Section 2 Applications

#### **Chapter 3**

## Bayesian Networks for Decision Support in Emergency Response: A Model for Missing Person Investigations

*Denis Reilly*

### **Abstract**

The successful operation of Emergency services (Police, Fire, Medical Emergency) relies heavily upon Information Systems and particularly Decision Support Systems. Missing person cases consume resources from the already overstretched resources of Police Forces. Such cases predominantly come from at-risk groups such as children in care, people suffering from depression, or elderly people suffering from dementia. This chapter reviews current practices used for missing person cases and describes a decision support model based on Bayesian networks.

**Keywords:** Bayesian networks, algorithms, missing persons, decision support, probability

#### **1. Introduction**

Emergency services face increasing demands in their challenges to keep the public safe and healthy. They typically utilize a variety of information systems to store data relating to previous incidents and recall data to assist with new incidents and tasks such as capacity planning. One particular class of information systems that play a vital role in emergency service operations is decision support systems. Such systems combine data and logic together with rules and heuristics to allow operational decisions to be made based on the domain knowledge embodied within the system. Typical examples of such systems are utilized by Police Forces in the development of search strategies for locating missing persons.

#### **1.1 Missing persons**

According to National Guidelines set out for UK Police Forces, A *missing person* is defined as:

'Anyone whose whereabouts cannot be established and where the circumstances are out of character or the context suggests the person may be subject of crime or at risk of harm to themselves or another'.

When someone is categorized as missing, the police will investigate their disappearance and try to find and safeguard them.

In 2013 the Guidelines introduced a second *absent person* category, defined as:

'A person not at a place where they are expected or required to be' and perceived to be 'not at any apparent risk'.

When someone is categorized as absent, no police response is required except to monitor and review the situation.

Typically absent cases involve individuals who go missing frequently (often referred to as frequent fliers). They are likely to be designated a missing person for the first few times that they are missing, but, if they return unharmed, thereafter they may be designated absent.

Missing person cases are both time consuming and resource intense, particularly in urban areas. **Figure 1** highlights the scale of misper cases facing UK Police Forces and the volume of calls generated from dealing with such cases.

Mispers come from a spectrum of the population. Many are children (teenagers) who go missing from care homes; others are adults with mental illness or depression. Cases also include elderly people suffering from dementia-related conditions. Murder (homicide) cases, manslaughter cases and death by misadventure often start out as misper cases until a body is located. Current practice relies on heuristics and localized domain knowledge. Social scientists will often interview mispers in the hope of eliciting knowledge in relation to mispers' intentions while they were missing. Typically, Police rely heavily on historical data and behavioral patterns. For example, many teenagers who go missing are found in local parks, where teenagers are known to congregate. Elderly people suffering from dementia may travel to a location associated with their past.

#### **1.2** *Bayesian networks*

Many problems in machine learning are solved by using supervised learning techniques, in which specific training input patterns are input to the model. Supervised learning is often the preferred solution of choice and powerful models such as Neural Networks and Support Vector Machines (SVMs) are available to implement supervised learning solutions. However, many cases exist where supervised learning is not applicable, typically when there is not one target variable of interest but many, or when different variables might be available or missing for each data point. Such examples include diagnosis in medicine, with many different types of diseases, symptoms, and context information available for a given patient. In a similar fashion, the problem of predicting the location of a missing person, or the distance that they may have traveled, poses similar problems to those found in medicine.

#### **Figure 1.**

*Key statistics for missing person in the UK, 2016–2017.*

#### *Bayesian Networks for Decision Support in Emergency Response: A Model for Missing Person… DOI: http://dx.doi.org/10.5772/intechopen.105047*

Bayesian networks (BNs) can deal with such challenges. BNs are seen as a popular choice for probabilistic reasoning and machine learning problems that are difficult to address with supervised learning techniques. BNs are undergoing a renaissance amongst the machine learning community as an effective probabilistic model that can be used to assist decision support. Implemented as a graphical network and supported by libraries in Python and R (e.g. bnlearn and Pomegranate), they allow probability inferences to generate 'what if'? and 'which is best'? In addition to medicine, BNs have been successfully applied to genetics, search and rescue (SAR) and general classification problems.

The particular strengths and weaknesses of BN may be summarized as:


The main drawback of BNs is their inability to deal with continuous data, which needs to be discretized. Section 3 describes the application of BNs to develop a model to assist the decision-making process for misper cases. A more detailed consideration of the approach is described in [1].

#### **2. Current approaches for missing person searches**

The sections below review the main research approaches for dealing with missing person cases, which range from empirical techniques to formalized approaches.

#### **2.1 Bayesian networks for search and rescue**

There is some notable research concerned with the use of BN for Search And Rescue (SAR), in relation to people and objects who have either become lost or gone missing by accident. The distinction of course is that at-risk misper groups have intentionally gone missing, whilst SAR cases deal with entities, which have unintentionally become lost. The most notable use of Bayesian inference for search techniques was that of the search for Air France Flight AF 447, which crashed into the Atlantic on 1st June 2009 [2]. After 2 years of unsuccessful searching, the team used a Bayesian procedure developed for search planning to produce the posterior target location distribution. The distribution was used to guide the search and the wreckage was located within a week.

Reference [3] describes a Bayesian approach to modeling lost person behaviors based on terrain features in Wilderness Search and Rescue. The approach uses a first-order Markov transition matrix for generating a temporal, posterior predictive probability distribution map. The approach also uses a Bayesian χ<sup>2</sup> test for goodness-of-fit and goes on to show that the model closely fits a synthetic dataset. Reference [4] provides a study of missing person behavior in Australia, conducted by Victoria Police. The study, which is part of the SARBayes project, considers a large dataset of parameters, some of which have more significance than others.

Terrain plays an important role and the range of activities, relating to the missing person, are also considered (e.g. climbing, canoeing, hunting).

#### **2.2 Machine learning and formal approaches**

There are also several other machine learning-related approaches for dealing with missing person cases. For example, [5] compares the use of neural networks and rule-based systems for missing person cases in Australia. In later work [6] considers the use of J48 to derive rules, based on the popular C4.5 decision tree generator.

In the author's own previous work [7] a missing person model was developed based on Situation Calculus. The approach represented the state changes that take place over time, whilst missing. The formalisms help to provide a consistent means to represent the uncertainty present in such investigations.

#### **2.3 Empirical approaches**

Two widely accepted empirical approaches are those of the UK booklet 'Missing Persons: Understanding, Planning and Responding' (colloquially referred to as the Grampian Study) [8] and the iFIND System [9], which is currently used by a number of UK Police forces.

The Grampian Study considers a similar set of at-risk groups to that of the author's work. For each group the study provides a number of tables, which portray useful information, such as likely time periods of missing, distance traveled and likely places where a misper could be found. The Grampian Study also translates data into useful search ranges that can be superimposed on a map (**Figure 2**).

iFIND follows a similar structure but is based on more recent data to provide more thorough coverage. iFIND provides more detail in terms of possible locations. Both Grampian and iFIND place emphasis on Time, Distance and Likely Location and these parameters also feature predominantly in the author's work. **Figure 3** shows a typical excerpt from iFIND in the form of a table, which highlights the places where mispers for the category were located. The majority are found outside

**Figure 2.** *Grampian search profiles for 5–8 year olds.*

*Bayesian Networks for Decision Support in Emergency Response: A Model for Missing Person… DOI: http://dx.doi.org/10.5772/intechopen.105047*


#### **Figure 3.**

*iFIND table of likely locations for 5–8 year olds.*

locally, with a smaller proportion either returning home or being found at a friend's house.

#### **2.4 Geospatial approaches**

Other research conducted by the author led to the development of the CASPER System (Computer Assisted Search Prioritization and Environmental Response) [10] to study the Geographies of Missing Persons. CASPER used primary and applied research and secondary data analysis to develop a Google map application to assist investigative and strategic decision-making. CASPER was developed to a prototype stage and demonstrated to several Police forces as a viable alternative to existing case management systems COMPACT [11] and NICHE [12] systems.

CASPER (**Figure 4**) was rich in terms of the geospatial information it provided, being able to display heatmaps, places of interest and even live CCTV footage. CAS-PER allows the search team to overlay a range of different layers onto a map region of interest. For example, the team may choose to overlay information on ATM cash machines if it is known that a misper is short of money. Alternatively, suicide hotspots can be overlaid (from precompiled suicide data) when dealing with a potential suicide case.

However, the algorithms used in CASPER were largely rule-based, developed from 'people like you' approaches, based on *if-elseif-else* structures.

