Redesigning care processes using an electronic health record: a system's experience

Dental Robotics: A Disruptive Technology

Robotics is a disruptive technology that will change diagnostics and treatment protocols in dental medicine. Robots can perform repeated workflows for an indefinite length of time while enhancing the overall quality and quantity of patient care. Early robots required a human operator, but robotic systems have advanced significantly over the past decade, and the latest medical robots can perform patient intervention or remote monitoring autonomously. However, little research data on the therapeutic reliability and precision of autonomous robots are available. The present paper reviews the promise and practice of robots in dentistry by evaluating published work on commercial robot systems in dental implantology, oral and maxillofacial surgery, prosthetic and restorative dentistry, endodontics, orthodontics, oral radiology as well as dental education. In conclusion, this review critically addresses the current limitations of dental robotics and anticipates the potential future impact on oral healthcare and the dental profession.

Dentronics: Towards robotics and artificial intelligence in dentistry

OBJECTIVES

This paper provides an overview of existing applications and concepts of robotic systems and artificial intelligence in dentistry. This review aims to provide the community with novel inputs and argues for an increased utilization of these recent technological developments, referred to as Dentronics, in order to advance dentistry.

METHODS

First, background on developments in robotics, artificial intelligence (AI) and machine learning (ML) are reviewed that may enable novel assistive applications in dentistry (Sec A). Second, a systematic technology review that evaluates existing state-of-the-art applications in AI, ML and robotics in the context of dentistry is presented (Sec B).

RESULTS

A systematic literature research in pubmed yielded in a total of 558 results. 41 studies related to ML, 53 studies related to AI and 49 original research papers on robotics application in dentistry were included. ML and AI have been applied in dental research to analyze large amounts of data to eventually support dental decision making, diagnosis, prognosis and treatment planning with the help of data-driven analysis algorithms based on machine learning. So far, only few robotic applications have made it to reality, mostly restricted to pilot use cases.

SIGNIFICANCE

The authors believe that dentistry can greatly benefit from the current rise of digital human-centered automation and be transformed towards a new robotic, ML and AI-enabled era. In the future, Dentronics will enhance reliability, reproducibility, accuracy and efficiency in dentistry through the democratized use of modern dental technologies, such as medical robot systems and specialized artificial intelligence. Dentronics will increase our understanding of disease pathogenesis, improve risk-assessment-strategies, diagnosis, disease prediction and finally lead to better treatment outcomes.

Using Electronic Health Records to Measure Quality Improvement Efforts: Findings from a Large Practice Facilitation Initiative

BACKGROUND

Federal incentives for electronic health record (EHR) use typically require quality measure reporting over calendar year or 90-day periods. However, required reporting periods may not align with time frames of real-world quality improvement (QI) efforts. This study described primary care practices' ability to obtain measures with reporting periods aligning with a large QI initiative.

METHODS

Researchers conducted a substudy of a randomized trial testing practice facilitation strategies for preventive cardiovascular care. Three quality measures (aspirin for ischemic vascular disease; blood pressure control for hypertension; smoking screening/cessation) were collected quarterly over one year. The primary outcome was a binary indicator of whether a practice facilitator obtained all three measures with "rolling 12-month" reporting periods (that is, the year preceding each study quarter).

RESULTS

The study included 107 practices, 63 (58.9%) of which met the primary outcome of obtaining all measures with rolling 12-month reporting periods. Smaller practices were less likely to meet the primary outcome (p < 0.001). Practices used 11 different EHRs, 3 of which were unable to consistently produce rolling 12-month measures; at 33 practices (30.8%) using these 3 EHRs, facilitators met a secondary outcome of obtaining prior calendar year and rolling 3-month measures. Facilitators reported barriers to data collection such as practices lacking optional EHR features, and EHRs' inability to produce reporting periods across two calendar years.

