Digitising an Australian university hospital: qualitative analysis of staff-reported impacts

Concerted adoption as an emerging strategy for digital transformation of healthcare-lessons from Australia, Canada, and England

OBJECTIVES

With an increasing focus on the digitalization of health and care settings, there is significant scope to learn from international approaches to promote concerted adoption of electronic health records.

MATERIALS AND METHODS

We review three large-scale initiatives from Australia, Canada, and England, and extract common lessons for future health and social care transformation strategy.

RESULTS

We discuss how, despite differences in contexts, concerted adoption enables sharing of experience and learning to streamline the digital transformation of health and care.

DISCUSSION AND CONCLUSION

Concerted adoption can be accelerated through building communities of expertise and partnerships promoting knowledge transfer and circulation of expertise; commonalities in geographical and cultural contexts; and commonalities in technological systems.

Adoption of Electronic Medical Records in Healthcare Facilities in the Emirate of Dubai

OBJECTIVES

This paper aimed to assess the adoption of electronic medical records (EMRs) in healthcare facilities in Dubai, the largest city in the United Arab Emirates (UAE) and a location where extensive healthcare services are provided. It explored the challenges, milestones, and accomplishments associated with this process.

METHODS

A situation analysis was conducted by contacting 2,089 healthcare facilities in Dubai to determine whether they had implemented EMR in their medical practices and to identify the challenges they faced during this process. Additionally, the Electronic Medical Record Adoption Model (EMRAM) was utilized to measure the maturity level of hospitals in terms of EMR adoption. The EMRAM stages were rated on a scale from 0 to 7, with 0 representing the least mature stage and 7 the most mature.

RESULTS

By September 2023, all hospitals (100%, n = 54) and 75% of private clinics (n = 1,460) in Dubai had implemented EMRs. Several challenges were identified, including the absence of EMRs within the healthcare facility, having an EMR with a low EMRAM score, or the lack of a unified interoperability standard. Additionally, the absence of a clear licensing program for EMR vendors, whether standalone or cloud-based, was among the other challenges noted.

CONCLUSIONS

EMR implementation in healthcare facilities in Dubai is at a mature stage. However, further efforts are required at both the decision-making and technical levels. We believe that our experience can benefit other countries in the region in implementing EMRs and using EMRAM to assess their health information systems.

The development and implementation of the Northern Health lung cancer digital care pathway: a case study in service change

This case study details the approach utilised to establish an easy to use, accessible and sustainable method for routine collection of Patient Reported Outcome Measures for patients newly diagnosed with lung cancer. We sought to enhance communication with patients and their families, particularly around shared decision making, their quality of life and symptoms, as well as the impacts of their care or treatment. We detail the co-design methodology utilised with consumers and healthcare providers to develop and implement a multi-lingual, fully automated digital care pathway which has been proven to be highly impactful and powerful for both healthcare providers working within the service and consumers enrolled within the digital pathway. This innovative initiative has changed the practice of the lung cancer service across a health service. Furthermore, its success has evolved the organisational strategy, to embed 'Outcomes for Impact' across the health service.

Investigating allied health professionals' attitudes, perceptions and acceptance of an electronic medical record using the Unified Theory of Acceptance and Use of Technology

Objective This study aimed to investigate allied health professionals' (AHPs') perspectives pre- and post-implementation of an electronic medical record (EMR) in a tertiary health service in Australia and examine factors influencing user acceptance. Methods Data were collected pre- and post-EMR implementation via cross-sectional online surveys based on the Unified Theory of Acceptance and Usage of Technology (UTAUT). All AHPs at a large tertiary hospital were invited to complete the surveys. Data analysis included descriptive analysis, Mann-Whitney U tests for pre-post item- and construct-level comparison and content analysis of free-text responses. The theoretical model was empirically tested using partial least squares structural equation modelling. Results AHPs had positive attitudes toward EMR use both pre- and post-implementation. Compared to pre-implementation, AHPs felt more positive post-implementation about system ease of use and demonstrated decreased anxiety and apprehension regarding EMR use. AHPs felt they had adequate resources and knowledge to use EMR and reported real-time data accessibility as a main advantage. Disadvantages of EMR included an unfriendly user interface, system outages and decreased efficiency. Conclusions As AHPs increase EMR system familiarity, their positivity towards its use increases. An understanding of what influences AHPs when implementing new compulsory technology can inform change management strategies to improve adoption.