**Figure 4.** *CASPER missing persons prototype.*

#### **3. Bayesian network theory**

BNs are directed graphical models that have been used extensively in the fields of cognitive science and artificial intelligence throughout the latter half of the 20th and early 21st centuries. The models are based on the theorem of Thomas Bayes [13], which allow probabilities to be updated in light of new evidence. BNs have been used for some time within the AI community and more recently amongst the machine learning community. Reference [14] provides an excellent account of how probability theory and decision theory began to attract the attention of the AI community in the late 1980s, which, when combined with graph theory, led to what we refer to today as Bayesian Networks.

Formally, for a discrete random variable *X* ¼ f g *X*1, ⋯,*Xn* , a BN is an annotated directed acyclic graph, which encodes a joint probability distribution (JPD) over *X.* Formally, a BN can be expressed as the pair *N* ¼ h i *G*, *Θ* . The first element in N, is a directed acyclic graph, *G* = (*V*, *E*). V denotes the random variables in *X*, and *E* denotes the edges, which represent direct dependencies between the variables. The second element *Θ* denotes the set of parameters, which quantify the network, via conditional probability tables. Each node is annotated with a conditional probability distribution, *P Xi* ð Þ j *Pa*ð Þ *Xi* , representing the conditional probability of the node *Xi* given its parents in *G*. The network *N* defines a unique JPD over *X* given by:

$$P(\mathbf{X}\_1, \dots, \mathbf{X}\_n) = \prod\_{i=1}^{N} P(\mathbf{X}\_i \mid \mathbf{Pa}(\mathbf{X}\_i)) \tag{1}$$

In a BN, a *conditional* probability *P(X | Y)* is the probability of an event *X* occurring given that *Y* occurs. A *marginal* probability is effectively an unconditional probability. A marginal probability is a distribution formed by calculating the subset of a larger probability distribution. For example, given a JPD *P(X, Y)* to determine the probability of *X* all the values for *X = False* and *X = True* can be summed in the joint table. When a node is queried in a BN, the result is often referred to as the *marginal* for that node.

For BNs, inference, is the computational method for deriving answers to queries given a probability model expressed as a BN. Inference in BNs can take on several

*Bayesian Networks for Decision Support in Emergency Response: A Model for Missing Person… DOI: http://dx.doi.org/10.5772/intechopen.105047*

different forms [15, 16], broadly speaking, it may be exact or approximate, depending upon the structure of the graph. Exact inference is not always possible when the number of combinations and paths is excessively large. However, it is often possible to refactor a BN graph (i.e. alter the graph structure) before resorting to approximate inference.

Let U be the set of random variables. Let *U<sup>e</sup>* ⊆ *U* be the set of known (evidence) variables. Let *<sup>X</sup><sup>q</sup>* <sup>∈</sup> *<sup>U</sup>* <sup>n</sup> *<sup>U</sup><sup>e</sup>* be the variables of interest (queries) and let *<sup>U</sup><sup>r</sup>* <sup>¼</sup> *<sup>U</sup>* <sup>n</sup> *<sup>U</sup><sup>e</sup>* <sup>∪</sup>*X<sup>q</sup>* ð Þ be the set of remaining variables.

The probability distribution of the evidence variables and the query variables via marginalization, can be calculated as:

$$P(X^q, U^\epsilon) = \sum\_{U^r} P(X\_1, \dots, X\_N) \tag{2}$$

The normalization may be calculated as:

$$P(U^{\epsilon}) = \sum\_{U^{\epsilon}} P(\mathbf{X}^{q}, U^{\epsilon}) \tag{3}$$

Then conditional probabilities may be calculated as:

$$P(\mathbf{X}^q \mid U^\epsilon) = \frac{P(\mathbf{X}^q, U^\epsilon)}{P(U^\epsilon)}\tag{4}$$

A range of different questions can be asked, via inference, in relation to the probability distribution, such as:


The different questions may be considered in relation to how classical statistical models help to estimate either the value of something - regression framework or the state of something - classification framework. Prediction and classification would be as per the classical statistical model framework. Diagnosis adds to this by defining the outcomes from the model in organizational terms (e.g. Policing terms, such as high priority cases). Decision-making adds further to this by using the diagnosis to guide Policing activities. Decision-making effectively translates the statistical model into operational terminology for operational decision-making.

Essentially, a BN defines a unique JPD over *X* and computationally the JPD takes the form of a large table, constructed from the tables defined at individual nodes, in accordance with the graph links. So computationally, inference is the process of scanning the joint table to find a value (or values), which correspond to evidence E, possibly summing values along the way. Often, the table will take the form of a sparse matrix and this property can be exploited to make inference tractable, even when the number of parameters is very large. There are certain legal rearrangements of the JPD table in which certain parameters can be marginalized.

Such rearrangements allow queries to be satisfied in linear-time methods by identifying a subgraph of the original graph relevant to the query [17].

#### **4. Misper-Bayes model for missing person investigations**

The Misper-Bayes model was developed from previous research conducted by the author [1]. The model represents the different categories of at-risk missing persons and their breakdown in terms of sex type and age. The model also represents the likely times that a person may be missing, and the distance traveled as well as the likely locations where they may be found. Data from iFIND was used to determine the male/female split and the same set of at-risk categories as iFIND were adopted. All of the iFIND data was examined and a set of network parameters were compiled.

The Misper-Bayes model is shown below (**Figure 5**) in terms of a digraph and associated conditional probability tables. The nodes in the graph represent the random variables, which are linked through the conditional probability tables. Most of the tables are fairly self-explanatory, with a couple of exceptions: the Cat(x) table reflects the different categories of at-risk mispers and the Loc(x) table reflects the different locations where mispers are likely to be found. Note that there is no edge connecting Cat(x) and Time(x) (although there was an edge in an earlier version of the model). It was found that Age(x) provides a better predictor of the time spend missing than Cat(x). For example, the age of a young child or an elderly subject has a direct bearing on the time that they are missing. Other variables were included in earlier versions of the model, such as race or ethnicity, but these were seen to have a lesser effect than the variables shown in **Figure 5**.

Recalling Eq. (1), which gives the JPD over *X* given as:

$$P(X\_1, \dots, X\_n) = \prod\_{i=1}^{N} P(X\_i \mid \mathbf{Pa}(X\_i))$$

**Figure 5.** *Misper-Bayes model.*

*Bayesian Networks for Decision Support in Emergency Response: A Model for Missing Person… DOI: http://dx.doi.org/10.5772/intechopen.105047*

The Misper-Bayes graphical model can be written as:

$$P(L, D, \mathcal{C}, T, \mathcal{S}, A) = P(L \mid D, \mathcal{C}) \, P(D \mid T) \, P(\mathcal{C} \mid \mathcal{S}, A) \, P(T \mid A) \, P(\mathcal{S}) \, P(A) \tag{5}$$

where:

*P*(*A*) is the probability of the different age groups.

*P*(*S*) is the probability of the sex types male and female.

*P*(*T* | *A*) is the conditional probability of time missing, based on age.

*P*(*C* | *S, A*) is the conditional probability of the different categories, based on sex type and age group.

*P*(*D* | *T*) is the conditional probability of distance traveled, based on time missing. *P*(*L* | *D, C*) is the conditional probability of the likely location, based on the different categories and the distance traveled.

Software libraries are available for common programming languages, which can be used to implement BNs. Two popular libraries for the Python programming language are pomegranate [18] and bnlearn [19]. bnlearn is a library, which can be used to learn the structure of a BN and estimate the parameters, based on a dataset [20]. bnlearn was used in this instance to learn the network structure based on data from iFIND. After several iterations and variable eliminations, the development process arrived at a graph similar to **Figure 5**. bnlearn starts with an empty network structure of all variables, then proceeds by adding, removing and reversing edges between nodes to maximize the goodness of fit of the model. The final structure, learned by bnlearn, contained an excessive number of edges, likely due to overfitting (i.e. noise within the data had been represented in the model itself). The unnecessary edges were thinned out, based on the interpretation of the causal relationships between variables to deliver the final structure of **Figure 5**. Finally, bnlearn was used to learn the parameters using iFIND data compiled from the summary table (**Figure 3**).

The model was trialed using a series of realistic misper cases and the results were promising (approx.. 90% agreement) in relation to those of iFIND. A full set of the results are available in [1].

#### **5. Conclusions**

The chapter has described the design and implementation of the Misper-Bayes model, which can be used to assist Police forces in determining the whereabouts of a missing person. Misper-Bayes provides a powerful tool, which can be used to good effect to whittle down the likely locations where the missing person may be found. The Misper-Bayes model was evaluated using a series of queries with a set of misper cases. For each query, the results of the model were cross-checked against the results of the iFIND system and the accuracy was approx.. 90%. The strength of the model lies in its simplicity yet versatility. When combined with a geospatial frontend (e.g. CASPER) [21–23], the Misper-Bayes model can be used to very good effect to assist Police Officers with the prioritization of their search strategy. The approach has also demonstrated the scope of BNs to support evidence-based policing beyond that of missing person cases.

