The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

The application of health information technology for the elderly care in the emergency department: a conceptual model

INTRODUCTION

In the emergency departments (EDs), usually the longest waiting time for treatment and discharge belongs to the elderly patients. Moreover, the number of the ED admissions for the elderly increases every year. It seems that the use of health information technology in geriatric emergency departments can help to reduce the burden of the healthcare services for this group of patients. This research aimed to develop a conceptual model for using health information technology in the geriatric emergency department.

METHODS

This study was conducted in 2021. The initial conceptual model was designed based on the findings derived from the previous research phases (literature review and interview with the experts). Then, the model was examined by an expert panel (n = 7). Finally, using the Delphi technique (two rounds), the components of the conceptual model were reviewed and finalized. To collect data, a questionnaire was used, and data were analyzed using descriptive statistics.

RESULTS

The common information technologies appropriate for the elderly care in the emergency departments included emergency department information system, clinical decision support system, electronic health records, telemedicine, personal health records, electronic questionnaires for screening, and other technologies such as picture archiving and communication systems (PACS), electronic vital sign monitoring systems, etc. The participants approved all of the proposed systems and their applications in the geriatric emergency departments.

CONCLUSION

The proposed model can help to design and implement the most useful information systems in the geriatric emergency departments. As the application of technology accelerates care processes, investing in this field would help to support the care plans for the elderly and improve quality of care services. Further research is recommended to investigate the efficiency and effectiveness of using these technologies in the EDs.

Differential effects of electronic patient record systems for wound care on hospital-acquired pressure injuries: Findings from a secondary analysis of German hospital data

INTRODUCTION

Despite the improvements made in recent decades, the OECD regards hospital-acquired pressure injuries (HAPI) as high priority areas for actions to ensure patient safety. This study was aimed at investigating the degree of utilization of two types of electronic patient record systems for wound care on lowering HAPI rates. Furthermore, the effect of user satisfaction with the systems and perceived alignment with clinical processes should be studied.

MATERIAL AND METHODS

A regression analysis of post-stratified data from German hospitals obtained from the Hospital Quality Reports (observed/expected HAPI ratio) and the IT Report Healthcare was performed. The sample comprised 319 hospitals reporting on digital wound record systems and 199 hospitals on digital nursing record systems for system utilization and the subset of hospitals using a digital system for user satisfaction and process alignment.

RESULTS

The study revealed a significant effect of hospital ownership for both types of systems and a significant interaction of ownership and system utilization for digital wound record systems: Only the for-profit hospitals benefited from a higher degree of system utilization with a lower HAPI ratio. In contrast, non-profit hospitals yielded a reversed pattern, with increasing HAPI rates matching an increased system utilization. User satisfaction (significant) and the perceived alignment of the clinical process (trend) of the digital nursing record system were related with lower HAPI ratios.

DISCUSSION

These findings point to a differential effect of system utilization on HAPI ratios depending on hospital ownership, and they demonstrate that those users who are satisfied with the system can act as catalysts for better care. The explained variance was small but comparable to other studies. Furthermore, it shows that explaining quality care is a complex undertaking. Sheer utilization has no effect while a differential perspective on the facilitators and barriers might help to explain the patient outcomes.

Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation

Background

Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable.

Aim

To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England.

Design

Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60).

Setting

Three Trusts, one orthopaedic and one older person ward in each.

Results

Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling.

Limitations

Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted.

Conclusions

(1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling.

Future work

(1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English.

Study registration

This study is registered as PROSPERO CRD42020184458.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Impact of a Decision Support System on Fall-Prevention Nursing Practices

OBJECTIVES

The aim of this study was to develop a computerized decision support system (CDSS) that could automatically calculate the risk of falls using electronic medical record data and provide evidence-based fall-prevention recommendations based on risk factors. Furthermore, we analyzed the usability and effect of the system on fall-prevention nursing practices.

METHODS

A computerized fall-prevention system was developed according to the system development life cycle, and implemented between March and August 2019 in a single medical unit with a high prevalence of falls. The usability was evaluated 1 month after CDSS implementation. In terms of time and frequency, changes in fall-prevention nursing practices were analyzed using survey data and nursing documentation, respectively. Finally, the incidence of falls before and after system implementation was compared to examine the clinical effectiveness of the CDSS.

