Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting

Evaluating a Public Health Information Service According to Users' Socioeconomic Position and Health Status: Protocol for a Cross-Sectional Study

BACKGROUND

The increasing use of information technology in the field of health is supposed to promote users' empowerment but can also reinforce social inequalities. Some health authorities in various countries have developed mechanisms to offer accurate and relevant information to health care system users, often through health websites. However, the evaluation of these sociotechnical tools is inadequate, particularly with respect to differences and inequalities in use by social groups.

OBJECTIVE

Our study aims to evaluate the access, understanding, appraisal, and use of the French website Santé.fr by users according to their socioeconomic position and perceived health status.

METHODS

This cross-sectional study involves the entire French population to which Santé.fr is offered. Data will be collected through mixed methods, including a web-based questionnaire for quantitative data and interviews and focus groups for qualitative data. Collected data will cover users' access, understanding, appraisal, and use of Santé.fr, as well as sociodemographic and socioeconomic characteristics, health status, and digital health literacy. A validation of the dimensions of access, understanding, appraisal, and use of Santé.fr will be conducted, followed by principal component analysis and ascendant hierarchical classification based on the 2 main components of principal component analysis to characterize homogeneous users' profiles. Regression models will be used to investigate the relationships between each dimension and socioeconomic position and health status variables. NVivo 11 software (Lumivero) will be used to categorize interviewees' comments into preidentified themes or themes emerging from the discourse and compare them with the comments of various types of interviewees to understand the factors influencing people's access, understanding, appraisal, and use of Santé.fr.

RESULTS

Recruitment is scheduled to begin in January 2024 and will conclude when the required number of participants is reached. Data collection is expected to be finalized approximately 7 months after recruitment, with the final data analysis programmed to be completed around December 2024.

CONCLUSIONS

This study would be the first in France and in Europe to evaluate a public health information service, in this case the Santé.fr website (the official website of the French Ministry of Health), according to users' socioeconomic position and health status. The study could discover issues related to inequalities in access to, and the use of, digital technologies for obtaining health information on the internet. Given that access to health information on the internet is crucial for health decision-making and empowerment, inequalities in access may have subsequent consequences on health inequalities among social categories. Therefore, it is important to ensure that all social categories have access to Santé.fr.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/51123.

Consequences of school closures due to COVID-19 in DRC, Nigeria, Senegal, and Uganda

In 2020 and 2021, Governments across the globe instituted school closures to reduce social interaction and interrupt COVID-19 transmission. We examined the consequences of school closures due to COVID-19 across four sub-Saharan African countries: the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda. We conducted a qualitative study among key informants including policymakers, school heads, students, parents, civil society representatives, and local leaders. The assessment of the consequences of school closures was informed by the Diffusion of Innovations theory which informed the interview guide and analysis. Interview transcripts were thematically analysed. Across the four countries, schools were totally closed for 120 weeks and partially closed for 48 weeks. School closures led to: i) Desirable and anticipated consequences: enhanced adoption of online platforms and mass media for learning and increased involvement of parents in their children's education. ii) Desirable and unanticipated consequences: improvement in information, communication, and technology (ICT) infrastructure in schools, development and improvement of computer skills, and created an opportunity to take leave from hectic schedules. iii) Undesirable anticipated consequences: inadequate education continuity among students, an adjustment in academic schedules and programmes, and disrupted student progress and grades. iv) Undesirable unanticipated: increase in sexual violence including engaging in transactional sex, a rise in teenage pregnancy, and school dropouts, demotivation of teachers due to reduced incomes, and reduced school revenues. v) Neutral consequences: engagement in revenue-generating activities, increased access to phones and computers among learners, and promoted less structured learning. The consequences of school closures for COVID-19 control were largely negative with the potential for both short-term and far-reaching longer-term consequences. In future pandemics, careful consideration of the type and duration of education closure measures and examination of their potential consequences in the short and long term is important before deploying them.

Unintended consequences of implementing non-pharmaceutical interventions for the COVID-19 response in Africa: experiences from DRC, Nigeria, Senegal, and Uganda

INTRODUCTION

The coronavirus (COVID 19) pandemic is one of the most terrifying disasters of the twenty-first century. The non-pharmaceutical interventions (NPIs) implemented to control the spread of the disease had numerous positive consequences. However, there were also unintended consequences-positively or negatively related to the nature of the interventions, the target, the level and duration of implementation. This article describes the unintended economic, Psychosocial and environmental consequences of NPIs in four African countries.

METHODS

We conducted a mixed-methods study in the Democratic Republic of Congo (DRC), Nigeria, Senegal and Uganda. A comprehensive conceptual framework, supported by a clear theory of change was adopted to encompass both systemic and non-systemic interventions. The data collection approaches included: (i) review of literature; (ii) analysis of secondary data for selected indicators; and (ii) key informant interviews with policy makers, civil society, local leaders, and law enforcement staff. The results were synthesized around thematic areas.

RESULTS

Over the first six to nine months of the pandemic, NPIs especially lockdowns, travel restrictions, curfews, school closures, and prohibition of mass gathering resulted into both positive and negative unintended consequences cutting across economic, psychological, and environmental platforms. DRC, Nigeria, and Uganda observed reduced crime rates and road traffic accidents, while Uganda also reported reduced air pollution. In addition, hygiene practices have improved through health promotion measures that have been promoted for the response to the pandemic. All countries experienced economic slowdown, job losses heavily impacting women and poor households, increased sexual and gender-based violence, teenage pregnancies, and early marriages, increased poor mental health conditions, increased waste generation with poor disposal, among others.

CONCLUSION

Despite achieving pandemic control, the stringent NPIs had several negative and few positive unintended consequences. Governments need to balance the negative and positive consequences of NPIs by anticipating and instituting measures that will support and protect vulnerable groups especially the poor, the elderly, women, and children. Noticeable efforts, including measures to avoid forced into marriage, increasing inequities, economic support to urban poor; those living with disabilities, migrant workers, and refugees, had been conducted to mitigate the negative effects of the NIPs.

Unintended consequences of pharmacy information systems: A case study

BACKGROUND

Pharmacy information systems (PhIS) can cause medication errors that pharmacists may overlook due to their increased workload and lack of understanding of maintaining information quality. This study seeks to identify factors influencing unintended consequences of PhIS and how they affect the information quality, which can pose a risk to patient safety.

MATERIALS AND METHODS

This qualitative, explanatory case study evaluated PhIS in ambulatory pharmacies in a hospital and a clinic. Data were collected through observations, interviews, and document analysis. We applied the socio-technical interactive analysis (ISTA) framework to investigate the socio-technical interactions of pharmacy information systems that lead to unintended consequences. We then adopted the human-organization-process-technology-fit (HOPT-fit) framework to identify their contributing and dominant factors, misfits, and mitigation measures.

RESULTS

We identified 28 unintended consequences of PhIS, their key contributing factors, and their interrelations with the systems. The primary causes of unintended consequences include system rigidity and complexity, unclear knowledge, understanding, skills, and purpose of using the system, use of hybrid paper and electronic documentation, unclear and confusing transitions, additions and duplication of tasks and roles in the workflow, and time pressure, causing cognitive overload and workarounds. Recommended mitigating mechanisms include human factor principles in system design, data quality improvement for PhIS in terms of effective use of workspace, training, PhIS master data management, and communication by standardizing workarounds.