*Contemporary Issues in Information Systems - A Global Perspective*

### **Author details**

Denis Reilly Liverpool John Moores University, United Kingdom

\*Address all correspondence to: d.reilly@ljmu.ac.uk

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Bayesian Networks for Decision Support in Emergency Response: A Model for Missing Person… DOI: http://dx.doi.org/10.5772/intechopen.105047*

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[2] Stone LD, Keller CM, Kratzke TM, Strumpfer JP. Search for the wreckage of air France flight AF 447. Statistical Science. 2014;**29**(1):69-80

[3] Lin L, Goodrich MA. A Bayesian approach to modeling lost person behaviors based on terrain features in wilderness search and rescue. Computational and Mathematical Organization Theory. 2010;**16**:300-323

[4] Sava E, Twardy C, Koester R, Sonwalkar M. Evaluating lost person behavior models. Transactions in GIS. 2016;**20**(1):38-53

[5] Blackmore K, Bossomaier T, Foy S, Thomson D. Data mining of missing persons data. In: Proc. 1st International Conference on Fuzzy Systems and Knowledge Discovery: Computational Intelligence for the E-Age, Singapore. Berlin, Heidelberg: Springer; 2002

[6] Blackmore K, Boosomaier T. Comparison of See5 and J48: PART algorithms for missing person profiling. In: Proc. 1st International Conference on Information Technology and Applications, ICITA 1–6, Australia. 2002

[7] Taylor MJ, Reilly D. Knowledge representation for missing persons investigations. Journal of Systems and Information Technology. 2017;**19**(2): 138-150

[8] Gibb G, Woolnough P. Missing Persons: Understanding, Planning, Responding – A Guide for Police Officers. Aberdeen: Grampian Police; 2017. Available from: http://www.sea rchresearch.org.uk/downloads/ukmpbs/ GGIbb\_missing\_person\_report.pdf

[9] N. Eales. "iFIND", National Crime Agency (NCA), London, UK [Online]. 2015. Available from: https://missingpe rsons.police.uk/en-gb/resources/ downloads/iFIND

[10] Reilly D, Wren C, Giles S, Cunnigham L, Hargreaves P. CASPER: Computer assisted search prioritisation and environmental response application. In: Proc. Sixth International Conference on Developments Is E-Systems Engineering (DeSE'06), Abu Dhabi, UAE. IEEE; 2013. pp. 225-230

[11] WPC Software. COMPACT. Available from: https://www.wpcsoft.c om/business-areas/compact

[12] NicheRMS. [Online]. Available from: https://nicherms.com/products

[13] Stone JV. Bayes Rule: A Tutorial Introduction to Bayesian Analysis. Sebtel Press; 2013. ISBN 978-0-9563728- 4-0

[14] D'Ambrosio B. Inference in Bayesian networks. AI Magazine. 1999; **20**(2):21

[15] Darwiche A. Modelling and Reasoning with Bayesian Networks. Cambridge: Cambridge University Press; 2009

[16] Larranaga P, Karshenas H, Bielza C, Santana R. A review on evolutionary algorithms in Bayesian network learning and inference tasks. Elsevier Information Sciences. 2013;**233**:109-125

[17] Geiger D, Verma T, Pearl J. d-separation: From theorems to algorithms. In: Proc. Fifth Workshop Uncertainty in Artificial Intelligence, Ontario, Canada. 1989. pp. 118-125

[18] Schreiber J. Pomegranate: Fast and flexible probabilistic modeling in

python. Journal of Machine Learning Research. 2018;**18**(164):1-6

[19] bnlearn – Graphical structure of Bayesian networks [Online]. Available from: https://pypi.org/project/bnlearn

[20] National Crime Agency. 2017. Missing Person Data Report 2015/2016. [Online]. Available from: http://missing persons.police.uk/en-gb/resources/ downloads/missing-person-statisticalbulletins

[21] Uusitalo L. Advantages and challenges of Bayesian networks in environmental modelling. Ecological Modelling. 2007;**203**:312-318

[22] Kyrimi E, Mossadegh S, Tai N, Marsh W. An incremental explanation of inference in Bayesian networks for increasing model trustworthiness and supporting clinical decision making. Artificial Intelligence in Medicine. 2020; **103**. ISSN 0933-3657

[23] McLachlan S, Dube K, Hitman GA, Fenton NE, Kyrimi E. Bayesian networks in healthcare: Distribution by medical condition. Artificial Intelligence in Medicine. 2020;**107**, ISSN 0933-3657

#### **Chapter 4**

## The Applicability of Internet Voting in Africa

*Paul Sambo*

#### **Abstract**

The covid-19 pandemic has brought about new ways of conducting business through the use of Information Communication Technologies and elections have not been spared either. Internet voting is another form of strengthening democracy through the use of Information Communication Technologies. Africa lags in the implementation of electronic voting, especially Internet voting. This chapter applied a critical socio-technical analysis that analyses factors that influence the applicability of Internet voting within the African context. The researcher applied desktop research which included 30 journals to gather data from the Internet and other documentation sources. The findings reveal that decision-makers can partially implement Internet voting in some of the countries in Africa like Kenya, Libya, Nigeria, Morocco, Mauritius, Tunisia, and Seychelles. To successfully implement Internet voting, the decision-makers in African nations have to fully invest in the Information Communication Technology infrastructure, provide the necessary security, legislation and carry out intensive voter education to build trust among voters.

**Keywords:** Covid-19, lockdown, pandemic, Internet voting, critical socio-technical analysis, democracy

#### **1. Introduction**

Democracy has formed the foundation of governance in the world, with every voter willing to express his/her views on the ballot [1, 2]. Elections have been held manually and electronically in both the developed and developing nations, some results have ended in contestations and wars erupting after the elections. Covid-19 has had a devastating effect on the political, social, and economic spheres in the world [3]. The way of running elections was also affected by this pandemic as nations sought to find ways of halting the spread of the disease. In developed nations countries like Estonia and other American states have been implementing Internet voting.

Africa is constituted by 54 countries with diversified democracies [4]. Eritrea is the only country that does not hold regular elections as has continuously postponed elections citing security threat from its neighbors Ethiopia and Djibouti. The African nations have diversified electoral systems, with some countries like Zimbabwe implementing first past the post and proportional representation, and South Africa, the proportional representation in their polls [5]. Most of the African countries hold regular manual elections as demanded by the United Nations Universal Declarations on elections.

The prospects for the growth of democracy in the 21st century in Africa depend on how the continent positions itself for value-adding services such as Internet voting. Covid −19 has forced the world to quickly develop and implement Information Communication Technologies (ICT) opportunities previously unimaginable. For Africa to take advantage of this, an effective enabling environment and use of ICTs is a particularly important contributor to modern democracy.

### **2. Literature review**

Internet voting is where a ballot is cast by the voter through the Internet [6]. The use of Internet voting gained popularity in Estonia since 2001. Estonia is the first country to carry out a successful pilot project in municipal elections in 2005. Estonia went on further to first use Internet voting in the 2007 parliamentary elections [7].

The four kinds of Internet voting are kiosk Internet voting, polling-place Internet voting, precinct Internet voting, and remote Internet voting (Canada-Europe Transatlantic [8]). Kiosk Internet voting involves the use of a computer at a specific location (an authorized internet polling station) that is controlled by election officials. This differs from a standalone electronic voting machine because the ballot is immediately transmitted over the Internet to the central vote-counting site. Polling-place Internet voting is conducted through the use of a computer at any polling station and is supervised by the usual election officials. Precinct Internet voting is very similar to polling-place voting except that it must occur at the voter's designated precinct polling station (voters are only allowed to cast their ballots at polling stations where they are registered). Remote Internet voting is where a voter cast the ballot from the comfort of their homes or where the is Internet provision [9]. The advantages, disadvantages, and countries that are implementing Internet voting are shown in **Table 1**.




#### **Table 1.**

*Comparison of internet voting methods.*

As shown in **Table 1**, Internet voting is necessitated by the demographics of a country especially people living abroad who would want to exercise their democratic right but will not be residing within the citizenry country during an election. Chisinau [11] argues that Internet voting will allow voters to cast their ballots at the comfort of their homes or convenient places. Voting through the Internet is easier as voters can cast ballots using their own devices and there is no time wasted in long queues. Voters do not travel long distances, thus reducing transportation costs and can do other business chores. It allows for inclusivity as people living with disabilities or serious medical conditions can exercise their democratic rights. Internet voting will also allow those people who will be traveling or will be on duty during election day to cast their ballots anywhere in the world [12].

