Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

Pharmacogenetics Clinical Decision Support Systems for Primary Care in England: Co-Design Study

BACKGROUND

Pharmacogenetics can impact patient care and outcomes through personalizing the selection of medicines, resulting in improved efficacy and a reduction in harmful side effects. Despite the existence of compelling clinical evidence and international guidelines highlighting the benefits of pharmacogenetics in clinical practice, implementation within the National Health Service in the United Kingdom is limited. An important barrier to overcome is the development of IT solutions that support the integration of pharmacogenetic data into health care systems. This necessitates a better understanding of the role of electronic health records (EHRs) and the design of clinical decision support systems that are acceptable to clinicians, particularly those in primary care.

OBJECTIVE

Explore the needs and requirements of a pharmacogenetic service from the perspective of primary care clinicians with a view to co-design a prototype solution.

METHODS

We used ethnographic and think-aloud observations, user research workshops, and prototyping. The participants for this study included general practitioners and pharmacists. In total, we undertook 5 sessions of ethnographic observation to understand current practices and workflows. This was followed by 3 user research workshops, each with its own topic guide starting with personas and early ideation, through to exploring the potential of clinical decision support systems and prototype design. We subsequently analyzed workshop data using affinity diagramming and refined the key requirements for the solution collaboratively as a multidisciplinary project team.

RESULTS

User research results identified that pharmacogenetic data must be incorporated within existing EHRs rather than through a stand-alone portal. The information presented through clinical decision support systems must be clear, accessible, and user-friendly as the service will be used by a range of end users. Critically, the information should be displayed within the prescribing workflow, rather than discrete results stored statically in the EHR. Finally, the prescribing recommendations should be authoritative to provide confidence in the validity of the results. Based on these findings we co-designed an interactive prototype, demonstrating pharmacogenetic clinical decision support integrated within the prescribing workflow of an EHR.

CONCLUSIONS

This study marks a significant step forward in the design of systems that support pharmacogenetic-guided prescribing in primary care settings. Clinical decision support systems have the potential to enhance the personalization of medicines, provided they are effectively implemented within EHRs and present pharmacogenetic data in a user-friendly, actionable, and standardized format. Achieving this requires the development of a decoupled, standards-based architecture that allows for the separation of data from application, facilitating integration across various EHRs through the use of application programming interfaces (APIs). More globally, this study demonstrates the role of health informatics and user-centered design in realizing the potential of personalized medicine at scale and ensuring that the benefits of genomic innovation reach patients and populations effectively.

Implementing and Evaluating a National Integrated Digital Registry and Clinical Decision Support System in Early Intervention in Psychosis Services (Early Psychosis Informatics Into Care): Co-Designed Protocol

BACKGROUND

Early intervention in psychosis (EIP) services are nationally mandated in England to provide multidisciplinary care to people experiencing first-episode psychosis, which disproportionately affects deprived and ethnic minority youth. Quality of service provision varies by region, and people from historically underserved populations have unequal access. In other disease areas, including stroke and dementia, national digital registries coupled with clinical decision support systems (CDSSs) have revolutionized the delivery of equitable, evidence-based interventions to transform patient outcomes and reduce population-level disparities in care. Given psychosis is ranked the third most burdensome mental health condition by the World Health Organization, it is essential that we achieve the same parity of health improvements.

OBJECTIVE

This paper reports the protocol for the program development phase of this study, in which we aimed to co-design and produce an evidence-based, stakeholder-informed framework for the building, implementation, piloting, and evaluation of a national integrated digital registry and CDSS for psychosis, known as EPICare (Early Psychosis Informatics into Care).

METHODS

We conducted 3 concurrent work packages, with reciprocal knowledge exchange between each. In work package 1, using a participatory co-design framework, key stakeholders (clinicians, academics, policy makers, and patient and public contributors) engaged in 4 workshops to review, refine, and identify a core set of essential and desirable measures and features of the EPICare registry and CDSS. Using a modified Delphi approach, we then developed a consensus of data priorities. In work package 2, we collaborated with National Health Service (NHS) informatics teams to identify relevant data currently captured in electronic health records, understand data retrieval methods, and design the software architecture and data model to inform future implementation. In work package 3, observations of stakeholder workshops and individual interviews with representative stakeholders (n=10) were subject to interpretative qualitative analysis, guided by normalization process theory, to identify factors likely to influence the adoption and implementation of EPICare into routine practice.

RESULTS

Stage 1 of the EPICare study took place between December 2021 and September 2022. The next steps include stage 2 building, piloting, implementation, and evaluation of EPICare in 5 demonstrator NHS Trusts serving underserved and diverse populations with substantial need for EIP care in England. If successful, this will be followed by stage 3, in which we will seek NHS adoption of EPICare for rollout to all EIP services in England.

CONCLUSIONS

By establishing a multistakeholder network and engaging them in an iterative co-design process, we have identified essential and desirable elements of the EPICare registry and CDSS; proactively identified and minimized potential challenges and barriers to uptake and implementation; and addressed key questions related to informatics architecture, infrastructure, governance, and integration in diverse NHS Trusts, enabling us to proceed with the building, piloting, implementation, and evaluation of EPICare.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50177.

The Large-Scale Implementation of a Health Information System in Brazilian University Hospitals: Process and Outcomes

Governments around the globe are paving the way for healthcare services that can have a profound impact on the overall well-being and development of their nations. However, government programs to implement health information technologies on a large-scale are challenging, especially in developing countries. In this article, the process and outcomes of the large-scale implementation of a hospital information system for the management of Brazilian university hospitals are analyzed. Based on a qualitative approach, this research involved 21 hospitals and comprised a documentary search, interviews with 24 hospital managers and two system user focus groups, and a questionnaire of 736 respondents. Generally, we observed that aspects relating to the wider context of system implementation (macro level), the managerial structure, cultural nuances, and political dynamics within each hospital (meso level), as well as the technology, work activities, and individuals themselves (micro level) acted as facilitators and/or obstacles to the implementation process. The dynamics and complex interactions established between these aspects had repercussions on the process, including the extended time necessary to implement the national program and the somewhat mixed outcomes obtained by hospitals in the national network. Mostly positive, these outcomes were linked to the eight emerging dimensions of practices and work processes; planning, control, and decision making; transparency and accountability; optimization in the use of resources; productivity of professionals; patient information security; safety and quality of care; and improvement in teaching and research. We argued here that to maximize the potential of information technology in healthcare on a large-scale, an integrative and cooperative vision is required, along with a high capacity for change management, considering the different regional, local, and institutional contexts.

Provenance Data Management in Health Information Systems: A Systematic Literature Review

AIMS

This article aims to perform a Systematic Literature Review (SLR) to better understand the structures of different methods, techniques, models, methodologies, and technologies related to provenance data management in health information systems (HISs). The SLR developed here seeks to answer the questions that contribute to describing the results.

METHOD

An SLR was performed on six databases using a search string. The backward and forward snowballing technique was also used. Eligible studies were all articles in English that presented on the use of different methods, techniques, models, methodologies, and technologies related to provenance data management in HISs. The quality of the included articles was assessed to obtain a better connection to the topic studied.

RESULTS

Of the 239 studies retrieved, 14 met the inclusion criteria described in this SLR. In order to complement the retrieved studies, 3 studies were included using the backward and forward snowballing technique, totaling 17 studies dedicated to the construction of this research. Most of the selected studies were published as conference papers, which is common when involving computer science in HISs. There was a more frequent use of data provenance models from the PROV family in different HISs combined with different technologies, among which blockchain and middleware stand out. Despite the advantages found, the lack of technological structure, data interoperability problems, and the technical unpreparedness of working professionals are still challenges encountered in the management of provenance data in HISs.

CONCLUSION

It was possible to conclude the existence of different methods, techniques, models, and combined technologies, which are presented in the proposal of a taxonomy that provides researchers with a new understanding about the management of provenance data in HISs.

Implementing a successful targeted neonatal echocardiography service and a training program: The ten stages of change

Implementing any new service or program in the health care system is not always straightforward; a multi-stage implementation process is required most of the time. With the advancements in neonatal care and increased survival rates, there has been an increased need for ongoing assessment of hemodynamic stability. At the Children's Hospital of Eastern Ontario and the Ottawa Hospital Neonatal Intensive Care Units (NICUs), University of Ottawa, Canada, Targeted Neonatal Echocardiography service (TnEcho) was successfully established and has led to improvement in the hemodynamic evaluation and decision making in neonatal intensive care. In this article, we describe our experience establishing this program and the process of ensuring its success. This review article highlights the ten steps taken by multiple stakeholders to achieve this goal; this may help other centres implement a similar program.

Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review

Background

The adoption of electronic health records (EHRs) and electronic medical records (EMRs) has been slow in the mental health context, partly because of concerns regarding the collection of sensitive information, the standardization of mental health data, and the risk of negatively affecting therapeutic relationships. However, EHRs and EMRs are increasingly viewed as critical to improving information practices such as the documentation, use, and sharing of information and, more broadly, the quality of care provided.

Objective

This paper aims to undertake a scoping review to explore the impact of EHRs on information practices in mental health contexts and also explore how sensitive information, data standardization, and therapeutic relationships are managed when using EHRs in mental health contexts.

Methods

We considered a scoping review to be the most appropriate method for this review because of the relatively recent uptake of EHRs in mental health contexts. A comprehensive search of electronic databases was conducted with no date restrictions for articles that described the use of EHRs, EMRs, or associated systems in the mental health context. One of the authors reviewed all full texts, with 2 other authors each screening half of the full-text articles. The fourth author mediated the disagreements. Data regarding study characteristics were charted. A narrative and thematic synthesis approach was taken to analyze the included studies’ results and address the research questions.

Results

The final review included 40 articles. The included studies were highly heterogeneous with a variety of study designs, objectives, and settings. Several themes and subthemes were identified that explored the impact of EHRs on information practices in the mental health context. EHRs improved the amount of information documented compared with paper. However, mental health–related information was regularly missing from EHRs, especially sensitive information. EHRs introduced more standardized and formalized documentation practices that raised issues because of the focus on narrative information in the mental health context. EHRs were found to disrupt information workflows in the mental health context, especially when they did not include appropriate templates or care plans. Usability issues also contributed to workflow concerns. Managing the documentation of sensitive information in EHRs was problematic; clinicians sometimes watered down sensitive information or chose to keep it in separate records. Concerningly, the included studies rarely involved service user perspectives. Furthermore, many studies provided limited information on the functionality or technical specifications of the EHR being used.

Conclusions

We identified several areas in which work is needed to ensure that EHRs benefit clinicians and service users in the mental health context. As EHRs are increasingly considered critical for modern health systems, health care decision-makers should consider how EHRs can better reflect the complexity and sensitivity of information practices and workflows in the mental health context.

The introduction of a single Electronic Health Record for maternity units in Ireland: an outline of the experiences of the project management team. (Preprint)

Electronic health records (EHRs) are being introduced worldwide. The change from paper to electronic records has not always been a seamless or quick process; however, EHRs are viewed as central to updating modern health care, especially organization structures and delivery of sustainable care with the potential for joint decision-making with the patient. The objective of this viewpoint paper is to outline how an EHR is being developed in Ireland. The focus of the Maternal & Newborn Clinical Management System project is the design and implementation of an EHR for all women and babies in the maternity services in the Republic of Ireland. The paper also outlines the lessons learned from the planning to the optimization stage of the project. The paper was developed through discussions with the project management team and their completed reports that outline the lessons they acquired from each project stage. Key lessons learned from each stage of the project are highlighted. This viewpoint paper explains how the national project management team is implementing the EHR and outlines the experiences and lessons learned and the challenges ahead following the phase one introduction. The Maternal & Newborn Clinical Management System is an example of a clinician-led, patient-focused, change management project from its inception to implementation. The introduction of EHRs is essential in modernizing health care and optimizing patient outcomes through the accurate and appropriate use of data.

Participatory co-design and normalisation process theory with staff and patients to implement digital ways of working into routine care: the example of electronic patient-reported outcomes in UK renal services

BACKGROUND

Successful implementation of digital health systems requires contextually sensitive solutions. Working directly with system users and drawing on implementation science frameworks are both recommended. We sought to combine Normalisation Process Theory (NPT) with participatory co-design methods, to work with healthcare stakeholders to generate implementation support recommendations for a new electronic patient reported outcome measure (ePRO) in renal services. ePROs collect data on patient-reported symptom burden and illness experience overtime, requiring sustained engagement and integration into existing systems.

METHODS

We identified co-design methods that could be mapped to NPT constructs to generate relevant qualitative data. Patients and staff from three renal units in England participated in empathy and process mapping activities to understand 'coherence' (why the ePRO should be completed) and 'cognitive participation' (who would be involved in collecting the ePRO). Observation of routine unit activity was completed to understand 'collective action' (how the collection of ePRO could integrate with service routines).

RESULTS

The mapping activities and observation enabled the research team to become more aware of the key needs of both staff and patients. Working within sites enabled us to consider local resources and barriers. This produced 'core and custom' recommendations specifying core needs that could be met with customised local solutions. We identified two over-arching themes which need to be considered when introducing new digital systems (1) That data collection is physical (electronic systems need to fit into physical spaces and routines), and (2) That data collection is intentional (system users must be convinced of the value of collecting the data).

CONCLUSIONS

We demonstrate that NPT constructs can be operationalised through participatory co-design to work with stakeholders and within settings to collaboratively produce implementation support recommendations. This enables production of contextually sensitive implementation recommendations, informed by qualitative evidence, theory, and stakeholder input. Further longitudinal evaluation is necessary to determine how successful the recommendations are in practice.

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study

Introduction

To explore the impact of a three-week downtime to an electronic pathology system on patient safety and experience.

Methods

Qualitative study consisting of semi-structured interviews and a focus group at a large NHS teaching hospital in England. Participants included NHS staff (n = 16) who represented a variety of staff groups (doctors, nurses, healthcare assistants) and board members. Data were collected 2–5 months after the outage and were analysed thematically.

Results

We present the implications which the IT breakdown had for both patient safety and patient experience. Whilst there was no actual recorded harm to patients during the crisis, there was strong and divided opinion regarding the potential for a major safety incident to have occurred. Formal guidance existed to assist staff to navigate the outage but there was predominantly a reliance on informal workarounds. Junior clinicians seemed to struggle without access to routine blood test results whilst senior clinicians seemed largely unperturbed. Patient experience was negatively affected due to the extensive wait time for manually processed diagnostic tests, increasing logistical problems for patients.

Conclusion

The potential negative consequences on patient safety and experience relating to IT failures cannot be underestimated. To minimise risks during times of crisis, clear communication involving all relevant stakeholders, and guidance and management strategies that are agreed upon and communicated to all staff are recommended. To improve patient experience flexible approaches to patient management are suggested.

Demonstrating the value of digital health: Guidance on contextual evidence gathering for companies in different stages of maturity

Application of value-based healthcare policies affects all actors in social and health care field, including the Digital Health Intervention (DHI) providers aiming to enter the industry or expand their market. Apparent lack of fit between evidence and expectations inhibits the growth of DHI companies. The companies need efficient and credible methods to access and demonstrate the value of their DHIs. Building on the stage-of-maturity logic presented in World Health Organization's (WHO) guide of monitoring and evaluating digital health interventions and Context-Intervention-Mechanism-Outcome (CIMO) logic, we provide a potential approach for DHI companies to assess the evidence needed in their current situation. The proposed approach takes into account the company's future development goals and the business environment, reflecting for every stage of technology maturity according to the WHO guidelines and through the CIMO lens. The focus is on specific intervention and its fit for different organizational and national contexts. The solution guides the research process of the company to understand which evidence-gathering topics should be addressed. This evidence can be beneficial for companies to enter into, occupy, expand or sustain in the domestic or international market.

Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study

BACKGROUND

The electronic patient record (EPR) has been introduced into nursing homes in order to facilitate documentation practices such as assessment and care planning, which play an integral role in the provision of dementia care. However, little is known about how the EPR facilitates or hinders these practices from the end-user's perspective. Therefore, the objective of this qualitative study was to explore the usability issues associated with the EPR for assessment and care planning for people with dementia in nursing homes from a staff perspective.

METHODS

An exploratory, qualitative research design with a multiple case study approach was used. Contextual Inquiry was carried out with a variety of staff members (n = 21) who used the EPR in three nursing homes situated in Belgium, Czech Republic and Spain. Thematic analysis was used to code interview data, with codes then sorted into a priori components of the Health Information Technology Evaluation Framework: device, software functionality, organisational support. Two additional themes, structure and content, were also added.

RESULTS

Staff provided numerous examples of the ways in which EPR systems are facilitating and hindering assessment and care planning under each component, particularly for people with dementia, who may have more complex needs in comparison to other residents. The way in which EPR systems were not customisable was a common theme across all three homes. A comparison of organisational policies and practices revealed the importance of training, system support, and access, which may be linked with the successful adoption of the EPR system in nursing homes.