CONCLUSION

Threats to information quality emerge in PhIS because of its poor design, a failure to coordinate its functions and clinical tasks, and pharmacists' lack of understanding of the system use. Therefore, safe system design, fostering awareness in maintaining the information quality of PhIS and cultivating its safe use in organizations is essential to ensure patient safety. The proposed evaluation approach facilitates the evaluator to identify complex socio-technical interactions and unintended consequences factors, impact, and mitigation mechanisms.

Personalized Mobile Health for Elderly Home Care: A Systematic Review of Benefits and Challenges

Mobile health as one of the new technologies can be a proper solution to support care provision for the elderly and provide personalized care for them. This study is aimed at reviewing the benefits and challenges of personalized mobile health (PMH) for elderly home care. With a systematic review methodology, 1895 records were retrieved by searching four databases. After removing duplicates, 1703 articles remained. Following full-text examination, 21 articles that met the inclusion criteria were studied in detail, and the output was presented in different tables. The results indicated that 25% of the challenges were related to privacy, cybersecurity, and data ownership (10%), technology (7.5%), and implementation (7.5%). The most frequent benefits were related to cost-saving (17.5%), nurse engagement improvement (10%), and caregiver stress reduction (7.5%). In general, the number of benefits in this study was slightly higher than the challenges, but in order to use PMH technologies, the challenges presented in this study must be carefully considered and a suitable solution must be adopted. Benefits can also be helpful in persuading individuals and health-care providers. This study shed light on those points that need to be highlighted for further work in order to convert the challenges toward benefits.

Challenges in inpatient care coordinators’ clinical workflow and opportunities in designing a health IT solution: A mixed methods study

Introduction

Inpatient care coordinators (ICCs) in the United States play a critical role in case management and care transition. ICCs spend a large amount of time in chart review and documentation through electronic health record (EHR) systems. However, significant knowledge gaps exist regarding their workflow barriers and their use of health information technology (Health IT). Using only quantitative or quantitative methods does not provide a comprehensive picture about ICC’s workflow due to its complex and dynamic nature. This work aimed to address this gap by conducting a mixed-methods study to understand the workflow of ICCs and identifying challenges in care deliver and documentation activities.

Methods

The study adopted a concurrent triangulation design including qualitative interviews with 12 ICC staff members in the United States followed by extraction of their EHR event logs for one month. The qualitative interview data were analyzed thematically, and the log data were analyzed statistically. The results were triangulated and interpreted.

Results

Three major workflow barriers faced by ICCs were identified: long travel time, heavy documentation load, and suboptimal communication. The event logs provided empirical evidence to support the workflow barriers identified in the interviews, especially in travel time and documentation load.

Discussion

ICC workflow has several inefficiencies. The study generated four design considerations to develop a Health IT solution: Mobility, EHR integration, Team-based Communication, and User Adoption to improve workflow efficiency and care coordination. Using a mixed-methods approach is effective and efficient in collecting and analyzing clinical workflow.

Principles for Designing and Developing a Workflow Monitoring Tool to Enable and Enhance Clinical Workflow Automation

BACKGROUND

Automation of health care workflows has recently become a priority. This can be enabled and enhanced by a workflow monitoring tool (WMOT).

OBJECTIVES

We shared our experience in clinical workflow analysis via three cases studies in health care and summarized principles to design and develop such a WMOT.

METHODS

The case studies were conducted in different clinical settings with distinct goals. Each study used at least two types of workflow data to create a more comprehensive picture of work processes and identify bottlenecks, as well as quantify them. The case studies were synthesized using a data science process model with focuses on data input, analysis methods, and findings.

RESULTS

Three case studies were presented and synthesized to generate a system structure of a WMOT. When developing a WMOT, one needs to consider the following four aspects: (1) goal orientation, (2) comprehensive and resilient data collection, (3) integrated and extensible analysis, and (4) domain experts.

DISCUSSION

We encourage researchers to investigate the design and implementation of WMOTs and use the tools to create best practices to enable workflow automation and improve workflow efficiency and care quality.

The Interplay Between Technology Performativity and Health Care Professionals in Hospital Settings: Service Design Approach

BACKGROUND

The unexpected outbreak of the COVID-19 pandemic and the preventive measures of physical distancing have further necessitated the application of information and communication technologies (ICTs) to enhance the efficiency of work activities in health care. Although the interplay between human agency and technology performativity is critical to the success or failure of ICTs use in routine practice, it is rarely explored when designing health ICTs for hospital settings within the sub-Saharan Africa context.

OBJECTIVE

The objective of this study is to explore how the service delivery quality is being influenced by the technology-enabled activities of health care professionals at points of care using a service design strategy.

METHODS

An interpretivist stance was assumed to understand the socially constructed realities of health care professionals at points of care in a hospital setting. A service design strategy was identified as suitable for engaging health care professionals in co-design sessions to collect data. A purposive sampling technique was used to identify the participants. Open-ended questions were administered to gain insights into the work activities of physicians and nurses at points of care. Qualitative (textual) data were analyzed using thematic analysis. Ethical concerns about the safety and privacy of participants' data were addressed as per the university ethics review committee and provincial department of health.

RESULTS

The findings show that the attributes of human agency and technology features that drive technology performativity result in an interplay between social concepts and technical features that influence the transformation of human-machine interactions. In addition, the interplay of the double dance of agency model can be divided into 2 successive phases: intermediate and advanced. Intermediate interplay results in the perceived suitability or discomfort of health ICTs as experienced by health care professionals at initial interactions during the execution of work activities. Subsequently, the advanced interplay determines the usefulness and effectiveness of health ICTs in aiding task performance, which ultimately leads to either the satisfaction or dissatisfaction of health care professionals in the completion of their work activities at points of care.

CONCLUSIONS

The adopted service design strategy revealed that the interaction moments of the tasks performed by health care professionals during the execution of their work activities at point of care determine the features of health ICTs relevant to work activities. Consequently, the ensuing experience of health care professionals at the completion of their work activities influences the use or discontinuation of health ICTs. Health care professionals consider the value-added benefits from the automation of their work activities to ultimately influence the quality of service delivery. The major knowledge contribution of this study is the awareness drawn to both the intermediate and advanced interplay of human-machine interaction when designing health ICTs.

Patient Safety Threats in Information Management Using Health Information Technology in Ambulatory Cancer Care: An Exploratory, Prospective Study

BACKGROUND

Cancer care is complex, involving highly toxic drugs, critically ill patients, and various different care providers. Because it is important for clinicians to have the latest and complete information about the patient available, this study focused on patient safety issues in information management developing from health information technology (HIT) use in oncology ambulatory infusion centers.

OBJECTIVE

The aim was to exploratively and prospectively assess patient safety risks from an expert perspective: instead of retrospectively analyzing safety events, we assessed the information management hazards inherent to the daily work processes; instead of asking healthcare workers at the front line, we used them as information sources to construct our patient safety expert view on the hazards.

METHODS

The work processes of clinicians in three ambulatory infusion centers were assessed and evaluated based on interviews and observations with a nurse and a physician of each unit. The 125 identified patient safety issues were described and sorted into thematic groups.

RESULTS

A broad range of patient safety issues was identified, such as data fragmentation, or information islands, meaning that patient data are stored across different cases or software and that different professional groups do not use the same set of information.

CONCLUSIONS

The current design and implementation of HIT systems do not support adequate information management: clinicians needed to play very close attention and improvise to avoid errors in using HIT and treat cancer patients safely. It is important to take the clinical front-end practice into account when evaluating or planning further HIT improvements.