Development of an Evidence-Based Conceptual Model of the Health Care Sector Under Digital Transformation: Integrative Review

BACKGROUND

Digital transformation is currently one of the most influential developments. It is fundamentally changing consumers' expectations and behaviors, challenging traditional firms, and disrupting numerous markets. Recent discussions in the health care sector tend to assess the influence of technological implications but neglect other factors needed for a holistic view on the digital transformation. This calls for a reevaluation of the current state of digital transformation in health care. Consequently, there is a need for a holistic view on the complex interdependencies of digital transformation in the health care sector.

OBJECTIVE

This study aimed to examine the effects of digital transformation on the health care sector. This is accomplished by providing a conceptual model of the health care sector under digital transformation.

METHODS

First, the most essential stakeholders in the health care sector were identified by a scoping review and grounded theory approach. Second, the effects on these stakeholders were assessed. PubMed, Web of Science, and Dimensions were searched for relevant studies. On the basis of an integrative review and grounded theory methodology, the relevant academic literature was systematized and quantitatively and qualitatively analyzed to evaluate the impact on the value creation of, and the relationships among, the stakeholders. Third, the findings were synthesized into a conceptual model of the health care sector under digital transformation.

RESULTS

A total of 2505 records were identified from the database search; of these, 140 (5.59%) were included and analyzed. The results revealed that providers of medical treatments, patients, governing institutions, and payers are the most essential stakeholders in the health care sector. As for the individual stakeholders, patients are experiencing a technology-enabled growth of influence in the sector. Providers are becoming increasingly dependent on intermediaries for essential parts of the value creation and patient interaction. Payers are expected to try to increase their influence on intermediaries to exploit the enormous amounts of data while seeing their business models be challenged by emerging technologies. Governing institutions regulating the health care sector are increasingly facing challenges from new entrants in the sector. Intermediaries increasingly interconnect all these stakeholders, which in turn drives new ways of value creation. These collaborative efforts have led to the establishment of a virtually integrated health care ecosystem.

CONCLUSIONS

The conceptual model provides a novel and evidence-based perspective on the interrelations among actors in the health care sector, indicating that individual stakeholders need to recognize their role in the system. The model can be the basis of further evaluations of strategic actions of actors and their effects on other actors or the health care ecosystem itself.

Allied health professionals' experiences and lessons learned in response to a big bang electronic medical record implementation: A prospective observational study

INTRODUCTION

There is limited evidence describing the impact of electronic medical record (EMR) implementation on allied health professionals' acceptance, expectations, and work efficiencies. This study aims to: A) identify clinician expectations and factors that influence EMR acceptance; B) evaluate perceived usability, technology proficiency and satisfaction; and C) assess the impact of EMR big bang implementation on allied health workflows at three Australian tertiary hospitals.

METHODS

Repeated measures study pre and six-months post EMR implementation. User acceptance was evaluated with online surveys: Unified Theory of Acceptance and Use of Technology (pre), System Usability Scale and open-ended questions (post). A four-hour time-motion study evaluated changes in allied health inpatient workflows.

RESULTS

Surveys were completed by 224 allied health clinicians (47% response rate) pre, and 196 (41%) post-implementation. Pre-implementation, 96% of respondents felt using the EMR was a good idea and they would find it useful. Six-months post-implementation 88% liked interacting with the EMR. 64% found it easy to use and most didn't require technical support (78%). While 68% of participants felt very confident, 51% believed they were not using the EMR's full potential. Post-implementation half of participants agreed significant upskilling was required and that EMR workflows were not quick to learn. Live demonstrations were considered the most helpful activity prior to training; hands-on practice in the training environment and superuser support were invaluable preparing for and during go-live. Time-motion data (mean difference (MD) (95% CI)) indicated that following implementation participants spent 2.27% (-3.53, 8.09, p = 0.731) more time in clinical tasks. More time was spent performing clinical documentation (5.39% (1.98, 8.8), p = 0.002).

CONCLUSIONS

Many factors can impact allied health professional's adoption of a new EMR. Institution-wide, simultaneous big bang EMR implementation, with strong allied health leadership, can lead to positive benefits, particularly in user experience. Ongoing evaluation will drive future improvements.

