User experiences with different regional health information exchange systems in Finland

Regulation and Use of Health Information Systems in Brazil and Abroad: Integrative Review

There is increasing debate about the importance of using information and communication technologies to strengthen health systems. Information systems are one of the most widespread technologies for this end in different healthcare contexts. The primary objective of this study was to highlight and discuss the main characteristics of the regulation and use of health information systems in Brazil and abroad. As a secondary objective, the main characteristics identified in Brazil were compared with the findings for other countries. A robust search strategy incorporated five electronic databases. The research question was defined using the SPIDER strategy, and thematic content analysis was applied. Fourteen articles composed the final sample, and three analytic categories were identified: "Use in the Context of Health Systems"; "Implications for Health Management"; and "Communication and Interoperability." The regulation and use of health information systems in different countries was directly related to their socioeconomic context. In Latin America and Africa, policy strengthening and implementation possibilities for health management were discussed. In the United States, Europe, and Asia, the discussions on interoperability between different services was emphasized. The complexity of the Brazilian health system leads to similarities in the data analysis with several countries from different regions and with distinct political configurations.

The negative impact of interface design, customizability, inefficiency, malfunctions, and information retrieval on user experience: A national usability survey of ICU clinical information systems in Finland

INTRODUCTION

Clinical information systems (CISs) used in intensive care units (ICU) integrate large amounts of patient data every minute, and from multiple systems and devices. Intensive care requires efficient use of information technology to acquire, synchronize, integrate, and analyze data in order to make quick decisions and implement interventions in a timely manner.

OBJECTIVES

To identify factors affecting poor user experience (UX) of CISs used in ICUs in Finland.

METHODS

Data from national Electronic Health Record (EHR) and user experience survey was undertaken in 2017. Those, who used the ICU CIS on a daily or weekly basis were asked supplementary questions and, therefore, comprise a subset of the responses reported in this article.

RESULTS

On a 4-10 scale (i.e., "Fail" to "Excellent"), the mean 'grade' for the principally used ICU CIS was 6.9 (SD 1.3) points. Of the respondents, 119 (57%) were categorized as having good UX. The factors identified as affecting poor UX of the ICU CISs related to poor interface design (OR 7.8; 95% CIs 12.5-24.1; p = 0.001), insufficient customizability (OR 7.2; 95% CIs 1.7-30.6; p = 0.008), the inefficiency of performing routine tasks (OR 4.3; 95% CIs 1.0-18.2; p = 0.044), malfunctions (OR 3.5; 95% CIs 1.2-9.6; p = 0.019), and difficulties in information retrieval (OR 3.0; 95% CIs 1.0-8.8; p = 0.044). The most commonly reported usability problems with the main EHR system and ICU CISs were also identified.

CONCLUSIONS

Overall satisfaction with the principally used ICU CIS was moderate. However, the overall grades varied significantly. Poor interface design, insufficient customizability, inefficiency, malfunctions, and difficulties in information retrieval all affect poor UX.

Health Information Technology and Doctor Shopping: A Systematic Review

Doctor shopping is the practice of visiting multiple physicians to obtain multiple prescriptions. Health information technology (HIT) allows healthcare providers and patients to leverage records or shared information to improve effective care. Our research objective was to determine how HIT is being leveraged to control for doctor shopping. We analyzed articles that covered a 10-year time period from four databases and reported using preferred reporting items for systematic reviews and meta-analysis (PRISMA). We compared intervention, study design, and bias, in addition to showing intervention interactions with facilitators, barriers, and medical outcomes. From 42 articles published from six countries, we identified seven interventions, five facilitator themes with two individual observations, three barrier themes with six individual observations, and two medical outcome themes with four individual observations. Multiple HIT mechanisms exist to control for doctor shopping. Some are associated with a decrease in overdose mortality, but access is not universal or compulsory, and data sharing is sporadic. Because shoppers travel hundreds of miles in pursuit of prescription drugs, data sharing should be an imperative. Research supports leveraging HIT to control doctor shopping, yet without robust data sharing agreements, the efforts of the system are limited to the efforts of the entity with the least number of barriers to their goal. Shoppers will seek out and exploit that organization that does not require participation or checking of prescription drug monitoring programs (PDMP), and the research shows that they will drive great distances to exploit this weakest link.