Burnout in clinicians

Burnout is a response to sustained job stressors manifesting as a classic triad of emotional exhaustion, depersonalization, and a sense of reduced accomplishment. With 42% of physicians demonstrating some symptoms of burnout, this has already reached epidemic proportions. The COVID-19 pandemic has only worsened this phenomenon.

Consequences of Rapid Telehealth Expansion in Nursing Homes: Promise and Pitfalls

BACKGROUND

Expectations regarding use and potential benefits of telehealth (TH) in nursing homes (NHs) are high; however, unplanned and unexpected consequences can occur as a result of major policy and technological changes.

OBJECTIVES

The goal of this study was to elicit stakeholder perspectives of consequences of rapid TH expansion in NHs.

METHODS

Using a qualitative descriptive design, we drew a sample based on findings from a national study examining trends in NH information and technology (IT) maturity, including TH use. We used maximum variation sampling to purposively select participants who (1) participated in our IT maturity survey for two consecutive years, (2) completed year 1 of the IT maturity survey prior to TH expansion (before March 6, 2020) and year 2 after TH expansion (after March 6, 2020), (3) represented a broad range of facility characteristics, and (4) were identified as an end user of TH or responsible for TH implementation. Using six questions from the IT maturity survey, we created a total TH score for each facility and selected participants representing a range of scores.

RESULTS

Interviews were conducted with (n = 21) NH administrators and clinicians from 16 facilities. We found similarities and differences in perceptions of TH expansion according to facility TH score, NH location, and participant role. Desirable consequences included four subthemes as follows: (1) benefits of avoiding travel for the NH resident, (2) TH saving organizational resources, (3) improved access to care, and (4) enhanced communication. Undesirable consequences include the following five subthemes: (1) preference for in-person encounters, (2) worsening social isolation, (3) difficulty for residents with cognitive impairment, (4) workflow and tech usability challenges, and (5) increased burden on NH staff/infrastructure. Participants from rural NHs perceived lack of training, poor video/sound quality, and internet/connectivity issues to be potential pitfalls.

CONCLUSION

Clinicians and NH administrators should consider leveraging the desirable consequences of rapid TH expansion and implement mitigation strategies to address the undesirable/unanticipated consequences.

Mitigating unintended consequences of co-design in health care

Background

Co‐design and associated terms are increasingly being used to facilitate values‐based approaches to health‐care improvement. It is messy and complex, involving diverse actors.

Methods

We explore the notion that initiatives have outcomes other than initially planned is neither new nor novel but is overlooked when thinking about co‐design. We explore some of the unintended consequences and outline some optimal conditions that can mitigate challenges.

Discussion

Although co‐design approaches are being applied in health care, questions remain regarding its ability to produce gains in health outcomes. Little is known about determining whether co‐design is the most suitable approach to achieve the given project goals, the levels of involvement required to realize the benefits of co‐design or the potential unintended consequences. There is a risk of further marginalizing or adding burden to under‐represented populations and/or over‐researched populations.

Conclusion

Undertaking a co‐design approach without the optimal conditions for inclusive involvement by all may not result in an equal partnership or improve health or care quality outcomes. Co‐design requires on‐going reflective discussions and deliberative thinking to remove any power imbalances. However, without adequate resources, a focus on implementation and support from senior leaders, it is a tough ask to achieve.

Patient or Public Contribution

This viewpoint article was written by two academics who have undertaken a significant amount of PPI and co‐design work with members of the public and patient's right across the health system. Our work guided the focus of this viewpoint as we reflected on our experiences.

A retrospective look at the predictions and recommendations from the 2009 AMIA policy meeting: did we see EHR-related clinician burnout coming?

Clinicians often attribute much of their burnout experience to use of the electronic health record, the adoption of which was greatly accelerated by the Health Information Technology for Economic and Clinical Health Act of 2009. That same year, AMIA's Policy Meeting focused on possible unintended consequences associated with rapid implementation of electronic health records, generating 17 potential consequences and 15 recommendations to address them. At the 2020 annual meeting of the American College of Medical Informatics (ACMI), ACMI fellows participated in a modified Delphi process to assess the accuracy of the 2009 predictions and the response to the recommendations. Among the findings, the fellows concluded that the degree of clinician burnout and its contributing factors, such as increased documentation requirements, were significantly underestimated. Conversely, problems related to identify theft and fraud were overestimated. Only 3 of the 15 recommendations were adjudged more than half-addressed.

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them

BACKGROUND

COVID-19 has led to the adoption of unprecedented mitigation measures which could trigger many unintended consequences. These unintended consequences can be far-reaching and just as important as the intended ones. The World Health Organization identified the assessment of unintended consequences of COVID-19 mitigation measures as a top priority. Thus far, however, their systematic assessment has been neglected due to the inattention of researchers as well as the lack of training and practical tools.

MAIN TEXT

Over six years our team has gained extensive experience conducting research on the unintended consequences of complex health interventions. Through a reflexive process, we developed insights that can be useful for researchers in this area. Our analysis is based on key literature and lessons learned reflexively in conducting multi-site and multi-method studies on unintended consequences. Here we present practical guidance for researchers wishing to assess the unintended consequences of COVID-19 mitigation measures. To ensure resource allocation, protocols should include research questions regarding unintended consequences at the outset. Social science theories and frameworks are available to help assess unintended consequences. To determine which changes are unintended, researchers must first understand the intervention theory. To facilitate data collection, researchers can begin by forecasting potential unintended consequences through literature reviews and discussions with stakeholders. Including desirable and neutral unintended consequences in the scope of study can help minimize the negative bias reported in the literature. Exploratory methods can be powerful tools to capture data on the unintended consequences that were unforeseen by researchers. We recommend researchers cast a wide net by inquiring about different aspects of the mitigation measures. Some unintended consequences may only be observable in subsequent years, so longitudinal approaches may be useful. An equity lens is necessary to assess how mitigation measures may unintentionally increase disparities. Finally, stakeholders can help validate the classification of consequences as intended or unintended.

CONCLUSION

Studying the unintended consequences of COVID-19 mitigation measures is not only possible but also necessary to assess their overall value. The practical guidance presented will help program planners and evaluators gain a more comprehensive understanding of unintended consequences to refine mitigation measures.

The role of telehealth in sexual and reproductive health services in the response to COVID-19

Abstract This opinion article brings considerations about advantages and challenges with the use of telehealth in sexual and reproductive health services aiming family planning in the face of COVID-19 pandemic new scenario.

The complex case of EHRs: examining the factors impacting the EHR user experience

Physicians can spend more time completing administrative tasks in their electronic health record (EHR) than engaging in direct face time with patients. Increasing rates of burnout associated with EHR use necessitate improvements in how EHRs are developed and used. Although EHR design often bears the brunt of the blame for frustrations expressed by physicians, the EHR user experience is influenced by a variety of factors, including decisions made by entities other than the developers and end users, such as regulators, policymakers, and administrators. Identifying these key influences can help create a deeper understanding of the challenges in developing a better EHR user experience. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs.

