An evaluation framework for Health Information Systems: human, organization and technology-fit factors (HOT-fit)

Perceptions of infection control professionals toward electronic surveillance software supporting inpatient infections: A mixed methods study

BACKGROUND

Electronic surveillance software (ESS) collects multiple patient data from hospital software to assist infection control professionals in the prevention and control of hospital-associated infections. This study aimed to understand the perceptions of end users (i.e., infection control professionals) and the facilitators and barriers related to a commercial ESS named ZINC and to assess its usability.

METHODS

A mixed-method research approach was adopted among infection control professionals 10 months after the implementation of commercial ESS in the university hospital of Nancy, France. A qualitative analysis based on individual semistructured interviews was conducted to collect professionals' perceptions of ESS and to understand barriers and facilitators. Qualitative data were systematically coded and thematically analyzed. A quantitative analysis was performed using the System Usability Scale (SUS).

RESULTS

Thirteen infection control professionals were included. Qualitative analysis revealed technical, organizational and human barriers to the installation and use stages and five significant facilitators: the relevant design of the ESS, the improvement of infection prevention and control practices, the designation of a champion/superuser among professionals, training, and collaboration with the developer team. Quantitative analysis indicated that the evaluated ESS was a "good" system in terms of perceived ease of use, with an overall median SUS score of 85/100.

CONCLUSIONS

This study shows the value of ESS to support inpatient infections as perceived by infection control professionals. It reveals barriers and facilitators to the implementation and adoption of ESS. These barriers and facilitators should be considered to facilitate the installation of the software in other hospitals.

Electronic Immunization Registry in Rwanda: Qualitative Study of Health Worker Experiences

BACKGROUND

Monitoring childhood immunization programs is essential for health systems. Despite the introduction of an electronic immunization registry called e-Tracker in Rwanda, challenges such as lacking population denominators persist, leading to implausible reports of coverage rates of more than 100%.

OBJECTIVE

This study aimed to assess the extent to which the immunization e-Tracker responds to stakeholders' needs and identify key areas for improvement.

METHODS

In-depth interviews were conducted with all levels of e-Tracker users including immunization nurses, data managers, and supervisors from health facilities in 5 districts of Rwanda. We used an interview guide based on the constructs of the Human, Organization, and Technology-Fit (HOT-Fit) framework, and we analyzed and summarized our findings using the framework.

RESULTS

Immunization nurses reported using the e-Tracker as a secondary data entry tool in addition to paper-based forms, which resulted in considerable dissatisfaction among nurses. While users acknowledged the potential of a digital tool compared to paper-based systems, they also reported the need for improvement of functionalities to support their work, such as digital client appointment lists, lists of defaulters, search and register functions, automated monthly reports, and linkages to birth notifications and the national identity system.

CONCLUSIONS

Reducing dual documentation for users can improve e-Tracker use and user satisfaction. Our findings can help identify additional digital health interventions to support and strengthen the health information system for the immunization program.

Barriers to and Facilitators of Key Stakeholders Influencing Successful Digital Implementation of Remote Monitoring Solutions: Mixed Methods Analysis

BACKGROUND

Implementation of remote monitoring solutions and digital alerting tools in health care has historically been challenging, despite the impetus provided by the COVID-19 pandemic. To date, a health systems-based approach to systematically describe barriers and facilitators across multiple domains has not been undertaken.

OBJECTIVE

We aimed to undertake a comprehensive mixed methods analysis of barriers and facilitators for successful implementation of remote monitoring and digital alerting tools in complex health organizations.

METHODS

A mixed methods approach using a modified Technology Acceptance Model questionnaire and semistructured interviews mapped to the validated fit among humans, organizations, and technology (HOT-fit) framework was undertaken. Likert frequency responses and deductive thematic analyses were performed.

RESULTS

A total of 11 participants responded to the questionnaire and 18 participants to the interviews. Key barriers and facilitators could be mapped onto 6 dimensions, which incorporated aspects of digitization: system use (human), user satisfaction (human), environment (organization), structure (organization), information and service quality (technology), and system quality (technology).

CONCLUSIONS

The recommendations proposed can enhance the potential for future remote sensing solutions to be more successfully integrated in health care practice, resulting in more successful use of "virtual wards."

TRIAL REGISTRATION

ClinicalTrials.gov NCT05321004; https://www.clinicaltrials.gov/study/NCT05321004.

Evaluating health information systems-related errors using the human, organization, process, technology-fit (HOPT-fit) framework

Complex socio-technical health information systems (HIS) issues can create new error risks. Therefore, we evaluated the management of HIS-related errors using the proposed human, organization, process, and technology-fit framework to identify the lessons learned. Qualitative case study methodology through observation, interview, and document analysis was conducted at a 1000-bed Japanese specialist teaching hospital. Effective management of HIS-related errors was attributable to many socio-technical factors including continuous improvement, safety culture, strong management and leadership, effective communication, preventive and corrective mechanisms, an incident reporting system, and closed feedback loops. Enablers of medication errors include system sophistication and process factors like workarounds, variance, clinical workload, slips and mistakes, and miscommunication. The case management effectiveness in handling the HIS-related errors can guide other clinical settings. The potential of HIS to minimize errors can be achieved through continual, systematic, and structured evaluation. The case study validated the applicability of the proposed evaluation framework that can be applied flexibly according to study contexts to inform HIS stakeholders in decision-making. The comprehensive and specific measures of the proposed framework and approach can be a useful guide for evaluating complex HIS-related errors. Leaner and fitter socio-technical components of HIS can yield safer system use.

Towards an evaluation framework for medical device-integrated electronic medical record

INTRODUCTION

Medical device (MD)-integrated (I) electronic medical record (EMR) (MDI-EMR) poses cyber threats that undermine patient safety, and thus, they require effective control mechanisms. We reviewed the related literature, including existing EMR and MD risk assessment approaches, to identify MDI-EMR comprehensive evaluation dimensions and measures.

AREAS COVERED

We searched multiple databases, including PubMed, Web of Knowledge, Scopus, ACM, Embase, IEEE and Ingenta. We explored various evaluation aspects of MD and EMR to gain a better understanding of their complex integration. We reviewed numerous risk management and assessment frameworks related to MD and EMR security aspects and mitigation controls and then identified their common evaluation aspects. Our review indicated that previous evaluation frameworks assessed MD and EMR independently. To address this gap, we proposed an evaluation framework based on the sociotechnical dimensions of health information systems and risk assessment approaches for MDs to evaluate MDI-EMR integratively.

EXPERT OPINION

The emergence of MDI-EMR cyber threats requires appropriate evaluation tools to ensure the safe development and application of MDI-EMR. Consequently, our proposed framework will continue to evolve through subsequent validations and refinements. This process aims to establish its applicability in informing stakeholders of the safety level and assessing its effectiveness in mitigating risks for future improvements.

Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review

BACKGROUND

Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity.

METHODS

We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists).

RESULTS

One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation.

CONCLUSION

This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.

[Evaluation of the impact of the implementation of the new primary health care information system on records of patient care and home visits in Brazil]

The replacement of the Primary Care Information System (SIAB, 1998-2015), as of January 2016, by the new Health Information System for Primary Care (SISAB) determined new forms of collecting, processing, and using information, with a possible impact on the records of activities carried out in primary health care in Brazil. This study aimed to evaluate the implementation impact of the new information system on records of physicians' and nurses' patient care and home visits of community health workers (CHW) in Brazil from 2007 to 2019. To this end, a Bayesian structural time-series model approach was used, based on a diffuse state-space regression. From 2016 to 2019, 463.47 million physician care, 210.61 million nursing care, and 1.28 billion CHW visits were recorded. Following the trend recorded before the implementation, 598.86 million, 430.46 million, and 1.5 billion physician and nursing appointments and CHW visits would be expected, respectively. In relative terms, there was a decrease of 25% in physician care, 51% in nursing care, and 15% in CHW visits when compared to the value expected by the Bayesian method. The negative impact on the records of patient care and home visits identified in this study, whether due to difficulties in adapting to the new system or a reduction in improper records, must be investigated so that the challenge of improving the primary care information system can be understood and overcome in a planned way.