#### *The Applicability of Internet Voting in Africa DOI: http://dx.doi.org/10.5772/intechopen.98576*

The disadvantage of Internet voting is that it consists of a large complex network which makes it difficult to monitor the entire network, thus posing a serious security threat. The monitoring of the network is very expensive of which there is no 100 percent guarantee that the network will be secure. Hackers could use malware to rig the outcome of the elections, by tampering with the way votes are submitted and counted or even casting votes for people who did not vote. Internet voting may be a source of conflict between political parties if one party considers that Internet voting might be beneficial to the other party/parties [12].

#### **2.1 Critical socio-technical analysis**

The critical socio-technical analysis [10] which is premised on analyzing an information system during the systems development life cycle was used to identify key factors in the applicability of Internet voting in Africa. By finding key factors affecting the applicability of Internet voting in Africa, it is expected that decision-makers would come up with strategies that support the successful implementation of such systems.

African Electoral Management Bodies (EMBs) have been using manual systems in general elections for the past decades which has resulted in disputed elections, high operating costs affecting the Gross Domestic Product (GDP) because of systems and processes inefficiency. Only two countries, the Democratic Republic of Congo and Namibia have used polling stationed-based electronic voting machines which do not have Internet connectivity [13]. Covid-19 has not helped the situation either as countries have been forced into lockdowns, compelling nations to postpone elections. The introduction of Internet voting especially casting a ballot outside a polling station is the most difficult technological upgrade for an Electoral Management Body (EMB) as it involves the core of the entire electoral process [14]. This chapter investigated 'why' and 'what' factors were affecting the applicability of Internet voting in African general elections.

#### **3. Methodology**

In this study, desktop research was used to collect data from 30 journals and other documentation about factors affecting the applicability of Internet voting in Africa. The critical socio-technical analysis was then used to guide this study in the search and analysis of factors such as political, social, technical, legal, security, privacy, trust, and transparency affecting the applicability of Internet voting in Africa. These factors were selected after critically analyzing contemporary issues in developing and developed countries successfully implementing, on trials or have abandoned the implementation of Internet voting.

#### **4. Findings**

While the benefits from Internet voting will guarantee the rights of citizens to exercise their democratic rights, the study discovered that no country in Africa is implementing Internet voting in general elections. The factors affecting the applicability of Internet voting in Africa are political, legal, social, technical, security, privacy, transparency, and trust.

#### **4.1 Political**

Africa has the most number of people that flee their countries seeking greater opportunities from developing and developed nations [15]. Citizens from African countries migrate to other countries due to the effects of climatic changes, such as droughts, storms, and flooding. Other factors such as economic and political stability (wars) also force nationals to migrate to other countries seeking better opportunities [16]. The migration of people allows African countries to offer their citizens their democratic rights by allowing them to vote through the Internet. Some African governments also tend Internet shutdowns citing national security or curbing the spread of fake news during elections, for example, the Ugandan, Libya, Malawi, and Sudan Presidential elections [17] which makes it difficult to implement Internet voting.

#### *4.1.1 Legal*

The legal framework allows voters to exercise their rights during an election or absentee voting through the Internet [18]. For African citizens living abroad or who will be committed during election day to exercise their democratic right, there must be legislation that supports Internet voting. The legal framework empowers the EMB and other stakeholders to remove the element of mistrust, as the voting process is done within the confines of the law. At the moment no country in Africa is exploring the use of Internet voting rendering the introduction of such legislation a futile exercise.

#### *4.1.2 Technical*

African countries are still facing challenges in the implementation of mobile communication and Internet technologies [19]. Countries like Somalia, South Sudan, and Mozambique have often been affected by ravaging wars, which destroys infrastructure and forcing these countries into retarded economic growth. As shown in **Table 1**, the limitation in the Internet penetration factor is that the network service providers do not provide 100% service coverage. This makes it practically impossible to offer Internet voting within the country for national general elections as some other communities will be disadvantaged by failing to access the service to cast their ballots. The penetration of internet communication in Africa is very low at 43% as shown in **Table 2**. Countries like Kenya, Libya, Mauritius, Nigeria, Morocco, Seychelles, and Tunisia have a higher national Internet penetration factor. These countries can partially implement Internet voting in some of their regions. Other African nations especially that are below 50% like Eretria, Togo, Western Sahara, South Sudan, Sierra Leone, and Somalia will have difficulties in implementing Internet voting nationally.

#### *4.1.3 Social*

There is a wide gap between the digital divide within the African nations especially between the urban and the rural community, the elderly, and the young generations [20]. The young generations have embraced technology as they use smartphones and laptops as communication and business tools. A large population in African countries live in rural communities. Some of these people cannot afford to buy gadgets, power, and data used for Internet services. There is also a lack of digital skills and literacy among the communities both in urban and rural setups especially among the elderly. The content or language used on the Internet makes it difficult for some African communities to comprehend the importance of using such services. Hence the use of Internet voting in African countries will be difficult because of the digital divide.

#### *4.1.4 Security*

Internet voting should be secure for the results to be credible [21]. Key factors such as freedom, and equality during an election are important aspects of security

#### *The Applicability of Internet Voting in Africa DOI: http://dx.doi.org/10.5772/intechopen.98576*



#### **Table 2.**

*Internet users statistics for Africa.*

requirements for Internet voting. The transmission of all voting data to servers or tabulation centers must be secure. All voting which is done whether on the Internet or otherwise should be granted the same status as any other vote cast in the same election. This means that each vote should be given the same weight as it also determines the outcome of an election [22]. Various encryption methods have been suggested for use with Internet voting including the blockchain [23]. African countries should have networks that can encrypt ballots cast over the Internet without the network being compromised, overloaded, or due to other disruptions like shutdowns.

#### *4.1.5 Privacy*

With the use of Internet voting, an EMB has to ensure that each vote cast remains a secret. A free election means that the voter must not be coerced by public or private pressure. After voting through the Internet, the voters should have an acknowledgment for the candidate that they have voted for. All ballots cast through the Internet should be accorded the same secrecy as in manual systems [24]. If a ballot is cast, the voter's identification details must be able to be authenticated and not linked to the ballot. The vote cast should also be accounted for in the outcome without identifying the voter. In Africa voter intimidation remains a serious challenge [25], thus through Internet voting, voters may be coerced to vote for undeserving candidates.

#### *4.1.6 Trust and transparency*

Trust in Internet voting can only be accepted if the results from this service are credible. The EMB should assure voters that their votes are secure and secret. To

#### *The Applicability of Internet Voting in Africa DOI: http://dx.doi.org/10.5772/intechopen.98576*

build trust voters should also be able to verify that all collected ballots were from eligible voters and that they have been accurately counted [26]. If Internet voting is to be implemented in African countries pilot testing has to be undertaken to allow voters to test the system before being fully implemented in a general election. To build trust among stakeholders (voters, activists, and media) an EMB should be transparent in all the activities involved with Internet voting. To avoid mistrust from the public, the stakeholders should be educated on how Internet voting works and also made to appreciate the qualities of the system. Relevant information should be availed in a language that can easily be understood by the public. The information should include full technical documentation of how the system is designed functionally and technically, all levels of software documentation, source code, and the technical and organizational environments where the system is hosted.

#### **4.2 Discussion and analysis**

With the advent of the Covid-19 pandemic causing deaths, and unavoidable shutdowns, elections cannot be suspended indefinitely, decision-makers have to find alternative ways of conducting elections without compromising the health and safety of the electorate. Internet voting is one such method that may guarantee the health and safety of the electorate where voters can vote in the comfort of their homes. Decision-makers have to take note of the following during feasibility studies and implementation of Internet voting:

Politically, it is fundamental to foster a broad consensus among political parties for the implementation of Internet voting. This involves transparency where the relevant actors have a voice. Internet voting should be seen as politically neutral that is the new procedure should not benefit disproportionally given factions of the political spectrum [27]. For electoral results to be accepted by voters, Internet voting must produce an outcome that reflects the will of the people in an environment that establishes transparency and trust [14].

Technological and security concerns are often pointed to as the main concern of Internet voting [28]. To validate and verify the technological voting system the set of technological requirements have to be consulted systematically. In Africa, some voters live in remote areas but may also want to cast their ballots using the Internet. African countries have limited Internet infrastructure which should prompt governments to improve this area if its citizens are to benefit from Internet voting. The improvement on the infrastructure would also benefit an EMB during the voter registration process, as voters will be able to register through the Internet.

There have been numerous attacks of electronic voting systems over the Internet with the 2016 American Presidential election being the most contentious election of the decade [29]. The stakes of any general election are always high, which may create interests chief among them malicious actors-particularly in countries with specific geopolitical adversaries who may specifically create and deploy attacks or malware designed to manipulate the vote. In Africa, the use of Internet voting which has got limited transparency and audit trail may lead to manipulation and voter fraud. It will be very difficult to monitor votes cast over the Internet, to build trust among the citizens an EMB has to be trusted in pursuing its mandate.

