The GRiST computer decision support system: a new tool for assessing and managing risks associated with mental-health problems.
Submitting InstitutionAston University
Unit of AssessmentComputer Science and Informatics
Summary Impact TypeTechnological
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Economics: Applied Economics
Summary of the impact
The Galatean Risk and Safety Tool (GRiST) is a clinical decision support
system (CDSS) conceived and developed by computer scientists at Aston
University from 2000 onwards, where it is being delivered as a
cloud-computing service. It is used every day by mental-health
practitioners in the NHS, charities, and private hospitals to assess and
manage risks associated with mental-health problems. Between 1/1/2011 and
31/7/2013, clinicians provided 285,426 completed patient risk assessments
using GRiST. It has changed organisational and clinical processes by its
systematic collection of risk information, explicitly linking data to
clinical risk judgements, and showing how those judgments are derived.
Increasing international awareness has come through presentations to
mental-health practitioners in Europe, America, and Australia.
Mental-health problems are experienced by one in four people every year
and are associated with risks of suicide, self-harm, harm to others,
neglect, and vulnerability. In Europe, fourteen people per 100,000 take
their own lives despite 40% having seen their GP within the previous
month. Detecting risks is difficult because it requires specialist
training and risk communication is hampered by assessment tools currently
recording unstructured data that is not easy to process or share by
machines. GRiST addresses these problems by using validated mental-health
expertise to produce a web-based system that helps people with or without
mental-health training to collect data systematically, evaluate risks, and
provide appropriate advice.
The key innovation of GRiST software is its psychological model of
classification for representing human expertise within an intelligent
knowledge-based system. This "Galatean" model was developed by Christopher
Buckingham, who has a first degree in psychology and joined Aston
University in 2000 as a Lecturer in Computer Science. At Aston, he
specified how the Galatean psychological model can build CDSSs [3.1] and
conducted parallel research building on interpreting clinical decision
making as three linked, iterative classification tasks: diagnosing,
assessing potential outcomes, and making intervention decisions.
Buckingham developed a coding scheme (2001-04) to encapsulate underlying
elements of these classification tasks that was applied to analysing
differences between US and UK primary-care practitioners' decision-making
behaviours [3.2, 3.3]. Together, these two research avenues lie at the
core of GRiST by providing the theory and framework for capturing risk
assessments as a classification process.
The GRiST CDSS development began in 2003 in collaboration with
researchers at Warwick Medical School, who provided the bridge to clinical
expertise. The psychological underpinnings of GRiST helped derive
knowledge engineering techniques [3.4] that elicited expertise in a format
that end users could fully understand. The result is a unique formal model
or "ontology" of the knowledge used in mental-health risk assessments
[3.5]. This ontology enables GRiST to exploit semantic-web technologies so
that evolving human expertise and varying contexts of CDSS deployment can
be flexibly accommodated with minimal additional programming requirements
[3.4]. It increased uptake of the GRiST CDSS in the NHS, private sector,
and third-sector (non-profit organisations) [5.1, sponsors] so that
impact and research continued in tandem, with three NHS trusts directly
funding it through EPSRC CASE PhD studentships [3, grants 7].
GRiST is the only mental-health risk-assessment approach that explicitly
combines clinical judgements with empirical evidence, as recommended by
the Department of Health [5.2]. It does this using its psychological model
of structured clinical judgement linked to and validated by sophisticated
probabilistic and statistical analyses of the patient database. GRiST's
web-based system helps clinicians: (i) collect and record relevant risk
data for particular patients and assessment circumstances; (ii) see how
data contribute to risk evaluations; and (iii) identify where patients
need help. It motivated additional research funding [3, grants 1, 2, 3]
that ensured GRiST incorporates variable end-user requirements [3.4],
integrates risk assessment data [3.6], and optimises risk evaluations.
International funding [3, grants 4, 5, 6] is using GRiST for investigating
suicide causes (March, 2013-15), analysing health inequalities
(2010-2015), and exploiting the generic nature of its technologies by
applying it to logistics (2010-2013).
References to the research
(the three most significant ones are marked by an asterisk)
Most papers are jointly authored with Adams from the University of
Warwick, who was the main clinical collaborator on GRiST. The software
impact is entirely the responsibility of Aston University and Warwick is
not putting in any impact case study using GRiST [5.3].
1. * Buckingham, C.D. (2002). Psychological cue use and implications for
a clinical decision support system. Medical Informatics and the Internet
in Medicine, 27(4), 237-251. DOI: 10.1080/1463923031000063342. An important
paper for presenting the theory underpinning the GRiST clinical decision
support system. It has 16 citations, with international authors using
the work to inform their decision making research including Canada (book
chapter on Clinical Decision Support Systems), America (book on Advanced
Practice Nursing), Serbia (paper on cardiology), and New Zealand (paper
on a tool investigating clinical decision making).