We're implementing AI now, so why not ask us what to do? - How AI providers perceive and navigate the spread of diagnostic AI in complex healthcare systems

Despite high expectations of artificial intelligence (AI) in medical diagnostics, predictions of its extensive and rapid adoption have so far not been matched by reality. AI providers seeking to promote and perpetuate the use of this technology are faced with the complex reality of embedding AI-enabled diagnostics across variable implementation contexts. In this study, we draw upon a complexity science approach and qualitative methodology to understand how AI providers perceive and navigate the spread of AI in complex healthcare systems. Using semi-structured, one-to-one interviews, we collected qualitative data from 14 providers of AI-enabled diagnostics. We triangulated the data by complementing the interviews with multiple sources, including a focus group of physicians with experience using these technologies. The notion of embedding allowed us to connect local implementation efforts with systemic diffusion. Our study reveals that AI providers self-organise to increase their adaptability when navigating the variable conditions and unpredictability of complex healthcare contexts. In addition to the tensions perceived by AI providers within the sociocultural, technological, and institutional subsystems of healthcare, we illustrate the practices emerging among them to mitigate these tensions: stealth science, agility, and digital ambidexterity. Our study contributes to the growing body of literature on the spread of AI in healthcare by capturing the view of technology providers and adding a new theoretical perspective through the lens of complexity science.

Factors facilitating the implementation of a clinical decision support system in primary care practices: a fuzzy set qualitative comparative analysis

BACKGROUND

Understanding how to implement innovations in primary care practices is key to improve primary health care. Aiming to contribute to this understanding, we investigate the implementation of a clinical decision support system (CDSS) as part of the innovation fund project AdAM (01NVF16006). Originating from complexity theory, the practice change and development model (PCD) proposes several interdependent factors that enable organizational-level change and thus accounts for the complex settings of primary care practices. Leveraging the PCD, we seek to answer the following research questions: Which combinations of internal and external factors based on the PCD contribute to successful implementation in primary care practices? Given these results, how can implementation in the primary care setting be improved?

METHODS

We analyzed the joint contributions of internal and external factors on implementation success using qualitative comparative analysis (QCA). QCA is a set-theoretic approach that allows to identify configurations of multiple factors that lead to one outcome (here: successful implementation of a CDSS in primary care practices). Using survey data, we conducted our analysis based on a sample of 224 primary care practices.

RESULTS

We identified two configurations of internal and external factors that likewise enable successful implementation. The first configuration enables implementation based on a combination of Strong Inside Motivation, High Capability for Development, and Strong Outside Motivation; the second configuration based on a combination of Strong Inside Motivators, Many Options for Development and the absence of High Capability for Development.

CONCLUSION

In line with the PCD, our results demonstrate the importance of the combination of internal and external factors for implementation outcomes. Moreover, the two identified configurations show that different ways exist to achieve successful implementation in primary care practices.

TRIAL REGISTRATION

AdAM was registered on ClinicalTrials.gov ( NCT03430336 ) on February 6, 2018.

A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability

BACKGROUND

A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way.

METHODS

A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.'s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs' usability, applicability, and testability.

RESULTS

A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability.

CONCLUSIONS

Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.

Barriers and facilitators of conducting research with team science approach: a systematic review

BACKGROUND

The present review aimed to systematically identify and classify barriers and facilitators of conducting research with a team science approach.

METHODS

PubMed, EMBASE, PsycINFO, Scopus, Web of Science, Emerald, and ProQuest databases were searched for primary research studies conducted using quantitative, qualitative, or mixed methods. Studies examining barriers and facilitators of research with a team science approach were included in search. Two independent reviewers screened the texts, extracted and coded the data. Quality assessment was performed for all 35 included articles. The identified barriers and facilitators were categorized within Human, Organization, and Technology model.

RESULTS

A total of 35 studies from 9,381 articles met the inclusion criteria, from which 42 barriers and 148 facilitators were identified. Human barriers were characteristics of the researchers, teaming skills, and time. We consider Human facilitators across nine sub-themes as follows: characteristics of the researchers, roles, goals, communication, trust, conflict, disciplinary distances, academic rank, and collaboration experience. The barriers related to organization were institutional policies, team science integration, and funding. Organizational facilitators were as follows: team science skills training, institutional policies, and evaluation. Facilitators in the field of technology included virtual readiness and data management, and the technology barriers were complexity of techniques and privacy issues.

CONCLUSIONS

We identified major barriers and facilitators for conducting research with team science approach. The findings have important connotations for ongoing and future implementation of this intervention strategy in research. The analysis of this review provides evidence to inform policy-makers, funding providers, researchers, and students on the existing barriers and facilitators of team science research.

TRIAL REGISTRATION

This review was prospectively registered on PROSPERO database (PROSPERO 2021 CRD42021278704).

An Evaluation Framework for a Novel Process to Codevelop Written and Computable Guidelines

Clinical practice guidelines (CPGs) support individual and population health by translating new, evidence-based knowledge into recommendations for health practice. CPGs can be provided as computable, machine-readable guidelines that support the translation of recommendations into shareable, interoperable clinical decision support and other digital tools (eg, quality measures, case reports, care plans). Interdisciplinary collaboration among guideline developers and health information technology experts can facilitate the translation of written guidelines into computable ones. The benefits of interdisciplinary work include a focus on the needs of end-users who apply guidelines in practice through clinic decision support systems as part of the Centers for Disease Control and Prevention's (CDC's) Adapting Clinical Guidelines for the Digital Age (ACG) initiative, a group of interdisciplinary experts proposed a process to facilitate the codevelopment of written and computable CPGs, referred to as the "integrated process (IP)."1 This paper presents a framework for evaluating the IP based on a combination of vetted evaluation models and expert opinions. This framework combines 3 types of evaluations: process, product, and outcomes. These evaluations assess the value of interdisciplinary expert collaboration in carrying out the IP, the quality, usefulness, timeliness, and acceptance of the guideline, and the guideline's health impact, respectively. A case study is presented that illustrates application of the framework.

Attitudes Toward the Adoption of 2 Artificial Intelligence-Enabled Mental Health Tools Among Prospective Psychotherapists: Cross-sectional Study

BACKGROUND

Despite growing efforts to develop user-friendly artificial intelligence (AI) applications for clinical care, their adoption remains limited because of the barriers at individual, organizational, and system levels. There is limited research on the intention to use AI systems in mental health care.

OBJECTIVE

This study aimed to address this gap by examining the predictors of psychology students' and early practitioners' intention to use 2 specific AI-enabled mental health tools based on the Unified Theory of Acceptance and Use of Technology.

METHODS

This cross-sectional study included 206 psychology students and psychotherapists in training to examine the predictors of their intention to use 2 AI-enabled mental health care tools. The first tool provides feedback to the psychotherapist on their adherence to motivational interviewing techniques. The second tool uses patient voice samples to derive mood scores that the therapists may use for treatment decisions. Participants were presented with graphic depictions of the tools' functioning mechanisms before measuring the variables of the extended Unified Theory of Acceptance and Use of Technology. In total, 2 structural equation models (1 for each tool) were specified, which included direct and mediated paths for predicting tool use intentions.

RESULTS

Perceived usefulness and social influence had a positive effect on the intention to use the feedback tool (P<.001) and the treatment recommendation tool (perceived usefulness, P=.01 and social influence, P<.001). However, trust was unrelated to use intentions for both the tools. Moreover, perceived ease of use was unrelated (feedback tool) and even negatively related (treatment recommendation tool) to use intentions when considering all predictors (P=.004). In addition, a positive relationship between cognitive technology readiness (P=.02) and the intention to use the feedback tool and a negative relationship between AI anxiety and the intention to use the feedback tool (P=.001) and the treatment recommendation tool (P<.001) were observed.

CONCLUSIONS

The results shed light on the general and tool-dependent drivers of AI technology adoption in mental health care. Future research may explore the technological and user group characteristics that influence the adoption of AI-enabled tools in mental health care.

Strengths, weaknesses, opportunities, and threats for the nation's public health information systems infrastructure: synthesis of discussions from the 2022 ACMI Symposium

OBJECTIVE

The annual American College of Medical Informatics (ACMI) symposium focused discussion on the national public health information systems (PHIS) infrastructure to support public health goals. The objective of this article is to present the strengths, weaknesses, threats, and opportunities (SWOT) identified by public health and informatics leaders in attendance.

MATERIALS AND METHODS

The Symposium provided a venue for experts in biomedical informatics and public health to brainstorm, identify, and discuss top PHIS challenges. Two conceptual frameworks, SWOT and the Informatics Stack, guided discussion and were used to organize factors and themes identified through a qualitative approach.