CONCLUSION

EHR vendors' compliance with federal reporting requirements is not necessarily sufficient to support real-world QI work. Improvements are needed in the flexibility and usability of EHRs' quality measurement functions, particularly for smaller practices.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Best Practices in Clinical Decision Support: the Case of Preventive Care Reminders

BACKGROUND: Evidence demonstrates that clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety. However, implementing and maintaining effective decision support interventions presents multiple technical and organizational challenges. PURPOSE: To identify best practices for CDS, using the domain of preventive care reminders as an example. METHODS: We assembled a panel of experts in CDS and held a series of facilitated online and in-person discussions. We analyzed the results of these discussions using a grounded theory method to elicit themes and best practices. RESULTS: Eight best practice themes were identified as important: deliver CDS in the most appropriate ways, develop effective governance structures, consider use of incentives, be aware of workflow, keep content current, monitor and evaluate impact, maintain high quality data, and consider sharing content. Keys themes within each of these areas were also described. CONCLUSION: Successful implementation of CDS requires consideration of both technical and socio-technical factors. The themes identified in this study provide guidance on crucial factors that need consideration when CDS is implemented across healthcare settings. These best practice themes may be useful for developers, implementers, and users of decision support.

How Does Learnability of Primary Care Resident Physicians Increase After Seven Months of Using an Electronic Health Record? A Longitudinal Study

Background

Electronic health records (EHRs) with poor usability present steep learning curves for new resident physicians, who are already overwhelmed in learning a new specialty. This may lead to error-prone use of EHRs in medical practice by new resident physicians.

Objective

The study goal was to determine learnability gaps between expert and novice primary care resident physician groups by comparing performance measures when using EHRs.

Methods

We compared performance measures after two rounds of learnability tests (November 12, 2013 to December 19, 2013; February 12, 2014 to April 22, 2014). In Rounds 1 and 2, 10 novice and 6 expert physicians, and 8 novice and 4 expert physicians participated, respectively. Laboratory-based learnability tests using video analyses were conducted to analyze learnability gaps between novice and expert physicians. Physicians completed 19 tasks, using a think-aloud strategy, based on an artificial but typical patient visit note. We used quantitative performance measures (percent task success, time-on-task, mouse activities), a system usability scale (SUS), and qualitative narrative feedback during the participant debriefing session.

Results

There was a 6-percentage-point increase in novice physicians’ task success rate (Round 1: 92%, 95% CI 87-99; Round 2: 98%, 95% CI 95-100) and a 7-percentage-point increase in expert physicians’ task success rate (Round 1: 90%, 95% CI 83-97; Round 2: 97%, 95% CI 93-100); a 10% decrease in novice physicians’ time-on-task (Round 1: 44s, 95% CI 32-62; Round 2: 40s, 95% CI 27-59) and 21% decrease in expert physicians’ time-on-task (Round 1: 39s, 95% CI 29-51; Round 2: 31s, 95% CI 22-42); a 20% decrease in novice physicians mouse clicks (Round 1: 8 clicks, 95% CI 6-13; Round 2: 7 clicks, 95% CI 4-12) and 39% decrease in expert physicians’ mouse clicks (Round 1: 8 clicks, 95% CI 5-11; Round 2: 3 clicks, 95% CI 1-10); a 14% increase in novice mouse movements (Round 1: 9247 pixels, 95% CI 6404-13,353; Round 2: 7991 pixels, 95% CI 5350-11,936) and 14% decrease in expert physicians’ mouse movements (Round 1: 7325 pixels, 95% CI 5237-10,247; Round 2: 6329 pixels, 95% CI 4299-9317). The SUS measure of overall usability demonstrated only minimal change in the novice group (Round 1: 69, high marginal; Round 2: 68, high marginal) and no change in the expert group (74; high marginal for both rounds).

Conclusions

This study found differences in novice and expert physicians’ performance, demonstrating that physicians’ proficiency increased with EHR experience. Our study may serve as a guideline to improve current EHR training programs. Future directions include identifying usability issues faced by physicians when using EHRs, through a more granular task analysis to recognize subtle usability issues that would otherwise be overlooked.

The value of clinical teachers for EMR implementations and conversions

Effective physician training is an essential aspect of EMR implementation. However, it can be challenging to find instructors who can present the material in a clinically relevant manner. The authors describe a unique physician-training program, utilizing medical students as course instructors. This approach resulted in high learner satisfaction rates and provided significant cost-savings compared to alternative options.

