Learning to work with electronic patient records and prescription charts: experiences and perceptions of hospital pharmacists

The Impact of Digital Hospitals on Patient and Clinician Experience: Systematic Review and Qualitative Evidence Synthesis

BACKGROUND

The digital transformation of health care is advancing rapidly. A well-accepted framework for health care improvement is the Quadruple Aim: improved clinician experience, improved patient experience, improved population health, and reduced health care costs. Hospitals are attempting to improve care by using digital technologies, but the effectiveness of these technologies is often only measured against cost and quality indicators, and less is known about the clinician and patient experience.

OBJECTIVE

This study aims to conduct a systematic review and qualitative evidence synthesis to assess the clinician and patient experience of digital hospitals.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and ENTREQ (Enhancing the Transparency in Reporting the Synthesis of Qualitative Research) guidelines were followed. The PubMed, Embase, Scopus, CINAHL, and PsycINFO databases were searched from January 2010 to June 2022. Studies that explored multidisciplinary clinician or adult inpatient experiences of digital hospitals (with a full electronic medical record) were included. Study quality was assessed using the Mixed Methods Appraisal Tool. Data synthesis was performed narratively for quantitative studies. Qualitative evidence synthesis was performed via (1) automated machine learning text analytics using Leximancer (Leximancer Pty Ltd) and (2) researcher-led inductive synthesis to generate themes.

RESULTS

A total of 61 studies (n=39, 64% quantitative; n=15, 25% qualitative; and n=7, 11% mixed methods) were included. Most studies (55/61, 90%) investigated clinician experiences, whereas few (10/61, 16%) investigated patient experiences. The study populations ranged from 8 to 3610 clinicians, 11 to 34,425 patients, and 5 to 2836 hospitals. Quantitative outcomes indicated that clinicians had a positive overall satisfaction (17/24, 71% of the studies) with digital hospitals, and most studies (11/19, 58%) reported a positive sentiment toward usability. Data accessibility was reported positively, whereas adaptation, clinician-patient interaction, and workload burnout were reported negatively. The effects of digital hospitals on patient safety and clinicians' ability to deliver patient care were mixed. The qualitative evidence synthesis of clinician experience studies (18/61, 30%) generated 7 themes: inefficient digital documentation, inconsistent data quality, disruptions to conventional health care relationships, acceptance, safety versus risk, reliance on hybrid (digital and paper) workflows, and patient data privacy. There was weak evidence of a positive association between digital hospitals and patient satisfaction scores.

CONCLUSIONS

Clinicians' experience of digital hospitals appears positive according to high-level indicators (eg, overall satisfaction and data accessibility), but the qualitative evidence synthesis revealed substantive tensions. There is insufficient evidence to draw a definitive conclusion on the patient experience within digital hospitals, but indications appear positive or agnostic. Future research must prioritize equitable investigation and definition of the digital clinician and patient experience to achieve the Quadruple Aim of health care.

Ensuring quality qualitative research reporting in community pharmacy: a systematic literature review

OBJECTIVES

To evaluate the reporting quality for a sample of community pharmacy qualitative research articles based on the Standards for Reporting Qualitative Research (SRQR) guidelines, data interpretation and use of theory.

METHODS

A systematic literature search was conducted using Ovid MEDLINE to identify qualitative research related to community pharmacy. Data were extracted and evaluated based on the SRQR standards, data interpretation level and use of theory. Adherence to standards was analysed using descriptive statistics.

KEY FINDINGS

Eighty-one studies were retrieved through the database search (n = 81). Then, 31 studies met the inclusion criteria after screening abstracts and full texts. Twelve out of 21 SRQR were present in more than 80% of the studies. However, essential standards, such as research approach, reflexivity and trustworthiness techniques, were absent or partially present in 30 (97%) studies, 30 (97%) studies and 21 (68%) studies, respectively. Data interpretation level was descriptive in 27 (87%) studies and interpretive or partially interpretive in 4 (13%) studies. Theory was absent in 19 (60%) and implied, partially integrated or retrospectively applied in 12 (40%) of the studies.

CONCLUSION

Trustworthiness and quality of qualitative inferences within community pharmacy research could be enhanced with increasing awareness about reporting; the approach and paradigm, reflexivity, trustworthiness techniques, data interpretation level and theoretical use.

Patient prioritisation for hospital pharmacy services: current approaches in the UK

OBJECTIVES

To survey and explore current approaches to deployment of pharmaceutical care prioritisation tools in acute hospitals in the UK.

METHODS

A national online survey was circulated electronically to chief pharmacists of hospitals to determine if they use a prioritisation tool or process. Where such mechanisms exist, respondents were invited to participate in a semistructured telephone interview to explore the development, evaluation and application of their tool and share relevant documentation. Interviews were transcribed and thematically analysed.

