Evaluating a post-implementation electronic medical record training intervention for diabetes management in primary care

Addressing complexity when developing an education program for the implementation of a stroke Electronic Medical Record (EMR) enhancement

BACKGROUND

Digital interventions in health services often fail due to an underappreciation of the complexity of the implementation. This study develops an approach to address complexity through an evidenced-based, theory-driven education and implementation program for an Electronic Medical Record (EMR) digital enhancement for acute stroke care.

METHODS

An action research approach was used to design, develop, and execute the education and implementation program over several phases, with iterative changes over time. The study involved collaboration with multiple statewide and local key stakeholders and was conducted across two tertiary teaching hospitals and a regional hospital in Australia.

RESULTS

Insights were gained over five phases. Phase 1 involved a review of evidence that supported blended learning strategies for the education and training of staff end-users. In Phase 2, contextual assessment was conducted via observation of study sites, providing awareness of local context variability and insight into key implementation considerations. The Non-adoption, Abandonment, Scale-Up, Spread and Sustainability (NASSS) framework assisted in Phase 3 to identify and manage the key domains of complexity. Phase 4 involved the design of the program which included group-based training and an e-learning package, endorsed and evaluated by key leaders. Throughout implementation in Phase 5, further barriers were identified, and iterative changes were tailored to each context.

CONCLUSIONS

The NASSS framework, combined with a multi-phased approach employing blended learning techniques, context evaluations, and iterative modifications, can serve as a model for generating theory-driven and evidence-based education strategies that adresss the complexity of the implementation process and context.

Exploring maturity of electronic medical record use among allied health professionals

BACKGROUND

Electronic medical records (EMRs) have the potential to improve and streamline the quality and safety of patient care. Harnessing the full benefits of EMR implementation depends on the utilisation of advanced features, defined as "mature usage." At present, little is known about the maturity of EMR usage by allied health professionals (AHPs).

OBJECTIVE

To examine current maturity of EMR use by AHPs and explore perceived barriers to mature EMR utilisation and optimisation.

METHOD

AHPs were recruited from three health services. Participants completed a 27-question electronic questionnaire based on the EMR Adoption Framework, which measures clinician EMR utilisation (0 = paper chart, 5 = theoretical maximum) across 10 EMR feature categories. Interviews were conducted with both clinicians and managers to explore the nature of current EMR utilisation and perceived facilitators and barriers to mature usage.

RESULTS

Questionnaire responses were obtained from 193 participants AHPs. The majority of questions (74%) showed a mean score of <3, indicating a lack of mature EMR use. Pockets of mature usage were identified in the categories of health information, referrals and administration processes. Interviews with 21 clinicians and managers revealed barriers to optimisation across three themes: (1) limited understanding of EMR opportunities; (2) complexity of the EMR change process and (3) end-user and environmental factors.

CONCLUSION

Mature usage across EMR feature categories of the EMR Adoption Framework was low. However, questionnaire and qualitative interview data suggested pockets of mature utilisation.

IMPLICATIONS

Achieving mature allied health EMR use will require strategies implemented at the clinician, EMR support, and service levels.

Healthcare Professionals’ Perceptions, Barriers, and Facilitators towards Adopting Computerised Clinical Decision Support Systems in Antimicrobial Stewardship in Jordanian Hospitals