2. Ann Adams, Christopher D. Buckingham, Sara Arber, John B.
McKinlay, Lisa Marceau and Carol Link (2006). The influence of patient's
age on clinical decision-making about coronary heart disease in the USA
and the UK, Ageing and Society, 26(02), 303-321. DOI:
10.1017/S0144686X05004265. The first paper applying the coding scheme
from linked classification models to interpret clinical decision making.
It has 16 citations and is jointly authored with Surrey and Warwick
Universities in England and the New England Research Institute, Boston,
3. * A.E. Adams, C. D. Buckingham, A. Lindenmeyer, John B. McKinlay,
Carol Link, Lisa Marceau, & Sara Arber (2008). The influence of
patient and doctor gender on diagnosing coronary heart disease. Sociology
of Health & Illness, 30(1), 1-18. DOI:
10.1111/j.1467-9566.2007.01025.x. International research with Surrey
and Warwick Universities in England and the New England Research
Institute, Boston, America. It also applies the classification model
coding scheme but in a more developed form. It has 33 citations.
4. Buckingham, C.D., Ahmed, A., & Adams, A.E. (2007). Using XML and
XSLT for flexible elicitation of mental-health risk knowledge. Informatics
for Health and Social Care, Vol.32 (1), pp. 65-81. DOI:
10.1080/14639230601097895. 10 citations but mainly a paper used as a
marker for the method we used, so often self-cited. Co-author Ahmed is a
postdoctoral research associate at Aston University having obtained his
PhD on the GRiST project.
5. * Buckingham, C. D., Adams, A.E. & Mace, C. (2008). Cues and
knowledge structures used by mental-health professionals when making risk
assessments. Journal of Mental Health, 17 (3): 299-314. DOI:
10.1080/09638230701498374. Prestigious Institute of Psychiatry journal
with 14 citations. The paper is important for validating the clinical
expertise within GRiST and is co-authored with the University of
6. Gilbert E., Adams A.E. and Buckingham C.D. (2012). "Examining the
relationship between risk assessment and risk management in mental
health". Journal of Psychiatric and Mental Health Nursing, 18(10),
862-868. DOI: 10.1111/j.1365-2850.2011.01737.x. Official journal of
HORATIO, the organisation for European Psychiatric Nurses with 2
international citations from Holland and Italy on assessing
mental-health risk. Co-authored with the University of Warwick.
Peer-reviewed grants providing evidence of research quality
(Buckingham was Principal or Co-investigator on all grants)
1. New and Emerging Applications of Technology (2003-2006), A
decision support system for mental-health risk screening and assessment.
Aston (£198,371) and Warwick (£75,305) Universities
2. Burdett Trust for Nursing (2008-09), Extending the GRiST for use
with adolescents and older people. Aston (£46,241) and Warwick
3. Judi Meadows Memorial Fund, Implementing GRiST within primary care
and the community (2011-2012): Aston (£48,967) and Warwick (£44,246)
4. American Foundation for Suicide Prevention, Improving Clinical
Evaluations of Suicide Risk and their Relationship to Care Planning
(2013-2015, awarded 2012): Aston (£31,903) and Warwick (£13,632)
5. European Commission FP7-ICT-2009-5 (2010-13), ADVANCE: Advanced
predictive-analysis-based decision-support engine for logistics:
Aston University (£480,518) and multiple European organisations
6. Joint US National Institutes of Health (NIH-USA) and UK ESRC, Understanding
Social Contributions to Disparities in Depression Care: US and UK
(2010-2015): Johns Hopkins (£370,000), Warwick (£254,000), and Aston
7. EPSRC CASE PhD studentships at Aston University related to GRiST:
Birmingham and Solihull Mental Health Foundation Trust, 2007-10, £80,000;
Humber Mental Health Foundation NHS Trust, 2010-13, £85,000; Birmingham
Children's Hospital, 2011-14, £66,000.
Details of the impact
Impact is integrally linked to the research process because involvement
of clinicians and service users was written into all grants. GRiST's
evolution in collaboration with end users, both prior to and post
implementation of the CDSS, provided a direct and immediate route for
research into practice.
GRiST helps mental health practitioners, service users, and carers detect
and explain risks associated with mental-health problems to reduce
suicides, self-harming, neglect, and violence. It has changed practice by
replacing paper risk tools and word-processed electronic documents that do
not structure information or analyse the results. It formalises data
collection, provides visual cues for where risks originate, analyses and
displays graphs of risks over time, enables customised risk reports
generated automatically from the data, and compares individual risk
judgements with expert consensus to improve accuracy and alert assessors
to potential errors. Economic impact has come from GRiST licences and
training. Clinical education impact comes from GRiST's risk explanations
during use and through workshops attended by healthcare professionals.