RESULTS

A total of 57 unique factors related to the current PHIS were identified, including 9 strengths, 22 weaknesses, 14 opportunities, and 14 threats, which were consolidated into 22 themes according to the Stack. Most themes (68%) clustered at the top of the Stack. Three overarching opportunities were especially prominent: (1) addressing the needs for sustainable funding, (2) leveraging existing infrastructure and processes for information exchange and system development that meets public health goals, and (3) preparing the public health workforce to benefit from available resources.

DISCUSSION

The PHIS is unarguably overdue for a strategically designed, technology-enabled, information infrastructure for delivering day-to-day essential public health services and to respond effectively to public health emergencies.

CONCLUSION

Most of the themes identified concerned context, people, and processes rather than technical elements. We recommend that public health leadership consider the possible actions and leverage informatics expertise as we collectively prepare for the future.

An Electronically Delivered Person-Centered Narrative Intervention for Persons Receiving Palliative Care: Protocol for a Mixed Methods Study

BACKGROUND

In the health care setting, electronic health records (EHRs) are one of the primary modes of communication about patients, but most of this information is clinician centered. There is a need to consider the patient as a person and integrate their perspectives into their health record. Incorporating a patient's narrative into the EHR provides an opportunity to communicate patients' cultural values and beliefs to the health care team and has the potential to improve patient-clinician communication. This paper describes the protocol to evaluate the integration of an adapted person-centered narrative intervention (PCNI). This adaptation builds on our previous research centered on the implementation of PCNIs. The adaptation for this study includes an all-electronic delivery of a PCNI in an outpatient clinical setting.

OBJECTIVE

This research protocol aims to evaluate the feasibility, usability, and effects of the all-electronic delivery of a PCNI in an outpatient setting on patient-reported outcomes. The first objective of this study is to identify the barriers and facilitators of an internet-based-delivered PCNI from the perspectives of persons living with serious illness and their clinicians. The second objective is to conduct acceptability, usability, and intervention fidelity testing to determine the essential requirements for the EHR integration of an internet-based-delivered PCNI. The third objective is to test the feasibility of the PCNI in an outpatient clinic setting.

METHODS

Using a mixed method design, this single-arm intervention feasibility study was delivered over approximately 3 to 4 weeks. Patient participant recruitment was conducted via screening outpatient palliative care clinic schedules weekly for upcoming new palliative care patient visits and then emailing potential patient participants to notify them about the study. The PCNI was delivered via email and Zoom app. Patient-reported outcome measures were completed by patient participants at baseline, 24 to 48 hours after PCNI, and after the initial palliative care clinic visit, approximately 1 month after baseline. Inclusion criteria included having the capacity to give consent and having an upcoming initial outpatient palliative care clinic visit.

RESULTS

The recruitment of participants began in April 2021. A total of 189 potential patient participants were approached via email, and 20 patient participants were enrolled, with data having been collected from May 2021 to September 2022. A total of 7 clinician participants were enrolled, with a total of 3 clinician exit interviews and 1 focus group (n=5), which was conducted in October 2022. Data analysis is expected to be completed by the end of June 2023.

CONCLUSIONS

The findings from this study, combined with those from other PCNI studies conducted in acute care settings, have the potential to influence clinical practices and policies and provide innovative avenues to integrate more person-centered care delivery.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41787.

Health information use and associated factors among healthcare professionals in Ilu Aba Bor zone, Oromia region, Ethiopia: an institution-based cross-sectional study

BACKGROUND

Health information systems are essential for collecting data for planning, monitoring and evaluating health services. Using reliable information over time is an important aid in improving health outcomes, tackling disparities, enhancing efficiency and encouraging innovation. Studies on the level of health information use among health workers at the health facility level in Ethiopia are limited.

OBJECTIVES

This study was designed to assess the level of health information use and associated factors among healthcare professionals.

METHODS

An institution-based cross-sectional study was conducted among 397 health workers in health centres in the Iluababor zone of Oromia region in southwest Ethiopia, who were chosen using a simple random sampling technique. Data were collected using a pretested, self-administered questionnaire and an observation checklist. The Strengthening the Reporting of Observational Studies in Epidemiology reporting checklist was used to report the summary of the manuscript. Bivariable and multivariable binary logistic regression analysis was used to identify the determinant factors. Variables with a p value <0.05 at 95% CIs were declared significant.

RESULTS

It was found that 65.8% of the healthcare professionals had good health information usage. Use of Health Management Information System (HMIS) standard materials (adjusted OR (AOR)=8.10; 95% CI 3.51 to 16.58), training on health information (AOR=8.31; 95% CI 4.34 to 14.90), completeness of report formats (AOR=10.24; 95% CI 5.0 to 15.14) and age (AOR=0.4; 95% CI 0.2 to 0.77) were found to be significantly associated with health information use.

CONCLUSION

More than three-fifths of healthcare professionals had good health information usage. Completeness of report format, training, use of standard HMIS materials and age were significantly associated with health information usage. Ensuring the availability of standard HMIS materials and report completeness and providing training, particularly for newly recruited health workers are highly recommended to enhance health information usage.

Development of an evaluation framework for health information communication technology in contemporary pharmacy practice

Background

Health information communication technology (ICT) has rapidly evolved in contemporary pharmacy practice worldwide. The Australian healthcare system is experiencing a paradigm shift to real-time interconnectivity for practitioners and consumers and interoperable digital health. With these developments come a need to evaluate use of technologies specifically in pharmacy practice to optimize their clinical functionality. There are no published frameworks for evaluating ICT needs or implementation in pharmacy practice.

Objective

This paper proposes a theoretical framework for evaluating health ICT in pharmacy.

Methods

Development of the evaluation framework was informed by a systematic scoping review and health informatics literature. Specifically, the framework drew upon critical appraisal and concept mapping of the TAM, ISS and HOT-fit validated models, with respect to health ICT in contemporary pharmacy practice.

Results

The proposed model was named the Technology Evaluation Key (TEK). The TEK comprises of 10 domains; healthcare system, organization, practitioner, user interface, ICT, use, operational outcomes, system outcomes, clinical outcomes and timely access to care.

Conclusions

This is the first published proposed evaluation framework developed for health ICT specifically in contemporary pharmacy practice. TEK represents a pragmatic way to ensure the development, refinement and implementation of new and existing technologies in contemporary pharmacy practice to keep pace with the clinical and professional requirements of community pharmacists. Operational, clinical and system outcomes should be evaluated as coexisting factors that may impact implementation. Validation research utilizing Design Science Research Methodology will enhance utility for end users and ensure the relevance and application of the TEK to contemporary pharmacy practice.

Integrating User Preferences for Asthma Tools and Clinical Guidelines Into Primary Care Electronic Medical Records: Mixed Methods Study

BACKGROUND

Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices.

OBJECTIVE

The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance.

METHODS

In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis.

RESULTS

Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care.

CONCLUSIONS

Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

The Reasons for Physicians and Pharmacists' Acceptance of Clinical Support Systems in Saudi Arabia

This research aims to identify the technological and non-technological factors influencing user acceptance of the CDSS in a group of healthcare facilities in Saudi Arabia. The study proposes an integrated model that indicates the factors to be considered when designing and evaluating CDSS. This model is developed by integrating factors from the "Fit between Individuals, Task, and Technology" (FITT) framework into the three domains of the human, organization, and technology-fit (HOT-fit) model. The resulting FITT-HOT-fit integrated model was tested using a quantitative approach to evaluate the currently implemented CDSS as a part of Hospital Information System BESTCare 2.0 in the Saudi Ministry of National Guard Health Affairs. For data collection, a survey questionnaire was conducted at all Ministry of National Guard Health Affairs hospitals. Then, the collected survey data were analyzed using Structural Equation Modeling (SEM). This analysis included measurement instrument reliability, discriminant validity, convergent validity, and hypothesis testing. Moreover, a CDSS usage data sample was extracted from the data warehouse to be analyzed as an additional data source. The results of the hypotheses test show that usability, availability, and medical history accessibility are critical factors influencing user acceptance of CDSS. This study provides prudence about healthcare facilities and their higher management to adopt CDSS.