Most electronic voting systems are now being developed with blockchain encryption [30, 31]. Blockchain technology is an end-to-end encryption method that secures ballots transmitted from voters' private devices to a centralized tabulation facility. However, it has been observed that most serious vulnerabilities threatening integrity and secrecy of voting happen before ballots ever reach the blockchain. Voters may be coerced by family members or other pressure groups to vote in a certain way that does not reflect their will. It is also difficult to validate if the voter is the real one casting the ballot which


*Source:http://www.europarl.europa.eu/RegData/etudes/BRIE/2018/625178/EPRS\_BRI(2018)625178\_E N.pdf*

**Table 3.**

*Countries that use internet voting (use of internet voting outside of polling stations in politically binding elections).*

#### *The Applicability of Internet Voting in Africa DOI: http://dx.doi.org/10.5772/intechopen.98576*

is crucial to the credibility of an election. Estonia, for instance, has resolved this issue without blockchain by using e-ID cards. Blockchain technology also does not protect against -denial-of-service attacks that make servers unable to operate, does not protect information as it travels on the Internet, and does not make servers and infrastructure more resistant to advanced persistent threats. Despite improvements in encryption techniques, security will always remain a challenge for Internet voting.

The major social challenge is the digital divide as some parts of the population remain excluded from Internet voting and that gap exists in African countries regarding computer literacy and household Internet usage and availability. The 'Digital transformation Strategy' adopted by African countries in February 2020 should be pursued to narrow the gap between the digital divide in urban and rural communities and also narrow the 'gender digital divide' [32].

Currently, most African countries do not have any legislation that supports Internet voting. The legal framework should be put in place to allow for Internet voting, which should clearly state who is eligible and the reasons that support eligibility.

Despite low usage in Internet voting around the world, Estonia is the only country that has fully utilized this service in general elections. **Table 3** highlights countries that have fully, partially, piloting and discontinued the use of Internet voting.

The success of Internet voting depends largely on how it is perceived by the people meant to use it: citizens. For example, Internet voting is difficult to be transparent as compared to manual systems. The transparency and reliability of Internet voting have been questioned, as this is electronically done. Therefore, it is fundamental to know what their attitudes towards the implementation of Internet voting would affect them.

#### **5. Conclusions**

The applicability of Internet voting in Africa largely depends on how the nation's willingness to adapt to new technology in the face of challenges such as political, legal, security, privacy, trust and transparency, the digital divide, and limited infrastructure. The successful experience of countries such as Estonia highlights the importance of a gradual, step-by-step design and implementation of Internet voting which may be used for benchmarking. It is also recommended that the perception of the citizens should be taken into consideration. African nations should also make an effort to improve the internal coverage of Internet services within their territories.

#### **Author details**

Paul Sambo Department of Mathematics and Computer Science, Great Zimbabwe University, Zimbabwe

\*Address all correspondence to: plzsambo@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 5**

## Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital

*Boy Subirosa Sabarguna*

#### **Abstract**

The explanation begins with the Clinical Pathway in Hospital which describes how the Clinical Pathway is used in relation to 2 things: Components-Linkages and Step-Problems-Optimal Solution, followed by Linkages Clinical Pathway with Quality Improvement and Cost Containment, which describes the relationship of each. Followed by the Clinical Pathway for Service Quality: which consists of: (1) Clinical Pathway for Service Quality, (2) Patient Safety for Service Quality Improvement, (3) The role of alogarithm, thereby clarifying the form of clinical pathways in quality improvement efforts that ensure service improvement by still maintain the quality that is maintained during the cost containment. The Clinical Pathway in Cost Containment describes the roles of: (1) Link of Components, (2) Procedure, (3) Unit Cost, so that cost containment efforts can be made in the form of cost containment optimally while maintaining quality does not need to decrease. Clinical Pathway in New Era is a newly developed algorithm related to current and future conditions. This is related to: (1) New Era in Pandemic Covid-19, (2) Clinical Pathway in Non Curative Service, (3) Clinical Pathway in Technology Services, (4) Clinical Pathway in Technological Rerelated while continuing to carry out quality improvement and cost containment simultaneously. Concluton: clinical pathway in hospital can be used as a system for Quality Improvement and Cost Containment, related to New Era in Pandemic Covid-19, Non Curative Service, Technology Services and Technological Rerelated.

**Keywords:** clinical pathway, quality improvement, cost containment, pandemic covid-19, non curative service, technology services, technological rerelated

#### **1. Introduction**

#### **1.1 Clinical pathway in hospital**

Clinical Pathway [1] is an effort made in order to:


#### 3.Describe services to patients;

4.Estimate possible clinical problems.

The description above provides directions to make it easier to discuss and try to get the same understanding, thus further formulation can be carried out to find clinical problems that may occur and provide directions for possible solutions, so that optimal conditions or the best conditions can be considered in existing conditions. This will be important for the following 3 things:


Now with more advanced and superior computerization advancements, help simplify the complex problems of the Clinical Pathway, thus providing a discussion space for clinicians and hospital management to:


The following are examples related to the role of clinical pathways in effectiveness [2]: clarity of admission, interventions, comparison of old and new therapies and clearer outcomes of clinical pathways. In this condition, the use of computerization makes it easier to explain and simulate events. The relationship of the above becomes clearer as described, as follows.

#### 1.Components-relation to clinical pathway

Components in the right and correct clinical pathway are important, because it determines the appropriate diagnosis and is associated with appropriate clinical reasoning [3], otherwise it will be very dangerous related to misdiagnosis. The existence of various components that can be replaced or substituted is a challenge to keep choosing the right and right choice, as well as linkages that remain in the right and precise order according to Clinical Resioning while still guided by the flow of diagnosis as well as the correct therapy. Any mistake in the association will be dangerous to diagnosis and therapy, which can be dangerous for the patient. In the use of algorithms in the use of information systems in the Clinical Pathway, components and relationships play an important role in maintaining compatibility between clinical Reasioning and computational logic. The role of the fields of Information Technology, Medical and Medical Informatics is to jointly guard the condition of the components and their activities correctly and correctly.

#### 2.Step-problem-optimal solution

Actually the best is the ideal or maximum, this is one that is intact from the world of medicine which is classified as an art, although some things have been replaced by tools and computerization. Determination of Step-Problem-Solution requires clinical reasoning, judgment, and experience so it is necessary to have an alternative companion, including still considering any possible side effects. Again, the role of Medical, Information Technology and Medical Informatics [4] or Information System experts is important to guard not only accuracy-truth, also Step-Problem-Solution, it is also necessary to consider the existence of patient safety [5].

#### **1.2 Linkages clinical pathway with quality improvement and cost containment**

The existence of Component-Linkage and Step-Problem-Solution is a necessity that needs to be considered in order to achieve an optimal Clinical Pathway, so the importance of being considered is related to things like the following.


It is important to note things like the following:

(1) It is necessary to pay attention to and select the quality that can be improved, related to examination, diagnosis and therapy as well as rehabilitation, in real terms with scientific developments, technology and community development, (2) so that components and steps that lead to costs are selected, and can be carried out without reducing the quality of service, related to science and technology, as well as the substitution and new sophisticated equipment at a higher or lower cost.

Thus the selection must be carried out by means of a formal and written review, so that the success rate can be measured. Described as follows, **Figure 1.**

In computerized technology, software development [8] and mobile phone applications [9] have many sophisticated technologies and procedures, but there is still a need for close cooperation between medical, information technology, hospital

#### **Figure 1.** *Linkages clinical pathway with quality improvement and cost Cotnaimnent.*

management and medical infromatics in order to manufacture form algorithm [10], so that it can be made faster and in accordance with the integrity and in harmony with the use of the application in the field with optimal results that can be achieved while still being used easily, simply and user friendly.

### **2. Clinical pathway for services quality improvement**

### **2.1 Clinical pathway for service quality**

The example of the Clinical Pathway algorithm for the management of malnourished patients in elderly patients, shows: clarity of steps, clarity of risk, clarity of size, clarity of time, which allows clinicians to collaborate with management; has demonstrated one quality improvement strategy [11]. Examples of the effectiveness of clinical pathways in infection disease [12], algorithms on diagnosis and therapy provide good pathways for quality improvement and also cost savings, because there are:


The 3 important things above provide evidence that a Clinical Pathway can provide simultaneous direction between:


**Figure 2.** *Clinical pathway for quality improvement.*

The relationship between Clinical Pathway and Quality Improvement [13], with its accompanying components, is illustrated as follows, **Figure 2.** The figure above shows:


#### **2.2 Patient safety for service quality improvement**

One of the ways of Service Quality Improvement is to use accreditation, accreditation is an effort to periodically assess the Quality Standard as the highest reference, so that our achievement is assessed against that standard. Service Quality Improvement which is important and must be a concern is Patient Safety [16], because it is one of the main goals of health services. Patient safety which is important in the hospital is the expected outcome as follows:


The four things above are related to the Quality Improvent of the service so that it will be clear what processes, outputs and outcomes will be achieved, and this effort needs to be carried out continuously and continuously, and is always a fun daily activity.