Successful physician training program for large scale EMR implementation

End-user training is an essential element of electronic medical record (EMR) implementation and frequently suffers from minimal institutional investment. In addition, discussion of successful EMR training programs for physicians is limited in the literature. The authors describe a successful physician-training program at Stanford Children's Health as part of a large scale EMR implementation. Evaluations of classroom training, obtained at the conclusion of each class, revealed high physician satisfaction with the program. Free-text comments from learners focused on duration and timing of training, the learning environment, quality of the instructors, and specificity of training to their role or department. Based upon participant feedback and institutional experience, best practice recommendations, including physician engagement, curricular design, and assessment of proficiency and recognition, are suggested for future provider EMR training programs. The authors strongly recommend the creation of coursework to group providers by common workflow.

Electronic Chemotherapy Order Entry: A Major Cancer Center's Implementation

Implementation of a computerized provider order entry system for complex chemotherapy regimens at a large cancer center required intense effort from a multidisciplinary team of clinical and systems experts with experience in all facets of the chemotherapy process. The online tools had to resemble the paper forms used at the time and parallel the successful established process as well as add new functionality. Close collaboration between the institution and the vendor was necessary. This article summarizes the institutional efforts, challenges, and collaborative processes that facilitated universal chemotherapy computerized electronic order entry across multiple sites during a period of several years.

Patient safety perceptions of primary care providers after implementation of an electronic medical record system

BACKGROUND

Increasing the use of electronic medical records (EMR) has been suggested as an important strategy for improving healthcare safety.

OBJECTIVE

To sequentially measure, evaluate, and respond to safety culture and practice safety concerns following EMR implementation.

DESIGN

Safety culture was assessed using a validated tool (Safety Attitudes Questionnaire; SAQ), immediately following EMR implementation (T1) and at 1.5 (T2) and 2.5 (T3) years post-implementation. The SAQ was supplemented with a practice-specific assessment tool to identify safety needs and barriers.

PARTICIPANTS

A large medical group practice with a primary care core of 17-18 practices, staffed by clinicians in family medicine, pediatrics, internal medicine.

INTERVENTIONS

Survey results were used to define and respond to areas of need between assessments with system changes and educational programs.

MAIN MEASURES

Change in safety culture over time; perceived impact of EMR on practice.

KEY RESULTS

Responses were received from 103 of 123 primary care providers in T1 (83.7 % response rate), 122 of 143 in T2 (85.3 %) and 142 of 181 in T3 (78.5 %). Safety culture improved over this period, with statistically significant improvement in all domains except for stress recognition. Time constraints, communications and patient adherence were perceived to be the most important safety issues. The majority of respondents in both T2 (77.9 %) and T3 (85.4 %) surveys agreed that the EMR improved their ability to provide care more safely.

CONCLUSIONS

Implementation of an EMR in a large primary care practice required redesign of many organizational processes, and was associated with improvements in safety culture. Most primary care providers agreed that the EMR allowed them to provide care more safely.

Large-system transformation in health care: a realist review

CONTEXT

An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation.

METHODS

We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS).

FINDINGS

Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms.

CONCLUSIONS

Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods.

The role of cognitive and learning theories in supporting successful EHR system implementation training: a qualitative study

Given persistent barriers to effective electronic health record (EHR) system implementation and use, the authors investigated implementation training practices in six organizations reputed to have ambulatory care EHR system implementation "best practices." Using the lenses of social cognitive and adult learning theories, they explored themes related to EHR implementation training using qualitative data collected through 43 key informant interviews and 6 physician focus groups conducted between February 2009 and December 2010. The authors found consistent evidence that training practices across the six organizations known for exemplary implementations were congruent with the tenets of these theoretical frameworks and highlight seven best practices for training. The authors' analyses suggest that effective training programs must move beyond technical approaches and incorporate social and cultural factors to make a difference in implementation success. Taking these findings into account may increase the likelihood of successful EHR implementation, thereby helping organizations meet "meaningful use" requirements for EHR systems.