[Beyond benefit evaluation: Considering the unintended consequences of telehealth]

La télésanté est considérée comme un levier incontournable dans les choix des politiques en santé. Toutefois, il subsiste de nombreux enjeux face à son intégration réussie dans les pratiques cliniques. À ce jour, un grand nombre d’initiatives en télésanté peine à dépasser le stade de projet pilote. Cette situation s’explique en partie par une culture de l’innovation qui est principalement focalisée sur les bénéfices attendus de la technologie et moins sur les changements et les transformations qu’elle peut entraîner. La télésanté est utilisée dans des établissements de santé dont la dynamique sociale est pour le moins complexe. Son introduction entraîne des conséquences inattendues pouvant affecter aussi bien les patients, les communautés, les professionnels, les établissements que les systèmes de santé et la société dans son ensemble. L’objectif de cet article est de discuter de certaines des conséquences inattendues découlant de l’utilisation de la télésanté dans les établissements et systèmes de santé.

Studying Workflow and Workarounds in Electronic Health Record-Supported Work to Improve Health System Performance

Clinical workflow is the enactment of a series of steps to perform a clinical activity. The transition from paper to electronic health records (EHRs) over the past decade has been characterized by profound challenges supporting clinical workflow, impeding frontline clinicians' ability to deliver safe, efficient, and effective care. In response, there has been substantial effort to study clinical workflow as well as workarounds-exceptions to routine workflow-in order to identify opportunities for improvement. This article describes predominant methods of studying workflow and workarounds and provides examples of the applications of these methods along with the resulting insights. Challenges to studying workflow and workarounds are described, and recommendations for how to approach such studies are given. Although there is not yet a set of standard approaches, this article helps advance workflow research that ultimately serves to inform how to coevolve the design of EHR systems and organizational decisions about processes, roles, and responsibilities in order to support clinical workflow that more consistently delivers on the potential benefits of a digitized health care system.

The precarization of the Mexican nursing labor market: a repeated cross-sectional analysis for the period 2005-2018

BACKGROUND

Precarization of labor conditions has been expanding over the last three decades as a consequence of global economic transformations. The health workforce labor market is exposed to these transformations as well. In Mexico, analyses of the nursing labor market have documented high levels of unemployment and underemployment; however, precarization has been not considered as a relevant indicator in these analyses. In this study, precarization is analyzed using a quantitative approach to show its prevalence and geographic distribution between 2005 and 2018.

METHODS

A repeated cross-sectional study was carried out with data from the population-based National Occupation and Employment Survey (ENOE in Spanish) which is administered quarterly to people 15 years or older in over 120 000 households. All individuals who reported having nursing training (technical or university level) were selected for this study. Our main variable was labor precariousness, which included three dimensions: (i) economic, (ii) regulatory, and (iii) occupational safety. We show the evolution of the relative weight of nursing activity between the years 2005 and 2018, the main socio-demographic characteristics of nurses as well as their main labor conditions, and the geographic distribution of precariousness for the 32 federal states in México.

RESULTS

Four of the five indicators of labor precariousness increased among the group of nurses analyzed: (a) the percentage of people with no written contract, (b) the percentage of people with incomes lower than two times the minimum wage, (c) the percentage of nurses without social security, and (d) the percentage of nurses without social benefits. The percentage of nurses that work under some condition of work precariousness increased from 46% in 2005-2006 to 54% in 2018. Finally, the number of states with high precariousness level increased from seven in 2005-2006 to 17 in 2018.

CONCLUSIONS

Throughout Mexico, nursing precariousness has expanded reaching 53% by 2018. The advancement of precarization of nursing jobs implies a reduction in the capacity of the Mexican health system to reach its coverage and care goals as nurses represent 52% of all available workers that provide direct services to the population.

Reconceptualizing the Electronic Health Record for a New Decade: A Caring Technology?

Since the 2009 publication by Petrovskaya et al on, "Dilemmas, Tetralemmas, Reimagining the Electronic Health Record," and passage of the Health Information Technology for Economic Clinical Health (HITECH) Act, 96% of hospitals and 78% of providers have implemented the electronic health record. While many positive outcomes such as guidelines-based clinical decision support and patient portals have been realized, we explore recent issues in addition to those continuing problems identified by Petrovskaya et al that threaten patient safety and integrity of the profession. To address these challenges, we integrate polarity thinking with the tetralemma model discussed by Petrovskaya et al and propose application of a virtue ethics framework focused on cultivation of technomoral wisdom.

Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis

Background: Telehealth initiatives have bloomed around the globe, but their integration and diffusion remain challenging because of the complex issues they raise. Available evidence around telehealth usually deals with its expected effects and benefits, but its unintended consequences (UCs) and influencing factors are little documented. This study aims to explore, describe and analyze multidimensional UCs that have been associated with the use of telehealth.

Methods: We performed a secondary analysis of the evaluations of 10 telehealth projects conducted over a 22-year period in the province of Quebec (Canada). All material was subjected to a qualitative thematic-pragmatic content analysis with triangulation of methodologies and data sources. We used the conceptual model of the UCs of health information technologies proposed by Bloomrosen et al to structure our analysis.

Results: Four major findings emerged from our analysis. First, telehealth utilization requires many adjustments, changes and negotiations often underestimated in the planning and initial phases of the projects. Second, telehealth may result in the emergence of new services corridors that disturb existing ones and involve several adjustments for organizations, such as additional investments and resources, but also the risk of fragmentation of services and the need to balance between standardization of practices and local innovation. Third, telehealth may accentuate power relations between stakeholders. Fourth, it may lead to significant changes in the responsibilities of each actor in the supply chain of services. Finally, current legislative and regulatory frameworks appear ill-adapted to many of the new realities brought by telehealth.

Conclusion: This study provides a first attempt for an overview of the UCs associated with the use of telehealth. Future research-evaluation studies should be more sensitive to the multidimensional and interdependent factors that influence telehealth implementation and utilization as well as its impacts, intended or unintended, at all levels. Thus, a consideration of potential UCs should inform telehealth projects, from their planning until their scaling-up.

[Patient safety hazards resulting from information technology usage in outpatient oncology infusion centers: A prospective analysis of information management]

OBJECTIVES

Thorough management of patient information is crucial in cancer care in order to avoid errors. Clinicians need complete, up-to-date information to be able to develop an adequate mental model of the patient's situation. The aim of the present study was to identify patient safety hazards coming with the use of health information technology (HIT): patient safety hazards in three outpatient oncology infusion centers were assessed and priority topics identified. Additionally, the number of information sources clinicians have to use in order to get an idea of the patient's situation was systematically assessed. Interviews and observations were conducted with one nurse and one doctor of each ambulatory infusion center.

PRINCIPAL RESULTS

Information management-related patient safety hazards were omnipresent in daily care: eleven topics were identified from 125 assessed patient safety hazards. Three of them were particularly relevant to the clinicians' development of an adequate mental model about the patient: patient-related information was not stored in one place but often fragmented in different HIT systems; despite the introduction of HIT, paper documentation remained in place for certain information, making access difficult and increasing the number of relevant sources; the lack of usability of the HIT systems made it difficult to retrieve patient information in a timely manner. Clinicians needed to use between 5 and 11 sources of information to get a more complete picture of a patient's situation.

MAJOR CONCLUSIONS

Overall, it has been shown that the design of the HIT systems is not sufficiently adapted to the work processes and does not support clinicians in being fully informed about a patient. The topics identified point to future system design and areas for improvement. In this process, it is very important to align the real work requirements with the design of the HIT and to evaluate and monitor the actual implementation and use of HIT.

Reinterpreting the nursing record for an electronic context

BACKGROUND

This article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements.

METHODS

A comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas - standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current 'state of the art', and recommendations for the future.