CONCLUSIONS

EPR systems introduced into the nursing home environment should be customisable and reflect best practice guidelines for dementia care, which may lead to improved outcomes and quality of life for people with dementia living in nursing homes. All levels of nursing home staff should be consulted during the development, implementation and evaluation of EPR systems as part of an iterative, user-centred design process.

A Real-world Evaluation of a Case-based Reasoning Algorithm to Support Antimicrobial Prescribing Decisions in Acute Care

Background

A locally developed case-based reasoning (CBR) algorithm, designed to augment antimicrobial prescribing in secondary care was evaluated.

Methods

Prescribing recommendations made by a CBR algorithm were compared to decisions made by physicians in clinical practice. Comparisons were examined in 2 patient populations: first, in patients with confirmed Escherichia coli blood stream infections (“E. coli patients”), and second in ward-based patients presenting with a range of potential infections (“ward patients”). Prescribing recommendations were compared against the Antimicrobial Spectrum Index (ASI) and the World Health Organization Essential Medicine List Access, Watch, Reserve (AWaRe) classification system. Appropriateness of a prescription was defined as the spectrum of the prescription covering the known or most-likely organism antimicrobial sensitivity profile.

Results

In total, 224 patients (145 E. coli patients and 79 ward patients) were included. Mean (standard deviation) age was 66 (18) years with 108/224 (48%) female sex. The CBR recommendations were appropriate in 202/224 (90%) compared to 186/224 (83%) in practice (odds ratio [OR]: 1.24 95% confidence interval [CI]: .392–3.936; P = .71). CBR recommendations had a smaller ASI compared to practice with a median (range) of 6 (0–13) compared to 8 (0–12) (P < .01). CBR recommendations were more likely to be classified as Access class antimicrobials compared to physicians’ prescriptions at 110/224 (49%) vs. 79/224 (35%) (OR: 1.77; 95% CI: 1.212–2.588; P < .01). Results were similar for E. coli and ward patients on subgroup analysis.

Conclusions

A CBR-driven decision support system provided appropriate recommendations within a narrower spectrum compared to current clinical practice. Future work must investigate the impact of this intervention on prescribing behaviors more broadly and patient outcomes.

Nurturing the digital baby: Open innovation for development and optimization

The primary aim around developing and optimizing an electronic health record is to improve patient care and population health. The objective of this study is to design and evaluate an action research approach for the optimization of the design of a summary page artefact within an electronic health record for newborn healthcare. An action research approach was chosen for its participatory democratic process for developing practical knowledge and solutions. Collaborative workshops lead by an independent graphic facilitator with a 'bottom up' approach, involving self-selected motivated members from multidisciplinary healthcare teams, were designed and conducted. To evaluate this approach, insights were drawn from behavioural and design science paradigms to demonstrate that knowledge and understanding of the design problem and its solution were acquired in building the optimized summary page artefact. Information system development for healthcare requires consideration not just of what we do but how and why we do things. Our analysis demonstrates that action design research represents an agile and lean approach for successful optimization and implementation of information system development in healthcare.

Personal electronic healthcare records: What influences consumers to engage with their clinical data online? A literature review

Background:

Online electronic records such as patient portals and personally controlled electronic health records (PEHRs) have been widely viewed as a key component to modernising the delivery of healthcare but the uptake of such systems has been slow.

Objective:

The purpose of this literature review was to determine what influences consumers to engage and interact with their clinical data online.

Method:

A scoping literature review following PRISMA guidelines was completed. Electronic patient record research published between January 2009 and December 2018 was included. Following screening and full-text reviews, a total of 64 records were included in this review.

Results:

Three key areas of influence on consumer engagement with their clinical data online emerged: demographic factors affecting consumer interaction with PEHRs; consumers’ perceived benefits and detriments of PEHR use; and the influence of PEHR use on consumer empowerment and responsibility.

Discussion:

Consumer motivation and readiness for engaging with their clinical data online and their long-term ongoing use of these systems requires further exploration.

Conclusion:

As worldwide rates of consumer interactions with individual online clinical data remain low, what influences consumer engagement with a PEHR remains unknown. Further research into the consumer perspective of, and interaction with, a PEHR, needs to be undertaken to determine if factors such as frequent usage of the system by consumers leads to improved clinical outcomes.

Why does the NHS struggle to adopt eHealth innovations? A review of macro, meso and micro factors

BACKGROUND

Having a tax-funded and supposedly 'National' Health Service (NHS), one might assume that the UK is well-positioned to roll out eHealth innovations at scale. Yet, despite a strong policy push, the English NHS has been limited in the extent to which it has exploited the potential of eHealth.

MAIN BODY

This paper considers a range of macro, meso and micro factors influencing eHealth innovation in the English NHS.

CONCLUSIONS

While barriers to eHealth innovation exist at all scales, the fragmentation of the NHS is the most significant factor limiting adoption and diffusion. Rather than addressing problems of fragmentation, national policy seems to have intensified the digital divide. As the recently published NHS Long Term Plan places great emphasis on the role of digital transformation in helping health and care professionals communicate better and enabling people to access the care they need quickly and easily, the implications for the digital divide are likely to be significant for effectiveness, efficiency and equity.

Twenty-five years of national health IT: exploring strategy, structure, and systems in the English NHS

Objective

There is global interest in implementing national information systems to support healthcare, and the National Health Service in England (NHS) has a troubled 25-year history in this sphere. Our objective was to chronicle structural reorganizations within the NHS from 1973 to 2017, alongside concurrent national information technology (IT) strategies, as the basis for developing a conceptual model to aid understanding of the organizational factors involved.

Materials and Methods

We undertook an exploratory, retrospective longitudinal case study by reviewing strategic plans, legislation, and health policy documents, and constructed schemata for evolving structure and strategy. Literature on multi-organizational forms, complexity, national-level health IT implementations, and mega-projects was reviewed to identify factors that mapped to the schemata. Guided by strong structuration theory, these factors were superimposed on a simplified structural schema to create the conceptual model.

Results

Against a background of frequent NHS reorganizations, there has been a logical and emergent NHS IT strategy focusing progressively on technical and data standards, connectivity, applications, and consolidation. The NHS has a complex and hierarchical multi-organization form in which restructuring may impact a range of intra- and inter-organizational factors.

Discussion

NHS-wide IT programs have generally failed to meet expectations, though evaluations have usually overlooked longer-term progress. Realizing a long-term health IT strategy may be impeded by volatility of the implementation environment as organizational structures and relationships change. Key factors influencing the strategy-structure dyad can be superimposed on the tiered NHS structure to facilitate analysis of their impact.

Conclusion

Alignment between incremental health IT strategy and dynamic structure is an under-researched area. Lessons from organizational studies and the management of mega-projects may help in understanding some of the ongoing challenges.

Telehealth in palliative care is being described but not evaluated: a systematic review

BACKGROUND

Telehealth is growing and its application in palliative care is seen as a solution to pressures on palliative care services. A 2010 UK review reported growing awareness of telehealth in palliative care but a lack of evidence-based research to support its use. The primary aim of this review was to describe the current use of telehealth in palliative care in the UK and evaluate telehealth initiatives against a digital service standard. The secondary aim was to explore whether telehealth results in a reduction in emergency care access.

METHODS

Systematic review of the literature with thematic synthesis. Records were screened and data extracted by two reviewers. EMBASE, MEDLINE, CINAHL, Psychinfo and Cochrane central register for controlled trials were searched using pre-defined terms. Hand searching of conference literature, thesis databases and citation tracking was also conducted. The protocol for this systematic review was registered with PROSPERO and can be found at http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017080038.

RESULTS

The search identified 3807 titles and 30 studies were included in the review. Telehealth was used to support patients and carers, electronic record keeping and professional education. Notably, the number of home telemonitoring initiatives for patients had increased from the 2010 review. Despite this variety, many studies were small scale, descriptive and provided little evidence of evaluation of the service. Ten papers were sufficiently detailed to allow appraisal against the digital service standard and only one of these met all of the criteria to some extent. Seven studies made reference to emergency care access.

CONCLUSIONS

Although there is growth of telehealth services, there remains a lack of evaluation and robust study design meaning conclusions regarding the clinical application of telehealth in palliative care cannot be drawn. There is insufficient evidence to appreciate any benefit of telehealth on access to emergency care. Future work is needed to evaluate the use of telehealth in palliative care and improve telehealth design in line with digital service standards.