An efficient architecture for medical high-resolution images transmission in mobile telemedicine systems

BACKGROUND AND OBJECTIVE

The medical high-resolution image is very important in image processing and computer vision applications, which plays a critical role in image-guided diagnosis, clinical trials, consultation, and case discussion. How to efficiently access medical high-resolution images in mobile telemedicine systems is becoming a big challenge. Therefore, this work proposes an efficient pyramid architecture for optimizing medical high-resolution images transmission and rendering.

METHODS

The proposed architecture consists of three core schemes: (1) unbalance pyramid scheme based on geometric relationship, (2) indexing scheme based on hash table and lattice partitioning and (3) query scheme based on similar matching. Then, we design the responsive service components: generating service, indexing service, and query service. Finally, these services are combined into a prototype system that enables efficient transmission and rendering of medical high-resolution images.

RESULTS

The result shows that the unbalance pyramid scheme can quickly generate the pyramid structure and the corresponding image files. The indexing scheme can create the index structure and the index file in real-time. The query scheme can not only match the best layer to which the image block belongs in real-time, but also can accurately capture the query image block.

CONCLUSIONS

The prototype system based on proposed architecture is fully compliant with the DICOM standard, which can be seamlessly integrated with other existing medical systems or mobile applications, and used in various scenarios such as diagnosis, research, and education.

Enabling Laboratory Medicine in Primary Care Through IT Systems Use

Important problems remain regarding the efficiency and quality of laboratory testing in primary care. In view of this, a significant function of electronic medical record (EMR) systems is to enable the practice of laboratory medicine by primary care physicians. The present study aims to deepen our understanding of the nature and extent of physicians' use of EMR and other laboratory information exchange systems for patient management and care within the laboratory testing process. We conducted a survey of 684 Canadian family physicians. Results indicate that physicians use 84 percent of the laboratory functionalities available in their EMR system. The two most important impacts are the ability to gain time in the post-analytical phase and to take faster action in this same phase as they follow-up on their patients' test results. Physicians who perceive to benefit most from their EMR use are those who make the most extensive use of their system. Extended use of an EMR system allows primary care physicians to better ascertain and monitor the health status of their patients, verify their diagnosis assumptions, and, if their system includes a clinical decision support module, apply evidence-based practices in laboratory medicine.

MedChain: Efficient Healthcare Data Sharing via Blockchain

Healthcare information exchange is an important research topic, which can benefit both healthcare providers and patients. In healthcare data sharing, many cloud-based solutions have been proposed, but the trustworthiness of a third-party cloud service is questionable. Recently, blockchain has been introduced in healthcare record sharing, which does not rely on trusting a third party. However, existing approaches only focus on the records collected from medical examination. They are not efficient in sharing data streams continuously generated from sensors and other monitoring devices. Today, IoT devices have been widely deployed and sensors and mobile applications can monitor patients’ body conditions. The collected data are shared to laboratories and institutions for diagnosis and further study. Moreover, existing approaches are too rigid to efficiently support metadata change. In this paper, an efficient data-sharing scheme is proposed, called MedChain, which combines blockchain, digest chain, and structured P2P network techniques to overcome the above efficiency issues in the existing approaches for sharing both types of healthcare data. Based on MedChain, a session-based healthcare data-sharing scheme is devised, which brings flexibility in data sharing. The evaluation results show that MedChain can achieve higher efficiency and satisfy the security requirements in data sharing.