Assessment of the Effectiveness, Socio-Economic Impact and Implementation of a Digital Solution for Patients with Advanced Chronic Diseases: The ADLIFE Study Protocol

Due to population ageing and medical advances, people with advanced chronic diseases (ACD) live longer. Such patients are even more likely to face either temporary or permanent reduced functional reserve, which typically further increases their healthcare resource use and the burden of care on their caregiver(s). Accordingly, these patients and their caregiver(s) may benefit from integrated supportive care provided via digitally supported interventions. This approach may either maintain or improve their quality of life, increase their independence, and optimize the healthcare resource use from early stages. ADLIFE is an EU-funded project, aiming to improve the quality of life of older people with ACD by providing integrated personalized care via a digitally enabled toolbox. Indeed, the ADLIFE toolbox is a digital solution which provides patients, caregivers, and health professionals with digitally enabled, integrated, and personalized care, supporting clinical decisions, and encouraging independence and self-management. Here we present the protocol of the ADLIFE study, which is designed to provide robust scientific evidence on the assessment of the effectiveness, socio-economic, implementation, and technology acceptance aspects of the ADLIFE intervention compared to the current standard of care (SoC) when applied in real-life settings of seven different pilot sites across six countries. A quasi-experimental trial following a multicenter, non-randomized, non-concurrent, unblinded, and controlled design will be implemented. Patients in the intervention group will receive the ADLIFE intervention, while patients in the control group will receive SoC. The assessment of the ADLIFE intervention will be conducted using a mixed-methods approach.

Unintended consequences of pharmacy information systems: A case study

BACKGROUND

Pharmacy information systems (PhIS) can cause medication errors that pharmacists may overlook due to their increased workload and lack of understanding of maintaining information quality. This study seeks to identify factors influencing unintended consequences of PhIS and how they affect the information quality, which can pose a risk to patient safety.

MATERIALS AND METHODS

This qualitative, explanatory case study evaluated PhIS in ambulatory pharmacies in a hospital and a clinic. Data were collected through observations, interviews, and document analysis. We applied the socio-technical interactive analysis (ISTA) framework to investigate the socio-technical interactions of pharmacy information systems that lead to unintended consequences. We then adopted the human-organization-process-technology-fit (HOPT-fit) framework to identify their contributing and dominant factors, misfits, and mitigation measures.

RESULTS

We identified 28 unintended consequences of PhIS, their key contributing factors, and their interrelations with the systems. The primary causes of unintended consequences include system rigidity and complexity, unclear knowledge, understanding, skills, and purpose of using the system, use of hybrid paper and electronic documentation, unclear and confusing transitions, additions and duplication of tasks and roles in the workflow, and time pressure, causing cognitive overload and workarounds. Recommended mitigating mechanisms include human factor principles in system design, data quality improvement for PhIS in terms of effective use of workspace, training, PhIS master data management, and communication by standardizing workarounds.

CONCLUSION

Threats to information quality emerge in PhIS because of its poor design, a failure to coordinate its functions and clinical tasks, and pharmacists' lack of understanding of the system use. Therefore, safe system design, fostering awareness in maintaining the information quality of PhIS and cultivating its safe use in organizations is essential to ensure patient safety. The proposed evaluation approach facilitates the evaluator to identify complex socio-technical interactions and unintended consequences factors, impact, and mitigation mechanisms.

Endocrinologists' Experiences With Telehealth: A Qualitative Study With Implications for Promoting Sustained Use

OBJECTIVE

Endocrinology is well-suited to telehealth, with high rates of use and known benefits. Clinician attitudes toward telehealth will be critical to ensuring sustained use after the pandemic. We examined endocrinologists' experiences with synchronous telehealth to identify factors affecting experiences with and acceptance of the technology.

METHODS

We conducted qualitative interviews and directed-content analysis with a purposive sample of 26 U.S. endocrinologists. Factors affecting clinicians' experiences were mapped to the human-organization-technology fit (HOT-fit) framework.

RESULTS

We found that clinicians' experiences with synchronous telehealth were influenced by: (1) Clinician factors: Clinicians welcomed telehealth but expressed concerns about patient interest, rapport building, and clinical appropriateness, desiring more data to support its use. Many clinicians feared missing clinical findings on virtual examination, despite no such personal experiences. Effects on professional and personal life contributed to satisfaction, through increased flexibility but also increased workload. (2) Organizational factors: Departmental meetings and trainings supported clinicians' technical, logistical, and clinical needs, reducing resistance to telehealth use. Shifting staff responsibilities in clinical workflows improved clinicians' experiences and supported telehealth use, while mixed telehealth and in-person schedules impeded workflow. (3) Technology factors: Most clinicians preferred video visits to telephone. Usability and reliability of telehealth platforms, integration of patient self-monitoring data, and availability of IT support were crucial to a positive experience.

CONCLUSION

Clinician acceptance of telehealth is influenced by clinician, organizational, and technology factors that can be leveraged to improve buy-in. Organizational leaders' attention to addressing these factors will be critical to support endocrinologists' continued provision of telehealth for their patients.

Health information communication technology evaluation frameworks for pharmacist prescribing: A systematic scoping review

BACKGROUND

Information communication technology (ICT) is instrumental in pharmacists' current practice and emerging roles. One such role is prescribing, which requires the use of clinical guidelines and documentation of decision-making, commonly via ICT. Development and refinement of ICT should be guided by evaluation frameworks that describe or measure features of ICT and its implementation. In the context of pharmacist prescribing, these evaluation frameworks should be specific to health stakeholders and the pharmacy setting.

OBJECTIVES

To identify ICT evaluation frameworks from health-related literature and review frameworks relevant to the development, implementation, and evaluation of pharmacist prescribing.

METHODS

A database search of CINAHL, Cochrane Library, EMBASE, Medline (Ovid), ProQuest, Scopus, Web of Science and grey literature was conducted, using combinations of keywords relating to 'ICT', 'utilization', 'usability', and 'evaluation framework'. Abstracts and titles were screened according to inclusion criteria. Identified evaluation frameworks were critiqued for relevance to pharmacy practice.

RESULTS

Twenty-two articles were identified, describing the development or application of 20 evaluation frameworks. None of the frameworks was developed specifically for pharmacy practice. The Technology Acceptance Model (TAM), describing use behavior, behavior intention, perceived usefulness, and perceived ease of use, was the most widely utilized framework. The Information System Success (ISS) and Human-Organization and Technology Fit (HOT-fit) are notable evaluation frameworks that address user and organizational influences in health ICT utility, and factors of both can address the limitation of TAM.

CONCLUSIONS

The findings call for development of an agile evaluation framework for the system under review; however, this can prove difficult due to the heterogenicity and complexity of the healthcare system, particularly contemporary pharmacy practice. While the TAM appears useful to evaluate user attitudes and intentions towards ICT, its relevance to ICT in contemporary community pharmacy practice requires exploration.

Web-based Guidance for Assisted Reproductive Technology With an Online App (myFertiCare): Quantitative Evaluation With the HOT-fit Framework

BACKGROUND

Assisted reproductive technologies (ARTs) are considered to be physically and mentally stressful. During their treatment trajectory, couples express high information and communication needs. They appreciate using the internet to obtain fertility-related information. In a previous study, we developed myFertiCare, an eHealth tool providing personalized information and interactive functionalities for infertile couples in order to improve patient-centered care. The app has already been successful in qualitative evaluations of usability.

OBJECTIVE

The aim of the current study is to quantitatively evaluate the implementation of myFertiCare by using the human, organizational, and technology-fit (HOT-fit) framework and to study the effects of using myFertiCare on couples' knowledge about infertility, their experience of the burden of infertility, and their experience of patient-centered care. With these results, implementation can be further improved, and patient-centered care can be enhanced.

METHODS

A quantitative study was performed based on the HOT-fit framework using validated questionnaires focusing on the human, organizational, and technology domains. Questions were added on the effect of using myFertiCare on couples' knowledge about infertility and treatment. Questions regarding the burden of infertility, the burden of infertility treatment, and the experience of patient-centeredness were based on the main items of the validated fertility quality of life (FertiQoL) and Patient-Centredness Questionnaire-Infertility questionnaires, respectively. Also, nonusers of the app were included to explore motivations for not using the app and identify opportunities for improvement. Finally, user data were analyzed to provide insight into multiple variables concerning app use.

RESULTS

In the human and technology domains, myFertiCare showed good system usability, high user satisfaction, and high information and interface quality. In the organizational domain, implementation was considered to be sufficient by both patients and staff. Use of the app increased knowledge about the treatment, improved coping with the treatment, and enhanced the experience of patient-centeredness. User data showed that women were the main app users and that use of the app gradually declined during the treatment trajectory.

CONCLUSIONS

A multi-faceted online app, myFertiCare, has been successfully evaluated quantitatively for implementation by using the HOT-fit framework. Use of the app increased knowledge about the treatment, improved coping with the treatment, and enhanced the experience of patient-centeredness. App use could be improved by creating more publicity. By providing myFertiCare, professionals in fertility care are supported in guiding patients through their treatment trajectory and in delivering patient-centered care.