Sustaining the implementation of alcohol management practices by community sports clubs: a randomised control trial

BACKGROUND

Risky alcohol consumption is responsible for a variety of chronic and acute harms. Individuals involved in organised sport have been identified as one population group who consume risky amounts of alcohol both at the elite and the non-elite level. 'Good Sports', an alcohol management intervention focused on the community sports setting has been successful in addressing risky alcohol use and alcohol-related harm amongst players and sports fans. Sustaining such implementation effects is a common challenge across a variety of community settings. The primary aim of this trial was to assess the effectiveness of a web-based program in sustaining the implementation of best-practice alcohol management practices by community football clubs, relative to usual program care (i.e. control clubs).

METHODS

Non-elite, community football clubs in the Australian states of New South Wales and Victoria, that were participating in an alcohol management program (Good Sports) were recruited for the study. Consenting clubs were randomised into intervention (N = 92) or control (N = 96) groups. A web-based sustainability intervention was delivered to intervention clubs over three consecutive Australian winter sports seasons (April-September 2015-2017). The intervention was designed to support continued (sustained) implementation of alcohol management practices at clubs consistent with the program. Control group clubs received usual support from the national Good Sports Program. Primary outcome data was collected through observational audits of club venues and grounds.

RESULTS

A total of 92 intervention clubs (574 members) and 96 control clubs (612 members) were included in the final analysis. At follow-up, sustained implementation of alcohol management practices was high in both groups and there was no significant difference between intervention or control clubs at follow-up for both the proportion of clubs implementing 10 or more practices (OR 0.53, 95%CI 0.04-7.2; p = 0.63) or for the mean number of practices being implemented (mean difference 0.10, 95%CI -0.23-0.42; p = 0.55). There were also no significant differences between groups on measures of alcohol consumption by club members.

CONCLUSIONS

The findings suggest that sustained implementation of alcohol management practices was high, and similar, between clubs receiving web-based implementation support or usual program support.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614000746639. Prospectively registered 14/7/2014.

Staff expectations for the implementation of an electronic health record system: a qualitative study using normalisation process theory

BACKGROUND

Global evidence suggests a range of benefits for introducing electronic health record (EHR) systems to improve patient care. However, implementing EHR within healthcare organisations is complex and, in the United Kingdom (UK), uptake has been slow. More research is needed to explore factors influencing successful implementation. This study explored staff expectations for change and outcome following procurement of a commercial EHR system by a large academic acute NHS hospital in the UK.

METHODS

Qualitative interviews were conducted with 14 members of hospital staff who represented a variety of user groups across different specialities within the hospital. The four components of Normalisation Process Theory (Coherence, Cognitive participation, Collective action and Reflexive monitoring) provided a theoretical framework to interpret and report study findings.

RESULTS

Health professionals had a common understanding for the rationale for EHR implementation (Coherence). There was variation in willingness to engage with and invest time into EHR (Cognitive participation) at an individual, professional and organisational level. Collective action (whether staff feel able to use the EHR) was influenced by context and perceived user-involvement in EHR design and planning of the implementation strategy. When appraising EHR (Reflexive monitoring), staff anticipated short and long-term benefits. Staff perceived that quality and safety of patient care would be improved with EHR implementation, but that these benefits may not be immediate. Some staff perceived that use of the system may negatively impact patient care. The findings indicate that preparedness for EHR use could mitigate perceived threats to the quality and safety of care.

CONCLUSIONS

Health professionals looked forward to reaping the benefits from EHR use. Variations in level of engagement suggest early components of the implementation strategy were effective, and that more work was needed to involve users in preparing them for use. A clearer understanding as to how staff groups and services differentially interact with the EHR as they go about their daily work was required. The findings may inform other hospitals and healthcare systems on actions that can be taken prior to EHR implementation to reduce concerns for quality and safety of patient care and improve the chance of successful implementation.

A framework for analysing learning health systems: Are we removing the most impactful barriers?

INTRODUCTION

Learning health systems (LHS) are one of the major computing advances in health care. However, no prior research has systematically analysed barriers and facilitators for LHS. This paper presents an investigation into the barriers, benefits, and facilitating factors for LHS in order to create a basis for their successful implementation and adoption.

METHODS

First, the ITPOSMO-BBF framework was developed based on the established ITPOSMO (information, technology, processes, objectives, staffing, management, and other factors) framework, extending it for analysing barriers, benefits, and facilitators. Second, the new framework was applied to LHS.

RESULTS

We found that LHS shares similar barriers and facilitators with electronic health records (EHR); in particular, most facilitator effort in implementing EHR and LHS goes towards barriers categorised as human factors, even though they were seen to carry fewer benefits. Barriers whose resolution would bring significant benefits in safety, quality, and health outcomes remain.LHS envisage constant generation of new clinical knowledge and practice based on the central role of collections of EHR. Once LHS are constructed and operational, they trigger new data streams into the EHR. So LHS and EHR have a symbiotic relationship. The implementation and adoption of EHRs have proved and continues to prove challenging, and there are many lessons for LHS arising from these challenges.

CONCLUSIONS

Successful adoption of LHS should take account of the framework proposed in this paper, especially with respect to its focus on removing barriers that have the most impact.

Utilisation of Electronic Health Records for Public Health in Asia: A Review of Success Factors and Potential Challenges

INTRODUCTION

Electronic health records offer a valuable resource to improve health surveillance and evaluation as well as informing clinical decision making. They have been introduced in many different settings, including low- and middle-income countries, yet little is known of the progress and effectiveness of similar information systems within Asia. This study examines the implementation of EHR systems for use at a population health level in Asia and to identify their current role within public health, key success factors, and potential barriers in implementation.

MATERIAL AND METHODS

A systematic search process was implemented. Five databases were searched with MeSH key terms and Boolean phrases. Articles selected for this review were based on hospital provider electronic records with a component of implementation, utilisation, or evaluation for health systems or at least beyond direct patient care. A proposed analytic framework considered three interactive components: the content, the process, and the context.

RESULTS

Thirty-two articles were included in the review. Evidence suggests that benefits are significant but identifying and addressing potential challenges are critical for success. A comprehensive preparation process is necessary to implement an effective and flexible system.

DISCUSSION

Electronic health records implemented for public health can allow the identification of disease patterns, seasonality, and global trends as well as risks to vulnerable populations. Addressing implementation challenges will facilitate the development and efficacy of public health initiatives in Asia to identify current health needs and mitigate future risks.

The role of patients and carers in diffusing a health-care innovation: A case study of "My Medication Passport"

Background

Patients are increasingly recognized as playing important roles in improving health services. Little is known about the mechanisms by which patients develop and diffuse local innovations in a complex health‐care system.

Objective

To ascertain how diffusion of an innovation, My Medication Passport, occurred and roles played by patients in it.

Design

Case study: quantitative mapping of innovation's diffusion and analysis of the routes and occupations of those through whom the innovation spread; documentary analysis; reflective assessment of patient's roles.

Setting and participants

NHS Trusts, third sector organizations, patients and health‐care professionals.

Interventions studied

Co‐produced action to raise awareness and influence use of the innovation; order database which enabled ease of access to the innovation.

Main outcome measures

Geographical spread of innovation; occupations of individuals; types of organizations using the innovation.

Results

The innovation spread from initial development and use in Northwest London across the UK and beyond. Key roles played by patients were as follows: co‐producer; advocate; relationship builder; relationship broker; planner; presenter; awareness raiser; trainer; networker. Patients identified and introduced potential audiences and users to MMP, using social, organizational, sectoral, lay and professional networks to do so. They organized a range of awareness‐raising and communication activities, monitored feedback, evaluated the impact and responded to new interest.

Discussion and conclusions

The roles of patients in diffusing innovations are under‐recognized. Collaborative working between patients, carers and health‐care professionals in planning and progressing the use and supporting diffusion of the innovation was important. Principles described in this study are relevant to progressing other patient‐led ideas for innovative changes relating to health service development.

Potential impact of data source and interoperability messaging on health information technology (HIT) users: a study series from the United States Department of Veterans Affairs

BACKGROUND

The promise of Health Information Exchange (HIE) systems rests in their potential to provide clinicians and administrative staff rapid access to relevant patient data to support judgement and decision-making. However, HIE systems can have usability and technical issues, as well as fail to support user workflow.

OBJECTIVE

Share the findings from a series of studies that address HIE system deficiencies for an Electronic Health Record (EHR) viewer which accesses multiple data sources.

METHODS

A variety of methods were used, in a series of studies, to gain a better understanding of issues and their mitigation through use of promising EHR viewer features.

RESULTS

The study series results are presented by the themes that underscore the importance for users to distinguish between data that are available but missing due to connection or system errors, data that are omitted entirely because they are not available and data that are excluded due to filtered search criteria.

CONCLUSIONS

The principal findings from this study series led to improvement recommendations for the EHR viewer, as well as citing areas that are ripe for further investigation and analysis.