Evidence-based Standardized Care Plans for Use Internationally to Improve Home Care Practice and Population Health

OBJECTIVES

To develop evidence-based standardized care plans (EB-SCP) for use internationally to improve home care practice and population health.

METHODS

A clinical-expert and scholarly method consisting of clinical experts recruitment, identification of health concerns, literature reviews, development of EB-SCPs using the Omaha System, a public comment period, revisions and consensus.

RESULTS

Clinical experts from Canada, the Netherlands, New Zealand, and the United States participated in the project, together with University of Minnesota School of Nursing graduate students and faculty researchers. Twelve Omaha System problems were selected by the participating agencies as a basic home care assessment that should be used for all elderly and disabled patients. Interventions based on the literature and clinical expertise were compiled into EB-SCPs, and reviewed by the group. The EB-SCPs were revised and posted on-line for public comment; revised again, then approved in a public meeting by the participants. The EB-SCPs are posted on-line for international dissemination.

CONCLUSIONS

Home care EB-SCPs were successfully developed and published on-line. They provide a shared standard for use in practice and future home care research. This process is an exemplar for development of evidence-based practice standards to be used for assessment and documentation to support global population health and research.

Nurse adoption of continuous patient monitoring on acute post-surgical units: managing technology implementation

AIM

To report an exploratory action-research process used during the implementation of continuous patient monitoring in acute post-surgical nursing units.

BACKGROUND

Substantial US Federal funding has been committed to implementing new health care technology, but failure to manage implementation processes may limit successful adoption and the realisation of proposed benefits. Effective approaches for managing barriers to new technology implementation are needed.

METHOD

Continuous patient monitoring was implemented in three of 13 medical/surgical units. An exploratory action-feedback approach, using time-series nurse surveys, was used to identify barriers and develop and evaluate responses. Post-hoc interviews and document analysis were used to describe the change implementation process.

RESULTS

Significant differences were identified in night- and dayshift nurses' perceptions of technology benefits. Research nurses' facilitated the change process by evolving 'clinical nurse implementation specialist' expertise.

CONCLUSIONS

Health information technology (HIT)-related patient outcomes are mediated through nurses' acting on new information but HIT designed for critical care may not transfer to acute care settings. Exploratory action-feedback approaches can assist nurse managers in assessing and mitigating the real-world effects of HIT implementations.

IMPLICATIONS FOR NURSING MANAGEMENT

It is strongly recommended that nurse managers identify stakeholders and develop comprehensive plans for monitoring the effects of HIT in their units.

Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review

PURPOSE

The aims of this systematic review were: (1) to analyze the content overlap between nurse and physician hospital-based handoff documentation for the purpose of developing a list of interdisciplinary handoff information for use in the future development of shared and tailored computer-based handoff tools, and (2) to evaluate the utility of the Continuity of Care Document (CCD) standard as a framework for organizing hospital-based handoff information for use in electronic health records (EHRs).

METHODS

We searched PubMed for studies published through July 2010 containing the indexed terms: handoff(s), hand-off, handover(s), shift-report, shift report, signout, and sign-out. Original, hospital-based studies of acute care nursing or physician handoff were included. Handoff information content was organized into lists of nursing, physician, and interdisciplinary handoff information elements. These information element lists were organized using CCD sections, with additional sections being added as needed.

RESULTS

Analysis of 36 studies resulted in a total of 95 handoff information elements. Forty-six percent (44/95) of the information overlapped between the nurse and physician handoff lists. Thirty-six percent (34/95) were specific to the nursing list and 18% (17/95) were specific to the physician list. The CCD standard was useful for categorizing 80% of the terms in the lists and 12 category names were developed for the remaining 20%.

CONCLUSION

Standardized interdisciplinary, nursing-specific, and physician-specific handoff information elements that are organized around the CCD standard and incorporated into EHRs in a structured narrative format may increase the consistency of data shared across all handoffs, facilitate the establishment of common ground, and increase interdisciplinary communication.