RESULTS

Included studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation.

CONCLUSION

There is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as 'data collectors'; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented.

Enabling older adults to carry out paperless falls-risk self-assessments using guidetomeasure-3D: A mixed methods study

BACKGROUND

The home environment falls-risk assessment process (HEFAP) is a widely used falls prevention intervention strategy which involves a clinician using paper-based measurement guidance to ensure that appropriate information and measurements are taken and recorded accurately. Despite the current use of paper-based guidance, over 30% of all assistive devices installed within the home are abandoned by patients. This is in part due to poor fit between the device, the patient, and the environment in which it is installed. Currently HEFAP is a clinician-led process, however, older adult patients are increasingly being expected to collect HEFAP measurements themselves as part of the personalisation agenda. Without appropriate patient-centred guidance, levels of device abandonment to are likely to rise to unprecedented levels. This study presents guidetomeasure-3D, a mobile 3D measurement guidance application designed to support patients in carrying out HEFAP self-assessments.

AIM

The aim of this study is to present guidetomeasure-3D, a web-enabled 3D mobile application that enables older-adult patients to carry out self-assessment measurement tasks, and to carry out a mixed-methods evaluation of its performance, and associated user perceptions of the application, compared with a 2D paper-based equivalent.

METHODS

Thirty-four older adult participants took part in a mixed-methods within-subjects repeated measures study set within a living lab. A series of HEFAP self-assessment tasks were carried out according to two treatment conditions: (1) using the 3D guidetomeasure-3D application; (2) using a 2D paper-based guide. SUS questionnaires and semi-structured interviews were completed at the end of the task. A comparative statistical analysis explored performance with regards to measurement accuracy, accuracy consistency, task efficiency, and system usability. Interview transcripts were analysed using inductive and deductive thematic analysis (informed by UTAUT).

RESULTS

The guidetomeasure-3D application outperformed the 2D paper-based guidance in terms of accuracy (smaller mean error difference in 11 out of 12 items), accuracy consistency (p < 0.05, for 6 out of 12 items), task efficiency (p = 0.003), system usability (p < 0.00625, for two out of 10 SUS items), and clarity of guidance (p < 0.0125, for three out of four items). Three high-level themes emerged from interviews: Performance Expectancy, Effort Expectancy, and Social Influence. Participants reported that guidetomeasure-3D provided improved visual quality, clarity, and more precise guidance overall. Real-time audio instruction was reported as being particularly useful, as was the use of the object rotation and zoom functions which were associated with improving user confidence particularly when carrying out more challenging tasks.

CONCLUSIONS

This study reveals that older adults using guidetomeasure-3D achieved improved levels of accuracy and efficiency along with improved satisfaction and increased levels of confidence compared with the 2D paper-based equivalent. These results are significant and promising for overcoming HEFAP equipment abandonment issue. Furthermore they constitute an important step towards overcoming challenges associated with older adult patients, the digitisation of healthcare, and realising the enablement of patient self-care and management via the innovative use of mobile technologies. Numerous opportunities for the generalisability and transferability of the findings of this research are also proposed. Future research will explore the extent to which mobile 3D visualisation technologies may be utilised to optimise the clinical utility of HEFAP when deployed by clinicians.

What's in a Name? Provider Perception of Injured John Doe Patients

BACKGROUND

We previously demonstrated that unidentified aliased patients, John Doe's (DOEs), are one of the highest risk and most medically fragile populations of injured patients. Aliasing can result in misplaced information and confusion that must be overcome by health care professionals. DOE alias use is institutionally dependent and not uniform, which may lead to significant variation in perception of confusion and error. We sought to determine if health care practitioners experience confusion that may result in compromised care when caring for injured DOE patients.

METHODS

After obtaining institutional review board approval, we surveyed critical care nurses, nurse practitioners, resident physicians, and surgeons who care for DOE patients at two academic level I trauma centers with separate DOE alias practices. Surveys asked whether caring for DOE patients created possible or actual confusion and possible or actual patient care errors. In one institution (Selective DOE), only unidentified patients were given an alias that was reconciled when information became available. At the other institution (All DOE), all trauma patients were admitted with an alias that was reconciled within 24 h. Respondents were invited to complete an anonymous questionnaire regarding the care for DOE patients. Results were analyzed with Wilcoxon rank-sum tests, and significance was assessed at a level of 0.05.

RESULTS

Of 176 total respondents, 120 (68.2%) reported from Selective DOE and 56 (31.8%) from All DOE. Overall 53.1% reported that DOE use can cause serious confusion. Specifically, 31.3% reported experiencing actual confusion, although only 4% reported actual errors. Nurses had significantly higher perceived risk of confusion in the system of All DOE versus Selective DOE assignment (17.9% versus 4.2%, P < 0.01). Resident physicians reported significantly more frequent actual mistakes within the All DOE versus Selective DOE (24.1% versus 6.6%, P < 0.01), despite finding no significant difference in resident perception of confusion (21.4% versus 12.5%, respectively, P = 0.18).

CONCLUSIONS

Our study sheds light on clinical consequences of EMR use and aliases for end users. We show that nurses perceive that there are greater potential complications associated with DOE aliases use, and this varies depending on the system used for managing unidentified patients. Minimizing DOE alias use may help to minimize provider confusion, risk for error, and patient safety.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective

Background

The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project.

Methods

The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015–2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis.

Results

Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels.

Conclusion

Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff’s experiences.

Experience of Emergency Department Patients With Using the Talking Pole Device: Prospective Interventional Descriptive Study

BACKGROUND

Patient engagement is important. However, it can be difficult in emergency departments (EDs).

OBJECTIVE

The aim of this study was to evaluate the satisfaction of ED patients using a patient-friendly health information technology (HIT) device, the "Talking Pole," and to assess the factors relevant to their satisfaction.

METHODS

This study was conducted in May 2017 at the ED of a tertiary hospital. The "Talking Pole" is a smartphone-based device attached to a intravenous infusion pole with sensors. It is capable of sensing patient movement and fluid dynamics. In addition, it provides clinical information from electronic medical records to patients and serves as a wireless communication tool between patients and nurses. Patients and caregivers who entered the observation room of the ED were selected for the study. The "Talking Pole" devices were provided to all participants, regardless of their need for an intravenous pole upon admittance to the ED. After 2 hours, each participant was given an 18-item questionnaire created for this research, measured on a 5-point Likert scale, regarding their satisfaction with "Talking Pole."

RESULTS

Among 52 participants recruited, 54% (28/52) were patients and the remaining were caregivers. In total, 38% (20/52) were male participants; the average age was 54.6 (SD 12.9) years, and 63% (33/52) of the participants were oncology patients and their caregivers. The overall satisfaction rate was 4.17 (SD 0.79 ) points. Spearman correlation coefficient showed a strong association of "overall satisfaction" with "comparison to the previous visit" (ρ=.73 ), "perceived benefit" (ρ=.73), "information satisfaction" (ρ=.70), and "efficiency" (ρ=.70).

CONCLUSIONS

In this study, we introduced a patient-friendly HIT device, the "Talking Pole." Its architecture focused on enhancing information delivery, which is regarded as a bottleneck toward achieving patient engagement in EDs. Patient and caregiver satisfaction with the "Talking Pole" was positive in the ED environment. In particular, correlation coefficient results improved our understanding about patients' satisfaction, HIT devices, and services used in the ED.