Assessing primary health care readiness for large-scale electronic health record system implementation: Project team perspective

INTRODUCTION

The introduction of information technology was one of the key priorities for policymakers in healthcare organisations over the last two decades, due to the potential benefits of this technology to improve healthcare services and quality. However, about 50% of those projects failed to achieve their intended aims. This was as a result of several factors and included the level of readiness to the new IT projects.

AIM

The aim of the study was to assess the readiness of Saudi primary health care centres (PHCCs) readiness for the implementation of an electronic health record system (EHRS) from the project team perspective.

METHODS

Explanatory mixed methods design was used with both qualitative and quantitative methods. Thirty-one members of project team at the ministry of health (MOH) participated in the online-based questionnaire, while 13 participants from the same population took part in the semi-structure interviews. Eight different readiness scales were quantitatively examined. These scales include resources, Knowledge, process, management structure and administrative support, end user, technology and values and goals.

RESULT

Although, very high level of readiness has been recorded at the process, management structure and administrative support levels, readiness was average at the end user, technology and values and goals levels. Moreover, the study findings revealed that primary health care centres readiness for an electronic health record system must be considered in the early stages of implementation (pre-implementation phase), particularly readiness at a technical level, such as preparedness of the infrastructure. A positive significant correlation has been recorded between all readiness scales with centralization of management system and financial resources.

CONCLUSION

Overall, the level of primary health care centres readiness recorded to be high, which indicates that primary health care centres are ready for implementation of the electronic health record system, and in this context, management structure, organizational process, financial recourses and administrative support play significant roles to increase the project success rate.

"It depends on the people!" - A qualitative analysis of contextual factors, prior to the implementation of digital health innovations for chronic condition management, in a German integrated care network

Objective

Integrated care and digital health technology interventions are promising approaches to coordinate services for people living with chronic conditions, across different care settings and providers. The EU-funded ADLIFE project intends to provide digitally integrated personalized care to improve and maintain patients' health with advanced chronic conditions. This study conducted a qualitative assessment of contextual factors prior to the implementation of the ADLIFE digital health platforms at the German pilot site. The results of the assessment are then used to derive recommendations for action for the subsequent implementation, and for evaluation of the other pilot sites.

Methods

Qualitative interviews with healthcare professionals and IT experts were conducted at the German pilot site. The interviews followed a semi-structured interview guideline, based on the HOT-fit framework, focusing on organizational, technological, and human factors. All interviews were audio recorded, transcribed, and subsequently analysed following qualitative content analysis.

Results

The results of the 18 interviews show the interviewees' high openness and motivation to use new innovative digital solutions, as well as an apparent willingness of cooperation between different healthcare professionals. Challenges include limited technical infrastructure and large variability of software to record health data, lacking standards and interfaces.

Conclusions

Considering contextual factors on different levels is critical for the success of implementing innovations in healthcare and the transfer into other settings. In our study, the HOT-fit framework proved suitable for assessing contextual factors, when implementing IT innovations in healthcare. In a next step, the methodological approach will be transferred to the six other European pilot sites, participating in the project, for a cross-national assessment of contextual factors.

Managing healthcare supply chain through artificial intelligence (AI): A study of critical success factors

Healthcare is one of the most critical sectors due to its importance in handling public health. With the outbreak of various diseases, more recently during Covid-19, this sector has gained further attention. The pandemic has exposed vulnerabilities in the healthcare supply chain (HSC). Recent advancements like the adoption of various advanced technologies viz. AI and Industry 4.0 in the healthcare supply chain are turning out to be game-changers. This study focuses on identifying critical success factors (CSFs) for AI adoption in HSC in the emerging economy context. Rough SWARA is used for ranking CSFs of AI adoption in HSC. Results indicate that technological (TEC) factors are the most influential factor that impacts the adoption of AI in HSC in the context of emerging economies, followed by institutional or environmental (INT), human (HUM), and organizational (ORG) dimensions.

Strengthening the evidence base for mHealth in clinical practice: Conducting research with standalone or interoperable systems - a viewpoint

Objective

The aim of this viewpoint is to inform mobile health (mHealth) evidence development in using standalone or interoperable systems in hospital practice.

Methods

There is a gap between mHealth research and its widespread uptake in clinical practice. Evidence generation is not keeping up with the introduction and implementation of technologies. This is partly a consequence of the technology characteristics and the way research is conducted in a clinical setting. Research and development of mHealth technology can be conducted standalone in a laboratory like setting, standalone in a clinical setting or interoperable with already existing technology in hospital practice.

Results

Standalone systems operate relatively independent from an organizations' existing infrastructure. Using laboratory settings does not reflect the complexity of real-life, but in clinical practice this may be suitable for research assessing usability, feasibility or even clinical and process outcomes at a small scale. Realizing research and development on interoperable mHealth technology solutions, especially with operational EMR systems, is a challenging, time- and resource intensive process and requires large(r) investments, as it is often complicated by a myriad of interfering factors. Interoperable systems are however a more sustainable option in the long run, and generated evidence reflects the real hospital care setting and this option may therefore facilitate dissemination. Choosing either a standalone or interoperable setting affects the research design, the implementation pace and ultimately widespread adoption of the mHealth technology.

Conclusion

We recommend to include these technology characteristics in implementation frameworks and think of evaluation research designs in an early phase.

Conceptual Framework for Smart Health: A Multi-Dimensional Model Using IPO Logic to Link Drivers and Outcomes

Smart health is considered to be a new phase in the application of information and communication technologies (ICT) in healthcare that can improve its efficiency and sustainability. However, based on our literature review on the concept of smart health, there is a lack of a comprehensive perspective on the concept of smart health and a framework for how to link the drivers and outcomes of smart health. This paper aims to interweave the drivers and outcomes in a multi-dimensional framework under the input-process-output (IPO) logic of the "system view" so as to promote a deeper understanding of the model of smart health. In addition to the collection of studies, we used the modified Delphi method (MDM) to invite 10 experts from different fields, and the views of the panelists were analyzed and integrated through a three-round iterative process to reach a consensus on the elements included in the conceptual framework. The study revealed that smart health contains five drivers (community, technology, policy, service, and management) and eight outcomes (efficient, smart, sustainable, planned, trustworthy, safe, equitable, health-beneficial, and economic). They all represent a unique aspect of smart health. This paper expands the research horizon of smart health, shifting from a single technology to multiple perspectives, such as community and management, to guide the development of policies and plans in order to promote smart health.

Exploring facilitators of the implementation of electronic health records in Saudi Arabia

INTRODUCTION

The introduction of information technology was one of the key priorities for policy-makers in health care organisations over the last two decades due to the potential benefits of this technology to improve health care services and quality. However, approximately 50% of those projects failed to achieve their intended aims. This was a result of several factors, including the cost of these projects. The Saudi Ministry of Health (MoH) planned to implement an electronic health record system (EHRS) in approximately 2100 primary health care centres nationwide. It was acknowledged that this project may face hurdles, which might result in the failure of the project if implementation facilitators were not first determined. According to the Saudi MoH, previous electronic health record system implementation in primary health care centres failed as a consequence of several barriers, such as poor infrastructure, lack of connectivity and lack of interoperability. However, the facilitators of successful electronic health record system implementation in Saudi primary health care centres are not understood.

AIM

To determine the facilitators that enhance the success of the implementation of an EHRS in public primary health care centres in SA.

METHOD

A mixed methods approach was used with both qualitative and quantitative methods (qualitative using semistructured interviews and quantitative with a closed survey). The purpose of the utilisation of exploratory mixed methods was to identify a wide range of facilitators that may influence EHRS implementation. The data were obtained from two different perspectives, primary health care centre practitioners and project team members. A total of 351 practitioners from 21 primary health care centres participated in the online survey, and 14 key informants at the Saudi Ministry of Health who were directly involved in the electronic health record system implementation in the primary health care centres agreed to be interviewed face to face.

RESULTS

The findings from both studies revealed several facilitators. Among these facilitators, financial resources were found to be the most influential factor that assisted in overcoming some barriers, such as software selection. The size of the primary health care centres was the second facilitator of successful implementation, despite the scale of the project. Perceived usefulness was another facilitator identified in both the interviews and the survey. More than 90% of the participants thought that the electronic health record system was useful and could contribute to improving the quality of health care services. While a high level of satisfaction was expressed towards the electronic health record system's usability and efficiency, low levels of satisfaction were recorded for organisational factors such as user involvement, training and support. Hence, system usability and efficiency were documented to be other facilitators of successful electronic health record system implementation in Saudi primary health care centres.