	- a.Create a clear clinical pathway component-Linkage and Step-Problem-Optimal Solution, and can be tracked for costs;
	- b.Make efforts to carry out a clear and directed Quality Improvement towards the expected quality standard;
	- c.Work on Cost Containment which takes into account the quality of service, service procedures, unit costs which are simultaneously reviewed in

order to create an optimal cost condition without reducing the specified quality.

#### **2.3 Algorithm usage**

The following is an example of an algorithm, which is the basis for making diagnosis and therapy, with this algorithm it can be used as a software or smartphone application. Like the following example, **Figure 3.**

The figure below shows:


**Figure 3.** *Example of algorithm [17].*

**Figure 4.** *Flowchart of APSIS [17].*

*Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital DOI: http://dx.doi.org/10.5772/intechopen.98596*

3.There is a flow for yes and no choices;

4.If the yes path is selected it will lead to the further path-Tets-Diagnosis-Therapy.

This simple algorithm image will provide an opportunity for programmers to create software and smartphone applications, which can then be developed to examine in each of the steps which allows for quality improvement, so that it is easier to analyze shortcomings and their relationship with other steps to be improved.

Research process in the context of making APSIS (*Aplikasi Pembelajaran Alur Diagnosis dan Terapi Kedokteran* = Learning Application Flowchart of Medical Diagnosis and Therapy) in Smartphone Application, related to algorithm development can be sown as above **Figure 4.**

The figure above shows:

1.There is direction about the beginning of the start,

2.There is a division of groups which contains relatively similar indicators,


#### **3. Clinical pathway in cost containment**

#### **3.1 Link of components**

Cost Containment is done by maintaining the quality of service, because that is the first and important value of medical services, so the thought of costs is the next thing to consider, not the other way around. This effort can be done in terms of: [18].

1.Rates that reflect costs, with the help of Clinical Pathway and software algorithms, will easily provide remedial options, and better still provide easy possibilities for simulations by performing simulation at various costs, so that lower costs will be found while still maintain quality;

**Figure 5.** *Link of component in cost containment.*

2.On investment, tools and instruments can now be selected which results in an easier and cheaper basis for diagnosis and therapy.

Described as follows, **Figure 5.**

#### **3.2 Prosedure**

Procedure is a series of activities that have been directed and specific in order to carry out the service, so that the service achieves the objectives as determined, in accordance with the competence of the specified executor, as **Figure 6.** The figure below shows:


The 3 things above must be considered with the standard of optimal cost, and the quality of service still occurs without a decrease in quality, this is a characteristic of cost containment that is carried out properly.

#### **3.3 Unit cost**

Description related to Unit Cost [19] which is the basis for Cost Containment, related to Billing for existing Services in accordance with Quality Standards and Coding in Clinical Pathways. The figure is as below, **Figure 7.**

**Figure 6.** *Link of procedure for cost containment.* *Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital DOI: http://dx.doi.org/10.5772/intechopen.98596*

**Figure 7.** *Link of unit cost for cost containment.*

Furthermore, the Unit Cost, as a breakdown of Cost in accordance with the required cost details, will be the basis for determining the tariff and the charging of investment, so that a complete loading will occur; thus the optimal efficiency conditions will be calculated. In this case, it will be a part that provides a limitation so that the Quality Standard does not decrease by keeping the Unit Cost from decreasing drastically which causes the Quality Standard also decline too.

### **4. Clinical pathway in new era**

#### **4.1 New era in pandemic Covid-19**

There are 4 important things related to the Covid-19 Era Pandemic: [20]


In connection with the matters above, how is the condition of the hospital: [22]


Throughout the current journey, no hospital has gone bankrupt, apart from being supported by the government with social assistance, also because the hospital can make good adjustments, or postpone the burden into the future. In this connection:


There are 3 important things that will immediately be used as important references in ministry in the new era, as below:


#### **4.2 Clinical pathway in non curative service**

The application of the Clinical Pathway now and in the future requires adjustments related to earlier approaches and prevention, not just therapy, because

*Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital DOI: http://dx.doi.org/10.5772/intechopen.98596*

technological advances and awareness of healthy living are being promoted. Advance clinic and treatment to an earlier direction, such as Promotive, Preventive and Rehabilitation which is more aggressive and earlier.

An example is illustrated as follows as **Figure 8.**

The current palliative approach still needs to be developed towards older and more productive patients who can still enjoy an optimal quality of life, requiring hard work and continued development.

The next explanation is as follows.


This condition is often mixed up so that efforts do not produce optimal results, the best way to suggest is to select the required picture, then adjust the handling according to need.

**Figure 8.** *Clinical pathway in non curative service.*


#### **4.3 Clinical pathway in technology services**

The era of Telemedicine [30], with the Covid-19 Pandemic, the need to maintain distance makes it imperative to use more massive telemedicine, it is necessary to develop algorithms that are in accordance with the following: (1) there is a standard procedure and still meets clinical reasoning, (2) services that can be carried out gradually Quality Improvement, (3) services that can be simultaneously carried out cost Contaiment optimally but reduce quality. This presents a challenge, not only for doctors, hospitals, Information Communication Technology and Medical Informatics experts, to collectively achieve the above expectations.

The robotic era [31] will be greatly stimulated by the Covid-19 Pandemic by trying to avoid contact between doctors and patients in order to prevent transmission. The differences that occur are: (1) the procedure will be relatively the same, dealing with the patient is a robot, (2) the doctor controls the robot, not the instrument, also the time and sequence will be clear and can be calculated. Increasingly sophisticated computer performance with large capacities, supported by Artificial Intelligent, provides challenges, and at the same time, care must be taken with regard to patient safety, not according to good tools, still violating the patient safety principle.

The era of the Internet of Things [32] is a challenge now in various countries with a large number of elderly people, several countries have happened, some countries are not less than 10 years old will be a heavy burden. Thus the use of: Clinical Pathway, Quality Improvement, Cost Contaiment and the Internet of Things will be the way out that is needed. An example illustration is as follows as **Figure 9.**

The description above provides options and accelerates the use of advanced technology and with large capacities more quickly and relatively forced, due to the Covid-19 Pandemic which requires maintaining distance, avoiding contact and avoiding relatively long trips. Anticipation must be developed immediately with the following standards:


#### **4.4 Clinical pathway in technological related**

1.Heath Electronic Record (HER) or Medical Record (MR) [33] related to electronic medical records, which is getting more and more advanced with regard to voice recognition which provides direct recording of the history, and video

*Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital DOI: http://dx.doi.org/10.5772/intechopen.98596*

#### **Figure 9.**

*Clinical pathway in technology services.*

recognition which records examination conditions using video in an integrated manner. The importance of an integrated and electronically based Medical Record (MR) provides:


The above description is broader as below.

1.Consultations, with real doctors, with robots that use voice or video can be carried out, which requires an unbeatable Clinical Pathway Algorithm, so the

#### **Figure 10.**

*Clinical pathway in technological related.*

Quality Improvement role is very important and must be made from the time the services and software are used.


#### **5. Conclution**

Clinical pathway in hospital is an effort made in order to: outlines the steps in detail, outlines the important steps that must be taken, describe services to patients and estimate possible clinical problems; it can be used as a system for Quality Improvement and Cost Containment. The effectiveness of clinical pathways in algorithms on diagnosis and therapy provide good pathways for quality improvement and also cost savings. Cost Containment is done by maintaining the quality of service, because that is the first and important value of medical services, so the thought of costs is the next thing to consider, not the other way around. The Cost Containment effort can be done in terms of rates that reflect costs, with the help of Clinical Pathway that lower costs will be found while still maintain quality. Clinical Pathway that is used on investment, tools and instruments can now be selected which results cheaper basis for diagnosis and therapy. There are important things that will immediately be used as references in the new era that related to New Era in Pandemic Covid-19, Non Curative Service, Technology Services and Technological Rerelated, biside that Clinical Pathway will be made more efficient and on matters that are important and that are not harmful.

*Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital DOI: http://dx.doi.org/10.5772/intechopen.98596*

#### **Author details**

Boy Subirosa Sabarguna Community Medicine Department, Faculty of Medicine, Universitas Indonesia, Indonesia

\*Address all correspondence to: sabarguna08@ui.ac.id

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 6**

## Interdisciplinary Integrated Tools to Problem Solving 2.0

*Maria J. Espona*

#### **Abstract**

Everyone understands the events they witness or read about according to their mental models, and that is one of the main reasons there are a lot of disagreements at workplaces and between friends and families. Considering this situation, plus the difficulty that most people face when trying to conceptualize problems, I suggest a course that includes series methodologies, working synergistically to deal with this problem that goes from understanding the differences between people to test multiple hypotheses and planning the solution implementation. Since 2014, I have been teaching with some colleagues this tool in the format of a short course that articulates systems thinking, mapping studies, information quality, and competing hypotheses. This course has been presented often not only in Argentina and also in Peru with great success. Considering the pandemic situation, since 2020, it has been taught virtually. The latest modification to the original structure of the course was the incorporation of the Gantt chart to design the implementation of the solution found. This paper will present our course and the logic behind it, its outcomes, and how it evolved with the different iterations.