SEWA: A framework for sociotechnical analysis of electronic health record system workarounds

OBJECTIVE

To develop a conceptual framework, SEWA, to address challenges of studying workarounds emerging from Electronic Health Record (EHR) system usage.

MATERIALS AND METHODS

SEWA is based on direct observations and follow-up interviews with physicians, nurses and clerks using their EHR at a large academic hospital. SEWA was developed by an iterative process: each new version was reviewed by experts (case study participants, hospital management, EHR developers) and refined accordingly till deemed final.

RESULTS

SEWA defines the work system and its five components constituting the context in which EHR workarounds are created. It also contains 15 rationales for creating EHR workarounds. Furthermore, four attributes are included that define EHR workarounds: cascadedness, anticipatedness, avoidability, and repetitiveness. Finally, SEWA lists the possible effects of workarounds on outcomes of clinical processes in terms of scope and impact.

DISCUSSION

SEWA provides a grounded foundation for performing sociotechnical analyses of EHR workarounds based on components of the work system. SEWA can likewise be supportive in planning redesign efforts of the work system. Finally, workarounds are subject to gradual change caused by e.g. changes in one's knowledge of the EHR, hospital policies, care directives, and system updates. Snapshots of SEWA can be taken over time and compared to gain insights into the evolution of workarounds.

CONCLUSION

Given the absence of a sociotechnical framework to study EHR workarounds, SEWA could aid researchers and practitioners to identify, analyze and resolve workarounds, and thereby contribute to improved patient safety, effectiveness of care and efficiency of care.

The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: A tale of two countries

Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders.

Evidence-Based Evaluation of eHealth Interventions: Systematic Literature Review

Background

Until now, the use of technology in health care was driven mostly by the assumptions about the benefits of electronic health (eHealth) rather than its evidence. It is noticeable that the magnitude of evidence of effectiveness and efficiency of eHealth is not proportionate to the number of interventions that are regularly conducted. Reliable evidence generated through comprehensive evaluation of eHealth interventions may accelerate the growth of eHealth for long-term successful implementation and help to experience eHealth benefits in an enhanced way.

Objective

This study aimed to understand how the evidence of effectiveness and efficiency of eHealth can be generated through evaluation. Hence, we aim to discern (1) how evaluation is conducted in distinct eHealth intervention phases, (2) the aspects of effectiveness and efficiency that are typically evaluated during eHealth interventions, and (3) how eHealth interventions are evaluated in practice.

Methods

A systematic literature review was conducted to explore the evaluation methods for eHealth interventions. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. We searched Google Scholar and Scopus for the published papers that addressed the evaluation of eHealth or described an eHealth intervention study. A qualitative analysis of the selected papers was conducted in several steps.

Results

We intended to see how the process of evaluation unfolds in distinct phases of an eHealth intervention. We revealed that in practice and in several conceptual papers, evaluation is performed at the end of the intervention. There are some studies that discuss the importance of conducting evaluation throughout the intervention; however, in practice, we found no case study that followed this. For our second research question, we discovered aspects of efficiency and effectiveness that are proposed to be assessed during interventions. The aspects that were recurrent in the conceptual papers include clinical, human and social, organizational, technological, cost, ethical and legal, and transferability. However, the case studies reviewed only evaluate the clinical and human and social aspects. At the end of the paper, we discussed a novel approach to look into the evaluation. Our intention was to stir up a discussion around this approach with the hope that it might be able to gather evidence in a comprehensive and credible way.

Conclusions

The importance of evidence in eHealth has not been discussed as rigorously as have the diverse evaluation approaches and evaluation frameworks. Further research directed toward evidence-based evaluation can not only improve the quality of intervention studies but also facilitate successful long-term implementation of eHealth in general. We conclude that the development of more robust and comprehensive evaluation of eHealth studies or an improved validation of evaluation methods could ease the transferability of results among similar studies. Thus, the resources can be used for supplementary research in eHealth.

From subconscious to conscious to artificial intelligence: A focus on electronic health records

A paradigm shift in human evolution, from our predecessors, the 'hunter-gatherers' to the 'era of digital revolution', has made certain human skills more and more machine driven. This digital revolution has made possible a constant connectivity, wearable technologies, customized platforms, enormous data storage and cloud computing at high speeds, smart phones and apps, internet of things, artificial intelligence, telemedicine, etc. These have made real-time monitoring and interventions possible in healthcare. Most advanced countries have made electronic health records (EHR) mandatory. The Government of India has an agenda of Digital India and digital healthcare and might insist on EHRs. EHR is a real-time, patient-centered digital version of a patient's paper record/chart, available instantly and securely to authorized users. EHR contains a patient's medical history, diagnosis, medications, treatment plans, immunization dates, allergies, radiological images, and laboratory results. It can access evidence-based tools that help to make safer decisions about a patient's care with enhanced decision support, clinical alerts, reminders and medical information. The procedure is also more reliable for dispensing medications and introduces the convenience of e-prescriptions. While the advanced technology and digital devices are well received by the healthcare providers, universal acceptance of the EHRs is far from achieving its full potential. The author, in this paper, discusses the current scenario and issues concerned with EHRs in the digital healthcare.

[Problems encountered by hospital pharmacists with information systems: Analysis of exchanges within social networks]

OBJECTIVE

The development of information systems in French hospitals is mandatory. The aim of this work was to analyze the content of exchanges carried out within social networks, dealing with problems encountered with hospital pharmacies information systems.

METHODS

Messages exchanged via the mailing list of the Association pour le Digital et l'Information en Pharmacie and abstracts of communications presented at hospital pharmacists trade union congresses were analyzed. Those referring to information systems used in hospital pharmacies were selected.

RESULTS

From March 2015 to June 2016, 122 e-mails sent by 80 pharmacists concerned information systems. From 2002 to 2016, 45 abstracts dealt with this topic. Problems most often addressed in these 167 documents were "parameterization and/or functionalities" (n=116), interfaces and complexity of the hospital information systems (n=52), relationship with health information technologies vendors and poor reactivity (n=32), additional workload (n=32), ergonomics (n=30), insufficient user training (n=22). These problems are interdependent, lead to errors and in order to mitigate their consequences, they compel pharmacy professionals to divert a significant amount of working hours to the detriment of pharmaceutical care and dispensing and preparing drugs.

CONCLUSION

Hospital pharmacists are faced with many problems of insecurity and inefficiency generated by information systems. Researches are warranted to determine their cost, specify their deleterious effects on care and identify the safest information systems.

Turning Data Into Information: Opportunities to Advance Rehabilitation Quality, Research, and Policy

Attention to health care quality and safety has increased dramatically. The internal focus of an organization is not without influence from external policy and research findings. Compared with other specialties, efforts to align and advance rehabilitation research, practice, and policy using electronic health record data are in the early stages. This special communication defines quality, applies the dimensions of quality to rehabilitation, and illustrates the feasibility and utility of electronic health record data for research on rehabilitation care quality and outcomes. Using data generated at the point of care provides the greatest opportunity for improving the quality of health care, producing generalizable evidence to inform policy and practice, and ultimately benefiting the health of the populations served.

eHealth readiness of dietitians

BACKGROUND

The present study aimed to determine the eHealth readiness and changes over time of dietitians in Australia.

METHODS

Two cross-sectional analyses of Australian dietitians were conducted in 2013 and 2016, using a survey adapted from one conducted in 2011 by the US Academy of Nutrition and Dietetics. The survey encompassed 30 questions on eHealth readiness across five dimensions: access, standards, attitude, aptitude and advocacy. Descriptive statistics, independent t-tests, chi-squared tests and Z-tests were computed to compare responses from the 2013 and 2016 surveys.

RESULTS

The survey completion rate represented 14.5% (747) of the Dietitians Association of Australia members in 2013 and 8% (417) in 2016. The survey responses in relation to access and standards suggest that dietitians are well positioned for eHealth. For attitude and aptitude, there is a moderate level of preparedness, with minor improvements over time. Although showing significant improvement (P < 0.05), advocacy highlights the area requiring the most development because the majority of dietitians (61%) reported 'no role' in eHealth solutions.

CONCLUSIONS

Dietitians are progressing in relation to access, attitudinal and aptitudinal readiness for eHealth, although they rate poorly with respect to advocacy readiness. It was concluded that dietitians are not yet ready, and also that valuable opportunities to achieve the benefits that eHealth can deliver will be missed, if dietitians do not take the lead in guiding the development, selection and implementation of nutrition-related technologies. Strengthening the dimension of advocacy and ensuring collaboration across the profession, drawing on the varying expertise demonstrated across the practice areas and by the different generations, will be central to improving dietitian eHealth readiness.