RESULTS

Seventy hospitals (70/130) used a tool or process to prioritise clinical pharmacy services. Thirty-six interviews were conducted, and two were excluded. The majority of tools had been developed in-house. Few hospitals had undertaken formal evaluations of their prioritisation tool. Pharmacy prioritisation tools ranged in complexity and often included a combination of pharmacy service prioritisation, such as medicines reconciliation, and a section to assign an individual patient prioritisation level. Determining the priority of a patient based on the identification of set indicators instilled confidence in pharmacists by ensuring they were not missing high-risk patients. Electronic prioritisation tools were especially useful at retrieving real-time data to prioritise workload, improving workflow and ensuring continuity in patient care. Drawbacks of using prioritisation tools included lack of tool sensitivity across certain specialties and time spent using the tool if not all information was accessible.

CONCLUSIONS

Prioritisation tools were seen to be useful for prioritising workload and ensuring the right patients are seen at the right time. As few hospitals had formally evaluated their tools, it is important to rigorously and systematically develop an evidence-based prioritisation tool that is both useable and acceptable. Further research to evaluate such tools would be needed to ensure it improves patient health outcomes and efficiency in pharmacy services.

The impact of electronic prescribing systems on healthcare professionals' working practices in the hospital setting: a systematic review and narrative synthesis

Background

The aim of this systematic review was to synthesise peer-reviewed literature assessing the impact of electronic prescribing (eP) systems on the working practices of healthcare professionals (HCPs) in the inpatient setting and identify implications for practice and research.

Methods

We searched PubMed, Medline, Embase, Cochrane and the Cumulative Index to Nursing Allied Health Literature databases for studies published from inception to November 2018. We included controlled, uncontrolled, observational and descriptive studies that explored the effect of eP on HCPs’ working practices in an inpatient setting. Data on setting, eP system and impact on working practices were extracted. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Emergent themes were identified and subjected to narrative synthesis. The protocol was registered with PROSPERO (registration CRD42017075804).

Results

Searches identified 1301 titles and abstracts after duplicate removal. 171 papers underwent full-text review. A total of 25 studies met the inclusion criteria, from nine different countries. Nineteen were of commercial eP systems. There were a range of study designs; most (n = 14) adopted quantitative methods such as cross-sectional surveys, ten adopted qualitative approaches and a further one used mixed methods. Fourteen of the 25 studies were deemed to be of high quality. Four key themes were identified: communication, time taken to complete tasks, clinical workflow, and workarounds. Within each theme, study findings differed as to whether the effects of eP on HCPs’ working practices were positive or negative.

Conclusion

There is a lack of consensus within the literature on the impact of eP on HCPs’ working practices. Future research should explore the strategies resulting in a positive impact on HCPs’ working practices and learn from those that have not been successful.

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background

Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research.

Methods

We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically.

Results

79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact.

Conclusions

Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation.

The impact of implementing a hospital electronic prescribing and administration system on clinical pharmacists' activities - a mixed methods study

Background

The increasing adoption of hospital electronic prescribing and medication administration (ePA) systems has driven a wealth of research around the impact on patient safety. Yet relatively little research has sought to understand the effects on staff, particularly pharmacists. We aimed to investigate the effects of ePA on pharmacists’ activities, including interactions with patients and health professionals, and their perceptions of medication safety risks.

Methods

A mixed methods study comprising quantitative direct observations of ward pharmacists before and after implementation of ePA in an English hospital, and semi-structured interviews post-ePA. Quantitative data comprised multi-dimensional work activity sampling to establish the proportion of time ward pharmacists spent on different tasks, with whom and where. These data were extrapolated to estimate task duration. Qualitative interviews with pharmacists explored perceived impact on (i) ward activities, (ii) interactions with patients and different health professionals, (iii) locations where tasks were carried out, and (iv) medication errors.

Results

Observations totalled 116 h and 50 min. Task duration analysis suggested screening inpatient medication increased by 16 mins per 10 patients reviewed (p = 0.002), and searching for paper drug charts or computer decreased by 2 mins per 10 patients reviewed (p = 0.001). Pharmacists mainly worked alone (58% of time pre- and 65% post-ePA, p = 0.17), with patient interactions reducing from 5 to 2% of time (p = 0.03). Seven main themes were identified from the interviews, underpinned by a core explanatory concept around the enhanced and shifting role of the ward pharmacist post-ePA. Pharmacists perceived there to be a number of valuable safety features with ePA. However, paradoxically, some of these may have also inadvertently contributed to medication errors.

Conclusion

This study provides quantitative and qualitative insights into the effects of implementing ePA on ward pharmacists’ activities. Some tasks took longer while others reduced, and pharmacists may spend less time with patients with ePA. Pharmacists valued a number of safety features associated with ePA but also perceived an overall increase in medication risk. Pharmacy staff demonstrated a degree of resilience to ensure ‘business as usual’ by enhancing and adapting their role.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3986-4) contains supplementary material, which is available to authorized users.

Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care

INTRODUCTION

Developments in information technology offer opportunities to enhance medication safety in primary care. We evaluated the implementation and adoption of a complex pharmacist-led intervention involving the use of an electronic audit and feedback surveillance dashboard to identify patients potentially at risk of hazardous prescribing or monitoring of medicines in general practices. The intervention aimed to create a rapid learning health system for medication safety in primary care. This study aimed to explore how the intervention was implemented, adopted and embedded into practice using a qualitative process evaluation.