Digital Transformation in Healthcare: Technology Acceptance and Its Applications

Technological innovation has become an integral aspect of our daily life, such as wearable and information technology, virtual reality and the Internet of Things which have contributed to transforming healthcare business and operations. Patients will now have a broader range and more mindful healthcare choices and experience a new era of healthcare with a patient-centric culture. Digital transformation determines personal and institutional health care. This paper aims to analyse the changes taking place in the field of healthcare due to digital transformation. For this purpose, a systematic bibliographic review is performed, utilising Scopus, Science Direct and PubMed databases from 2008 to 2021. Our methodology is based on the approach by Wester and Watson, which classify the related articles based on a concept-centric method and an ad hoc classification system which identify the categories used to describe areas of literature. The search was made during August 2022 and identified 5847 papers, of which 321 fulfilled the inclusion criteria for further process. Finally, by removing and adding additional studies, we ended with 287 articles grouped into five themes: information technology in health, the educational impact of e-health, the acceptance of e-health, telemedicine and security issues.

Understanding the Digital Disruption of Health Care: An Ethnographic Study of Real-Time Multidisciplinary Clinical Behavior in a New Digital Hospital

Background Understanding electronic medical record (EMR) implementation in digital hospitals has focused on retrospective “work as imagined” experiences of multidisciplinary clinicians, rather than “work as done” behaviors. Our research question was “what is the behavior of multidisciplinary clinicians during the transition to a new digital hospital?”

Objectives The aim of the study is to: (1) Observe clinical behavior of multidisciplinary clinicians in a new digital hospital using ethnography. (2) Develop a thematic framework of clinical behavior in a new digital hospital.

Methods The setting was the go-live of a greenfield 182-bed digital specialist public hospital in Queensland, Australia. Participants were multidisciplinary clinicians (allied health, nursing, medical, and pharmacy). Clinical ethnographic observations were conducted between March and April 2021 (approximately 1 month post-EMR implementation). Observers shadowed clinicians in real-time performing a diverse range of routine clinical activities and recorded any clinical behavior related to interaction with the digital hospital. Data were analyzed in two phases: (1) content analysis using machine learning (Leximancer v4.5); (2) researcher-led interpretation of the text analytics to generate contextual meaning and finalize themes.

Results A total of 55 multidisciplinary clinicians (41.8% allied health, 23.6% nursing, 20% medical, 14.6% pharmacy) were observed across 58 hours and 99 individual patient encounters. Five themes were derived: (1) Workflows for clinical documentation; (2) Navigating a digital hospital; (3) Digital efficiencies; (4) Digital challenges; (5) Patient experience. There was no observed harm attributable to the digital transition. Clinicians primarily used blended digital and paper workflows to achieve clinical goals. The EMR was generally used seamlessly. New digital workflows affected clinical productivity and caused frustration. Digitization enabled multitasking, clinical opportunism, and benefits to patient safety; however, clinicians were hesitant to trust digital information.

Conclusion This study improves our real-time understanding of the digital disruption of health care and can guide clinicians, managers, and health services toward digital transformation strategies based upon “work as done.”

The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review

BACKGROUND

 Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice.

OBJECTIVES

 The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting.

METHODS

 Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork.

RESULTS

 The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption.

CONCLUSION

 There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.

Synthesizing Dimensions of Digital Maturity in Hospitals: Systematic Review

Background

Digital health in hospital settings is viewed as a panacea for achieving the “quadruple aim” of health care, yet the outcomes have been largely inconclusive. To optimize digital health outcomes, a strategic approach is necessary, requiring digital maturity assessments. However, current approaches to assessing digital maturity have been largely insufficient, with uncertainty surrounding the dimensions to assess.

Objective

The aim of this study was to identify the current dimensions used to assess the digital maturity of hospitals.

Methods

A systematic literature review was conducted of peer-reviewed literature (published before December 2020) investigating maturity models used to assess the digital maturity of hospitals. A total of 29 relevant articles were retrieved, representing 27 distinct maturity models. The articles were inductively analyzed, and the maturity model dimensions were extracted and consolidated into a maturity model framework.