Randomised controlled trial of a web-based programme in sustaining best practice alcohol management practices at community sports clubs: a study protocol

INTRODUCTION

Community-based interventions have been found to effectively increase the implementation of alcohol management practices and reduce excessive alcohol use and alcohol-related harm at sports clubs. However, once implementation support ceases there may be a reduction in such intervention effects. Thus, ongoing contribution to improving the health of the community is diminished; sustaining practice implementation is a key determinant to address this. One possible solution to the strategic and logistical challenges of sustainability involves the use of the web. The primary aim of this study is to assess the effectiveness of a web-based programme in sustaining the implementation of alcohol management practices by community football clubs. The secondary aim is to assess the effectiveness of the programme in preventing excessive alcohol consumption and alcohol-related harm among members of community football clubs.

METHODS AND ANALYSIS

The study will employ a repeat randomised controlled trial design and be conducted in regional and metropolitan areas within two states of Australia. Community level football clubs who are currently accredited with an existing alcohol management programme ('Good Sports') and implementing at least 10 of the 13 core alcohol management practices (eg, not serving alcohol to <18-year-olds) required by the programme will be recruited and randomised to either a web-based sustainability programme or a 'minimal contact' programme. The primary outcome measures are the proportion of football clubs implementing ≥10 of the 13 required alcohol management practices and the mean number of those practices being implemented at 3-year follow-up. Secondary outcomes include: the proportion of club members who report risky drinking at their club, the Alcohol Use Disorder Identification Test (AUDIT) score and mean AUDIT score of club members. Outcome data will be collected via observation at the club during a 1-day visit to a home game, conducted by trained research assistants at baseline and follow-up.

ETHICS AND DISSEMINATION

The study was approved by The University of Newcastle Human Research Ethics Committee (reference: H-2013-0429). Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12614000746639; Pre-results.

Barriers and facilitators to Electronic Medical Records usage in the Emergency Centre at Komfo Anokye Teaching Hospital, Kumasi-Ghana

INTRODUCTION

The use of paper for record keeping (or a manual system) has been the order of the day in almost all health care facilities in resource poor countries. This system has presented numerous challenges, which the use of Electronic Medical Records (EMR) seeks to address. The objectives of the study were to identify the facilitators and barriers to EMR implementation in Komfo Anokye Teaching Hospital's (KATH) Emergency Centre (EC) and to identify lessons learned. These will help in implementation of EMR in ECs in similar settings.

METHODS

This was a non-interventional, descriptive cross-sectional and purely qualitative study using a semi-structured interview guide for a study population of 24. The interviews were manually recorded and analysed thematically. EMR implementation was piloted in the EC. Some of the EC staff doubled as EMR personnel. An open source EMR was freely downloaded and customised to meet the needs of the EC. The EMR database created was a hybrid one comprising of digital bio-data of patients and scanned copies of their paper EC records.

RESULTS

The facilitators for utilising the system included providing training to staff, the availability of some logistics, and the commitment of staff. The project barriers were funding, full-time information technology expertise, and automatic data and power backups. It was observed that with the provision of adequate human and financial resources, the challenges were overcome and the adoption of the EMR improved.

DISCUSSION

The EMR has been a partial success. The facilitators identified in this study, namely training, provision of logistics, and staff commitment represent foundations to work from. The barriers identified could be addressed with additional funding, provision of information technology expertise, and data and power back up. It is acknowledged that lack of funding could substantially limit EMR implementation.

Workarounds Emerging From Electronic Health Record System Usage: Consequences for Patient Safety, Effectiveness of Care, and Efficiency of Care

BACKGROUND

Health care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow unintendedly imposed by electronic health record systems (EHRs). Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness of care, and efficiency of care.

OBJECTIVE

Research into the scope and impact of EHR workarounds on patient care processes is scarce. This paper provides insight into the effects of EHR workarounds on organizational workflows and outcomes of care services by identifying EHR workarounds and determining their rationales, scope, and impact on health care providers' workflows, patient safety, effectiveness of care, and efficiency of care. Knowing the rationale of a workaround provides valuable clues about the source of origin of each workaround and how each workaround could most effectively be resolved. Knowing the scope and impact a workaround has on EHR-related safety, effectiveness, and efficiency provides insight into how to address related concerns.

METHODS

Direct observations and follow-up semistructured interviews with 31 physicians, 13 nurses, and 3 clerks and qualitative bottom-up coding techniques was used to identify, analyze, and classify EHR workarounds. The research was conducted within 3 specialties and settings at a large university hospital. Rationales were associated with work system components (persons, technology and tools, tasks, organization, and physical environment) of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to reveal their source of origin as well as to determine the scope and the impact of each EHR workaround from a structure-process-outcome perspective.

RESULTS

A total of 15 rationales for EHR workarounds were identified of which 5 were associated with persons, 4 with technology and tools, 4 with the organization, and 2 with the tasks. Three of these 15 rationales for EHR workarounds have not been identified in prior research: data migration policy, enforced data entry, and task interference.

CONCLUSIONS

EHR workaround rationales associated with different SEIPS work system components demand a different approach to be resolved. Persons-related workarounds may most effectively be resolved through personal training, organization-related workarounds through reviewing organizational policy and regulations, tasks-related workarounds through process redesign, and technology- and tools-related workarounds through EHR redesign efforts. Furthermore, insights gained from knowing a workaround's degree of influence as well as impact on patient safety, effectiveness of care, and efficiency of care can inform design and redesign of EHRs to further align EHR design with work contexts, subsequently leading to better organization and (safe) provision of care. In doing so, a research team in collaboration with all stakeholders could use the SEIPS framework to reflect on the current and potential future configurations of the work system to prevent unfavorable workarounds from occurring and how a redesign of the EHR would impact interactions between the work system components.

Health Information Technology (HIT) Adaptation: Refocusing on the Journey to Successful HIT Implementation

In past years, policies and regulations required hospitals to implement advanced capabilities of certified electronic health records (EHRs) in order to receive financial incentives. This has led to accelerated implementation of health information technologies (HIT) in health care settings. However, measures commonly used to evaluate the success of HIT implementation, such as HIT adoption, technology acceptance, and clinical quality, fail to account for complex sociotechnical variability across contexts and the different trajectories within organizations because of different implementation plans and timelines. We propose a new focus, HIT adaptation, to illuminate factors that facilitate or hinder the connection between use of the EHR and improved quality of care as well as to explore the trajectory of changes in the HIT implementation journey as it is impacted by frequent system upgrades and optimizations. Future research should develop instruments to evaluate the progress of HIT adaptation in both its longitudinal design and its focus on adaptation progress rather than on one cross-sectional outcome, allowing for more generalizability and knowledge transfer.

The Feasibility and Acceptability of a Web-Based Alcohol Management Intervention in Community Sports Clubs: A Cross-Sectional Study

Background

The implementation of comprehensive alcohol management strategies can reduce excessive alcohol use and reduce the risk of alcohol-related harm at sporting venues. Supporting sports venues to implement alcohol management strategies via the Web may represent an effective and efficient means of reducing harm caused by alcohol in this setting. However, the feasibility and acceptability of such an approach is unknown.

Objective

This study aimed to identify (1) the current access to and use of the Web and electronic devices by sports clubs; (2) the perceived usefulness, ease of use, and intention to use a Web-based program to support implementation of alcohol management policies in sports clubs; (3) the factors associated with intention to use such a Web-based support program; and (4) the specific features of such a program that sports clubs would find useful.

Methods

A cross-sectional survey was conducted with club administrators of community football clubs in the state of New South Wales, Australia. Perceived usefulness, ease of use and intention to use a hypothetical Web-based alcohol management support program was assessed using the validated Technology Acceptance Model (TAM) instrument. Associations between intention to use a Web-based program and club characteristics as well as perceived ease of use and usefulness was tested using Fisher’s exact test and represented using relative risk (RR) for high intention to use the program.

Results

Of the 73 football clubs that were approached to participate in the study, 63 consented to participate and 46 were eligible and completed the survey. All participants reported having access to the Web and 98% reported current use of electronic devices (eg, computers, iPads/tablets, smartphones, laptops, televisions, and smartboards). Mean scores (out of a possible 7) for the TAM constructs were high for intention to use (mean 6.25, SD 0.87), perceived ease of use (mean 6.00, SD 0.99), and perceived usefulness (mean 6.17, SD 0.85). Intention to use the Web-based alcohol management program was significantly associated with perceived ease of use (P=.02, RR 1.4, CI 1.0-2.9), perceived usefulness (P=.03, RR 1.5, CI 1.0-6.8) and club size (P=.02, RR 0.8, CI 0.5-0.9). The most useful features of such a program included the perceived ability to complete program requirements within users’ own time, complete program accreditation assessment and monitoring online, develop tailored action plans, and receive email reminders and prompts to complete action.