Health information exchange in Finland: Usage of different access types and predictors of paper use

INTRODUCTION

Timely, complete and accurate patient data is needed in care decisions along the continuum of care. To access patient data from other organizations, there are three types of regional health information exchange systems (RHIS) in use In Finland. Some regions use multiple RHISs while others do not have a RHIS available. The recently introduced National Patient Data Repository (Kanta) is increasingly used for health information exchange (HIE).

OBJECTIVES

The purpose of this study was to assess usage of paper, RHISs and Kanta by context in 2017; evolution of paper use over the years; and predictors of paper use in 2017 among Finnish physicians for HIE system development.

METHODS

Data from national electronic health record (EHR) usage and user experience surveys were taken from 2010 (prior to ePrescription system implementation), 2014 (prior to implementation of Kanta) and 2017 (Kanta was in full use in the public sector and in large private organizations). The web-based surveys were targeted to all physicians engaged in clinical work in Finland.

RESULTS

Kanta was the most frequently used means of HIE in 2017. Paper use had reduced significantly from 2010 to 2014. The trend continued in 2017. Still, up to half of the physicians reported using paper daily or weekly in 2017. There were great variations in paper use by healthcare sector, available RHIS type and EHR system used. In multivariable analysis (with all other variables constant), predictors of more frequent use of paper than electronic means for HIE were: private sector or hospital, access to Master Patient Index RHIS (type 1), multiple RHIS (type 4) or no RHIS (type 5), two particular EHR systems, older age, less experience, operative, psychiatric or diagnostic specialties, and male gender.

CONCLUSIONS

Usability of HIE systems including EHRs as access points to HIE need to be improved to facilitate usage of electronic HIE. Usage ensures more timely and complete patient data for safe, coordinated care. Specialty-specific needs and requirements call for more user participation in HIE design. Especially older professionals need training to better exploit HIS for HIE.

Improving performance in the ED through laboratory information exchange systems

Background

The accessibility of laboratory test results is crucial to the performance of emergency departments and to the safety of patients. This study aims to develop a better understanding of which laboratory information exchange (LIE) systems emergency care physicians (ECPs) are using to consult their patients’ laboratory test results and which benefits they derive from such use.

Methods

A survey of 163 (36%) ECPs in Quebec was conducted in collaboration with the Quebec’s Department of Health and Social Services. Descriptive statistics, chi-square tests, cluster analyses, and ANOVAs were conducted.

Results

The great majority of respondents indicated that they use several LIE systems including interoperable electronic health record (iEHR) systems, laboratory results viewers (LRVs), and emergency department information systems (EDIS) to consult their patients’ laboratory results. Three distinct profiles of LIE users were observed. The extent of LIE usage was found to be primarily determined by the functional design differences between LIE systems available in the EDs. Our findings also indicate that the more widespread LIE usage, the higher the perceived benefits. More specifically, physicians who make extensive use of iEHR systems and LRVs obtain the widest range of benefits in terms of efficiency, quality, and safety of emergency care.

Conclusions

Extensive use of LIE systems allows ECPs to better determine and monitor the health status of their patients, verify their diagnostic assumptions, and apply evidence-based practices in laboratory medicine. But for such benefits to be possible, ECPs must be provided with LIE systems that produce accurate, up-to-date, complete, and easy-to-interpret information.

Information and knowledge processes as a knowledge management framework in health care

Purpose

Effective knowledge management (KM) enables the health care organisations to reach their goals. In modern health care the empowered patients are active partners, whose preferences, needs and values should be taken into account. Shared decision making (SDM) aims at involving the patient and the health professionals as equal partners in care. The purpose of this paper is to present a new model of health care information and knowledge processes (IKPs) as a KM framework. The aim is to scrutinise what types of knowing can be identified the IKPs and how do the knowledge processes support SDM. The role of patients in the IKPs is discussed.

Design/methodology/approach

The qualitative case study was conducted in two Finnish university hospital districts in integrated care pathways of childhood obesity. In total, 30 professionals and three mothers and children were interviewed 2009-2011 and the findings were supported with a survey (n=13) and document material.