CONCLUSION

The findings of the present study suggest that sufficient financial support is essential to enhance the success of electronic health record system implementation despite the scale of the project. Additionally, effective leadership and project management are core factors to overcome many obstacles and ensure the success of large-scale projects.

Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation

Background

Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS—exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems.

Methods

A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach.

Results

Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care; user confidence gained through training and post training follow-up; external contexts comprised of strong clinical champions, allocated personnel, and technical support; and CDS technical features that are both highly functional, and attractive.

Conclusion

This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research.

Trial registration

PROSPERO CRD42020203716

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00326-x.

Transition to a new nursing information system embedded with clinical decision support: a mixed-method study using the HOT-fit framework

BACKGROUND

Nursing information systems embedded with standardized nursing language and clinical decision support have been increasingly introduced in health care settings. User experience is key to the adoption of health information technologies. Despite extensive research into the user experience with nursing information systems, few studies have focused on the interaction between user, technology and organizational attributes during its implementation. Guided by the human, organization and technology-fit framework, this study aimed to investigate nurses' perceptions and experiences with transition to a new nursing information system (Care Direct) 2 years after its first introduction.

METHODS

This is a mixed-method study using an embedded design. An online survey was launched to collect nurses' self-reported use of the new system, perceived system effectiveness and experience of participation in system optimization. Twenty-two semi structured interviews were conducted with twenty nurses with clinical or administrative roles. The quantitative and qualitative data were merged using the Pillar Integration Process.

RESULTS

The average score of system use behavior was 3.76 ± 0.79. Regarding perceived system effectiveness, the score of each dimension ranged 3.07-3.34 out of 5. Despite large variations in approaches to participating in system optimization, nurses had generally positive experiences with management and technical support. Eight main categories emerged from the integrated findings, which were further condensed into three themes: perceptions on system content, structure, and functionality; perceptions on interdisciplinary and cross-level cooperation; and embracing and accepting the change.

CONCLUSIONS

Effective collaboration between clinicians, administrators and technical staff is required during system promotion to enhance system usability and user experience. Clear communication of organizational missions to staff and support from top management is needed to smooth the system implementation process and achieve broader system adoption.

Beyond monitoring functionality to results evaluation of eHealth interventions: Development and validation of an eHealth evaluation framework

Evidencing eHealth interventions, benefits generates data as a basis for assessing whether observed changes in behavior, processes or healthcare outcomes can be attributed to the eHealth interventions. Generating such evidence requires the use of frameworks or some other type of organizing schemes to help in guiding the process and making sense of eHealth systems and the findings. The frameworks available in literature do not clearly guide on how to monitor eHealth implementation and evaluate eHealth implementation results. This study aimed to develop and validate an eHealth evaluation framework to guide the process of monitoring eHealth implementations and evaluation of eHealth results in terms of outcomes and impact on healthcare in developing countries. The Design Science Research Methodology was followed to conduct this study. Recommendations from an eHealth evaluation exploratory study in Uganda and other eHealth evaluation literature formed key inputs into the design and development of the framework. The framework consists of a generic reference model with eHealth monitoring and evaluation dimensions, performance indicators, and guidelines on how to conduct eHealth monitoring and evaluation. The eHealth evaluation framework received high acceptance (>80%) as regards its fitness for purpose during its validation.

Barriers and facilitators to implementing a nursing clinical decision support system in a tertiary hospital setting: A qualitative study using the FITT framework

OBJECTIVE

Clinical decision support systems (CDSSs) have been increasingly introduced to health care settings; however, their adoption is far from ideal. Guided by the FITT framework, this study aims to explore barriers and facilitators to the implementation of a CDSS from the perspective of nurses.

METHODS

A qualitative study with 200 h of participatory observation and 21 semi structured interviews was conducted from February to August 2021 in four medical-surgical wards in a 2000-bed tertiary hospital in Shanghai, China. The field notes were typed and the audio-recorded interviews were transcribed to texts verbatim and were coded with a four-step approach. We used the FITT framework to interpret our findings based on the technology, individual and task attributes and the fit between them.

RESULTS

A total of twelve categories were identified, which were integrated into two themes: barriers and facilitators to system implementation. All categories but one can be mapped to the three attributes of the FITT framework: technology, individual and task. We assumed that management has a vital role to play in the following areas: addressing user resistance, improving system usability, setting standards on practice and, finally, building connectivity between nurses and the technical staff to improve the fit between the technology, individual and task attribute and thus promote system implementation.

CONCLUSION

Barriers and facilitators to CDSS implementation include system-related, user-related and organizational factors which can largely be fit io the FITT framework. There is potential to extend the FITT framework to represent management intervention on inter-disciplinary collaboration. Future empirical studies on facilitating strategies from the management to improve user experience and willingness of CDSS adoption are needed.

Nutrition Telemonitoring for CKD-HD Patients: A Qualitative Study on Patients, Patients’ Families, Medical Teams, and Hospital Management

BACKGROUND: CKD-HD patients require a nutritional monitoring system to control the amount of protein, fluid, sodium, potassium, and phosphate intake to reduce readmission rates and to improve their life quality. The Nutrition Telemonitoring Application (NTA) has a potential to resolve this problem. AIM: Therefore, this study aims to prepare NTA design materials conditioned to the needs of patients, families, medical teams, and hospital management. METHODS: A qualitative study with semi-structured interviews was conducted on 16 informants consisting of patients, families, medical teams, and hospital management teams. Furthermore, a purposive sampling technique was used to recruit participants, and the thematic analysis of the audio recording was conducted. RESULTS: Three main themes and seven sub-themes were identified. First, all participants in support of NTA will be beneficial. Second, NTA implementation requires family, medical team, hospital management, and BPJS (Health Social Security Agency). Third, all participants demand an easy Indonesian language interface equipped with pictures of food portions, additional alarm features, exercise, food recipes, educational videos, and free of charge. CONCLUSIONS: This study provides important insights considering the issues associated with the sustainability of NTA design and long-term benefits for CKD-HD patients.

End-users feedback and perceptions associated with the implementation of a clinical-rule based Check of Medication Appropriateness service

Background

To support appropriate prescribing hospital-wide, the ‘Check of Medication Appropriateness’ (CMA) service was implemented at the University Hospitals Leuven. The CMA concerns a clinical rule based and pharmacist-led medication review service. The aim of this study was to explore both physicians’ and pharmacists’ feedback on the optimised CMA service to further improve the service.

Methods

An anonymous e-questionnaire was sent to all physicians active in the University Hospitals Leuven (n = 1631) and to all clinical pharmacists performing the CMA service (n = 16). Feedback was collected using multiple choice questions. During a 5-month period, physicians were also contacted in case of non-acceptance of recommendations to investigate barriers affecting implementation. Thematic analysis was performed and additional acceptance after telephone contact within 24 h was registered.

Results

A total of 119 physicians (7.3%) and 16 pharmacists (100%) completed the e-questionnaire. The overall service was assessed as clinically relevant to highly relevant by 77.7% of physicians. The main reasons for non-acceptance of recommendations were related to workload, work environment and time constraints. About two thirds (66.3%) of initially not-accepted recommendations were accepted after phone contact. A nearly full consensus was reached among pharmacists (15/16) on the centralised CMA being complementary to current clinical pharmacy activities. Two major barriers were reported by pharmacists: (1) too limited time allocation and (2) a large number of irrelevant alerts.

Conclusions

The CMA was perceived as clinically relevant by the majority of end-users. Acceptance rate of pharmaceutical recommendations was further increased by calling the physician. Increasing the specificity of clinical rules in the future is imperative.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01921-7.

An implementation framework and a feasibility evaluation of a clinical decision support system for diabetes management in secondary mental healthcare using CogStack

BACKGROUND

Improvements to the primary prevention of physical health illnesses like diabetes in the general population have not been mirrored to the same extent in people with serious mental illness (SMI). This work evaluates the technical feasibility of implementing an electronic clinical decision support system (eCDSS) for supporting the management of dysglycaemia and diabetes in patients with serious mental illness in a secondary mental healthcare setting.

METHODS

A stepwise approach was taken as an overarching and guiding framework for this work. Participatory methods were employed to design and deploy a monitoring and alerting eCDSS. The eCDSS was evaluated for its technical feasibility. The initial part of the feasibility evaluation was conducted in an outpatient community mental health team. Thereafter, the evaluation of the eCDSS progressed to a more in-depth in silico validation.