Understanding healthcare professionals’ perceptions towards a computerised decision support system (CDSS) may provide a platform for the determinants of the successful adoption and implementation of CDSS. This cross-sectional study examined healthcare professionals’ perceptions, barriers, and facilitators to adopting a CDSS for antibiotic prescribing in Jordanian hospitals. This study was conducted among healthcare professionals in Jordan’s two tertiary and teaching hospitals over four weeks (June–July 2021). Data were collected in a paper-based format from senior and junior prescribers and non-prescribers (n = 254) who agreed to complete a questionnaire. The majority (n = 184, 72.4%) were aware that electronic prescribing and electronic health record systems could be used specifically to facilitate antibiotic use and prescribing. The essential facilitator made CDSS available in a portable format (n = 224, 88.2%). While insufficient training to use CDSS was the most significant barrier (n = 175, 68.9%). The female providers showed significantly lower awareness (p = 0.006), and the nurses showed significantly higher awareness (p = 0.041) about using electronic prescribing and electronic health record systems. This study examined healthcare professionals’ perceptions of adopting CDSS in antimicrobial stewardship (AMS) and shed light on the perceived barriers and facilitators to adopting CDSS in AMS, reducing antibiotic resistance, and improving patient safety. Furthermore, results would provide a framework for other hospital settings concerned with implementing CDSS in AMS and inform policy decision-makers to react by implementing the CDSS system in Jordan and globally. Future studies should concentrate on establishing policies and guidelines and a framework to examine the adoption of the CDSS for AMS.

Physician awareness of social determinants of health documentation capability in the electronic health record

Healthcare organizations are increasing social determinants of health (SDH) screening and documentation in the electronic health record (EHR). Physicians may use SDH data for medical decision-making and to provide referrals to social care resources. Physicians must be aware of these data to use them, however, and little is known about physicians' awareness of EHR-based SDH documentation or documentation capabilities. We therefore leveraged national physician survey data to measure level of awareness and variation by physician, practice, and EHR characteristics to inform practice- and policy-based efforts to drive medical-social care integration. We identify higher levels of social needs documentation awareness among physicians practicing in community health centers, those participating in payment models with social care initiatives, and those aware of other advanced EHR functionalities. Findings indicate that there are opportunities to improve physician education and training around new EHR-based SDH functionalities.

A review of electronic medical records and safe transfusion practice for guideline development

BACKGROUND AND OBJECTIVES

Electronic medical records (EMRs) are often composed of multiple interlinking systems, each serving a particular task, including transfusion ordering and administration. Transfusion may not be prioritized when developing or implementing electronic platforms. Uniform guidelines may assist information technology (IT) developers, institutions and healthcare workforces to progress with shared goals.

MATERIALS AND METHODS

A narrative review of current clinical guidance, benefits and risks of electronic systems for clinical transfusion practice was combined with feedback from experienced transfusion practitioners.

RESULTS

There is opportunity to improve the safety, quality and efficiency of transfusion practice, particularly through decision support and better identification procedures, by incorporating transfusion practice into EMRs. However, these benefits should not be assumed, as poorly designed processes within the electronic systems and the critically important electronic-human process interfaces may increase risk while creating the impression of safety.

CONCLUSION

Guidelines should enable healthcare and IT industries to work constructively together so that each implementation provides assurance of safe practice.

Effect of a primary-care-team focused diabetes educational program project on diabetes care quality indicators in a large health maintenance organization

AIMS

In 2011 the central district of Leumit Health Services (LHS) (a health maintenance organization in Israel) implemented a chronic care program to improve diabetes care in general practice: MESSAGE program (Motivation, Education, Skills and Supervision to Achieve better diabetes care in General practice Environment), included training phase and ongoing time allocation for diabetes care.

METHODS

A population-based retrospective analysis of LHS Electronic Medical Records of all patients with diabetes in LHS between 1 June 2015 and 31 May 2018. Data was processed according to the definitions of the Israeli national program for quality indicators in community healthcare. ~442,000 adults were included, ~49,000 in MESSAGE engaged clinics.

RESULTS

The prevalence of diabetes in LHS was ~9.7-9.31% during study period. Over 3 years follow up, the prevalence of patients with A1C ≥ 9% declined in all districts of LHS but to a significantly greater extent in MESSAGE clinics [2015: MESSAGE 12.4%, LHS-combined 13.09%; OR 0.92 (0.83-1.01) p = 0.075; 2018: MESSAGE 8.51%, LHS-combined 10.85%; 0.76 (0.69-0.85) p < 0.001]. Other indicators of diabetes care did not change.