Conclusions

A Web-based alcohol management approach to support sports clubs in the implementation of recommended alcohol management policies appears both feasible and acceptable. Future research should aim to determine if such intended use leads to actual use and club implementation of alcohol management policies.

Exploring Workarounds Related to Electronic Health Record System Usage: A Study Protocol

Background

Health care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow that are unintentionally imposed by electronic health record (EHR) systems. Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness, and efficiency of care. Identifying workarounds and understanding their motivations, scope, and impact is pivotal to support the design of user-friendly EHRs and achieve closer alignment between EHRs and work contexts.

Objective

We propose a study protocol to identify EHR workarounds and subsequently determine their scope and impact on health care providers’ workflows, patient safety, effectiveness, and efficiency of care. First, knowing whether a workaround solely affects the health care provider who devised it, or whether its effects extends beyond the EHR user to the work context of other health care providers, is key to accurately assessing its degree of influence on the overall patient care workflow. Second, knowing whether the consequence of an EHR workaround is favorable or unfavorable provides insights into how to address EHR-related safety, effectiveness, and efficiency concerns. Knowledge of both perspectives can provide input on optimizing EHR designs.

Methods

In the study, a combination of direct observations, semistructured interviews, and qualitative coding techniques will be used to identify, analyze, and classify EHR workarounds. The research project will be conducted within three distinct pediatric care processes and settings at a large university hospital.

Results

Data was collected using the described approach from January 2016 to March 2017. Data analysis is underway and is expected to be completed in May 2017. We aim to report the results of this study in a follow-up publication.

Conclusions

This study protocol provides a grounded framework to explore EHR workarounds from a holistic and integral perspective. Insights from this study can inform the design and redesign of EHRs to further align with work contexts of healthcare professionals, and subsequently lead to better organization and safer provision of care.

Constructive eHealth evaluation: lessons from evaluation of EHR development in 4 Danish hospitals

BACKGROUND

Information and communication sources in the healthcare sector are replaced with new eHealth technologies. This has led to problems arising from the lack of awareness of the importance of end-user involvement in eHealth development and of the difficulties caused by using traditional summative evaluation methods. The Constructive eHealth evaluation method (CeHEM) provides a solution to these problems by offering an evaluation framework for supporting and facilitating end-user involvement during all phases of eHealth development. The aim of this paper is to support this process by sharing experiences of the eHealth evaluation method used in the introduction of electronic health records (EHR) in the North Denmark Region of Denmark. It is the first time the fully developed method and the experiences on using the CeHEM in all five phases of a full lifecycle framework is presented.

METHODS

A case study evaluation of the EHR development process in the North Denmark Region was conducted from 2004 to 2010. The population consisted of clinicians, IT professionals, administrators, and vendors. The study involved 4 hospitals in the region. Data were collected using questionnaires, observations, interviews, and insight gathered from relevant documents.

RESULTS

The evaluation showed a need for a) Early involvement of clinicians, b) The best possible representation of clinicians, and c) Workload reduction for those involved. The consequences of not providing this were a lack of ownership of decisions and negative attitudes towards the clinical benefits related to these decisions. Further, the result disclosed that by following the above recommendations, and by providing feedback to the 4 actor groups, the physicians' involvement was improved. As a result they took ownership of decisions and gained a positive attitude to the clinical benefits.

CONCLUSIONS

The CeHEM has proven successful in formative evaluation of EHR development and can point at important issues that need to be taken care of by management. The method provides a framework that takes care of feedback and learning during eHealth development. It can thus support successful eHealth development in a broader context while building on a well-known success factor: end-user involvement in eHealth development.

Understanding the implementation and adoption of a technological intervention to improve medication safety in primary care: a realist evaluation

Background

Monitoring for potentially hazardous prescribing is increasingly important to improve medication safety. Healthcare information technology can be used to achieve this aim, for example by providing access to prescribing data through surveillance of patients’ electronic health records. The aim of our study was to examine the implementation and adoption of an electronic medicines optimisation system that was intended to facilitate clinical audit in primary care by identifying patients at risk of an adverse drug event. We adopted a sociotechnical approach that focuses on how complex social, organisational and institutional factors may impact upon the use of technology within work settings.

Methods

We undertook a qualitative realist evaluation of the use of an electronic medicines optimisation system in one Clinical Commissioning Group in England. Five semi-structured interviews, four focus groups and one observation were conducted with a range of stakeholders. Consistent with a realist evaluation methodology, the analysis focused on exploring the links between context, mechanism and outcome to explain the ways the intervention might work, for whom and in what circumstances.

Results

Using the electronic medicines optimisation system could lead to a number of improved patient safety outcomes including pre-emptively reviewing patients at risk of adverse drug events. The effective use of the system depended upon engagement with the system, the flow of information between different health professionals centrally placed at the Clinical Commissioning Group and those locally placed at individual general practices, and upon variably adapting work practices to facilitate the use of the system. The use of the system was undermined by perceptions of ownership, lack of access, and lack of knowledge and awareness.

Conclusions

The use of an electronic medicines optimisation system may improve medication safety in primary care settings by identifying those patients at risk of an adverse drug event. To fully realise the potential benefits for medication safety there needs to be better utilisation across primary care and with a wider range of stakeholders. Engaging with all potential stakeholders and users prior to implementation of such systems might allay perceptions that the system is owned centrally and increase knowledge of the potential benefits.

Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory

Background

To explore the benefits, barriers and disadvantages of implementing an electronic record system (ERS). The extent that the system has become ‘normalised’ into routine practice was also explored.

Methods

Qualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives of different grades, health care assistants) and wards within a maternity unit at a NHS teaching hospital. Interviews were conducted during the first year of the phased implementation of ERS and were analysed thematically. The four mechanisms of Normalisation Process Theory (NPT) (coherence, cognitive participation, collective action and reflexive monitoring) were adapted for use within the study and provided a theoretical framework to interpret the study’s findings.

Results

Coherence (participants’ understanding of why the ERS has been implemented) was mixed – whilst those involved in ERS implementation anticipated advantages such as improved access to information; the majority were unclear why the ERS was introduced. Participants’ willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records. Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system. Whilst some individuals reported benefits such as improved legibility of records, others felt benefits were yet to emerge. The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use. When appraising the ERS (reflexive monitoring) participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety.

Conclusions

Despite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of ‘clinical benefits’. The study highlights the complexity of implementing electronic systems and the associated longevity before they can become ‘embedded’ into routine practice. Through the identification of barriers to the employment of electronic systems this process could be streamlined with the avoidance of any potential detriment to clinical services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0406-0) contains supplementary material, which is available to authorized users.

The use of electronic health records in Spanish hospitals

The aims of this study were to describe the level of adoption of electronic health records in Spanish hospitals and to identify potential barriers and facilitators to this process. We used an observational cross-sectional design. The survey was conducted between September and December 2011, using an electronic questionnaire distributed through email. We obtained a 30% response rate from the 214 hospitals contacted, all belonging to the Spanish National Health Service. The level of adoption of electronic health records in Spanish hospitals was found to be high: 39.1% of hospitals surveyed had a comprehensive EHR system while a basic system was functioning in 32.8% of the cases. However, in 2011 one third of the hospitals did not have a basic electronic health record system, although some have since implemented electronic functionalities, particularly those related to clinical documentation and patient administration. Respondents cited the acquisition and implementation costs as the main barriers to implementation. Facilitators for EHR implementation were: the possibility to hire technical support, both during and post implementation; security certification warranty; and objective third-party evaluations of EHR products. In conclusion, the number of hospitals that have electronic health records is in general high, being relatively higher in medium-sized hospitals.

Embedding new technologies in practice - a normalization process theory study of point of care testing

Background

Many point of care diagnostic technologies are available which produce results within minutes, and offer the opportunity to deliver acute care out of hospital settings. Increasing access to diagnostics at the point of care could increase the volume and scope of acute ambulatory care. Yet these technologies are not routinely used in many settings. We aimed to explore how point of care testing is used in a setting where it has become ‘normalized’ (embedded in everyday practice), in order to inform future adoption and implementation in other settings. We used normalization process theory to guide our case study approach.

Methods

We used a single case study design, choosing a community based ambulatory care unit where point of care testing is used routinely. A focused ethnographic approach was taken, including non-participant observation of all activities related to point of care testing, and semi-structured interviews, with all clinical staff involved in point of care testing at the unit. Data were analysed thematically, guided by normalization process theory.