RESULTS

A digital health intervention that enables monitoring and alerting of at-risk patients based on an approved diabetes management guideline was developed. The eCDSS generated alerts according to expected standards and in line with clinical guideline recommendations.

CONCLUSIONS

It is feasible to design and deploy a functional monitoring and alerting eCDSS in secondary mental healthcare. Further work is required in order to fully evaluate the integration of the eCDSS into routine clinical workflows. By describing and sharing the steps that were and will be taken from concept to clinical testing, useful insights could be provided to teams that are interested in building similar digital health interventions.

Barriers and facilitators of personal health record adoption in Indonesia: Health facilities' perspectives

BACKGROUND

Personal health record (PHR) has been extensively used in developed countries; however, it has been limitedly adopted in developing countries. This study was conducted in Indonesia: a developing country with the largest population in Southeast Asia. PHR that is integrated with health providers is needed to achieve a transformation from a health provider-centered to a patient-centered healthcare system.

OBJECTIVE

To qualitatively analyze barriers and facilitators of PHR adoption by health facilities in Indonesia from the technological, organizational, environmental, and individual factors.

METHODS

In this qualitative study, we used semi-structured interviews with three health facility directors, 17 IT heads, eight physicians, and three nurses from 10 primary healthcare facilities, nine government hospitals, and six private hospitals in Indonesia. Interview data were analyzed using thematic analysis in NVivo 12. The analysis stages involved familiarizing data, generating initial codes, searching themes, evaluating themes, defining and naming themes, and writing reports.

RESULTS

Regarding technological factors, the barriers to PHR adoption include security and privacy, interoperability, and infrastructure. Organizational support can facilitate PHR adoption in terms of organizational factors, while a lack of human resources is a barrier to PHR adoption. Regarding environmental factors, the lack of government regulations is the barrier to PHR adoption, while competition between health facilities and vendor support could facilitate PHR adoption. Finally, regarding individual factors, perceived usefulness and ease of use can be facilitators of PHR adoption, while user attitudes and e-health literacy can be barriers to PHR adoption.

CONCLUSIONS

This study is expected to comprehensively understand PHR adoption in Indonesia and could be applied to other developing countries with similar technological, legal, or cultural characteristics as Indonesia. This study also provides information that can guide health regulators, health facilities, or PHR vendors in planning the implementation of integrated PHR.

Development an extended-information success system model (ISSM) based on nurses' point of view for hospital EHRs: a combined framework and questionnaire

Background

Understanding the hospital EHR success rate has great benefits for hospitals. The present study aimed to 1-Propose an extended-ISSM framework and a questionnaire in a systematic manner for EHR evaluation based on nurses’ perspectives, 2-Determine the EHR success rate, and 3-Explore the effective factors contributing to EHR success.

Methods

The proposed framework was developed using ISSM, TAM3, TTF, HOT-FIT, and literature review in seven steps. A self-administrated structured 65-items questionnaire was developed with CVI: 90.27% and CVR: 94.34%. Construct validity was conducted using EFA and CFA. Eleven factors were identified, collectively accounting for 71.4% of the total variance. In the EFA step, 15 questions and two questions in EFA were excluded. Finally, 48 items remained in the framework including dimensions of technology, human, organization, ease of use, usefulness, and net benefits. The overall Cronbach’s alpha value was 93.4%. In addition, the hospital EHR success rate was determined and categorized. In addition, effective factors on EHR success were explored.

Results

In total, 86 nurses participated in the study. On average, the “total hospital EHR success rate” was moderate. The total EHR success rates was ranging from 47.09 to 74.96%. The results of the Kruskal–Wallis test showed that there was a significant relationship between “gender” and “self-efficacy” (p-value: 0.042). A reverse relation between “years of experience using computers” and “training” (p-value: 0.012) was observed. “Years of experience using EHR” as well as “education level” (p-value: 0.001) and “ease of use” had a reverse relationship (p-value: 0.034).

Conclusions

Our findings underscore the EHR success based on nurses’ viewpoint in a developing country. Our results provide an instrument for comparison of EHR success rates in various hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01800-1.

Evaluation in Life Cycle of Information Technology (ELICIT) framework: Supporting the innovation life cycle from business case assessment to summative evaluation

OBJECTIVE

Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation.

METHODS

The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies.

RESULTS

The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment.

DISCUSSION

Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation.

CONCLUSION

As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations.

User-Centric Design Methodology for mHealth Apps. The PainApp Paradigm for Chronic Pain

The paper presents a user-centric methodology in order to design successful mobile health (mHealth) applications. In addition to the theoretical background, such an example is presented with an application targeting chronic pain. The pain domain was decided due to its significance in many aspects: its complexity, dispersion in the population, the financial burden it causes, etc. The paper presents a step-by-step plan in order to build mobile health applications. Participatory design and interdisciplinarity are only some of the critical issues towards the desired result. In the given example (development of the PainApp), a participatory design was followed with a team of seventeen stakeholders that drove the design and development phases. Three physicians, one behavioral scientist, three IT and UX experts, and ten patients collaborated together to develop the final solution. The several features implemented in the PainApp solution are presented in details. The application is threefold: it supports the management, reporting, and treatment effectiveness monitoring. The paper is giving details on the methodological approach while presenting insights on the actual plan and the steps followed for having a patient-centric solution. Key success factors and barriers to mobile health applications that support the need for such an approach are also presented.

State of the practice of health information systems: a survey study amongst health care professionals in intellectual disability care

BACKGROUND

Care for people with an Intellectual Disability (ID) is complex: multiple health care professionals are involved and use different Health Information Systems (HISs) to store medical and daily care information on the same individuals. The objective of this study is to identify the HISs needs of professionals in ID care by addressing the obstacles and challenges they meet in their current HISs.

METHODS

We distributed an online questionnaire amongst Dutch ID care professionals via different professional associations and care providers. 328 respondents answered questions on their HISs. An inventory was made of HIS usage purposes, problems, satisfaction and desired features, with and without stratification on type of HIS and care professional.

RESULTS

Typical in ID care, two types of HISs are being used that differ with respect to their features and users: Electronic Client Dossiers (ECDs) and Electronic Patient Dossiers (EPDs). In total, the respondents mentioned 52 unique HISs. Groups of care professionals differed in their satisfaction with ECDs only. Both HIS types present users with difficulties related to the specifics of care for people with an ID. Particularly the much needed communication between the many unique HISs was reported a major issue which implies major issues with inter-operability. Other problems seem design-related as well.

CONCLUSION

This study can be used to improve current HISs and design new HISs that take ID care professionals requirements into account.

Measuring factors influencing quality of software-as-a-service

Various industrial and business sectors use Software-as-a-Service due to its fast services. However, Software-as-a-Service providers face various challenges in providing high-quality services while simultaneously managing vast multi-tenant infrastructure models and increasingly complex user requirements. To address these problems, we identified those factors that affect the quality of Software-as-a-Service from the perspective of provider–user relationship and investigated how service providers can objectively improve user satisfaction. In a case study, we evaluated the perceived service quality of an information system in the public sector based on user satisfaction with the quality of external outsourcing service in terms of assurance, empathy, responsiveness, reliability, and communication. We identified new sub factors (commitment, skills, effectiveness, change management, business processes, and motivation) and proposed action steps that can guide best practices in ensuring Software-as-a-Service quality. These factors are greatly influenced by the communication between providers and users.

Development and validation of a framework to improve neglected tropical diseases surveillance and response at sub-national levels in Kenya

BACKGROUND

Assessment of surveillance and response system functions focusing on notifiable diseases has widely been documented in literature. However, there is limited focus on diseases targeted for elimination or eradication, particularly preventive chemotherapy neglected tropical diseases (PC-NTDs). There are limited strategies to guide strengthening of surveillance and response system functions concerning PC-NTDs. The aim of this study was to develop and validate a framework to improve surveillance and response to PC-NTDs at the sub-national level in Kenya.

METHODS

A multi-phased approach using descriptive cross-sectional mixed-method designs was adopted. Phase one involved a systematic literature review of surveillance assessment studies to derive generalised recommendations. Phase two utilised primary data surveys to identify disease-specific recommendations to improve PC-NTDs surveillance. The third phase utilised a Delphi survey to assess stakeholders' consensus on feasible recommendations. The fourth phase drew critical lessons from existing conceptual frameworks. The final validated framework was based on resolutions and inputs from concerned stakeholders.