A Real-Time Autonomous Dashboard for the Emergency Department: 5-Year Case Study

Background

The task of monitoring and managing the entire emergency department (ED) is becoming more important due to increasing pressure on the ED. Recently, dashboards have received the spotlight as health information technology to support these tasks.

Objective

This study aimed to describe the development of a real-time autonomous dashboard for the ED and to evaluate perspectives of clinical staff on its usability.

Methods

We developed a dashboard based on three principles—“anytime, anywhere, at a glance;” “minimal interruption to workflow;” and “protect patient privacy”—and 3 design features—“geographical layout,” “patient-level alert,” and “real-time summary data.” Items to evaluate the dashboard were selected based on the throughput factor of the conceptual model of ED crowding. Moreover, ED physicians and nurses were surveyed using the system usability scale (SUS) and situation awareness index as well as a questionnaire we created on the basis of the construct of the Situation Awareness Rating Technique.

Results

The first version of the ED dashboard was successfully launched in 2013, and it has undergone 3 major revisions since then because of geographical changes in ED and modifications to improve usability. A total of 52 ED staff members participated in the survey. The average SUS score of the dashboard was 67.6 points, which indicates “OK-to-Good” usability. The participants also reported that the dashboard provided efficient “concentration support” (4.15 points), “complexity representation” (4.02 points), “variability representation” (3.96 points), “information quality” (3.94 points), and “familiarity” (3.94 points). However, the “division of attention” was rated at 2.25 points.

Conclusions

We developed a real-time autonomous ED dashboard and successfully used it for 5 years with good evaluation from users.

The unintended consequences of combining equity measures with performance-based financing in Burkina Faso

BACKGROUND

User fees and poor quality of care contribute to low use of healthcare services in Burkina Faso. The government implemented an innovative intervention that combines equity measures with performance-based financing (PBF). These health equity measures included a community-based selection of indigents to receive user fee exemptions and paying healthcare centres higher purchase prices for services provided to indigents. Research suggests complex interventions can trigger changes not targeted by program planners. To date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining PBF with health equity measures. Our objective is to document unintended consequences of the equity measures in this complex intervention.

METHODS

We developed a conceptual framework using the diffusion of innovations theory. For the design, we conducted a multiple case study. The cases were four healthcare facilities in one district. We collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. We conducted thematic analysis using a hybrid deductive-inductive approach. We also used secondary data to describe the monthly evolution of services provided to indigent and non-indigent patients before and after indigent cards were distributed. Time series graphs were used to validate some results.

RESULTS

Local actors, including members of indigent selection committees and healthcare workers, re-invented elements of the PBF equity measures over which they had control to increase their relative advantage or to adapt to implementation challenges and context. Some individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. Healthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. Healthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. Ultimately, selected indigents received uncertain and unequal coverage.

CONCLUSIONS

The severity of unintended consequences undermined the effectiveness and equity of the intervention. If the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.

Data-driven approach to Early Warning Score-based alert management

Background

Increasing adoption of electronic health records (EHRs) with integrated alerting systems is a key initiative for improving patient safety. Considering the variety of dynamically changing clinical information, it remains a challenge to design EHR-driven alerting systems that notify the right providers for the right patient at the right time while managing alert burden. The objective of this study is to proactively develop and evaluate a systematic alert-generating approach as part of the implementation of an Early Warning Score (EWS) at the study hospitals.

Methods

We quantified the impact of an EWS-based clinical alert system on quantity and frequency of alerts using three different alert algorithms consisting of a set of criteria for triggering and muting alerts when certain criteria are satisfied. We used retrospectively collected EHRs data from December 2015 to July 2016 in three units at the study hospitals including general medical, acute care for the elderly and patients with heart failure.

Results

We compared the alert-generating algorithms by opportunity of early recognition of clinical deterioration while proactively estimating alert burden at a unit and patient level. Results highlighted the dependency of the number and frequency of alerts generated on the care location severity and patient characteristics.

Conclusion

EWS-based alert algorithms have the potential to facilitate appropriate alert management prior to integration into clinical practice. By comparing different algorithms with regard to the alert frequency and potential early detection of physiological deterioration as key patient safety opportunities, findings from this study highlight the need for alert systems tailored to patient and care location needs, and inform alternative EWS-based alert deployment strategies to enhance patient safety.

The Challenges of a Complex and Innovative Telehealth Project: A Qualitative Evaluation of the Eastern Quebec Telepathology Network

Background: The Eastern Quebec Telepathology Network (EQTN) has been implemented in the province of Quebec (Canada) to support pathology and surgery practices in hospitals that are lack of pathologists, especially in rural and remote areas. This network includes 22 hospitals and serves a population of 1.7 million inhabitants spread over a vast territory. An evaluation of this network was conducted in order to identify and analyze the factors and issues associated with its implementation and deployment, as well as those related to its sustainability and expansion.

Methods: Qualitative evaluative research based on a case study using: (1) historical analysis of the project documentation (newsletters, minutes of meetings, articles, ministerial documents, etc); (2) participation in meetings of the committee in charge of telehealth programs and the project; and (3) interviews, focus groups, and discussions with different stakeholders, including decision-makers, clinical and administrative project managers, clinicians (pathologists and surgeons), and technologists. Data from all these sources were cross-checked and synthesized through an integrative and interpretative process.

Results: The evaluation revealed numerous socio-political, regulatory, organizational, governance, clinical, professional, economic, legal and technological challenges related to the emergence and implementation of the project. In addition to technical considerations, the development of this network was associated with major changes and transformations of production procedures, delivery and organization of services, clinical practices, working methods, and clinicaladministrative processes and cultures (professional/organizational).

Conclusion: The EQTN reflects the complex, structuring, and innovative projects that organizations and health systems are required to implement today. Future works should be more sensitive to the complexity associated with the emergence of telehealth networks and no longer reduce them to technological considerations.

Near Real-time Surveillance for Consequences of Health Policies Using Sequential Analysis

BACKGROUND

New health policies may have intended and unintended consequences. Active surveillance of population-level data may provide initial signals of policy effects for further rigorous evaluation soon after policy implementation.

OBJECTIVE

This study evaluated the utility of sequential analysis for prospectively assessing signals of health policy impacts. As a policy example, we studied the consequences of the widely publicized Food and Drug Administration's warnings cautioning that antidepressant use could increase suicidal risk in youth.

METHOD

This was a retrospective, longitudinal study, modeling prospective surveillance, using the maximized sequential probability ratio test. We used historical data (2000-2010) from 11 health systems in the US Mental Health Research Network. The study cohort included adolescents (ages 10-17 y) and young adults (ages 18-29 y), who were targeted by the warnings, and adults (ages 30-64 y) as a comparison group. Outcome measures were observed and expected events of 2 possible unintended policy outcomes: psychotropic drug poisonings (as a proxy for suicide attempts) and completed suicides.

RESULTS

We detected statistically significant (P<0.05) signals of excess risk for suicidal behavior in adolescents and young adults within 5-7 quarters of the warnings. The excess risk in psychotropic drug poisonings was consistent with results from a previous, more rigorous interrupted time series analysis but use of the maximized sequential probability ratio test method allows timely detection. While we also detected signals of increased risk of completed suicide in these younger age groups, on its own it should not be taken as conclusive evidence that the policy caused the signal. A statistical signal indicates the need for further scrutiny using rigorous quasi-experimental studies to investigate the possibility of a cause-and-effect relationship.