Results

Fourteen days of observation and six interviews were completed. Staff had a shared understanding of the purpose, value and benefits of point of care testing, believing it to be integral to the running of the unit. They organised themselves as a team to ensure that point of care testing worked effectively; and one key individual led a change in practice to ensure more consistency and trust in procedures. Staff assessed point of care testing as worthwhile for the unit, their patients, and themselves in terms of job satisfaction and knowledge. Potential barriers to adoption of point of care testing were evident (including lack of trust in the accuracy of some results compared to laboratory testing; and lack of ease of use of some aspects of the equipment); but these did not prevent point of care testing from becoming embedded, because the importance and value attributed to it were so strong.

Conclusions

This case study offers insights into successful adoption of new diagnostic technologies into every day practice. Such analyses may be critical to realising their potential to change processes of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1834-3) contains supplementary material, which is available to authorized users.

Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings: protocol for a systematic review of qualitative studies

INTRODUCTION

There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support.

METHODS AND ANALYSIS

Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies (ClinicalTrials.gov) and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method.

ETHICS AND DISSEMINATION

The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42016035552.

Advanced Technology in Pediatric Intensive Care Units: Have They Improved Outcomes?

In medicine, providers strive to produce quality outcomes and work to continually improve those outcomes. Whether it is reducing cost, decreasing length of stay, mitigating nosocomial infections, or improving survival, there are a myriad of complex factors that contribute to each outcome. One of the greatest challenges to outcome improvement is in pediatric intensive care units, which tend to host the sickest, most complex, smallest, and frailest of pediatric patients. This article highlights some studies and advances in informatics that have influenced intensive care unit outcomes.

Taxonomy of delays in the implementation of hospital computerized physician order entry and clinical decision support systems for prescribing: a longitudinal qualitative study

BACKGROUND

Implementation delays are common in health information technology (HIT) projects. In this paper, we sought to explore the reasons for delays in implementing major hospital-based HIT, through studying computerized physician order entry (CPOE) and clinical decision support (CDS) systems for prescribing and to develop a provisional taxonomy of causes of implementation delays.

METHODS

We undertook a series of longitudinal, qualitative case studies to investigate the implementation and adoption of CPOE and CDS systems for prescribing in hospitals in the U.K. We used a combination of semi-structured interviews from six case study sites and two whole day expert roundtable discussions to collect data. Interviews were carried out with users, implementers and suppliers of CPOE/CDS systems. We used thematic analysis to examine the results, drawing on perspectives surrounding the biography of artefacts.

RESULTS

We identified 15 major factors contributing to delays in implementation of CPOE and CDS systems. These were then categorized in a two-by-two delay classification matrix: one axis distinguishing tactical versus unintended causes of delay, and the second axis illustrating internal i.e., (the adopting hospital) versus external (i.e., suppliers, other hospitals, policymakers) related causes.

CONCLUSIONS

Our taxonomy of delays in HIT implementation should enable system developers, implementers and policymakers to better plan and manage future implementations. More detailed planning at the outset, considering long-term strategies, sustained user engagement, and phased implementation approaches appeared to reduce the risks of delays. It should however be noted that whilst some delays are likely to be preventable, other delays cannot be easily avoided and taking steps to minimize these may negatively affect the longer-term use of the system.

Understanding and evaluating the effects of implementing an electronic paediatric prescribing system on care provision and hospital work in paediatric hospital ward settings: a qualitatively driven mixed-method study protocol

INTRODUCTION

Electronic prescribing systems can improve the quality and safety of healthcare services, but their implementation is not straightforward and may create unexpected change. However, the added complexity of paediatric prescribing (eg, dose calculations, dilutions, manipulations) may pose additional challenges. This study will aim to (1) understand the complex organisational reality of a paediatric hospital in which a new electronic paediatric prescribing (ePP) system will be introduced; (2) describe ePP-related change, over time, in paediatric hospital ward settings; (3) explore staff perspectives in relation to currently established practices and processes; and (4) assess the impact of ePP on care provision and hospital work from the perspective of paediatricians, paediatric nurses and managers.

METHODS AND ANALYSIS

A qualitatively driven mixed-method approach will be adopted, including 3 inter-related substudies. The core component of the study will be qualitative (substudy 1): we will use ethnographic research methods, including non-participant observation in wards and informal conversational interviews with members of staff. In addition, the design will include 2 embedded supplementary components: a qualitative 1 (substudy 2) based on in-depth interviews and/or focus groups with paediatricians, paediatric nurses, paediatric pharmacists/pharmacy technicians and managers; and a quantitative 1 (substudy 3) in which a staff survey will be developed and administered before and after the ePP implementation. Analytic themes will be identified from ethnographic field notes and interview data. Survey data will be analysed using descriptive statistics and baseline and follow-up data compared to establish impact evaluation measures.

ETHICS AND DISSEMINATION

A favourable ethical opinion has been obtained from a National Health Service (NHS) Research Ethics Committee (15/SS/0157). NHS research governance approval has been obtained at the relevant hospital site. The results of the study will be disseminated through conferences and peer-reviewed journals, as well as fed back to those involved in clinical practice and policy development at the study site.

Are there specific translational challenges in regenerative medicine? Lessons from other fields

There is concern that translation 'from bench to bedside' within regenerative medicine (RM) will fail to materialize, or will be dismally slow, due to various challenges arising from the highly novel and disruptive nature of RM. In this article, we provide a summary of these challenges, and we critically engage with the notion that such challenges are specific to RM. It is important, we argue, not to overstate the exceptional nature of RM, as valuable lessons can be learned from elsewhere in medicine. Using several examples of technology adoption, we suggest that emerging RM products and procedures will have to work hard to find or create an adoption space if translation into the clinic is to be successful.

The impact of electronic prescribing systems on pharmacists' time and workflow: protocol for a time-and-motion study in English NHS hospitals

INTRODUCTION

Electronic prescribing (ePrescribing) systems are rapidly being introduced into National Health Systems (NHS) hospitals in England following their widespread earlier adoption into primary care settings. Such systems require substantial changes in the way pharmacists organise their work and perform their roles. There is however as yet limited evidence on the extent to which these changes may support or compromise efficient and safe working practices by pharmacists. Identifying and quantifying these changes, and their effects, is central to informing system and work practice design, as well as informing training and implementation processes. This protocol describes a study to measure the impact of ePrescribing systems on pharmacists' time and workflow.

METHODS AND ANALYSIS

A direct observational controlled pre-post implementation time-and-motion study will be conducted in six wards at one NHS Trust over two observational periods. Pharmacists will be shadowed and details of all work tasks performed will be collected and time-stamped. Task distribution, frequency and duration will be measured and changes in these measures preimplementation and postimplementation, and between control and intervention wards will be measured. Interviews with pharmacists will investigate their perceptions of the impact of the ePrescribing systems on their work and will be conducted in both periods. The extent to which pharmacists' expectations of the impact of the ePrescribing systems on their work with postimplementation reports will be qualitatively explored, as will any differences between perceptions and results from the time-and-motion analysis.

ETHICS AND DISSEMINATION

Institutional research ethics approval has been obtained from The University of Edinburgh. Local approval from the participating NHS Trust and informed consent from participating pharmacists have been obtained, while also complying with local governance requirements. The results of the study will be presented at conferences, published in peer-reviewed journals, and shared with members of our Patient and Public Involvement Group, to facilitate wider dissemination.

From maternity paper hand-held records to electronic health records: what do women tell us about their use?

The paper hand-held record (PHR) has been used extensively in general practice (GP) shared care management of pregnant women, and recently, the first Mater Shared Electronic Health Record (MSEHR) was introduced. The aim of this qualitative study was to examine women's experiences using the records and the contribution of the records to integrate care. At the 36-week antenatal visit in a maternity tertiary centre clinic, women were identified as a user of either the PHR or the MSEHR and organised into Phase 1 and Phase 2 studies respectively. Fifteen women were interviewed in Phase 1 and 12 women in Phase 2. Semi-structured interviews were used for data collection, and analysed using qualitative content analysis. Four main themes were identified: (1) purpose of the record, (2) perceptions of the record; (3) content of the record, and (4) sharing the record. Findings indicate that the PHR is a well-liked maternity tool. The findings also indicate there is under-usage of the MSEHR due to health-care providers failing to follow up and discuss the option of using the electronic health record option or if a woman has completed the log-in process. This paper adds to an already favourable body of knowledge about the use of the PHR. It is recommended that continued implementation of the MSEHR be undertaken to facilitate its use.