RESULTS

The first phase identified thirty studies that provided a combination of recommendations for improving surveillance functions. Second phase described PC-NTDs specific recommendations linked to simplified case definitions, enhanced laboratory capacity, improved reporting tools, regular feedback and supervision, enhanced training and improved system stability and flexibility. In the third phase, consensus was achieved on feasibility for implementing recommendations. Based on these recommendations, framework components constituted human, technical and organisational inputs, four process categories, ten distinct outputs, outcomes and overall impact encompassing reduced disease burden, halted disease transmission and reduced costs for implementing treatment interventions to achieve PC-NTDs control and elimination.

CONCLUSION

In view of the mixed methodological approach used to develop the framework coupled with further inputs and consensus among concerned stakeholders, the validated framework is relevant for guiding decisions by policy makers to strengthen the existing surveillance and response system functions towards achieving PC-NTDs elimination.

A Human, Organization, and Technology Perspective on Patients' Experiences of a Chat-Based and Automated Medical History-Taking Service in Primary Health Care: Interview Study Among Primary Care Patients

Background

The use of e-visits in health care is progressing rapidly worldwide. To date, studies on the advantages and disadvantages of e-consultations in the form of chat services for all inquiries in primary care have focused on the perspective of health care professionals (HCPs) rather than those of end users (patients).

Objective

This study aims to explore patients’ experiences using a chat-based and automated medical history–taking service in regular, tax-based, not-for-profit primary care in Sweden.

Methods

Overall, 25 individual interviews were conducted with patients in the catchment areas of 5 primary care centers (PCCs) in Sweden that tested a chat-based and automated medical history–taking service for all types of patient inquiries. The semistructured interviews were transcribed verbatim before content analysis using inductive and deductive strategies, the latter including an unconstrained matrix of human, organization, and technology perspectives.

Results

The service provided an easily managed way for patients to make written contact with HCPs, which was considered beneficial for some patients and issues but less suitable for others (acute or more complex cases). The automated medical history–taking service was perceived as having potential but still derived from what HCPs need to know and how they address and communicate health and health care issues. Technical skills were not considered as necessary for a mobile phone chat as for handling a computer; however, patients still expressed concern for people with less digital literacy. The opportunity to take one’s time and reflect on one’s situation before answering questions from the HCPs was found to reduce stress and prevent errors, and patients speculated that it might be the same for the HCPs on the other end of the system. Patients appreciated the ability to have a conversation from almost anywhere, even from places not suitable for telephone calls. The asynchronicity of the chat service allowed the patients to take more control of the conversation and initiate a chat at any time at their own convenience; however, it could also lead to lengthy conversations where a single issue in the worst cases could take days to close. The opportunity to upload photographs made some visits to the PCC redundant, which would otherwise have been necessary if the ordinary telephone service had been used, saving patients both time and money.

Conclusions

Patients generally had a positive attitude toward e-visits in primary care and were generally pleased with the prospects of the digital tool tested, somewhat more with the actual chat than with the automated history-taking system preceding the chat. Although patients expect their PCC to offer a range of different means of communication, the human, organization, and technology analysis revealed a need for more extensive (end) user experience design in the further development of the chat service.

Obstacles and features of health information systems: A systematic literature review

BACKGROUND

Currently many healthcare systems are supported by an increasing set of Health Information Sys-tems (HISs), which assist the activities for multiple stakeholders. The literature on HISs is, however, fragmented and a solid overview of the current state of HISs is missing. This impedes the understanding and characterization of the required HISs for the healthcare domain.

METHODS

In this article, we present the results of a Systematic Literature Review (SLR) that identifies the HISs, their domains, stakeholders, features, and obstacles.

RESULTS

In the SLR, we identified 1340 papers from which we selected 136 studies, on which we performed a full-text analysis. After the synthesis of the data, we were able to report on 33 different domains, 41 stakeholders, 73 features, and 69 obstacles. We discussed how these domains, features, and obstacles interact with each other and presented suggestions to overcome the identified obstacles. We recognized five groups of obstacles: technical problems, operational functionality, maintenance & support, usage problems, and quality problems. Obstacles from all groups require to be solved to pave the way for further research and application of HISs.

CONCLUSION

This study shows that there is a plentitude of HISs with unique features and that there is no consensus on the requirements and types of HISs in the literature.

A theory-based meta-regression of factors influencing clinical decision support adoption and implementation

OBJECTIVE

The purpose of the study was to explore the theoretical underpinnings of effective clinical decision support (CDS) factors using the comparative effectiveness results.

MATERIALS AND METHODS

We leveraged search results from a previous systematic literature review and updated the search to screen articles published from January 2017 to January 2020. We included randomized controlled trials and cluster randomized controlled trials that compared a CDS intervention with and without specific factors. We used random effects meta-regression procedures to analyze clinician behavior for the aggregate effects. The theoretical model was the Unified Theory of Acceptance and Use of Technology (UTAUT) model with motivational control.

RESULTS

Thirty-four studies were included. The meta-regression models identified the importance of effort expectancy (estimated coefficient = -0.162; P = .0003); facilitating conditions (estimated coefficient = 0.094; P = .013); and performance expectancy with motivational control (estimated coefficient = 1.029; P = .022). Each of these factors created a significant impact on clinician behavior. The meta-regression model with the multivariate analysis explained a large amount of the heterogeneity across studies (R2 = 88.32%).

DISCUSSION

Three positive factors were identified: low effort to use, low controllability, and providing more infrastructure and implementation strategies to support the CDS. The multivariate analysis suggests that passive CDS could be effective if users believe the CDS is useful and/or social expectations to use the CDS intervention exist.

CONCLUSIONS

Overall, a modified UTAUT model that includes motivational control is an appropriate model to understand psychological factors associated with CDS effectiveness and to guide CDS design, implementation, and optimization.

The appropriateness of clinical decision support systems alerts in supporting clinical workflows: A systematic review

A CDSS generates a high number of inappropriate alerts that interrupt the clinical workflow. As a result, clinicians silence, disable, or ignore alerts, thereby undermining patient safety. Therefore, the effectiveness and appropriateness of CDSS alerts need to be evaluated. A systematic review was carried out to identify the factors that affect CDSS alert appropriateness in supporting clinical workflow. Seven electronic databases (PubMed, Scopus, ACM, Science Direct, IEEE, Ovid Medline, and Ebscohost) were searched for English language articles published between 1997 and 2018. Seventy six papers met the inclusion criteria, of which 26, 24, 15, and 11 papers are retrospective cohort, qualitative, quantitative, and mixed-method studies, respectively. The review highlights various factors influencing the appropriateness and efficiencies of CDSS alerts. These factors are categorized into technology, human, organization, and process aspects using a combination of approaches, including socio-technical framework, five rights of CDSS, and Lean. Most CDSS alerts were not properly designed based on human factor methods and principles, explaining high alert overrides in clinical practices. The identified factors and recommendations from the review may offer valuable insights into how CDSS alerts can be designed appropriately to support clinical workflow.

Evaluating the appropriateness of clinical decision support alerts: A case study

RATIONALE, AIMS, AND OBJECTIVES

Clinical decision support (CDS) generates excessive alerts that disrupt the workflow of clinicians. Therefore, inefficient clinical processes that contribute to the misfit between CDS alert and workflow must be evaluated. This study evaluates the appropriateness of CDS alerts in supporting clinical workflow from a socio-technical perspective.

METHOD

A qualitative case study evaluation was conducted at a 620-bed public teaching hospital in Malaysia using interview, observation, and document analysis to investigate the features and functions of alert appropriateness and workflow-related issues in cardiological and dermatological settings. The current state map for medication prescribing process was also modelled to identify problems pertinent to CDS alert appropriateness.

RESULTS

The main findings showed that CDS was not well designed to fit into a clinician's workflow due to influencing factors such as technology (usability, alert content, and alert timing), human (training, perception, knowledge, and skills), organizational (rules and regulations, privacy, and security), and processes (documenting patient information, overriding default option, waste, and delay) impeding the use of CDS with its alert function. We illustrated how alert affect workflow in clinical processes using a Lean tool known as value stream mapping. This study also proposes how CDS alerts should be integrated into clinical workflows to optimize their potential to enhance patient safety.

CONCLUSION

The design and implementation of CDS alerts should be aligned with and incorporate socio-technical factors. Process improvement methods such as Lean can be used to enhance the appropriateness of CDS alerts by identifying inefficient clinical processes that impede the fit of these alerts into clinical workflow.