Use by healthcare providers in the period from 1/1/2011 to
31/7/2013: 2,152 mental-health practitioners have used GRiST on
52,334 patients and completed 285,426 individual risk assessments [5.1,
sponsors]. GRiST is used in secondary care (mental-health
hospitals) in the NHS (Humber NHS Foundation Trust, Cumbria Partnership
Trust, Birmingham Children's Hospital) and private sector (Raphael
Healthcare, Craegmoor Hospital group, Barchester Healthcare). In primary
care and the community, GRiST is being used in the NHS Improving
Access for Psychological Therapies (IAPT) services in Cumbria
Partnership Trust, Lincoln Partnership Foundation Trust, Coventry and
Warwickshire Partnership Trust, East Riding Psychological Wellbeing
Service, and the Hull IAPT service. Mental-health charities (Mental
Health Matters, mcch, Imagine Mental Health, Welmede Housing
Association) have over 200 practitioners using GRiST for mental-health
Use by service users for self-assessments (1/1/2012 to 31/7/2013):
The self-assessment version of GRiST, myGRiST, has been trialled by mcch
and Imagine charities, Lincoln IAPT, and two GP practices (190 service
users in the time period). Positive feedback has been received from GPs
("it gave me a very detailed picture of how he is feeling and helped me
empathise with him. It led to a useful consultation", 2012, [5.3]) and
service users ("I found myGRiST a helpful way to explore my own
vulnerability ... I would have benefitted from using this tool when I
first started to suffer from suicidal ideation", 2012, [5.1,
Continuous improvement of clinical practice (1/1/2011 to
31/7/2013): GRiST is being delivered to mental-health
organisations as a cloud-computing service from Aston University. The
database enables analysis of how mental-health clinicians make risk
judgements. Results feed directly back into practice through the GRiST
CDSS and have generated international interest for collaboration [5.4,
5.5]. The American Foundation for Suicide Prevention [5.6] said the
research "has potential for exceptional impact from the perspective of
clinical care, patient outcomes, and public health" (2012).
Practitioners and organisations have confirmed how much GRiST helps
their clinical practice [5.1, testimonials; 5.3, 5.7].
Raising awareness and understanding among healthcare professionals
(1/1/2008 to 31/7/2013): GRiST has been presented at international
workshops attended by mental-health practitioners and service users in
Boston, USA [5.4], the US Department of Veterans Affairs [invited
speaker, 5.4], Orange, Bathhurst (Kenote speaker, "Rural and Remote"
mental-health conference [5.5]), Moree, Newcastle, and Dubbo in
Australia [5.5], and more than 30 venues around Europe [5.1, timeline],
including a conference (May, 2013) hosted by GRiST at Aston for
mental-health service providers and commissioners [5.1, timeline].
International outcomes include GRiST being used in America by the North
Carolina, Department of Health and Human Services in a mental-health
clinical decision making study (2009, [5.8]) and plans are underway for
piloting myGRiST for self-assessments in New South Wales, Australia
[5.5]. GRiST is an example of a tool following best practice given in
guidance by the Department of Health (2007, but updated in 2009 and
still followed by UK Trusts [5.2]) and the Irish Health Service
Executive [2009, 5.2].
Improving market potential for patient-record companies: Mayden
[5.9] is a company providing patient record software, IAPTus, for two
thirds of the English NHS IAPT services, which offer psychological
support as part of primary care. IAPTus had no validated risk tool until
GRiST was linked to it in 2012, which has improved IAPTus functionality.
Three IAPT services already use GRiST via IAPTus (July 2012 to July
2013) and negotiations are underway for 5 more, with the licence fee
shared between GRiST and Mayden.
Improving market potential for private health companies: GRiST
is being used by 7 private hospitals and care homes (one in Ireland),
increasing potential for patient referrals because they can point to a
validated risk tool, which they did not previously possess [5.1, GRiST
Training: All the charities using GRiST and Cumbria NHS Trust
have paid for external GRiST training (1/1/2010-31/7/2013, [5.10]).
Sources to corroborate the impact
- GRiST website at www.egrist.org.
Access the following links: testimonials, timeline, and sponsors,
as indicated by the references within square brackets in the impact
- Department of Health (2007/09) "Best Practice in Managing Risk" (p.
35). London, HMSO.
Irish Health Service Executive (2009, p. 35). "Risk Management in Mental
- Principal Research Fellow, Warwick Medical School, University of
- Assistant Professor, Department of Health Policy and Management,
Boston University School of Public Health, Research Health Scientist,
Center for Health Quality, Outcomes and Economic Research, Department of
Veterans Affairs, 200 Spring Road (152), Bedford, MA 01730, 781.687.2861
- Director of the Centre for Rural and Remote Mental Health, a joint
initiative of NSW Ministry of Health and University of Newcastle Faculty
of Health, New South Wales, Australia. www.crrmh.com.au
- American Foundation for Suicide Prevention.
- GRiST change manager, governance, and trainer at Humber Mental Health
NHS Foundation Trust during the impact period.
- North Carolina, Department of Health and Human Services, Division of
Mental Health (2009, pages 5, 9-13).
- IAPTus patient record system: Mayden www.mayden.co.uk/what-we-do/patient-management/iaptus/
- Independent GRiST trainer, http://www.selfmotiv8.co.uk/.