Findings

The findings indicate that the patients and families involvement in the IKPs is modest. This implies that SDM is not completely fulfilled which may affect the families commitment to positive lifestyle changes.

Research limitations/implications

The data of the patients and families were limited due to the challenges with recruitment.

Practical implications

The detailed IKP model enables the health organisations to scrutinise their own IKPs and to identify the shortages in order to change practices.

Originality/value

This paper presents a new model of health care KM which recognises the patients as active partners.

Enabling Health Reform through Regional Health Information Exchange: A Model Study from China

Objective. To investigate and share the major challenges and experiences of building a regional health information exchange system in China in the context of health reform. Methods. This study used interviews, focus groups, a field study, and a literature review to collect insights and analyze data. The study examined Xinjin's approach to developing and implementing a health information exchange project, using exchange usage data for analysis. Results. Within three years and after spending approximately $2.4 million (15 million RMB), Xinjin County was able to build a complete, unified, and shared information system and many electronic health record components to integrate and manage health resources for 198 health institutions in its jurisdiction, thus becoming a model of regional health information exchange for facilitating health reform. Discussion. Costs, benefits, experiences, and lessons were discussed, and the unique characteristics of the Xinjin case and a comparison with US cases were analyzed. Conclusion. The Xinjin regional health information exchange system is different from most of the others due to its government-led, government-financed approach. Centralized and coordinated efforts played an important role in its operation. Regional health information exchange systems have been proven critical for meeting the global challenges of health reform.

International health IT benchmarking: learning from cross-country comparisons

OBJECTIVE

To pilot benchmark measures of health information and communication technology (ICT) availability and use to facilitate cross-country learning.

MATERIALS AND METHODS

A prior Organization for Economic Cooperation and Development-led effort involving 30 countries selected and defined functionality-based measures for availability and use of electronic health records, health information exchange, personal health records, and telehealth. In this pilot, an Organization for Economic Cooperation and Development Working Group compiled results for 38 countries for a subset of measures with broad coverage using new and/or adapted country-specific or multinational surveys and other sources from 2012 to 2015. We also synthesized country learnings to inform future benchmarking.

RESULTS

While electronic records are widely used to store and manage patient information at the point of care-all but 2 pilot countries reported use by at least half of primary care physicians; many had rates above 75%-patient information exchange across organizations/settings is less common. Large variations in the availability and use of telehealth and personal health records also exist.

DISCUSSION

Pilot participation demonstrated interest in cross-national benchmarking. Using the most comparable measures available to date, it showed substantial diversity in health ICT availability and use in all domains. The project also identified methodological considerations (e.g., structural and health systems issues that can affect measurement) important for future comparisons.

CONCLUSION

While health policies and priorities differ, many nations aim to increase access, quality, and/or efficiency of care through effective ICT use. By identifying variations and describing key contextual factors, benchmarking offers the potential to facilitate cross-national learning and accelerate the progress of individual countries.

Integrated precision medicine: the role of electronic health records in delivering personalized treatment

Precision Medicine involves the delivery of a targeted, personalized treatment for a given patient. By harnessing the power of electronic health records (EHRs), we are increasingly able to practice precision medicine to improve patient outcomes. In this article, we introduce the scientific community at large to important building blocks for personalized treatment, such as terminology standards that are the foundation of the EHR and allow for exchange of health information across systems. We briefly review different types of clinical decision support (CDS) and present the current state of CDS, which is already improving the care patients receive with genetic profile-based tailored recommendations regarding diagnostic and treatment plans. We also report on limitations of current systems, which are slowly beginning to integrate new genomic data into patient records but still present many challenges. Finally, we discuss future directions and how the EHR can evolve to increase the capacity of the healthcare system in delivering Precision Medicine at the point of care. WIREs Syst Biol Med 2017, 9:e1378. doi: 10.1002/wsbm.1378 For further resources related to this article, please visit the WIREs website.