**Keywords:** problem-solving, systemic thinking, information quality, decision making

#### **1. Introduction**

Being part of the information society and live in this time has a lot of advantages but pose a lot of challenges. The superabundance of information and the difficulties we face to evaluate its quality complicates our decision-making processes.

The COVID-19 pandemic has shown us clearly the impact of misinformation and how the constant influx of a lot of information -of which we know just littleaffects our emotional and physical health and our understanding of reality and its evolution.

Since we are running like headless chickens most of the time after many objectives that become difficult to identify, when it comes the moment to think and conceptualize a problem, we need extra help to do it properly and get the expected result. This situation also affects how we look for information and based on which parameters we select it or not, how we validate our hypothesis, and how we plan what we need to do to implement the desired solution.

Here, I will describe the course and the different methodologies included in it and show how they articulate to give the students an easy way to understand and solve their problems.

#### **2. Related research**

There are several problem-solving methods, nevertheless, almost all of them follow this logic (**Figure 1**). But only a few of them include methodologies to implement the different steps in a structured and auditable way. Also, in most of the cases, the people involved in the problems are not considered as no not only as possible sources of solutions but as the ones who know the most about the situation and, at the end, the ones who will be involved in the change.

Methodologies as the TRIZ/USIT [2], Six Sigma [3], the VSM (Viable Systems Model) [4] and the many problem-solving in 4 steps or 6 steps that exists in the literature offer different tactics to approach the problems and find a solution [5]. Even when they are helpful in many specific fields, they are not do not look for a fluid tool, easy to implement in all possible problems as the one presented here.

The Six Step Problem Solving Model [6], developed at the University of Arkansas at Pine Bluff, is worth to highlight because of its characteristics and reasoning close to the one that laid behind I designed. This method includes for each step one or more tools and considers the participation of the people involved.

In closing, even though many problem-solving methodologies exist, the one presented in this paper could be consider as a combination of the best of others that exist with a twist of innovation.

#### **3. The course**

This problem-solving course entails integrating five methodologies: systems theory, mapping studies, data quality, and competing hypothesis, plus the Gantt chart. Together, they allow us to go from the problem conceptualization to the hypothesis testing and plan the solution in a methodologically consistent, unbiased, and structured way.

Using a combination of methodologies in an articulated way has its origin in a request made by the Peruvian Air Force. They wanted to have a dedicated course on research methodologies. After that, the course has been successfully presented in many places. Finally, the INAP (National Institute for the Public Administration, Argentina) requested an upgrade to include implementing the solution found, and the Gantt chart was included. So now the course goes from problem identification to solution implementation.

This course starts with a discussion about mental models and how their impact in the understanding of the reality. In this specific context, helps to realize why we all disagree about problems or circumstance and facilitate the communication and agreements [7].

**Figure 1.** *Problem-solving logic [1].*

#### **3.1 General systems theory**

This problem-solving course starts with understanding the first out of the five methods that conform to this proposal, the systemic method, developed after the general systems theory. This tool is well known and widely used in many disciplines.

Ludwig Von Bertalanffy, the biologist who developed the general systems theory, recognized that his theory started to be developed back in Aristotle times when he said: "the whole is greater than the sum of its parts", describing the synergy, one of the core characteristics of the system when working [8].

Von Bertalanffy included the three premises that set the basis of the General Systems Theory in his book published in 1969 [9]. Those assumptions are:

1.Systems exist within systems;

2.The systems are open; and

3.The functions of a system depend on its structure.

Von Bertalanffy has described the systems' functioning considering the inputs, processes and components and output (**Figure 2**).

In the representation of how the systems work, it is implicit a time spam since the input enters into the system, then a process takes place, and finally the product of the process exits the system as output. Therefore, applying this method to understand a problem or situation provides us with a dynamic vision of reality, including its components.

One of the most intuitive examples of a system is the ecosystem. The word itself results from the merge of eco (house) and system. According to the Encyclopaedia Britannica, a definition of the term is: "Ecosystem, the complex of living organisms, their physical environment, and all their interrelationships in a particular unit of space" [10].

A graphic representation of the ecosystem definition using systems theory could be (**Figure 3**):

The components of an ecosystem are related so a balance between them is achieved. This is another property of the systems, and it is called homeostasis.

Feedback is one of the essential properties of the systems and what means is that the system's output re-enters again as an input. This cyclic process is also linked with the homeostasis.

Let us analyze the feedback in other system, for example in a workplace where a modification is included. One role it will play will be informing if the changes have a positive or a negative impact.

**Figure 2.** *How the system works (designed by the author).*

**Figure 3.**

*Representation of an ecosystem using the systems theory (designed by the author).*

The study of the systems has two possible approaches, one is the study of the system and its components and the processes that take place between them; and another is considering the border of the system, characterizing and studying what happens there. But in both cases the context is considered and the inputs and outputs (and feedback).

During the course, since this is the starting point, this method is used to conceptualize the problem and understand its components, the process, and its dynamic.

At this point, the students decide with which problem or situation they want to analyze and solve. By doing this, they move out from thinking to drafting and putting in words their ideas. This process takes time and requires reflection, and also decisions should be made to set up the limits (system border) and the components -and relations between them- of the problem under study.

When doing this conceptualization process, the system is developed with a specific objective and if the objective changes, the system will also do.

#### **3.2 Structured searches**

Once the problem is identified and described the look for answers and solutions start. At this point two possibilities exists: look for an existing solution or innovate if nothing has been done successfully by others. In both cases the search of the information in a structured way is optimal.

Considering the abundance of information, it is relevant to search on the internet following specific parameters and minimize the impact of our cognitive bias.

Systematic literature review or systematic mapping studies is the name of a methodology to execute searches in a structured way by following a detailed procedure.

The origins of this technique can be traced back to the problems the clinicians faced when relying in the available literature for their decision-making process. "In answer to this challenge, the worldwide Cochrane Collaboration was formed in 1992 to provide an expanding resource of updateable systematic reviews of randomized controlled trials (RCTs) relating to health care. Thus began the modern incarnation of the review article, a tool that had for many centuries been the mainstay for updating scientific knowledge" [11].

Later, this methodology was discovered and widely implemented by academics from the areas of systems engineering and informatics mostly to develop the state of the art of research topics. And later, considering its usefulness, it was adopted by other sciences and also used in projects design.

*Interdisciplinary Integrated Tools to Problem Solving 2.0 DOI: http://dx.doi.org/10.5772/intechopen.101456*

The author who is a reference for this methodology is Barbara Kitchencham [12] from Keele University. And Dr. Marcela Genero Bocco from the Alarcos Group (University of Castilla La Mancha -UCLM- Spain) is leading the field in Spanishspeaking countries [13].

This method is relevant in this problem-solving tool because it helps to minimize the impact of our cognitive bias when doing a search, particularly for selecting among the results. As humans, we have the tendency to tend to choose what agrees with our mental models or the concept or ideas we have in mind. Because of this, we may avoid reading relevant articles with a different perspective on the topic under study.

The methodology includes three phases: planning the review, executing it and writing the report.

In the first phase, many tasks will take place. First, the need for a review must be identified, particularly considering that applying this methodology takes time and effort and it is not for a simple quick search. By doing a review, it is possible to summarize all the information on a topic, in a format that resembles a database.

To begin with the practical steps of this tool, the research questions formulation is the next step. These research questions will be the tool to select the publications, considering whether they answer or not to them, and not how they do (this is important for the later analysis of the results). This way of selecting the publications helps to minimize the impact of our cognitive bias, allowing us to have the whole set of possible answers, and not only the ones we like.

Before performing the search, a protocol must be developed. This plan includes:


In the second phase, the review takes place, and what was planned on the first phase here it is executed.

Once the search engine is selected, the terms are introduced, and the results appear. Now, it is important to check all the results, one by one, and the publications that answer the research questions will be transferred to the Excel file and the different fields will be completed. The inclusion and exclusion criteria will help to filter the results obtained, and finally the result will be a set of publications that fulfill the requirements and answer the research questions.

This methodology was designed to be implemented on virtual libraries. But it works perfectly in Google and other search engines like it.

After doing the search and filling the Excel, it will be possible to identify if an adjustment of the protocol is needed or not (new keywords, rephrase of the research questions, etc).