RESULTS

According to the usability test, the average ease of learning score (5.083 of 7) was the highest among 4 dimensions. The time spent engaged in fall-prevention nursing care per patient per shift increased, particularly for nursing diagnoses and planning. Moreover, the mean frequency of daily documented fall-prevention interventions per patient also increased. Particularly, nursing statements related to nonspecific interventions such as environmental modifications increased. However, the incidence of falls did not decrease after implementation of the CDSS.

CONCLUSIONS

Although adoption of the computerized system increased the time spent and number of records created in terms of fall-prevention practices in nurses, no improvement in clinical outcomes was observed, particularly in terms of fall rate reduction.

Exploring variation in implementation of multifactorial falls risk assessment and tailored interventions: a realist review

BACKGROUND

Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals.

METHODS

A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers.

RESULTS

Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging.

CONCLUSIONS

Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate.

TRIAL REGISTRATION

PROSPERO: CRD42020184458.

The effects of computerised decision support systems on nursing and allied health professional performance and patient outcomes: a systematic review and user contextualisation

Background

Computerised decision support systems (CDSS) are widely used by nurses and allied health professionals but their effect on clinical performance and patient outcomes is uncertain.

Objectives

Evaluate the effects of clinical decision support systems use on nurses', midwives' and allied health professionals' performance and patient outcomes and sense-check the results with developers and users.

Eligibility criteria

Comparative studies (randomised controlled trials (RCTs), non-randomised trials, controlled before-and-after (CBA) studies, interrupted time series (ITS) and repeated measures studies comparing) of CDSS versus usual care from nurses, midwives or other allied health professionals.

Information sources

Nineteen bibliographic databases searched October 2019 and February 2021.

Risk of bias

Assessed using structured risk of bias guidelines; almost all included studies were at high risk of bias.

Synthesis of results

Heterogeneity between interventions and outcomes necessitated narrative synthesis and grouping by: similarity in focus or CDSS-type, targeted health professionals, patient group, outcomes reported and study design.

Included studies

Of 36,106 initial records, 262 studies were assessed for eligibility, with 35 included: 28 RCTs (80%), 3 CBA studies (8.6%), 3 ITS (8.6%) and 1 non-randomised trial, a total of 1318 health professionals and 67,595 patient participants. Few studies were multi-site and most focused on decision-making by nurses (71%) or paramedics (5.7%). Standalone, computer-based CDSS featured in 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile or handheld technology. Care processes - including adherence to guidance - were positively influenced in 47% of the measures adopted. For example, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling, and documenting care were improved if they used CDSS. Patient care outcomes were statistically - if not always clinically - significantly improved in 40.7% of indicators. For example, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity, and accurate triaging were features of professionals using CDSS compared to those who were not.

Evidence limitations

Allied health professionals (AHPs) were underrepresented compared to nurses; systems, studies and outcomes were heterogeneous, preventing statistical aggregation; very wide confidence intervals around effects meant clinical significance was questionable; decision and implementation theory that would have helped interpret effects - including null effects - was largely absent; economic data were scant and diverse, preventing estimation of overall cost-effectiveness.

Interpretation

CDSS can positively influence selected aspects of nurses', midwives' and AHPs' performance and care outcomes. Comparative research is generally of low quality and outcomes wide ranging and heterogeneous. After more than a decade of synthesised research into CDSS in healthcare professions other than medicine, the effect on processes and outcomes remains uncertain. Higher-quality, theoretically informed, evaluative research that addresses the economics of CDSS development and implementation is still required.

Future work

Developing nursing CDSS and primary research evaluation.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in Health and Social Care Delivery Research; 2023. See the NIHR Journals Library website for further project information.

Registration

PROSPERO [number: CRD42019147773].

