Are Regulations Safe? Reflections From Developing a Digital Cancer Decision-Support Tool

Abstract

Purpose: Informatics solutions to early diagnosis of cancer in primary care are increasingly prevalent, but it is not clear whether existing and planned standards and regulations sufficiently address patients' safety nor whether these standards are fit for purpose. We use a patient safety perspective to reflect on the development of a computerized cancer risk assessment tool embedded within a UK primary care electronic health record system.

Methods: We developed a computerized version of the CAncer Prevention in ExetER studies risk assessment tool, in compliance with the European Union's Medical Device Regulations. The process of building this tool afforded an opportunity to reflect on clinical concerns and whether current regulations for medical devices are fit for purpose. We identified concerns for patient safety and developed nine practical recommendations to mitigate these concerns.

Results: We noted that medical device regulations (1) were initially created for hardware devices rather than software, (2) offer one-shot approval rather than supporting iterative innovation and learning, (3) are biased toward loss-transfer approaches that attempt to manage the fallout of harm instead of mitigating hazards becoming harmful, and (4) are biased toward known hazards, despite unknown hazards being an expected consequence of health care as a complex adaptive system. Our nine recommendations focus on embedding less-reductionist and stronger system perspectives into regulations and standards.

Conclusion: Our intention is to share our experience to support research-led collaborative development of health informatics solutions in cancer. We argue that regulations in the European Union do not sufficiently address the complexity of healthcare information systems with consequences for patient safety. Future standards and regulations should continue to follow a system-based approach to risk, safety, and accident avoidance.

FIG 1.

(A) Adaption of the paper-based CAPER colorectal risk assessment tool (approved by original authors). (B) Screenshot of the eRAT prompt that is automatically generated when a consultation has begun or generated on demand by the user. CAPER, CAncer Prevention in ExetER; eRAT, electronic-RAT.

FIG 2.

Software development lifecycle with five stages (S1-S5), each involving tasks (T1-T10) that produce outputs (O1-O20). Red nodes indicate tasks not undertaken as part of this exploratory development study.