METHODS

Twenty two participants were purposively recruited from eighteen out of forty-three general practices receiving the intervention as well as clinical commissioning group staff across Salford UK, which reflected the range of contexts in which the intervention was implemented. Interviews explored how pharmacists and GP staff implemented the intervention and how this affected care practice. Data analysis was thematic with emerging themes developed into coding frameworks based on Normalisation Process Theory (NPT).

RESULTS

Engagement with the dashboard involved a process of sense-making in which pharmacists considered it added value to their work. The intervention helped to build respect, improve trust and develop relationships between pharmacists and GPs. Collaboration and communication between pharmacists and clinicians was primarily initiated by pharmacists and was important for establishing the intervention. The intervention operated as a rapid learning health system as it allowed for the evidence in the dashboard to be translated into changes in work practices and into transformations in care.

CONCLUSIONS

Our study highlighted the importance of the combined use of information technology and the role of pharmacists working in general practice settings. Medicine optimisation activities in primary care may be enhanced by the implementation of a pharmacist-led electronic audit and feedback system. This intervention established a rapid learning health system that swiftly translated data from electronic health records into changes in practice to improve patient care. Using NPT provided valuable insights into the ways in which developing relationships, collaborations and communication between health professionals could lead to the implementation, adoption and sustainability of the intervention.

Understanding the implementation and adoption of an information technology intervention to support medicine optimisation in primary care: qualitative study using strong structuration theory

OBJECTIVES

Using strong structuration theory, we aimed to understand the adoption and implementation of an electronic clinical audit and feedback tool to support medicine optimisation for patients in primary care.

DESIGN

This is a qualitative study informed by strong structuration theory. The analysis was thematic, using a template approach. An a priori set of thematic codes, based on strong structuration theory, was developed from the literature and applied to the transcripts. The coding template was then modified through successive readings of the data.

SETTING

Clinical commissioning group in the south of England.

PARTICIPANTS

Four focus groups and five semi-structured interviews were conducted with 18 participants purposively sampled from a range of stakeholder groups (general practitioners, pharmacists, patients and commissioners).

RESULTS

Using the system could lead to improved medication safety, but use was determined by broad institutional contexts; by the perceptions, dispositions and skills of users; and by the structures embedded within the technology. These included perceptions of the system as new and requiring technical competence and skill; the adoption of the system for information gathering; and interactions and relationships that involved individual, shared or collective use. The dynamics between these external, internal and technological structures affected the adoption and implementation of the system.

CONCLUSIONS

Successful implementation of information technology interventions for medicine optimisation will depend on a combination of the infrastructure within primary care, social structures embedded in the technology and the conventions, norms and dispositions of those utilising it. Future interventions, using electronic audit and feedback tools to improve medication safety, should consider the complexity of the social and organisational contexts and how internal and external structures can affect the use of the technology in order to support effective implementation.

The pharmacist and the EHR

The adoption of electronic health records (EHRs) across the United States has impacted the methods by which health care professionals care for their patients. It is not always recognized, however, that pharmacists also actively use advanced functionality within the EHR. As critical members of the health care team, pharmacists utilize many different features of the EHR. The literature focuses on 3 main roles: documentation, medication reconciliation, and patient evaluation and monitoring. As health information technology proliferates, it is imperative that pharmacists' workflow and information needs are met within the EHR to optimize medication therapy quality, team communication, and patient outcomes.

Are we ready to accept the challenge? Addressing the shortcomings of contemporary qualitative health research

BACKGROUND

Qualitative approaches represent an important contributor to health care research. However, several researchers argue that contemporary qualitative research does not live up to its full potential. By presenting a snapshot of contemporary qualitative research in the field of social and administrative pharmacy, this study challenges contributors to the field by asking: Are we ready to accept the challenge and take qualitative research one step further?

PURPOSE

The purpose of this study was to initiate a constructive dialogue on the need for increased transparency in qualitative data analysis, including explicitly reflecting upon theoretical perspectives affecting the research process.

METHODS

Content analysis was used to evaluate levels of theoretical visibility and analysis transparency in selected qualitative research articles published in Research in Social and Administrative Pharmacy between January 2014 and January 2015.

MAIN FINDINGS

In 14 out of 21 assessed papers, the use of theory was found to be Seemingly Absent (lowest level of theory use), and the data analyses did not include any interpretive endeavors. Only two papers consistently applied theory throughout the entire study and clearly took the data analyses from a descriptive to an interpretive level. It was found that the aim of the majority of assessed papers was to change or modify a given practice, which however, resulted in a lack of both theoretical underpinnings and analysis transparency.

CONCLUSION

This study takes the standpoint that theory and high-quality analysis go hand-in-hand. Based on the content analysis, articles that were deemed to be high in quality were explicit about the theoretical framework of their study and transparent in how they analyzed their data. It was found that theory contributed to the transparency of how the data were analyzed and interpreted. Two ways of improving contemporary qualitative research in the field of social and administrative pharmacy are discussed: engaging with social theory and establishing close collaboration with social scientists.