CONCLUSION

The MESSAGE intervention program resulted in improved glycemic control. It is currently being modified to address all aspects of diabetes care and is implemented across all districts of LHS in Israel.

Personalization of health information prescription in diabetes clinical setting: A qualitative study

BACKGROUND

The prevalence of diabetes makes considerable costs for health-care organizations. The increase of patient's self-care abilities by use of personalizing health information prescription can reduce these costs. This study was conducted to explore the benefits and challenges related to personalizing health information prescription in diabetes clinical settings.

MATERIALS AND METHODS

The samples included diabetes education officials working in specialized diabetes clinics and Diabetes Research Centre managers of Iran and Tehran Universities of Medical Sciences. They were 21 cases and selected through purposeful sampling method. Semi-structured interview and focus discussion groups were used to collect the viewpoints of specialists. Interview guide, based on literature review and the documents of diabetes, was used in interviews and focus groups. Their validity was affirmed by specialists. The interview texts were coded in MAXQDA10 software and analyzed through content analysis method.

RESULTS

The most important benefits of personalizing health information prescription were classified into five themes as follows: medical services improvement, facilitation of consumers to information resources, improvement in patients' knowledge and awareness, increase in self-care ability and disease management, reinforcing the relation between physician and patient and keeping physician in the information prescription cycle. The challenges of personalizing of health information prescription were revealed as follows: Recognition of patients' personal characteristics at the turn of entering the system, systems' functional modifiers especially bilateral interaction and relation to patient's health file, content recognition, and creating suitable protocol.

CONCLUSION

This study showed that diabetes clinical settings face different organizational and process challenges for establishing the personalization of health information prescription. The most important challenges which should be considered in designing information prescription in diabetes clinical environments are as follows: reinforcing physicians' recognition of information prescription benefits, lack of integrative electronic health information system, and patient primary assessment in the first stage of entering the patient into the system in respect of clinical and personal aspects in information needs of consumer.

Factors affecting the mature use of electronic medical records by primary care physicians: a systematic review

BACKGROUND

Despite a substantial increase in the adoption of electronic medical records (EMRs) in primary health care settings, the use of advanced EMR features is limited. Several studies have identified both barriers and facilitating factors that influence primary care physicians' (PCPs) use of advanced EMR features and the maturation of their EMR use. The purpose of this study is to explore and identify the factors that impact PCPs' mature use of EMRs.

METHODS

A systematic review was conducted in accordance with the Cochrane Handbook. The MEDLINE, Embase, and PsycINFO electronic databases were searched from 1946 to June 13, 2019. Two independent reviewers screened the studies for eligibility; to be included, studies had to address factors influencing PCPs' mature use of EMRs. A narrative synthesis was conducted to collate study findings and to report on patterns identified across studies. The quality of the studies was also appraised.

RESULTS

Of the 1893 studies identified, 14 were included in this study. Reported factors that influenced PCPs' mature use of EMRs fell into one of the following 5 categories: technology, people, organization, resources, and policy. Concerns about the EMR system's functionality, lack of physician awareness of EMR functionality, limited physician availability to learn more about EMRs, the habitual use of successfully completing clinical tasks using only basic EMR features, business-oriented organizational objectives, lack of vendor training, limited resource availability, and lack of physician readiness were reported as barriers to PCPs' mature use of EMRs. The motivation of physicians, user satisfaction, coaching and peer mentoring, EMR experience, gender, physician perception, transition planning for changes in roles and work processes, team-based care, adequate technical support and training, sharing resources, practices affiliated with an integrated delivery system, financial incentives, and policies to increase EMR use all had a favorable impact on PCPs' use of advanced EMR features.

CONCLUSIONS

By using a narrative synthesis to synthesize the evidence, we identified interrelated factors influencing the mature use of EMRs by PCPs. The findings underline the need to provide adequate training and policies that facilitate the mature use of EMRs by PCPs.

TRIAL REGISTRATION

PROSPERO CRD42019137526.