The Impact of Electronic Health Records and Meaningful Use on Inpatient Quality

ABSTRACT

It is unclear if national investments of the HITECH Act have resulted in significant improvements in care processes and outcomes by making "Meaningful Use (MU)" of Electronic Health Record (EHR) systems. The objective of this study is to determine the impact of EHRs and MU on inpatient quality. We used inpatient hospitalization data, American Hospital Association annual survey, and the Centers for Medicare and Medicaid Services attestation records to study the impact of EHRs on inpatient quality composite scores. Agency for Healthcare Research and Quality Inpatient Quality Indicator (IQI) software version 5.0 was used to compute the hospital-level risk-adjusted standardized rates for IQI indicators and composite scores. After adjusting for confounding factors, EHRs that attested to MU had a positive impact on IQI 90 and IQI 91 composite scores with an 8% decrease in composites for mortality for selected procedures and 18% decrease in composites for mortality for selected conditions. Meaningful Use attestation may be an important driver related to inpatient quality. Health care leaders may need to focus on quality improvement initiatives and advanced analytics to better leverage their EHRs to improve IQI 90 composite score for mortality for selected procedures, because we observed a lesser impact on IQI 90 compared with IQI 91.

Effects of computerised clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes: a systematic review of experimental and observational studies

OBJECTIVE

Computerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals' performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this.

MATERIALS AND METHODS

The following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion.

RESULTS

A total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile/handheld-technology.

DISCUSSION

CDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness.

CONCLUSION

CDSS may have a positive impact on selected aspects of nurses' and AHPs' performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing.

Health technologies for the prevention and detection of falls in adult hospital inpatients: a scoping review

OBJECTIVE

The objective of this scoping review was to examine and map the evidence relating to the reporting and evaluation of technologies for the prevention and detection of falls in adult hospital inpatients.

INTRODUCTION

Falls are a common cause of accidental injury, leading to significant safety issues in hospitals globally, and resulting in substantial human and economic costs. Previous research has focused on community settings with less emphasis on hospital settings.

INCLUSION CRITERIA

Participants included adult inpatients, aged 18 years and over; the concept included the use of fall-prevention or fall-detection technologies; the context included any hospital ward setting.

METHODS

This scoping review was conducted according to JBI methodology for scoping reviews, guided by an a priori protocol. A wide selection of databases including MEDLINE, CINAHL, AMED, Embase, PEDro, Epistimonikos, and Science Direct were searched for records from inception to October 2019. Other sources included gray literature, trial registers, government health department websites, and websites of professional bodies. Only studies in the English language were included. A three-step search strategy was employed, with all records exported for subsequent title and abstract screening prior to full-text screening. Screening was performed by two independent reviewers and data extraction by one reviewer following agreement checks. Data are presented in narrative and tabular form.

RESULTS

Over 13,000 records were identified with 404 included in the scoping review: 336 reported on fall-prevention technologies, 51 targeted detection, and 17 concerned both. The largest contributions of studies came from the USA (n=185), Australia (n=65), the UK (n=36), and Canada (n=18). There was a variety of study designs including 77 prospective cohort studies, 33 before-after studies, and 35 systematic reviews; however, relatively few randomized controlled trials were conducted (n = 25). The majority of records reported on multifactorial and multicomponent technologies (n = 178), followed by fall detection devices (n = 86). Few studies reported on the following interventions in isolation: fall risk assessment (n = 6), environment design (n = 8), sitters (n = 5), rounding (n = 3), exercise (n = 3), medical/pharmaceutical (n = 2), physiotherapy (n = 1), and nutritional (n = 1). The majority (57%) of studies reported clinical effectiveness outcomes, with smaller numbers (14%) reporting feasibility and/or acceptability outcomes, or cost-effectiveness outcomes (5%).

CONCLUSIONS

This review has mapped the literature on fall-prevention and fall-detection technology and outcomes for adults in the hospital setting. Despite the volume of available literature, there remains a need for further high-quality research on fall-prevention and fall-detection technologies.