CONCLUSIONS

This was a proof-of-concept study. Prospective, periodic evaluation of administrative health care data using sequential analysis can provide timely population-based signals of effects of health policies. This method may be useful to use as new policies are introduced.

Determining Inappropriate Medication Alerts from "Inaccurate Warning" Overrides in the Intensive Care Unit

OBJECTIVE

This article aims to understand provider behavior around the use of the override reason "Inaccurate warning," specifically whether it is an effective way of identifying unhelpful medication alerts.

MATERIALS AND METHODS

We analyzed alert overrides that occurred in the intensive care units (ICUs) of a major academic medical center between June and November 2016, focused on the following high-significance alert types: dose, drug-allergy alerts, and drug-drug interactions (DDI). Override appropriateness was analyzed by two independent reviewers using predetermined criteria.

RESULTS

A total of 268 of 26,501 ICU overrides (1.0%) used the reason "Inaccurate warning," with 93 of these overrides associated with our included alert types. Sixty-one of these overrides (66%) were identified to be appropriate. Twenty-one of 30 (70%) dose alert overrides were appropriate. Forty of 48 drug-allergy alert overrides (83%) were appropriate, for reasons ranging from prior tolerance (n = 30) to inaccurate ingredient matches (n = 5). None of the 15 DDI overrides were appropriate.

CONCLUSION

The "Inaccurate warning" reason was selectively used by a small proportion of providers and overrides using this reason identified important opportunities to reduce excess alerts. Potential opportunities include improved evaluation of dosing mechanisms based on patient characteristics, inclusion of institutional dosing protocols to alert logic, and evaluation of a patient's prior tolerance to a medication that they have a documented allergy for. This resource is not yet routinely used for alert tailoring at our institution but may prove to be a valuable resource to evaluate available alerts.

Trauma Surgeons Save Lives—Scribes Save Trauma Surgeons!

With the advent of the electronic medical record, the documentation burden of the trauma surgeon has become overwhelming. To help, our trauma division added scribes to the rounding team. We hypothesized that scribe utilization would improve our documentation efficiency and offer a financial benefit to the institution. A review of trauma surgeon documentation and billing was performed at a Level I trauma center over two time periods: January to May 2014 (no scribes) and January to May 2015 (scribes). The number of notes written by trauma surgeons was obtained, as were documentation charges. Documentation efficiency was determined by noting both the hour of the day in which inpatient progress notes were written and the number of notes written after patient discharge. In the 2014 period, a total of 9726 notes were written by trauma attendings. In the 2015 period, 10,933 were written. Despite having 407 fewer trauma patient-days in the 2015 period, the group wrote 343 notes/week versus 298 notes/week ( P = 0.008). More inpatient progress notes were written earlier in the working day and fewer were written in the evening. Fewer notes were written after patient discharge (12.7 vs 8.4%). A total of 1,664 hours of scribe time were used over the 5-month period, generating an expense of $32,787. The additional notes generated by scribes resulted in $191,394 in charges. Conservatively, assuming a 20 per cent charge reimbursement, the cost of the scribes was covered. The addition of scribes to the daily trauma rounding team improved note efficiency and increased charge capture at our center.

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis of the impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay (LOS), and mortality in intensive care units (ICUs).

Methods

We searched for English-language literature published between January 2000 and January 2016 using Medline, Embase, and CINAHL. Titles and abstracts of 586 unique citations were screened. Studies were included if they: (1) reported results for an ICU population; (2) evaluated the impact of CPOE or the addition of CDSSs to an existing CPOE system; (3) reported quantitative data on medication errors, ICU LOS, hospital LOS, ICU mortality, and/or hospital mortality; and (4) used a randomized controlled trial or quasi-experimental study design.

Results

Twenty studies met our inclusion criteria. The transition from paper-based ordering to commercial CPOE systems in ICUs was associated with an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. Overall meta-analyses of LOS and hospital mortality did not demonstrate a significant change.

Discussion and Conclusion

Critical care settings, both adult and pediatric, involve unique complexities, making them vulnerable to medication errors and adverse patient outcomes. The currently limited evidence base requires research that has sufficient statistical power to identify the true effect of CPOE implementation. There is also a critical need to understand the nature of errors arising post-CPOE and how the addition of CDSSs can be used to provide greater benefit to delivering safe and effective patient care.

Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver

A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15-22.].

Balancing measures or a balanced accounting of improvement impact: a qualitative analysis of individual and focus group interviews with improvement experts in Scotland

BACKGROUND

As quality improvement (QI) programmes have become progressively larger scale, the risks of implementation having unintended consequences are increasingly recognised. More routine use of balancing measures to monitor unintended consequences has been proposed to evaluate overall effectiveness, but in practice published improvement interventions hardly ever report identification or measurement of consequences other than intended goals of improvement.

METHODS

We conducted 15 semistructured interviews and two focus groups with 24 improvement experts to explore the current understanding of balancing measures in QI and inform a more balanced accounting of the overall impact of improvement interventions. Data were analysed iteratively using the framework approach.

RESULTS

Participants described the consequences of improvement in terms of desirability/undesirability and the extent to which they were expected/unexpected when planning improvement. Four types of consequences were defined: expected desirable consequences (goals); expected undesirable consequences (trade-offs); unexpected undesirable consequences (unpleasant surprises); and unexpected desirable consequences (pleasant surprises). Unexpected consequences were considered important but rarely measured in existing programmes, and an improvement pause to take stock after implementation would allow these to be more actively identified and managed. A balanced accounting of all consequences of improvement interventions can facilitate staff engagement and reduce resistance to change, but has to be offset against the cost of additional data collection.

CONCLUSION

Improvement measurement is usually focused on measuring intended goals, with minimal use of balancing measures which when used, typically monitor trade-offs expected before implementation. This paper proposes that improvers and leaders should seek a balanced accounting of all consequences of improvement across the life of an improvement programme, including deliberately pausing after implementation to identify and quantitatively or qualitatively evaluate any pleasant or unpleasant surprises.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

The unintended consequences of community verifications for performance-based financing in Burkina Faso

Performance-based financing (PBF) is being widely implemented to improve healthcare services in Africa. An essential component of PBF involves conducting community verifications, wherein investigators from local associations attempt to trace samples of patients. Community surveys are administered to patients to verify whether healthcare workers reported fictitious services to increase their revenue. At the same time, client satisfaction surveys are administered to assess whether patients are satisfied with the services received. Although some global health actors are concerned that PBF can trigger unintended consequences, this topic remains neglected. The objective of this study was to document the unintended consequences of community verification. Guided by the diffusion of innovations theory, we conducted a multiple case study. The cases were the catchment areas of seven healthcare facilities in Burkina Faso. Data were collected between January 2016 and May 2016 using non-participant observation, 92 semi-structured interviews, and informal discussions. Participants included a wide range of stakeholders, such as community verifiers, investigators, patients, and healthcare providers. Data were coded using QDA Miner, and thematic analysis was conducted. Healthcare workers did not significantly disturb or try to influence community verifiers during patient selection for community verifications. Unintended consequences included stakeholders' dissatisfaction regarding compensation modalities, work overload for community verifiers, and falsification of verification data by investigators. Community verifications led to loss of patient confidentiality as well as fears and apprehensions, although some patients were pleased to share their views regarding healthcare services. Community verifications also triggered marital issues, resulting in conflicts with, or interference from, husbands. The numerous challenges associated with locating patients in their communities led stakeholders to question the validity and utility of the results. These unintended consequences could jeopardize the overall effectiveness of community verifications. Attention should be paid to these unintended consequences to inform effective implementation and refine future interventions.