An appraisal of published usability evaluations of electronic health records via systematic review

OBJECTIVE

In this systematic review, we aimed to evaluate methodological and reporting trends present in the current literature by investigating published usability studies of electronic health records (EHRs).

METHODS

A literature search was conducted for articles published through January 2015 using MEDLINE (Ovid), EMBASE, Scopus, and Web of Science, supplemented by citation and reference list reviews. Studies were included if they tested the usability of hospital and clinic EHR systems in the inpatient, outpatient, emergency department, or operating room setting.

RESULTS

A total of 4848 references were identified for title and abstract screening. Full text screening was performed for 197 articles, with 120 meeting the criteria for study inclusion.

CONCLUSION

A review of the literature demonstrates a paucity of quality published studies describing scientifically valid and reproducible usability evaluations at various stages of EHR system development. A lack of formal and standardized reporting of EHR usability evaluation results is a major contributor to this knowledge gap, and efforts to improve this deficiency will be one step of moving the field of usability engineering forward.

Usability problems do not heal by themselves: National survey on physicians' experiences with EHRs in Finland

PURPOSE

Survey studies of health information systems use tend to focus on availability of functionalities, adoption and intensity of use. Usability surveys have not been systematically conducted by any healthcare professional groups on a national scale on a repeated basis. This paper presents results from two cross-sectional surveys of physicians' experiences with the usability of currently used EHR systems in Finland. The research questions were: To what extent has the overall situation improved between 2010 and 2014? What differences are there between healthcare sectors?

METHODS

In the spring of 2014, a survey was conducted in Finland using a questionnaire that measures usability and respondents' user experiences with electronic health record (EHR) systems. The survey was targeted to physicians who were actively doing clinical work. Twenty-four usability-related statements, that were identical in 2010 and 2014, were analysed from the survey. The respondents were also asked to give an overall rating of the EHR system they used. The study data comprised responses from 3081 physicians from the year 2014 and from 3223 physicians in the year 2010, who were using the nine most commonly used EHR system brands in Finland.

RESULTS

Physicians' assessments of the usability of their EHR system remain as critical as they were in 2010. On a scale from 1 ('fail') to 7 ('excellent') the average of overall ratings of their principally used EHR systems varied from 3.2 to 4.4 in 2014 (and in 2010 from 2.5 to 4.3). The results show some improvements in the following EHR functionalities and characteristics: summary view of patient's health status, prevention of errors associated with medication ordering, patient's medication list as well as support for collaboration and information exchange between the physician and the nurses. Even so, support for cross-organizational collaboration between physicians and for physician-patient collaboration were still considered inadequate. Satisfaction with technical features had not improved in four years. The results show marked differences between the EHR system brands as well as between healthcare sectors (private sector, public hospitals, primary healthcare). Compared to responses from the public sector, physicians working in the private sector were more satisfied with their EHR systems with regards to statements about user interface characteristics and support for routine tasks. Overall, the study findings are similar to our previous study conducted in 2010.

CONCLUSIONS

Surveys about the usability of EHR systems are needed to monitor their development at regional and national levels. To our knowledge, this study is the first national eHealth observatory questionnaire that focuses on usability and is used to monitor the long-term development of EHRs. The results do not show notable improvements in physician's ratings for their EHRs between the years 2010 and 2014 in Finland. Instead, the results indicate the existence of serious problems and deficiencies which considerably hinder the efficiency of EHR use and physician's routine work. The survey results call for considerable amount of development work in order to achieve the expected benefits of EHR systems and to avoid technology-induced errors which may endanger patient safety. The findings of repeated surveys can be used to inform healthcare providers, decision makers and politicians about the current state of EHR usability and differences between brands as well as for improvements of EHR usability. This survey will be repeated in 2017 and there is a plan to include other healthcare professional groups in future surveys.