Personalized treatment options for chronic diseases using precision cohort analytics

To support point-of-care decision making by presenting outcomes of past treatment choices for cohorts of similar patients based on observational data from electronic health records (EHRs), a machine-learning precision cohort treatment option (PCTO) workflow consisting of (1) data extraction, (2) similarity model training, (3) precision cohort identification, and (4) treatment options analysis was developed. The similarity model is used to dynamically create a cohort of similar patients, to inform clinical decisions about an individual patient. The workflow was implemented using EHR data from a large health care provider for three different highly prevalent chronic diseases: hypertension (HTN), type 2 diabetes mellitus (T2DM), and hyperlipidemia (HL). A retrospective analysis demonstrated that treatment options with better outcomes were available for a majority of cases (75%, 74%, 85% for HTN, T2DM, HL, respectively). The models for HTN and T2DM were deployed in a pilot study with primary care physicians using it during clinic visits. A novel data-analytic workflow was developed to create patient-similarity models that dynamically generate personalized treatment insights at the point-of-care. By leveraging both knowledge-driven treatment guidelines and data-driven EHR data, physicians can incorporate real-world evidence in their medical decision-making process when considering treatment options for individual patients.

Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

OBJECTIVES

Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.

DESIGN

Scoping review to map existing evidence and identify gaps for future research.

DATA SOURCES

PubMed, the Cochrane Library, EMBASE, Trial registers.

STUDY SELECTION

Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.

RESULTS

The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.

CONCLUSIONS

Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.

Routine Health Information System (RHIS) improvements for strengthened health system management

BACKGROUND

A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management.

OBJECTIVES

To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed.

SELECTION CRITERIA

Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence).

AUTHORS' CONCLUSIONS

The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

Characteristics of people with pressure ulcers using one year's routinely collected data in a defined diverse community

OBJECTIVE

To determine if meaningful patient characteristics pertaining to pressure ulcers (PU) can be derived from routinely collected community health data.

METHODS

A retrospective cohort analysis of records was carried out. To provide a detailed dataset on PU for the community of interest, demographic, general medical and PU data were extracted from mandatory incident reports and audit of electronic and paper medical records. This study is reported in accordance with the RECORD Guidelines from the Equator Network. Adult patients were enrolled from a district nursing service in the target region (n=1085) during 2015. The target region was based on a geographical region bounded by a single postcode district (target region) consisting of 62,000 people of whom approximately 50,000 were adults, 3000 of whom were aged >75 years.

RESULTS

The total number of recorded PUs was n=137 in 103 individuals. Data from mandatory incident reports was obtainable for nearly all variables. Electronic and paper medical records were less reliable due to missing data.

CONCLUSION

Detailed characteristics of community-dwelling PU patients can be derived from routinely collected data, and provides various forms and levels of information which could feed into different projects. The use of mandatory reporting fields increases the level of reporting and reduces missing data. Data enriched with information from electronic and paper records could inform the addition of variables to mandatory forms to improve characterisation of community dwellers with PUs.

Impact of repeated hospital accreditation surveys on quality and reliability, an 8-year interrupted time series analysis

OBJECTIVE

To evaluate whether hospital re-accreditation improves quality, patient safety and reliability over three accreditation cycles by testing the accreditation life cycle model on quality measures.

DESIGN

The validity of the life cycle model was tested by calibrating interrupted time series (ITS) regression equations for 27 quality measures. The change in the variation of quality over the three accreditation cycles was evaluated using the Levene's test.

SETTING

A 650-bed tertiary academic hospital in Abu Dhabi, UAE.

PARTICIPANTS

Each month (over 96 months), a simple random sample of 10% of patient records was selected and audited resulting in a total of 388 800 observations from 14 500 records.

INTERVENTIONS

The impact of hospital accreditation on the 27 quality measures was observed for 96 months, 1-year preaccreditation (2007) and 3 years postaccreditation for each of the three accreditation cycles (2008, 2011 and 2014).

MAIN OUTCOME MEASURES

The life cycle model was evaluated by aggregating the data for 27 quality measures to produce a composite score (Y_C) and to fit an ITS regression equation to the unweighted monthly mean of the series.

RESULTS

The results provide some evidence for the validity of the four phases of the life cycle namely, the initiation phase, the presurvey phase, the postaccreditation slump and the stagnation phase. Furthermore, the life cycle model explains 87% of the variation in quality compliance measures (R²=0.87). The best-fit ITS model contains two significant variables (β₁ and β₃) (p≤0.001). The Levene's test (p≤0.05) demonstrated a significant reduction in variation of the quality measures (Y_C) with subsequent accreditation cycles.

CONCLUSION

The study demonstrates that accreditation has the capacity to sustain improvements over the accreditation cycle. The significant reduction in the variation of the quality measures (Y_C) with subsequent accreditation cycles indicates that accreditation supports the goal of high reliability.