Electronic Health Records and the Disappearing Patient

With rapid consolidation of American medicine into large-scale corporations, corporate strategies are coming to the forefront in health care delivery, requiring a dramatic increase in the amount and detail of documentation, implemented through use of electronic health records (EHRs). EHRs are structured to prioritize the interests of a myriad of political and corporate stakeholders, resulting in a complex, multi-layered, and cumbersome health records system, largely not directly relevant to clinical care. Drawing on observations conducted in outpatient specialty clinics, we consider how EHRs prioritize institutional needs manifested as a long list of requisites that must be documented with each consultation. We argue that the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician's role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative.

Improving a health information system for real-time data entries: An action research project using socio-technical systems theory

BACKGROUND/PURPOSE

This paper presents the findings of an action research (AR) project to improve a health information system (HIS) at the Operating Theater Department (OTD) of a National Health Service (NHS) hospital in South East England, the UK.

METHODS

Informed by socio-technical systems (STS) theory, AR was used to design an intervention to enhance an existing patient administration system (PAS) to enable data entries in real time while contributing to the literature. The study analyzed qualitative data collected through interviews, participant observations, and document reviews.

RESULTS

The study found that the design of the PAS was unsuitable to the work of the three units of the OTD. Based on the diagnoses and STS theory, the project developed and implemented a successful intervention to enhance the legacy system for data entries in real time.

CONCLUSIONS

The study demonstrates the value of AR from a socio-technical perspective for improving existing systems in healthcare settings. The steps adopted in this study could be applied to improve similar systems. A follow-up study will be essential to assess the sustainability of the improved system.

A Novel Survey to Examine the Relationship between Health IT Adoption and Nurse-Physician Communication

BACKGROUND

As EHR adoption in US hospitals becomes ubiquitous, a wide range of IT options are theoretically available to facilitate physician-nurse communication, but we know little about the adoption rate of specific technologies or the impact of their use.

OBJECTIVES

To measure adoption of hardware, software, and telephony relevant to nurse-physician communication in US hospitals. To assess the relationship between non-IT communication practices and hardware, software, and telephony adoption. To identify hospital characteristics associated with greater adoption of hardware, software, telephony, and non-IT communication practices.

METHODS

We conducted a survey of 105 hospitals in the National Nursing Practice Network. The survey captured adoption of hardware, software, and telephony to support nurse-physician communication, along with non-IT communication practices. We calculated descriptive statistics and then created four indices, one for each category, by scoring degree of adoption of technologies or practices within each category. Next, we examined correlations between the three technology indices and the non-IT communication practices index. We used multivariate OLS regression to assess whether certain types of hospitals had higher index scores.

RESULTS

The majority of hospitals surveyed have a range of hardware, software, and telephony tools available to support nurse-physician communication; we found substantial heterogeneity across hospitals in non-IT communication practices. More intensive non-IT communication was associated with greater adoption of software (r=0.31, p=0.01), but was not correlated with hardware or telephony. Medium-sized hospitals had lower adoption of software (r =-1.14,p=0.04) in comparison to small hospitals, while federally-owned hospitals had lower software (r=-2.57, p=0.02) and hardware adoption (r=-1.63, p=0.01).

CONCLUSIONS

The positive relationship between non-IT communication and level of software adoption suggests that there is a complementary, rather than substitutive, relationship. Our results suggest that some technologies with the potential to further enhance communication, such as CPOE and secure messaging, are not being utilized to their full potential in many hospitals.

Nursing Informatics Certification Worldwide: History, Pathway, Roles, and Motivation

INTRODUCTION

Official recognition and certification for informatics professionals are essential aspects of workforce development.

OBJECTIVE

To describe the history, pathways, and nuances of certification in nursing informatics across the globe; compare and contrast those with board certification in clinical informatics for physicians.

METHODS

(1) A review of the representative literature on informatics certification and related competencies for nurses and physicians, and relevant websites for nursing informatics associations and societies worldwide; (2) similarities and differences between certification processes for nurses and physicians, and (3) perspectives on roles for nursing informatics professionals in healthcare Results: The literature search for 'nursing informatics certification' yielded few results in PubMed; Google Scholar yielded a large number of citations that extended to magazines and other non-peer reviewed sources. Worldwide, there are several nursing informatics associations, societies, and workgroups dedicated to nursing informatics associated with medical/health informatics societies. A formal certification program for nursing informatics appears to be available only in the United States. This certification was established in 1992, in concert with the formation and definition of nursing informatics as a specialty practice of nursing by the American Nurses Association. Although informatics is inherently interprofessional, certification pathways for nurses and physicians have developed separately, following long-standing professional structures, training, and pathways aligned with clinical licensure and direct patient care. There is substantial similarity with regard to the skills and competencies required for nurses and physicians to obtain informatics certification in their respective fields. Nurses may apply for and complete a certification examination if they have experience in the field, regardless of formal training. Increasing numbers of informatics nurses are pursuing certification.

CONCLUSIONS

The pathway to certification is clear and wellestablished for U.S. based informatics nurses. The motivation for obtaining and maintaining nursing informatics certification appears to be stronger for nurses who do not have an advanced informatics degree. The primary difference between nursing and physician certification pathways relates to the requirement of formal training and level of informatics practice. Nurse informatics certification requires no formal education or training and verifies knowledge and skill at a more basic level. Physician informatics certification validates informatics knowledge and skill at a more advanced level; currently this requires documentation of practice and experience in clinical informatics and in the future will require successful completion of an accredited two-year fellowship in clinical informatics. For the profession of nursing, a graduate degree in nursing or biomedical informatics validates specialty knowledge at a level more comparable to the physician certification. As the field of informatics and its professional organization structures mature, a common certification pathway may be appropriate. Nurses, physicians, and other healthcare professionals with informatics training and certification are needed to contribute their expertise in clinical operations, teaching, research, and executive leadership.

Impact of Patient-centered eHealth Applications on Patient Outcomes: A Review on the Mediating Influence of Human Factor Issues

OBJECTIVES

To examine the evidence of the impact of patient- centered eHealth applications on patient care and to analyze if and how reported human factor issues mediated the outcomes.

METHODS

We searched PubMed (2014-2015) for studies evaluating the impact of patient-centered eHealth applications on patient care (behavior change, self-efficacy, and patient health-related outcomes). The Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model was used as a guidance framework to identify the reported human factors possibly impacting the effectiveness of an eHealth intervention.

RESULTS

Of the 348 potentially relevant papers, 10 papers were included for data analysis. None of the 10 papers reported a negative impact of the eHealth intervention. Seven papers involved a randomized controlled trial (RCT) study. Six of these RCTs reported a positive impact of the eHealth intervention on patient care. All 10 papers reported on human factor issues possibly mediating effects of patient-centered eHealth. Human factors involved patient characteristics, perceived social support, and (type of) interaction between patient and provider.

CONCLUSION

While the amount of patient-centered eHealth interventions increases, many questions remain as to whether and to what extent human factors mediate their use and impact. Future research should adopt a formal theory-driven approach towards human factors when investigating those factors' influence on the effectiveness of these interventions. Insights could then be used to better tailor the content and design of eHealth solutions according to patient user profiles, so as to enhance eHealth interventions impact on patient behavior, self-efficacy, and health-related outcomes.