Health Information Exchange (HIE): A literature review, assimilation pattern and a proposed classification for a new policy approach

OBJECTIVES

Literature shows existence of barriers to Healthcare Information Exchange (HIE) assimilation process. A number of studies have considered assimilation of HIE as a whole phenomenon without regard to its multifaceted nature. Thus, the pattern of HIE assimilation in healthcare providers has not been clearly studied due to the effects of contingency factors on different assimilation phases. This study is aimed at defining HIE assimilation phases, recognizing assimilation pattern, and proposing a classification to highlight unique issues associated with HIE assimilation.

METHODS

A literature review of existing studies related to HIE efforts from 2005 was undertaken. Four electronic research databases (PubMed, Web of Science, CINAHL, and Academic Search Premiere) were searched for articles addressing different phases of HIE assimilation process.

RESULTS

Two hundred and fifty-four articles were initially selected. Out of 254, 44 studies met the inclusion criteria and were reviewed. The assimilation of HIE is a complicated and a multi-staged process. Our findings indicated that HIE assimilation process consisted of four main phases: initiation, organizational adoption decision, implementation and institutionalization. The data helped us recognize the assimilation pattern of HIE in healthcare organizations.

CONCLUSIONS

The results provide useful theoretical implications for research by defining HIE assimilation pattern. The findings of the study also have practical implications for policy makers. The findings show the importance of raising national awareness of HIE potential benefits, financial incentive programs, use of standard guidelines, implementation of certified technology, technical assistance, training programs and trust between healthcare providers. The study highlights deficiencies in the current policy using the literature and identifies the "pattern" as an indication for a new policy approach.

Clinical malaria diagnosis: rule-based classification statistical prototype

In this study, we identified predictors of malaria, developed data mining, statistically enhanced rule-based classification to diagnose malaria and developed an automated system to incorporate the rules and statistical models. The aim of the study was to develop a statistical prototype to perform clinical diagnosis of malaria given its adverse effects on the overall healthcare, yet its treatment remains very expensive for the majority of the patients to afford. Model validation was performed using records from two hospitals (training and predictive datasets) to evaluate system sensitivity, specificity and accuracy. The overall sensitivity of the rule-based classification obtained from the predictive dataset was 70 % [68–74; 95 % CI] with a specificity of 58 % [54–66; 95 % CI]. The values for both sensitivity and specificity varied by age, generally showing better performance for the data mining classification rules for the adult patients. In summary, the proposed system of data mining classification rules provides better performance for persons aged at least 18 years. However, with further modelling, this system of classification rules can provide better sensitivity, specificity and accuracy levels. In conclusion, using the system provides a preliminary test before confirmatory diagnosis is conducted in laboratories.

The Role of Clinical Virology Laboratory and the Clinical Virology Laboratorian in Ensuring Effective Surveillance for Influenza and Other Respiratory Viruses: Points to Consider and Pitfalls to Avoid

Influenza and respiratory viruses have a global impact on public health. Clinical virology laboratories and laboratorians play an important role in not only the diagnosis but also the surveillance of these pathogens. Surveillance for influenza and other respiratory pathogens is important, as it informs public health decision making in terms of influenza vaccine and antiviral effectiveness, informs clinicians and public health practitioners about the pathogenicity of specific viral strains, guides clinical practice, and supports laboratory panning activities. Key background issues include the following: the fact that the laboratory is only one of several data providers to a surveillance system, the biologic nature of influenza and respiratory viruses and the laboratory needs to keep up to date on the diagnosis of these agents, the need for laboratorians to be involved in case definition development, the impact of push and pull data flow models on laboratory resources, and the fact that laboratories may be asked to provide more than just test results to surveillance programs. This review also identifies some key issues or questions that arise during the pre-analytic, analytic, and post-analytic phases that could impact on the ability of the laboratory to link to surveillance programs. Finally, issues surrounding virus characterization programs and how they link to surveillance programs are identified and discussed.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

Barriers and facilitators to exchanging health information: a systematic review

OBJECTIVES

We conducted a systematic review of studies assessing facilitators and barriers to use of health information exchange (HIE).

