthel’s Score A2 Karnfsky Scale (K Scale) B1 Consciousness B2 Emotions B3 Communications B4 Breathing B5 Skin B6 Nutrition C1 Main caregiver(s) C2 Assessment on learning health education of main caregiver(s) C3 Interaction of the case and families C4 Educational background of main caregiver(s) D1 Economic/Financial situation D2 Connection of community resources D3 Emphasis and support degree of the family to patient E1 Bedsores E2 Breathing machine E3 Passageway (nasal-gastric tube, tracheotomy tube, urinary drainage catheters) E4 Wounds E5 Mucus suctioning F1 Identification category of the case F2 Disease diagnosis of the case G1 Motives of learning self-care skills
0.0825 0.0435 0.0154 0.0098 0.0118 0.0244 0.0113 0.0153 0.0384 0.0595
D Evaluation of support systems
0.180
E Evaluation of nursing care
0.184
F Evaluation of basic information
G Evaluation of medical care awareness
0.073
0.151
G2 Condition explanation of physicians G3 Awareness of discharge planning of the case and families G4 Awareness of illness of the case and families
5. Verification of continuing care information system of discharge planning In order to verify the feasibility of Continuing Care Information System of Discharge Planning, this research adopted real discharged cases. Information saved in the system database is cases of ‘discharge planning in a selected medical center in 2002.’ Data includes division of neurology and pulmonary, with 141 and 123 numbers of data, respectively, 264 in total. In addition, cases adopted for system verification are those in 2001. There are 15 data being randomly selected each from division of neurology and pulmonary medicine for case-based reasoning diagnosis system to conduct diagnosis. The case verification of this system selected previously searched five cases as subjects of calculating reasoning accuracy of the system. The overall system verification results are illustrated in Table 4, from which
0.0708 0.0293 0.0532 0.0359 0.0909
0.0275 0.0527 0.0342
0.0244 0.0452 0.0382 0.0348 0.0606 0.0268 0.0331
0.0305
it is indicated that the average similarity of the previous five cases reasoned by the system is 0.8609 while the average accuracy of the system is 0.8089. These two figures indicate a high level of average accuracy of the average similarity for the old cases reasoned by this system. Therefore, it presents a high feasibility of this continuing care information system of discharge planning, and can be used as a supporting system in decision making of staff of discharge planning while drafting plans for cases. The definition of ‘accuracy’ in this research is: the care models of the system include five categories and 24 options, i.e. medical care supporting facility and equipment (12 items), referred continuing care institute (1 item), skills and education of health (8 items), rehabilitation instruction (1 item), consultation (2 item); compare the two care models of reasoned old and new case, count ratio of matched items, and then calculate it.
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Table 4 overall result of system verification Ranking of similarity
Average similarity
Standard deviation
Average accuracy
Standard deviation
1 2 3 4 5
0.9027 0.8756 0.8609 0.8414 0.8241
0.0653 0.0689 0.0695 0.0753 0.0771
0.8306 0.8181 0.8083 0.8097 0.7778
0.1252 0.1041 0.1182 0.1087 0.1028
Total Mean/Average
0.8609
0.0712
0.8089
0.1118
6. Conclusions This research obtained many findings through the process of planning, analysis, establishment, and verification of the comprehensive system. They are organized and inducted into the following four focal points as the final conclusions of this research: 1. Evaluate the relative weight of each evaluation dimension and evaluation index by distributing AHP questionnaire It is found through AHP questionnaire that the relative importance degree of major caregiver evaluation dimension is ranked first, nursing care evaluation dimension second, and then followed by dimensions of medical care awareness, functional condition, physical condition, and basic information assessment. Therefore, it is clearly understood that the most important factor for cases to consider for their initial discharge plans is the main caregiver evaluation dimension, coordinated with other important factors such as the required nursing care models by the cases, and condition of learning general hygiene of the families, condition of the support system of the case, etc. These consideration factors can be used as future references in discharge planning. 2. Assist discharge-planning staff in making discharge plans by utilizing the ‘Continuing Care Information System of Discharge Planning’ The utilization of the continuing care information system of discharge planning designed by this research enables fast reasoning of the current care model required by the case after discharged. When operating case-based reasoning diagnosis system, users simply need to input 26 items of evaluation index for analysis and reasoning. There will be five old cases in suggestion after evaluation, and the information of the previous five cases will be listed by the system as well to provide reference basis for discharge-planning professionals to make plans. 3. Conduct result evaluation of system verification to test system feasibility This research conducted system verification using 30 cases. The reasoning mean of case similarity is 0.8609, and that of accuracy, 0.8089, indicating a high level of verification results of this system, and thereby verifying
a high level of feasibility of the ‘Continuing Care Information System of Discharge Planning’ designed by this research to be the supporting system utilized by discharge -planning staff for making discharge plans. 4. Simplify the work process of discharge planning to uplift overall efficiency and to consolidate customer service data Applying the ‘Continuing Care Information System of Discharge Planning’, many procedures can be combined to reduce repetitive work. When the case completed the evaluation process, case data can be saved into system database for ‘Case-Base Maintenance System’ to conduct case administrations. Furthermore, dischargeplanning professionals can instruct cases and their families, through ‘Customer Inquiry System’, each type of health education and skills and to convey messages of continuing care resources. Insodoing, overall dischargeplanning work process will be more systematic, and thereby enhance overall job efficiency and able to fully provide information required by customers.
7. Suggestions This research simply focused on providing recommendations and assistance when the discharge -planning professional is drafting the individual plan for the case. However, it does not consider other relevant information network of procedures regarding the overall discharge planning process. Neither did it take into account the actual needs of the patients and their families. Therefore, it is recommended for future researchers to further expand the scope based on these two aspects, which are described in general below: 1. Establish an overall discharge planning information network Utilizing the function of inner networking in the hospital to transfer documents of case information, to promote communications among each department, and thereby reduce waste of time in document transfer and trivial office jobs. Then, in cooperation with outer networking, connect with continuing care institutes and provide discharged patients and their families with related caring knowledge and inquiring service of
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medical care information to make the overall care system of discharge planning more sound and complete. 2. Consider from the aspect of the cases and their families to set up discharge plans The discharge plans made for individual cases are the responsibility of the professional nursing staff in the hospital or the discharge-planning staff. Even better, a team, consisted of other related medical care professionals (including nutritionist, social workers, attending physicians, etc), is organized to provide postdischarged services. However, in most cases, discharge plans are considered from the angle of medical care or its relevant without further understanding the problems and challenges that the cases and their families will face after discharged. For instance, the problems of meal preparation at home, self-changing clothing, getting up and out of bed, using the restroom, etc, or shopping, taking a walk, or other recreational activities. In this case, it is problematic whether the discharge plan made by these medical care professionals truly fits the need of the case. Therefore, this research suggests further discussion and exploration on this direction in order to better understand the real needs of the case and families to provide a care model that fits. References Department of Health Executive Yuan, ROC, (2001), Discharge Planning Process Standard. Council for Economical Planning and Development Executive Yuan, ROC, (2003). Table of World Population Estimates. Wu, S.-C., & Ju, Z.-M. (1994). Public attitudes towards long-term care arrangement of the elderly-findings of society condition investigation in Taiwan area in 1994. China Magazine, 14, 369–382.
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