Results

The consolidated maturity model framework consisted of 7 dimensions: strategy; information technology capability; interoperability; governance and management; patient-centered care; people, skills, and behavior; and data analytics. These 7 dimensions can be evaluated based on 24 respective indicators.

Conclusions

The maturity model framework developed for this study can be used to assess digital maturity and identify areas for improvement.

Understanding nurses' perceptions of barriers and enablers to use of a new electronic medical record system in Australia: A qualitative study

BACKGROUND

Electronic medical record system implementations impact nurses, their work and workflows. The aim of this study was to understand nurses' perceptions of barriers and enablers to using a new electronic medical record in an acute hospital environment.

METHODS

Data were collected just prior to an organisation-wide new electronic medical record implementation at a large tertiary healthcare organization in Victoria, Australia. Sixty-three nurses from five hospital sites participated in 12 focus group interviews. Transcripts were transcribed and deductive content analysis used the 14-domain Theoretical Domains Framework to identify barriers and enablers.

RESULTS

Coded data mapped to 13 of the 14 domains. Nurse motivation emerged as a dominant theme among both barriers and enablers. Nurses' most common perceived barriers related to emotions (24.1%) and environmental context and resources (21.3%). Conversely, the most common enablers related to social influences (21%) and reinforcement (20.8%).

DISCUSSION

In addition to effecting changes in their work and workflows, the dominance of nurses' emotional responses reveals the potential for implementation of a new electronic medical record to negatively affect nurses' psychological well-being. Using data aligned to the Theoretical Domains Framework assisted identification of behavior change strategies to target the barriers and enablers perceived by nurses. Strategies aligned with nine behavioral intervention categories are recommended for successful implementation and optimization of an electronic medical record by nurses.

CONCLUSIONS

Multifaceted strategies targeting multiple behaviors are required to support adoption of the electronic medical record by nurses, and reduce the risk for nurse attrition in the workforce.

Nurses

ObjectiveThe aim of this study was to describe nurses' and midwives' experiences following the first phase of the implementation of an electronic medical record (EMR) system at a large public health service in metropolitan Melbourne, Australia.MethodsFour focus groups were held 8-10 months after implementation of the EMR. Transcripts were analysed using thematic analysis.ResultsOf 39 participants, 25 were nurses (64%), 12 were midwives (31%) and two did not provide this information. The mean (±s.d.) duration of clinical experience was 15.6±12.2 years (range 2-40 years). Three main themes were identified: (1) effects on workflow: although some participants reported that EMR facilitated easier access to real-time patient data, others indicated that workflow was disrupted by the EMR being slow and difficult to navigate, system outages and lack of interoperability between the EMR and other systems; (2) effects on patient care and communication: some participants reported that the EMR improved their communication with patients and reduced medication errors, whereas others reported a negative effect on patient care and communication; and (3) negative effects of the EMR on nurses' and midwives' personal well-being, including frustration, stress and exhaustion. These experiences were often reported in the context of cognitive workload due to having to use multiple systems simultaneously or extra work associated with EMR outages.ConclusionNurses' and midwives' experiences of the EMR were complex and mixed. Nurses and midwives require significant training and ongoing technical support in the first 12 months after implementation of an EMR system. Including nurses and midwives in the design and refinement of the EMR will ensure that the EMR aligns with their workflow.What is known about the topic?Studies reporting nurses' and midwives' experiences of using EMR are scarce and mostly based in countries where whole-of-service implementations are carried out, funded by governments.What does this paper add?Nurses and midwives perceive benefits of using an EMR relatively soon after implementation in terms of their workflow and patient care. However, in the first year after EMR implementation, nurses and midwives experience some negative effects on workflow, patient care and their own well-being. The effects on clinical workflow are further compounded by EMR downtime (scheduled and unscheduled) and hybrid systems that require users to access other technology systems alongside the EMR.What are the implications for practitioners?In countries like Australia, whole-of-service, simultaneous implementation of EMR systems using best-available server technology may not be possible due to funding constraints. In these circumstances, nurses and midwives may initially experience increased workload and frustration. Ongoing training and technical support should be provided to nurses and midwives for several months following implementation. Including nurses and midwives in the design of the EMR will result in better alignment with their specific workflow, thus maximising benefits of EMR implementation.