METHODS

We searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Library databases between January 1990 and February 2015 using terms related to HIE. English-language studies that identified barriers and facilitators of actual HIE were included. Data on study design, risk of bias, setting, geographic location, characteristics of the HIE, perceived barriers and facilitators to use were extracted and confirmed.

RESULTS

Ten cross-sectional, seven multiple-site case studies, and two before-after studies that included data from several sources (surveys, interviews, focus groups, and observations of users) evaluated perceived barriers and facilitators to HIE use. The most commonly cited barriers to HIE use were incomplete information, inefficient workflow, and reports that the exchanged information that did not meet the needs of users. The review identified several facilitators to use.

DISCUSSION

Incomplete patient information was consistently mentioned in the studies conducted in the US but not mentioned in the few studies conducted outside of the US that take a collective approach toward healthcare. Individual patients and practices in the US may exercise the right to participate (or not) in HIE which effects the completeness of patient information available to be exchanged. Workflow structure and user roles are key but understudied.

CONCLUSIONS

We identified several facilitators in the studies that showed promise in promoting electronic health data exchange: obtaining more complete patient information; thoughtful workflow that folds in HIE; and inclusion of users early in implementation.

Health information exchange and information gaps in referrals to a pediatric emergency department

OBJECTIVE

to assess the extent of information gaps between three information sources available at admission to a pediatric Emergency Department (ED): Health Information Exchange (HIE) system, physicians' referral letters and information collected from patients/parents at admission to the ED (patient's medical history).

MATERIALS AND METHODS

A retrospective cohort study of 170 medical records of children aged 6 months to 18 years referred to a pediatric ED for a common childhood disease. Each record was reviewed for information on lab and imaging tests, vaccinations, allergies, previous diagnoses, recent and chronic medical treatment in the HIE system and referral letter, or from the patient's medical history taken on admission to the ED. The percent overlap between information sources and information gaps was assessed.

RESULTS

The most informative source, in terms of addressing all key areas, was the patient's medical history, with an average of 73.5% indication of each information key area. Next was the HIE system, with 54.1% indication of each key area; the least informative was the referral letter (43.9%). The overall overlap in data availability among all information sources occurred on average in 23% of the cases. HIE's ability to provide data missing from other routinely available sources was mainly in the area of chronic medication dosages (37% of cases).

CONCLUSIONS

Each of the three major information sources available at admission to a pediatric ED lack important data and each makes its own unique contribution. Improving documentation in electronic health records, on which HIE systems feed from can narrow significant information gaps at the most critical time-point-admission to a pediatric ED.

Medical high-resolution image sharing and electronic whiteboard system: A pure-web-based system for accessing and discussing lossless original images in telemedicine

There are various medical image sharing and electronic whiteboard systems available for diagnosis and discussion purposes. However, most of these systems ask clients to install special software tools or web plug-ins to support whiteboard discussion, special medical image format, and customized decoding algorithm of data transmission of HRIs (high-resolution images). This limits the accessibility of the software running on different devices and operating systems. In this paper, we propose a solution based on pure web pages for medical HRIs lossless sharing and e-whiteboard discussion, and have set up a medical HRI sharing and e-whiteboard system, which has four-layered design: (1) HRIs access layer: we improved an tile-pyramid model named unbalanced ratio pyramid structure (URPS), to rapidly share lossless HRIs and to adapt to the reading habits of users; (2) format conversion layer: we designed a format conversion engine (FCE) on server side to real time convert and cache DICOM tiles which clients requesting with window-level parameters, to make browsers compatible and keep response efficiency to server-client; (3) business logic layer: we built a XML behavior relationship storage structure to store and share users' behavior, to keep real time co-browsing and discussion between clients; (4) web-user-interface layer: AJAX technology and Raphael toolkit were used to combine HTML and JavaScript to build client RIA (rich Internet application), to meet clients' desktop-like interaction on any pure webpage. This system can be used to quickly browse lossless HRIs, and support discussing and co-browsing smoothly on any web browser in a diversified network environment. The proposal methods can provide a way to share HRIs safely, and may be used in the field of regional health, telemedicine and remote education at a low cost.