Acute care nurses' perceptions of electronic health record use: A mixed method study

AIM

The overall aim of this study is to examine nurses' perceptions of electronic health record use in an acute care hospital setting.

DESIGN

This study uses a sequential mixed methods design in two phases.

METHODS

Phase one consists of a survey of Registered Nurses to understand nurses' perceptions of electronic health record use. Phase two is comprised of focus groups of a subsample from phase one. Data collection occurred from November 2015 - August 2016 and was done in Toronto, Canada.

RESULTS

In phase one, navigation was found to be a predictor of nurses' perceptions of electronic health record use. In phase two, participants discussed the following five topics: (1) navigation; (2) functionality; (3) organizational standards; (4) documentation workload and (5) issues of system performance and response time. This study has implications for organizations implementing electronic health records, nursing leaders and electronic health record vendors.

Helping Older Adults Improve Their Medication Experience (HOME) by Addressing Medication Regimen Complexity in Home Healthcare

In skilled home healthcare (SHHC), communication between nurses and physicians is often inadequate for medication reconciliation and needed changes to the medication regimens are rarely made. Fragmentation of electronic health record (EHR) systems, transitions of care, lack of physician-nurse in-person contact, and poor understanding of medications by patients and their families put patients at risk for serious adverse outcomes. The aim of this study was to develop and test the HOME tool, an informatics tool to improve communication about medication regimens, share the insights of home care nurses with physicians, and highlight to physicians and nurses the complexity of medication schedules. We used human computer interaction design and evaluation principles, automated extraction from standardized forms, and modification of existing EHR fields to highlight key medication-related insights that had arisen during the SHHC visit. Separate versions of the tool were developed for physicians/nurses and patients/caregivers. A pilot of the tool was conducted using 20 SHHC encounters. Home care nurses and physicians found the tool useful for communication. Home care nurses were able to implement the HOME tool into their clinical workflow and reported improved communication with physicians about medications. This simple and largely automated tool improves understanding and communication around medications in SHHC.

A qualitative study of new graduates' readiness to use nursing informatics in acute care settings: clinical nurse educators' perspectives

BACKGROUND

There is an increase in demand for newly graduated nurses who are ready to use nursing informatics (NI) efficiently in technology-rich healthcare environments. However, the progress of embedding NI into curricula has been slow worldwide, and literature reports graduates are not ready to use NI tools effectively in the workplace, posing potential threats to patient safety. In the absence of National Standards for NI competencies, graduates' NI needs on entering the workplace need to be explored.

AIM

To identify graduates' NI needs on entering the workplace in acute care settings from the perspectives of clinical nurse educators.

METHODS

A qualitative study using interpretive description with one focus group of six clinical nurse educators was conducted. Clinical nurse educators who are significantly involved in supporting graduates from their first day in the workplace were purposively recruited. The focus group was audiotaped, transcribed verbatim and analysed using thematic analysis.

RESULTS

Graduates were found to be inadequately prepared to use NI tools on entering the workplace. Inefficient hospital systems and a ward culture that was discouraging graduates' NI practice were identified as major barriers to the implementation of NI practice. Lack of exposure to specific hospital systems as undergraduates was also identified as a significant barrier to NI practice among graduates.

CONCLUSIONS

As well as supporting the pre-existing studies on NI skills in graduates and barriers to graduates' NI practice, this current study identified the need for nursing schools to further integrate NI into formal curricula and increased opportunity for exposure to hospital systems as undergraduates. Further studies in multiple settings across Australia are recommended to ensure the transferability of the findings of this study.

Evaluation of Electronic Health Record Implementation in Hospitals

The effectiveness of electronic health records has not previously been widely evaluated. Thus, this national cross-sectional study was conducted to evaluate electronic health records, from the perspective of nurses, by examining how they use the records, their opinions on the quality of the systems, and their overall levels of satisfaction with electronic health records. The relationship between these constructs was measured, and its predictors were investigated. A random sample of Jordanian hospitals that used electronic health records was selected, and data were gathered using a self-administered questionnaire, based on the DeLone and McLean Information Systems Success model. In total, 1648 nurses from 17 different hospitals participated in the study. Results indicated that nurses were largely positive about the use and quality of the systems and were satisfied with electronic health records. Significant positive correlations were found between these constructs, and a number of demographical and situational factors were found to have an effect on nurses' perceptions. The study provides a systematic evaluation of different facets of electronic health records, which is fundamental for recognizing the motives and challenges for success and for further enhancing this success. The work proves that nurses favor the use of electronic health records and are satisfied with it and perceive its high quality, and the findings should therefore encourage their ongoing implementation.