The publications database we will have as a result will include fields specific to each publication (author, date, publisher, title, etc.), and other relevant information, considered metadata, which will help perform a broader analysis.

The methodology concludes with the report writing. The text must include a detailed presentation of the protocol, an explanation of how the search was executed, and all the decisions made during the process to make the search repeatable and auditable.

The report will also include the analysis of the answers to the research questions, not only in writing but graphs could be performed considering the information will be included in an Excel.

This file will be the starting point to the execution of these methodologies, information quality (to evaluate the quality of the selected publications) and competing hypothesis (to identify the scenario with more support in the available literature).

#### **3.3 Information quality core concepts**

Having the possibility to access many sources of information when looking for something is fantastic. Still, the growing amount of data and information and the difficulties in knowing its quality created the need to develop a specific method to evaluate its properties [14].

Experts at the Massachusetts Institute of Technology (MIT) (Cambridge, Massachusetts, USA) developed an information quality method. Lately, professionals from other universities and countries expanded and added more elements to it.

The part of the method which will used in this problem-solving methodology is the one of categories and dimensions. The other two, that explore the role of the different stakeholders involved in the information management and the total data quality management (TDQM) cycle will not be considered here.

Wang and Strong [15], back in 1996 developed a framework to evaluate and hierarchically organize information. To create this method, they sent a survey to information consumers and master's in business administration (MBA) students asking about the most critical attributes that information should have. The result was a list of 179 attributes. After that, they performed a second survey to learn and understand the importance of the attributes identified. Finally, they come out with a list of 15 dimensions, grouped into four categories (see **Table 1**).

As the next step on the problem-solving methodology, the selected dimensions (not all are relevant in every circumstance) will be placed in Excel (from the structured search) as columns after the publication's details. A quantitative evaluation of each publication will be performed, getting at the end a value that entails the document's quality. Having these results will make it possible to rank the publications hierarchically.

#### **3.4 Competing hypothesis**

The competing hypothesis methodology was developed by Richards J. Heuer Jr., an intelligence analysis expert from the Central Intelligence Agency (CIA), during the Cold War, and a few years later was provided to the public [16].

This tool is especially useful in cases of complex problems, with many possible scenarios and a lot of evidence to analyze. It allows to study simultaneously all likely hypothesis and verify them with all the available information simultaneously. The outcome will be a table including the evidence and the hypotheses and the results of the evaluation performed (**Table 2**).

In this evaluation, the level correlation is showed:



**Table 1.**

*MIT information quality categories and dimensions (designed by the author, adapted from [15]).*


#### **Table 2.**

*Resulting table as consequence of the execution of the competing hypothesis method (designed by the author, adapted from [16]).*

Not apply: there is no relation between the hypothesis and the evidence.

The winning hypothesis, in the **Table 2** example will be the hypotheses 1, is according to Heuer [16]: "The result of the methodology is which hypothesis has more support according to with the available evidence and not which is the hypothesis with a higher probability of occurrence."

This next to the last step will allow taking the publications selected in the structured searches after the quality evaluation and considering them as the evidence for this method. The hypotheses will be elaborated considering the objective of the systemic method along with the research questions.

This step will identify the winning hypothesis, which means the solution to the problem with more support in the available information.

#### **3.5 Gantt chart**

Now that the solution has been found, it is time to design its implementation. To do it, the Gantt chart will be used as method.

To design a Gantt chart, identify objectives and tasks for each implementation phase: design, planning, execution and evaluation.

The objectives preferable must be SMART, which means:

S: Specific, what do you want to achieve? Who needs to participate? When do you want to accomplish your objective? Why is it important?

M: measurable, how can the be progress measured? How do you know if the objective has been achieved?

A: Attainable or Achievable, can you achieve the objective? Do you have the skills needed to achieve the objective? If not, could you build them?

R: Relevant, why it is important? The impact?

T: Timely (or time-bound), when the objective must be accomplished? Is it possible?

George T. Doran coined the concept of SMART objectives, and he published them in the November 1981 issue of Management Review [17]. Since then, some authors added more letters to the acronym, and others created different ones. Still, the general concept remains the same: the objectives gain meaning when a task to be performed is associated to them.

In this final step of the problem-solving tool, the first step is to go back to the systemic method and use it as starting point. Over this scenario, the diagnosis will be performed, but also considering the winning hypotheses from the previous method applied. Considering this information, the specific objectives, and tasks (including the intended duration) must be identified. At this point, a qualitative evaluation is recommended. Asking the people involved in the project for their opinions and suggestions could bring relevant information to the objectives and tasks design for the whole project.

Next to the diagnosis, the planning of what needs to be done is the next stage. It is critical to carefully plan and link the objectives and tasks from this planning stage to the ones in the implementation or execution phase. One of the most common errors is to plan activities that have no correlation on the execution phase or design activities not planned in advance. And also, to put both phases in parallel, when they must be one after the other, sequentially.

Finally, the evaluation phase, it is time to measure if what was implemented has led to the desired scenario or to another. At this point, a qualitative evaluation is recommended.

#### **4. Executing the tool**

When we initiate the course discussing the mental models, the participants think about how they see the world and why we all have different opinions. Also, they usually increase their awareness about how bias they are because of their high engagement with the situation they are trying to improve.

It is like they experience Eureka moments.

After this, they can reduce the tension associated with the analysis of the situation and how they consider the other people. This is a first step that facilitates the following ones, when they apply the different methodologies to their problem.

Using the systemic thinking to conceptualize the situation or problem the participants are trying to solve is the next step. This stage is time and energy consuming since a lot of self-questioning and reflection upon not only the scenario but its components, relationships, inputs and outputs and understanding the objective of the system.

Often the participants think they have a problem, but after this phase of deep analysis, they discover sometimes that they were right and in others that it was not the case.

Forcing the participants to prepare the systemic method diagrams, helps them to visualize clearly the situation and they get ready for the next step, which is finding a solution.

Looking for answers and solutions in a structured way is what the participants to this course do when executing the mapping studies.

When performing this task, they complaint a lot because of the effort it takes, but later they realize how important is to have an Excel file that acts as database which condenses all the information.

The link between this method and the systemic thinking is given by the objective of the system which becomes the main research question in the structured search. Using this main question as cornerstone, the relevant aspects to it (and to find answers to the problem) can be easily identified.

Once the relevant publications are selected, its quality is measured using the information quality method. By doing this, since many options or potentials solutions are now identified, this evaluation could be a way to consider which of the available answers have better support.

Competing hypothesis method uses as evidences the publications obtained during the structured search, that also has been evaluated to measure their quality, and ranked. The hypotheses are related to both the objective of the systemic method and the research questions of the mapping. The winning hypotheses, since sets of hypotheses linked to the different aspects of the problem are expected, will be the ones considered to design the implementation plan using the Gantt chart.

The different phases of the Gantt chart, diagnosis, planning, execution and evaluation are developed following the objective of the system (3.1), as guidance, and using winning hypotheses (3.4) as clues to internally organize what must be done to solve the components or aspects of the main problem.

Using this tool, participant to the course solved and implemented problems related to the administrative functioning of a workplace; design new regulations; design and implement customer care systems, etc.

#### **5. Conclusions**

This problem-solving course has been presented in different formats over a dozen times, always successfully. A previous publication summarizes the accomplishments until 2016 [18], which were largely surpassed with the new editions of the course and the new venues where it was taught.

Considering the audience and their specific needs, the focus on the different methodologies changes. Usually, the most demanding stage is the implementation of the systemic method in order to conceptualize the problem and also the Gantt design.

The problems that were considered during the courses range from improving to make significant changes. Often, the students implemented what they design during the course, and the results were the ones expected. The effectiveness of this method is proved.

The methodologies included led to finding the solution to many problems, in an unbiased, structured, auditable and at the same time, simple way.

Finally, I consider there is still room for improvements, and maybe shortly more methods or resources will be added to have a more usable and easier to implement tool. Those that are under evaluation are the formal incorporation at the beginning of the curse of an introduction to different decision-making models so the participants would have more information to be applied not only during the problem conceptualisation phase but also to use them at the time of communicating and implemented the solutions. Other resource under evaluation to be added after the Gantt chart is the elaboration of dashboards, which will be useful to monitor the different processes under implementation.

*Contemporary Issues in Information Systems - A Global Perspective*

#### **Author details**

Maria J. Espona ArgIQ, Argentina Information Quality, Buenos Aires, Argentina

\*Address all correspondence to: mariaespona@argiq.com.ar

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Interdisciplinary Integrated Tools to Problem Solving 2.0 DOI: http://dx.doi.org/10.5772/intechopen.101456*

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Contemporary Issues in Information Systems - A Global Perspective

Contemporary Issues in

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A Global Perspective

*Edited by Denis Reilly*