Challenges to the implementation of a nationwide electronic prescribing network in primary care: a qualitative study of users' perceptions

BACKGROUND AND OBJECTIVE

The objective of this study was to identify physicians' and pharmacists' perceptions of the challenges and benefits to implementing a nationwide electronic prescribing network linking medical clinics and community pharmacies in Quebec, Canada.

METHODS

Forty-nine people (12 general practitioners, 2 managers, 33 community pharmacists, and 2 pharmacy staff members) from 40 points of care (10 primary care clinics (42% of all the connected sites) and 30 community pharmacies (44%)) were interviewed in 2013. Verbatim transcripts were analyzed using thematic analysis.

RESULTS

A low level of network use was observed. Most pharmacists processed e-prescriptions by manual entry instead of importing electronically. They reported concerns about potential errors generated by importing e-prescriptions, mainly due to the instruction field. Paper prescriptions were still perceived as the best means for safe and effective processing of prescriptions in pharmacies. Speed issues when validating e-prescription messages were seen as an irritant by physicians, and resulted in several of them abandoning transmission. Displaying the medications based on the dispensing data was identified as the main obstacle to meaningful use of medication histories.

CONCLUSIONS

Numerous challenges impeded realization of the benefits of this network. Standards for e-prescription messages, as well as rules for message validation, need to be improved to increase the potential benefits of e-prescriptions. Standard drug terminology including the concept of clinical medication should be developed, and the implementation of rules in local applications to allow for the classification and reconciliation of medication lists from dispensing data should be made a priority.

Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments

Recently, the healthcare sector has shown a growing interest in information technologies. Two popular health IT (HIT) products are the electronic health record (EHR) and health information exchange (HIE) networks. The introduction of these tools is believed to improve care, but has also raised some important questions and legal and privacy issues. The implementation of these systems has not gone smoothly, and still faces some considerable barriers. This article reviews EHR and HIE to address these obstacles, and analyzes the current state of development and adoption in various countries around the world. Moreover, legal and ethical concerns that may be encountered by EHR users and purchasers are reviewed. Finally, links and interrelations between EHR and HIE and several quality of care issues in today's healthcare domain are examined with a focus on EHR and HIE in the emergency department (ED), whose unique characteristics makes it an environment in which the implementation of such technology may be a major contributor to health, but also faces substantial challenges. The paper ends with a discussion of specific policy implications and recommendations based on an examination of the current limitations of these systems.

How could health information exchange better meet the needs of care practitioners?

BACKGROUND

Health information exchange (HIE) has the potential to improve the quality of healthcare by enabling providers with better access to patient information from multiple sources at the point of care. However, HIE efforts have historically been difficult to establish in the US and the failure rates of organizations created to foster HIE have been high.

OBJECTIVES

We sought to better understand how RHIO-based HIE systems were used in practice and the challenges care practitioners face using them. The objective of our study were to so investigate how HIE can better meet the needs of care practitioners.

METHODS

We performed a multiple-case study using qualitative methods in three communities in New York State. We conducted interviews onsite and by telephone with HIE users and non-users and observed the workflows of healthcare professionals at multiple healthcare organizations participating in a local HIE effort in New York State.

RESULTS

The empirical data analysis suggests that challenges still remain in increasing provider usage, optimizing HIE implementations and connecting HIE systems across geographic regions. Important determinants of system usage and perceived value includes users experienced level of available information and the fit of use for physician workflows.

CONCLUSIONS

Challenges still remain in increasing provider adoption, optimizing HIE implementations, and demonstrating value. The inability to find information reduced usage of HIE. Healthcare organizations, HIE facilitating organizations, and states can help support HIE adoption by ensuring patient information is accessible to providers through increasing patient consents, fostering broader participation, and by ensuring systems are usable.