Software development to support decision making in the selection of nursing diagnoses and interventions for children and adolescents

OBJECTIVE

to report the development of a software to support decision-making for the selection of nursing diagnoses and interventions for children and adolescents, based on the nomenclature of nursing diagnoses, outcomes and interventions of a university hospital in Paraiba.

METHOD

a methodological applied study based on software engineering, as proposed by Pressman, developed in three cycles, namely: flow chart construction, development of the navigation interface, and construction of functional expressions and programming development.

RESULT

the software consists of administrative and nursing process screens. The assessment is automatically selected according to age group, the nursing diagnoses are suggested by the system after information is inserted, and can be indicated by the nurse. The interventions for the chosen diagnosis are selected by structuring the care plan.

CONCLUSION

the development of this tool used to document the nursing actions will contribute to decision-making and quality of care.

Implementation of Electronic Health Records in US Nursing Homes

While electronic health records have emerged as promising tools to help improve quality of care, nursing homes have lagged behind in implementation. This study assessed electronic health records implementation, associated facility characteristics, and potential impact on quality indicators in nursing homes. Using national Centers for Medicare & Medicaid Services and survey data for nursing homes, a cross-sectional analysis was conducted to identify variations between nursing homes that had and had not implemented electronic health records. A difference-in-differences analysis was used to estimate the longitudinal effect of electronic health records on commonly used quality indicators. Data from 927 nursing homes were examined, 49.1% of which had implemented electronic health records. Nursing homes with electronic health records were more likely to be nonprofit/government owned (P = .04) and had a lower percentage of Medicaid residents (P = .02) and higher certified nursing assistant and registered nurse staffing levels (P = .002 and .02, respectively). Difference-in-differences analysis showed greater quality improvements after implementation for five long-stay and two short-stay quality measures (P = .001 and .01, respectively) compared with those who did not implement electronic health records. Implementation rates in nursing homes are low compared with other settings, and better-resourced facilities are more likely to have implemented electronic health records. Consistent with other settings, electronic health records implementation improves quality in nursing homes, but further research is needed to better understand the mechanism for improvement and how it can best be supported.

Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider

INTRODUCTION

There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services.

OBJECTIVES

We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration.

METHODS

Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange.

RESULTS

Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system.

CONCLUSIONS

There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients.

Computerized nursing process in the Intensive Care Unit: ergonomics and usability

Abstract OBJECTIVE Analyzing the ergonomics and usability criteria of the Computerized Nursing Process based on the International Classification for Nursing Practice in the Intensive Care Unit according to International Organization for Standardization(ISO). METHOD A quantitative, quasi-experimental, before-and-after study with a sample of 16 participants performed in an Intensive Care Unit. Data collection was performed through the application of five simulated clinical cases and an evaluation instrument. Data analysis was performed by descriptive and inferential statistics. RESULTS The organization, content and technical criteria were considered "excellent", and the interface criteria were considered "very good", obtaining means of 4.54, 4.60, 4.64 and 4.39, respectively. The analyzed standards obtained means above 4.0, being considered "very good" by the participants. CONCLUSION The Computerized Nursing Processmet ergonomic and usability standards according to the standards set by ISO. This technology supports nurses' clinical decision-making by providing complete and up-to-date content for Nursing practice in the Intensive Care Unit.

Effects of health information technology on patient outcomes: a systematic review

OBJECTIVE

To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes.

MATERIALS AND METHODS

The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes.

RESULTS

Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry.

DISCUSSION AND CONCLUSION

Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

Student and Faculty Perceptions of iPad Integration in a Prelicensure Program

This article provides an overview of strategies for integration of iPads into a prelicensure nursing program. The study evaluated the actual use of iPads in the classroom, skills and simulation laboratories, and clinical settings and examined the satisfaction of students and faculty with the iPad platform. The study findings provide guidance for a phased-in iPad implementation for prelicensure nursing programs.

In Search of Social Translucence: An Audit Log Analysis of Handoff Documentation Views and Updates

Communication and information sharing are critical parts of teamwork in the hospital; however, achieving open and fluid communication can be challenging. Finding specific patient information within documentation can be difficult. Recent studies on handoff documentation tools show that resident handoff notes are increasingly used as an alternative information source by non-physician clinicians. Previous findings also show that residents have become aware of this unintended use. This study investigated the alignment of resident note updating patterns and team note viewing patterns based on usage log data of handoff notes. Qualitative interviews with clinicians were used to triangulate findings based on the log analysis. The study found that notes that were frequently updated were viewed significantly more frequently than notes updated less often (p < 2.2 × 10(-16)). Almost 44% of all notes had aligned frequency of views and updates. The considerable percentage (56%) of mismatched note utilization suggests an opportunity for improvement.

Nurses' use of an integrated electronic health record: results of a case site analysis

PURPOSE

To explore how nurses use an integrated Electronic Health Record (EHR) in practice.

METHODS

A multi-site case study across two hospitals in Kaiser Permanente Northern California. Non-participant observation was used to explore nurses' use of the EHR, while semi-structured interviews with nurses and managers explored their perceptions of the EHR and how it affected their practice. Data were analyzed thematically using codes derived deductively from the literature and inductively from the data.

RESULTS

Key themes arising from the analysis suggest that the EHR changed various elements of the way nurses practiced. Introducing the EHR was thought to have improved communication, ease of access to information and the safety of medication administration processes. At an organizational level, there was variability in how the EHR was used to support care documentation and initiatives to improve the quality of care provided by nurses.

CONCLUSION

The EHR was perceived to improve efficiency, safety and communication by the majority of nurses who were interviewed. However, it is likely that a number of other factors such as individual nurse's characteristics and organizational culture influence how an EHR can be used effectively to improve outcomes for patients.

Congruency between educators' teaching beliefs and an electronic health record teaching strategy

BACKGROUND

Technology has changed healthcare institutions into automated settings with the potential to greatly enhance the quality of healthcare. Implementation of electronic health records (EHRs) to replace paper charting is one example of the influence of technology on healthcare worldwide. In the past decade nursing higher education has attempted to keep pace with technological changes by integrating EHRs into learning experiences. Little is known about educators' teaching beliefs and the use of EHRs as a teaching strategy.

AIM

This study explores the composition of core teaching beliefs of nurse educators and their related teaching practices within the context of teaching with EHRs in the classroom.

METHODS

A collective case study and qualitative research approach was used to explore and describe teaching beliefs of seven nurse educators teaching with EHRs. Data collection included open-ended, audio-taped interviews and non-participant observation. Content analysis of transcribed interviews and observational field notes focused on identification of teaching belief themes and associated practices.

FINDINGS

Two contrasting collective case studies of teaching beliefs emerged. Constructivist beliefs were dominant, focused on experiential, student-centered, contextual and collaborative learning, and associated with expanded and a futuristic view of EHRs use. Objectivist beliefs focused on educators' control of the context of learning and were associated with a constrained, limited view of EHRs. Constructivist educators embrace technological change, an essential ingredient of educational reform.

CONCLUSIONS

We encourage nurse educators to adopt a constructivist view to using technology in teaching in order to prepare nurses for a rapidly changing, technologically sophisticated practice.

Nursing informatics year in review

Nurses' role in patient care has evolved and so has their role in the use of technology to improve health care delivery. Nursing informatics research seeks to study the science of nursing, computer technology, and information science to enhance the quality of nursing practice. In an effort to increase patient safety and reduce health care-associated costs, nursing administrators have been challenged to incorporate technology and nursing practice. Unfortunately, health care institutions may not benefit from this body of work, as nursing informatics research associated with increased patient safety and cost containment may not be readily accessible for nursing administrators. The purpose of this study was to present the findings of a nursing informatics literature review and highlight those publications seen as most influential in the last year. In addition, we seek identify common topics and emerging themes in nursing informatics published research.